The present study provides initial evidence that CBT may increase parental perceptions of daily living skills in children with ASD and concurrent anxiety disorders, and decrease corresponding unnecessary parental involvement in their children’s personal self-care tasks. Furthermore, gains in daily living skills for a subgroup of children who received treatment were maintained over 3 months. The CBT intervention techniques employed may promote adaptive skill acquisition among children while encouraging parents to support their children’s skill use and grant opportunities to become more self-sufficient. Conversely, other factors may have affected these outcomes, such as parental reporting bias. Additionally, further study of the efficacious components of CBT is warranted. That is, behavioral therapy alone may prove equally efficacious. Nonetheless, the results of this study could have theoretical as well as practical implications.
As hypothesized, parents of children in the IT condition perceived an increase in personal daily living skills regularly performed by children, such as grooming, toileting, dressing, and simple healthcare, as compared with children in the WL group. However, although statistically significant, we must consider whether the gain is clinically significant. The standard and age-equivalency scores indicate that children in the IT condition continued to fall well below the expected total and personal daily living skills range for their age group at posttreatment. It is unclear whether more intervention emphasis on daily living skills within the current intervention framework (i.e., devoting a higher proportion of each session to helping children build skills and training parents how to support independence) is needed to affect greater improvements or whether the current intervention would produce additional gains if it were longer in duration. Due to the pervasive and chronic pattern of adaptive functioning impairments in social reciprocity, communication, and flexibility with behavior and activities, ASD may cause children to “hit a wall” in their development of daily living skills. Without even more extensive external support and guidance, children with ASD and their parents may find it challenging to develop daily living skills that match children’s chronological age. On the other hand, naturalistic studies of children with autism show little to no gains in adaptive behavior, including daily living skills, over similar timeframes (Smith et al. 2000
), indicating that any improvement may be meaningful.
Consistently, studies investigating the adaptive functioning and daily living skills of individuals with ASD have found great variability in skills (Howlin et al. 2004
; Howlin et al. 2000
; Liss et al. 2001
); however, the overwhelming majority of individuals with ASD are reported to have “poor” outcomes, including little independence from caregivers. Similarly, the present study found variability in parental perceptions of their children’s total and personal daily living skills at intake. This variability continued through the intervention for children in the immediate treatment and waitlist conditions. This pattern of findings suggests that additional variables may contribute to the maintenance of impaired daily living skills. Age, cognitive scores, symptom severity of autism, and memory have been associated with the adaptive functioning and daily living skills of children with ASD. For example, Freeman et al. (1999
) found that adaptive functioning increased with age for individuals with ASD and was related to individual initial cognitive scores. Liss et al. (2001
) and Baghdadli et al. (2007
) found severity of autistic symptoms related to poorer adaptive functioning outcomes, suggesting that symptoms of autism may interfere with the development of daily living skills. Finally, poorer memory has been related with poor adaptive functioning skills (Liss et al. 2001
). Future studies should investigate the role of these child factors in determining the efficacy of the CBT intervention involving subgroups of children with ASD.
In addition, parent motivation, beliefs about treatment credibility and expectancies, and treatment adherence may play a role in the variance of Daily Living Skills scores at posttreatment. CBT requires parents play an active role in treatment implementation; parents are asked to use treatment strategies independently, regularly, and correctly. Studies of parent beliefs find that treatment credibility is significantly associated with parental motivation to perform treatment techniques, while parental expectations of treatment outcome predict parental treatment adherence (Nock et al. 2007
). Therefore, variability in children’s daily living skills may partially be a function of parents’ motivation and beliefs. Research regarding these factors may provide additional details regarding the variable treatment response despite seemingly efficacious intervention techniques.
Recently, the Research Units on Pediatric Psychopharmacology [RUPP] Autism Network (2007
) reported on the feasibility of a manualized parent training program involving parents of children with ASD in which children’s noncompliance behaviors and daily living skills were targets of intervention. Parents attended and adhered to the parent training intervention, and children were reported to decrease noncompliance and increase their daily living skills, as reported on the parent-reported VABS Daily Living Skills subscale, by 22.3% over the entirety of the intervention. While this study did not include a control group, it provides additional support for parental training as essential for facilitating independence in children with ASD.
Finally, parents of children in the immediate treatment condition reported that their own involvement in their child’s private daily self-care tasks significantly decreased when compared with parents of children in the waitlist condition. A medium effect size was found when comparing pretreatment and posttreatment parental involvement scores for parents whose children received treatment, while a negligible effect was found for parents of children in the WL group. This is an important contribution to the treatment literature because parental behaviors, such as involvement in their children’s basic self-care tasks, have been implicated as a factor in the maintenance of anxiety and impaired daily living skills (Wood 2006
). According to Wood’s model of parental intrusiveness, when caregivers take over tasks that children could be performing independently, they limit children’s mastery and facilitate dependence, maintaining anxiety. Alternatively, children with daily living skill deficits may become anxious due to their excessive reliance on caregivers for assistance with tasks that peers are capable of performing independently. Therefore, decreases in parental intrusiveness in their children’s personal self-care tasks likely facilitate independence and may assist in skill acquisition and mastery, as well as potentially lower anxiety levels.
In fact, a correlation was found between changes in anxiety severity and daily living change scores, indicating some relation between these constructs. In particular, these results may indicate that possibility of a mediating effect of daily living skills. That is, increasing daily living skills may be related to a reduction in anxiety severity. Interestingly, when examining the correlation strength, correlations are not stronger in the IT versus WL group, which would be expected in a true mediation relationship. Overall, however, these results indicate that if there is a change in anxiety severity then daily living skills are also likely to change. Only further testing will determine whether a mediating relationship exists and the nature of the relation.
It is particularly notable that parent perceptions of treatment gains resulting from the CBT intervention remained stable over time without continued intervention. Parent reports suggested the maintenance of their reduced involvement with their children’s private self-care routines such as dressing and bathing, intrusions on children’s personal space, and infantilizing behaviors. These findings are provocative because of the difficulty sustaining treatment gains across time and settings when involving children with ASD (Lord et al. 2005
). This maintenance may be due to several factors. During treatment, therapists do not continue to progress onto new and more complex daily living skills until the previous skill or step is mastered and generalization is evident. Thus, skills are developed and performed reliably, increasing the likelihood that they will be maintained. Even if children do not become fully self-motivating, parents are likely to continue adhering to treatment techniques due to their own observation of their children’s abilities.
Parent reports were used to determine the children’s daily living skills as well as their own involvement in their child’s personal self-care tasks at intake and posttreatment/postwaitlist. Because parents are aware of the treatment condition to which they are assigned, parent reports could have been influenced by a desire to provide responses consistent with treatment goals. However, childhood anxiety disorders were the main focus of the intervention and parent’s primary reason to seek treatment; most of the questionnaires completed by parents focused on anxiety disorders and related interference. Therefore, questionnaires and semi-structured interviews related to daily living skills may not have been the primary construct considered during assessments by parents and thus may have been more accurately reported. Future studies would benefit from multiple informants reporting on children’s daily living skills.
Of particular importance is the discussion of generalization of the intervention outcomes across varying families with children with ASD and anxiety. Our sample was slightly skewed towards including families in middle and upper middle class income (18 families reported earning $90,000 a year or more), with approximately 60% of the primary caregivers having completed college. However, ANCOVA was used to analyze group differences in posttreatment VABS total and Personal Daily Living Skills and PCIQ parental intrusiveness across the three income groups (less than $40,000; $40,001–$89,999; more than $90,000), with pretreatment VABS total and Personal Daily Living Skills and PCIQ scores as covariates. Results indicate these analyses were not significant (p’s ranged from .26 to .94, respectively).
Implications and Conclusions
Family CBT techniques appear to produce statistically and (potentially) clinically significant gains in daily living skills among children with ASD. Parents perceived that their children with ASD who received treatment were able to perform more total and personal daily living skills independently at the end of treatment. Facilitating the acquisition of age-appropriate daily living skills early in life may contribute to a trajectory promoting more opportunities for independent functioning as children develop. Parents who received treatment reported that they reduced their intrusions in their children’s private self-care tasks, which may give them more time for other activities and allow them to disengage in small ways from their children’s moment-to-moment functioning. With its focus on taking small steps and emphasizing each accomplishment, the CBT model appears well suited for supporting ongoing growth. In future research on daily living skills interventions for ASD, it will be important to determine if parents and children are able to maintain gains over the course of years, not just months, if a focus on the importance of this domain of functioning in CBT might lead to an acceleration in growth that eventually helps children and youth attain age-appropriate levels of independence, and how mastering daily living skills relates to ameliorating anxiety disorder symptoms or severity.