Keywords workplace training; social and communication skills; adults with autism and intellectual disability

Transcription

1 RESEARCH ARTICLE Effectiveness of a Workplace Training Programme in Improving Social, Communication and Emotional Skills for Adults with Autism and Intellectual Disability in Hong Kong A Pilot Study Karen P. Y. Liu 1,3 *, Denys Wong 2, Anthony C. Y. Chung 3, Natalie Kwok 3, Madeleine K. Y. Lam 3, Cheri M. C. Yuen 3, Karen Arblaster 1 & Aldous C. S. Kwan 2 1 University of Western Sydney, Australia 2 Fu Hong Society, Hong Kong 3 c/o Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong Abstract This pilot study explored the effectiveness of workplace training programme that aimed to enhance the work-related behaviours in individuals with autism and intellectual disabilities. Fourteen participants with autism and mild to moderate intellectual disability (mean age = 24.6 years) were recruited. The workplace training programme included practices in work context and group educational sessions. A pre-test post-test design was used with the Work Personality Profile, the Scale of Independent Behaviour Revised and the Observational Emotional Inventory Revised to evaluate the targeted behaviours. Improvement in social and communication skills specific to the workplace was achieved. For emotional control, participants became less confused and had a better self-concept. However, improvement in other general emotional behaviours, such as impulse control, was limited. The results indicated that a structured workplace training programme aimed at improving social, communication and emotional behaviours can be helpful for people with autism and intellectual disability. Further study with a larger sample size and a control group is recommended. The development of specific programme to cater for the emotional control needs at workplace for people with autism is also suggested. Copyright 2013 John Wiley & Sons, Ltd. Received 29 January 2013; Revised 24 June 2013; Accepted 25 June 2013 Keywords workplace training; social and communication skills; adults with autism and intellectual disability *Correspondence Karen P. Y. Liu, PhD, University of Western Sydney, School of Science and Health, Locked Bag 1797, Penrith NSW 2751, Australia. Karen.Liu@uws.edu.au Published online 16 July 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI: /oti.1356 Introduction Adults with autism face enormous difficulties gaining employment (Cimera and Cowan, 2009). It is estimated that 90% are unemployed or underemployed, and 80% remain dependent on their parents (Gerhardt and Lainer, 2011). A key reason for these difficulties is the well-documented set of core social interaction deficits including socialization, communication, emotional 198 Occup. Ther. Int. 20 (2013) John Wiley & Sons, Ltd.

2 Liu et al. Workplace Training for Adults with Autism control and stereotypical behaviours (see, for example, Brereton et al., 2006; Shattuck et al., 2007; Hume et al., 2009). Specific problems include an inability to form age-appropriate peer relationships and limited understanding of social cues and thus engagement into social situations (Hillier et al., 2007). These problems impede adults with autism, especially those also with intellectual disability, in their efforts to gain employment. Appropriate training and education can in fact help young adults with autism to successfully integrate into the community and gain competitive employment (Hendricks and Wehman, 2009). It is documented that the gains in improved education opportunities for children with autism are not necessarily improving the experience of transition into adulthood (Hillier et al., 2007), of which a key aspect is getting and sustaining a job. Recent studies from Spain (Saldaña et al., 2009) and the United States (Cimera and Cowan, 2009) found that there is a lack of support for young adults with autism to help them engage with work life. Adolescents and adults with autism require intensive assistance in their transition to work environments and independent living (Howlin et al., 2000; Moxon and Gates, 2001). There is also evidence showing the effectiveness of specialized programmes in skills learning (for example, Allen et al., 2010). However, the evidence is not directly related to the socialization needs in the workplace. To be effective, services target behavioural management of individual's internalizing behaviours such as anxiety during social interaction and dyadic relationships. Further, there is a need to assist young adults with autism to understand the subtle social cues and social expectations in workplace interactions (Bloom, 1967). Using a psychoeducational approach, continuing education, creation of different but structured daily scenarios using a work context and offering instant and individualized feedback are important aspects of social skills training programmes for young adults with autism (Baker, 2001; Moxon and Gates, 2001; Walton and Ingersoll, 2013). Methods A programme was developed on the basis of the psychoeducational approach to provide workplace training by tackling the specific social, communication and emotional performance problems that people with autism have. The purpose of this pilot study was to evaluate the effectiveness of the autism-specific workplace training programme. It was hypothesized that the programme would improve socialization, communication and emotional control necessary for the adults with autism to fulfil their life role as productive workers. Design A one-group, pre-intervention post-intervention design was adopted for this study. A series of outcome measures were used to assess participants who enrolled in the workplace training programme with three training themes, namely workplace social behaviours, communication skills and emotional control. Participants In this pilot study, a total of 14 participants (10 men and four women), with a mean age of 24.6 years (range = 18 40; SD = 10.04; median = 19.50), were recruited by means of convenience sampling. Most of them resided in private housing with family (n = 11) and some in hostels (n = 3). They all entered into the training centre where the workplace training programme was held. All participants were recorded as having a formal diagnosis of autism using the DSM-IV and mild to moderate grade of intellectual disability. On the Test of Non-verbal Intelligence (Brown et al., 1997), all participants fell within a deviation quotient range from 65 to 83 (mean = 72.52, SD = 5.74), which indicated mild to moderate intellectual disability. They were all verbal and able to express their needs. Their educational experience varied greatly and included special school (n = 7), primary school (n = 4) and secondary school (n = 3). All participants had not engaged in open employment before and were new to the centre where the programme was conducted. The intervention The workplace training programme was designed by a group of eight occupational therapists working in the field of adolescents and adults with autism for over 10 years. It was based on the specific social, communication and emotional needs of the participants with autism and incorporated the psychoeducational principles including 1) structure, predictability and clarity; 2) management of stimulation; 3) management of achievement issues; and 4) participant instructor relationship (Baker, 2001). Occup. Ther. Int. 20 (2013) John Wiley & Sons, Ltd. 199

3 Workplace Training for Adults with Autism Liu et al. The workplace training programme was run by a registered occupational therapist with two rehabilitation assistants acting as instructors. The instructors received training regarding the programme running, provision of services and feedback to the participants. The programme was provided 5 days a week, 6 hours a day, for 6 months. The participants received instruction on the requirement of the work tasks to do during the start of the day. They then performed according to the instruction. A debriefing session was held at the end of each day to give overall feedback on the participants' performance. The programme made use of the workplace as a training context and included office cleaning, car washing, clerical work and goods packaging. These work tasks were generated according to the participants' workrelated choices. Participants were trained on the required work skills in these work tasks. The centre where the programme was held was built specifically for people with autism and intellectual disabilities. Some of the work tasks such as clerical work were performed inside the centre. Some others such as car washing were carried out in the nearby community. Besides the individual work tasks, 1-hour group educational sessions were held twice a week, which included teaching, modelling and role playing of social and work behaviours. This was provided to reinforce the participants' socialization, communication and emotional control skills. Special scenarios with social, communication and/or emotional issues were used. The occupational therapist and instructors were involved in the group education sessions using a roleplaying method. In addition to the work skills practised, immediate feedback was also offered by instructors throughout the training programme regarding the three workplace training themes: social behaviours, communication skills and emotional control. Social and communication skills training incorporated daily practice with other members and instructors in social greeting etiquette, and verbal and non-verbal communication was provided. It also provided a positive social climate among participants and instructors. The emotional control training consisted of practice in emotional management and expression through both the workplace training and group education sessions. Posters as visual reminders in the form of cartoons and speech bubbles around the centre demonstrating the appropriate social, communication and emotional behaviours covered during the group education sessions of that week were used to enhance the performance of the participants in all areas of training. Outcome instruments Three outcome instruments in workplace social behaviours, communication skills and emotional control were administered. Workplace social behaviours Work Personality Profile (Siu et al., 1998) The Work Personality Profile (WPP) was used to measure job maintenance skills. It has 58 items grouped into five factors including measurements for task orientation, social skills, work performance, teamwork and personal presentation. The WPP has a satisfactory test retest reliability (r = ) and good internal consistency (r = ). It has good validity, and it correctly identified more than 80% of the work rehabilitation placements of the 179 persons with psychiatric disabilities (Law et al., 2006). Social communication skills Scale of Independent Behaviour Revised (Bruininks et al., 1996) The Scale of Independent Behaviour Revised (SIB-R) is a checklist measure of adaptive and problem behaviours. The communication subscales selected for this study include social interaction, language comprehension and language expression. The subscale selected takes about 15 minutes to complete. It showed good test retest reliability (r = 0.95), interrater reliability (r = 0.95) and good discriminative validity differentiating individuals with learning disabilities, mental retardation and behaviour disorders. Emotional control Observational Emotional Inventory Revised (McCarron and Dial, 1986) The Observational Emotional Inventory Revised (OEI-R) was used to assess emotional-coping abilities. There are 70 observational behaviours that are divided into seven subscales: impulsivity frustration, anxiety, depression withdrawal, socialization, self-concept, aggression and confusion. The assessment requires a daily 2-hour situational observation of the participants for five consecutive days. The total number of observed behaviours in the seven subfactors is reported. 200 Occup. Ther. Int. 20 (2013) John Wiley & Sons, Ltd.

4 Liu et al. Workplace Training for Adults with Autism The OEI-R has been shown to have high interrater reliability (r = 0.96) and acceptable validity in measuring the emotional-coping domain for injured workers under the work retraining programme. The raters were occupational therapy students who undertook a 1-day training in using the measures including briefing and practising on the administration and scoring, and using the measures on people with similar background as the participants and a feedback session to ensure their interrater reliability. The interrater reliability was calculated using the intraclass correlation coefficient (3, 1). All items yielded satisfactory to excellent interrater reliability (Tooth and Ottenbacher, 2004). The range for each measure was as follows: WPP ( ), SIB-R ( ) and OEI-R ( ). Procedure After obtaining the informed consent from the participants and their guardian or caregiver, the participants were assessed for their performance. They were also assessed on their work tasks preference. With the information on their performance in social, communication and emotional control and their preference of work tasks, they then participated in the workplace training programme. Ongoing evaluation on their performance was conducted monthly to adjust the appropriateness in the level of social, communication and emotional skills required in the programme. The same outcome measures were conduced 6 months after the commencement of the programme. Ethical considerations Ethics approval was granted by both research committees at the Hong Kong Polytechnic University and Fu Hong Society before the commencement of the study. Informed written consent was obtained from the participants and their guardians or family caregivers. Participants or their guardians or family caregivers could decide to stop the participations at any time during the study period without any consequence incurred. Data analysis Effectiveness of training in the three general themes (social behaviours, communication skills and emotional control) was measured, before and after the programme, using the Wilcoxon signed ranks test (Portney and Watkins, 2009). A non-parametric test was used in view of the relatively small sample size. Statistical analyses were performed using the SPSS computer software (version 16.0 (IBM Corporation, USA)). Results All participants had over 90% of attendance in the 6- month intervention programme. A summary of the results is shown in Table I. For workplace social behaviours, significant improvementswereshowninthewpp(p = 0.089). Significant differences occurred in Appearance, Self-control and Level of supervision ( p = 0.03, 0.05 and 0.02 respectively) on the subscales of WPP. Participants looked tidier with combed hair and appropriate work attire. They showed improved self-control, for example, with less screaming at work. Borderline significant improvements were also found for Work social skills and Work adaptation ( p = 0.06 on both subscales). The decreased maladaptive social behaviours included inappropriate social etiquette, social distance and personal presentation. However, there was still a lack of eye contact and initiation of conversation with co-workers. Significant improvement in social communication skills was noted in the SIB-R ( p = 0.028). All three subscales in Social interaction, Language comprehension and Language expression showed significant improvement (p range from 0.01 to 0.03). This rise in score indicated more positive performance component behaviour during social gathering in the centre. Consistent with the improvement in Social skills on the WPP and Social interaction on the SIB-R, there was a significant difference in the Socialization score on the OEI-R ( p =0.01). This finding indicated an improved emotional response in relation to socialization in the work context. Significant improvement was also noted in the Confusion score on the OEI-R after the programme ( p = 0.04). The decrease in confused behaviour included confused speech, muttering to self and self-stimulatory rocking or shaking. In addition, borderline improvements were noted in the Depression and Self-concept scores on the OEI-R ( p = 0.06 in both subscales). The overall score in OEI-R also indicated a significant improvement after the programme (p = 0.008). Discussion The results of this study indicated that the workplace training programme was effective for people with autism Occup. Ther. Int. 20 (2013) John Wiley & Sons, Ltd. 201

5 Workplace Training for Adults with Autism Liu et al. Table I. Results of outcomes over 6 months Mean (SD) Areas of assessment Assessment items Pre-programme Post-programme p-value Work WPP: Work adaptation (19.02) (16.05) 0.06 WPP: Social skills (11.97) (11.41) 0.06 WPP: Self-control (4.13) (3.90) 0.05* WPP: Level of supervision (5.87) (7.13) 0.02* WPP: Appearance 6.20 (2.10) 7.00 (1.63) 0.03* Social SIB-R: Language comprehension 25.1 (13.8) 28.5 (9.77) 0.01* SIB-R: Language expression 30.9 (14.3) 37.1 (6.12) 0.01* SIB-R: Social interaction 27.8 (15.4) 34.2 (8.70) 0.03* Emotion #OEI-R: Impulsivity frustration 1.50 (1.96) 2.40 (3.66) 0.68 #OEI-R: Anxiety 1.20 (2.30) 0.70 (1.34) 0.45 #OEI-R: Depression 4.00 (8.79) 1.70 (3.65) 0.06 #OEI-R: Socialization 5.30 (6.07) 1.90 (2.42) 0.01* #OEI-R: Self-concept 1.70 (2.45) 0.60 (1.07) 0.06 #OEI-R: Aggression 0.50 (1.58) 0.00 (0.0) 0.31 #OEI-R: Confusion 3.90 (4.99) 1.60 (3.09) 0.04* Note: # A lower score represents a higher level of performance in the specified area. WPP, Work Personality Profile; OEI-R, Observational Emotional Inventory Revised; SIB-R, Scale of Independent Behaviour Revised. *p and intellectual disability. Such programme was designed using the psychoeducational approach based on their needs in socialization, communication and emotional control necessary for them to participate in work. Workplace social behaviours Social behaviours, being one of the very challenging areas to work with for people with autism, are always reported to be a major hurdle that limits their workplace performance (Saldaña et al., 2009). The results on workplace social behaviours in this study were promising. They indicate that a structured programme, based on the psychoeducational approach, can be successful in improving workplace social skills (Howlin, 1997). Very importantly, the work tasks were generated according to the participants' work-related choices. This helped to increase their motivation for improvement. Desired workplace social behaviours vary according to the situation, such as working together with co-workers, requesting information from work supervisors and responding to work instructions and feedback on work performance (Tsang and Pearson, 2001). Participants in this study who were trained in a structured simulated workplace showed improvement in the workplace social behaviours measured. Generalization to an open workplace might be questionable. On the basis of the findings of this study, it is recommended to provide a structured, predictable schedule for them in an environment with controlled stimulation. It is suggested that supervisors are provided with training so they can offer appropriate and immediate feedback on the workers' performance. Communication skills As with social behaviours, the participants demonstrated improvement in communication skills in this study. Participants constantly joined in social interactions during the workplace training programme, including group educational sessions, general daily encounters and practice in the simulated workplace. More important, participants also received immediate and appropriate feedback on their performance and rectified their behaviour in real time. The improvements were consistent with Preis's (2007) assertion that for this population, teaching of direct skills is effective for both the acquisition and maintenance of skills learnt and skills should be taught directly with opportunities to practise them immediately. Emotional control The participants were required to use and practise the emotional control skills learnt in the vocational training context. The emotions of the participants were more 202 Occup. Ther. Int. 20 (2013) John Wiley & Sons, Ltd.

6 Liu et al. Workplace Training for Adults with Autism stable: they showed less confusion, less depression and a better self-concept within the work environment after attending the emotional control training sessions. It appears that the highly structured day programme had created a routinized safety zone with well-defined roles for the participants. This stability likely led to the observed decrease in confused behaviour including confused speech, muttering to self and self-stimulatory rocking or shaking. Furthermore, in this structured environment, the participants showed improvement in their focus on assigned tasks and in their self-concept. This finding is consistent with the assertion of Garcia-Villamisar and Hughes (2007) that the provision of a stable and predictable environment can facilitate the general functioning of people with autism. In comparison with workplace social behaviours and communication skills, emotional control revealed the least significant improvement in the subscale improvements in each outcome measure. In terms of general emotional responses such as impulse control, anxiety management and control of aggression, the participants did not show significant improvements after the programme. This might be related to the fact that emotional control requires one's own regulation that could be both person dependent and context specific (Liu et al., 2007; Müller et al., 2008). A well-adapted environment that provides clear instructions, controlled stimulation and appropriate feedback could certainly help in one's emotional control. However, as emotional control is dependent on the person's own ability of regulation and cognitive control, even after learning the techniques through the educational sessions, the participants might have had difficulty in generalizing the learnt techniques to the relatively less-structured arena of emotional control. Limitations and implication for research and practice The day programme designed specifically for people with autism and intellectual disabilities currently focuses on training within a sheltered work context. Given the knowledge of the difficulties that this group has with generalizing skills taught to the community (Hume et al., 2009), it is recommended that the programme shifts the emphasis from a segregated simulated workplace to real workplaces and to include a community living context, for example, shopping and use of public facilities. Regarding future research, it would be worthwhile to solicit the participants' perspectives in terms of their improvement and their comments about the programme's design. Moreover, it is recommended that further research with a larger sample size be conducted to study the differences in outcome between participants trained in a sheltered workshop and those in community settings. In addition, there should be specific workplace programmes developed for the individual emotional control needs for people with autism. Acknowledgements The authors would like to thank all participants, their family members and colleagues at the Fu Hong Society for their participation and assistance in the project. REFERENCES Allen KD, Wallace DP, Greene DJ, Bowen SL, Burke RV (2010). Community-based vocational instruction using videotaped modeling for young adults with Autism Spectrum Disorders performing in air-inflated mascots. Focus on Autism and Other Developmental Disabilities 25: Baker SB (2001). Coping-skills training for adolescents: applying cognitive behavioral principles to psychoeducational groups. Journal for Specialists in Group Work 26: Bloom GE (1967). The psychoeducational approach to learning disabilities. Paper presented at the Geigy Symposium on Clinical Aspects of Learning Disabilities, Indiana University School of Medicine. Brereton AV, Tonge BJ, Einfeld SL (2006). Psychopathology in children and adolescents with autism compared to young people with intellectual disability. Journal of Autism and Developmental Disorders 36: Brown L, Sherbenou RJ, Johnsen SK (1997). Test of Nonverbal Intelligence TONI-3 (3rd ed.). Austin, TX: Pro-Ed. Bruininks RH, Woodcock RW, Weatherman RF, Hill BK (1996). Scales of Independent Behaviour-Revised. Boston, MA: Riverside Publishing Company. Cimera RE, Cowan RJ (2009). The costs of services and employment outcomes achieved by adults with autism in the US. Autism 13: Garcia-Villamisar D, Hughes C (2007). Supported employment improves cognitive performance in adults with autism. Journal of Intellectual Disability Research 51: Gerhardt PF, Lainer I (2011). Addressing the needs of adolescents and adults with autism: a crisis on the horizon. Journal of Contemporary Psychotherapy 41: Occup. Ther. Int. 20 (2013) John Wiley & Sons, Ltd. 203

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