**4. Activities of daily living**

Activities of daily living (ADLs) are oriented toward taking care of one's own body and include bathing, dressing, eating, feeding, bowel and bladder management, functional mobility, personal device care, personal hygiene and grooming, sexual activity and toilet hygiene. These activities are "fundamental to living in a social world; they enable basic survival and wellbeing". Instrumental activities of daily living (IADLs) may require more complex interactions with one's environment; these activities support daily life within the client's home and community. IADLs include: communication management, home establishment and manage‐ ment, meal preparation and clean up, financial and health management and maintenance, community mobility, shopping, safety and emergency maintenance, care of others and pets, child rearing and religious observance. Children and young people learn to perform ADL and IADL activities with socially appropriate ways in order to engage in education in family and society, game playing, leisure, social participation and work occupations [65].

Individuals with autism generally have the risk of limited engagement in activities. Studies show that such individuals engage in less activities less frequently and have weaker daily life skills when compared with individuals with other developmental disorders or with typical development [66-70]. Most common areas reported by families are limited independence in dressing, rigid eating routines, interruption of eating time because of difficult behaviour, limited independence and discomfort in many hygiene tasks, obvious difficulty in toilet training, limited engagement in chores and continuous and intense supervision to provide safety [71]. Engagement of individuals with autism in daily living activities may be effected by core characteristics specific to autism as well as sensory processes. Studies show that 42-88 % of individuals with autism experience sensory integration disorders [72-76]. Koenig and Rudney demonstrate in a review that children and adolescents who have sensory processing deficits have difficulties in completing their daily occupations, including ADLs and IADLs [77]. While the literature underlines the need to increase evidence-based studies, sensory integration deficits of individuals and sensory features of environment should not be ignored in assessments and interventions for activity engagements of individuals with autism.

#### **4.1. Assessment**

ADL and IADL assessments start with analysis of occupational performance. For this purpose, interviews, inventories, observation and various standardized tests can be used as an assess‐ ment method. In the initial stage, interview with family, child, teacher and other care givers is important in learning child's skills, habits, routines and roles, environmental features, goals and dreams [78]. If the family reports difficulties about some ADL or IADLs of child, therapist should observe the child in clinic or ideally at home if possible and in child's environment during the activity. Assessment should contain information on social, cultural and physical environment, which affect activity performance as much as motor, process and communica‐ tion/ interaction skills of the child. Environmental factors such as division of labour division of family members for child's care, safety issues in physical environment and cultural habits and social routines of family may be registered. Task analysis is made to define activity demand, activity is divided into steps and reviewed, steps are listed and requirements are defined. The Functional Independence Measure for Children (WEFIM), Waisman Activities of Daily Living (W-ADL) Scale, The Paediatric Evaluation of Disability Inventory (PEDI), The Vineland Adaptive Behaviour Scales, The Assessment of Motor and Process Skills (AMPS), The Canadian Occupational Performance Measure (COPM) and Sensory Profile (SP) for sensory integration are some of the examples of standardized methods that can be used in the assessment of performance in daily living activities [29, 79-85].

#### **4.2. Intervention**

personal device care, personal hygiene and grooming, sexual activity and toilet hygiene. These activities are "fundamental to living in a social world; they enable basic survival and wellbeing". Instrumental activities of daily living (IADLs) may require more complex interactions with one's environment; these activities support daily life within the client's home and community. IADLs include: communication management, home establishment and manage‐ ment, meal preparation and clean up, financial and health management and maintenance, community mobility, shopping, safety and emergency maintenance, care of others and pets, child rearing and religious observance. Children and young people learn to perform ADL and IADL activities with socially appropriate ways in order to engage in education in family and

Individuals with autism generally have the risk of limited engagement in activities. Studies show that such individuals engage in less activities less frequently and have weaker daily life skills when compared with individuals with other developmental disorders or with typical development [66-70]. Most common areas reported by families are limited independence in dressing, rigid eating routines, interruption of eating time because of difficult behaviour, limited independence and discomfort in many hygiene tasks, obvious difficulty in toilet training, limited engagement in chores and continuous and intense supervision to provide safety [71]. Engagement of individuals with autism in daily living activities may be effected by core characteristics specific to autism as well as sensory processes. Studies show that 42-88 % of individuals with autism experience sensory integration disorders [72-76]. Koenig and Rudney demonstrate in a review that children and adolescents who have sensory processing deficits have difficulties in completing their daily occupations, including ADLs and IADLs [77]. While the literature underlines the need to increase evidence-based studies, sensory integration deficits of individuals and sensory features of environment should not be ignored in assessments and interventions for activity engagements of individuals with autism.

ADL and IADL assessments start with analysis of occupational performance. For this purpose, interviews, inventories, observation and various standardized tests can be used as an assess‐ ment method. In the initial stage, interview with family, child, teacher and other care givers is important in learning child's skills, habits, routines and roles, environmental features, goals and dreams [78]. If the family reports difficulties about some ADL or IADLs of child, therapist should observe the child in clinic or ideally at home if possible and in child's environment during the activity. Assessment should contain information on social, cultural and physical environment, which affect activity performance as much as motor, process and communica‐ tion/ interaction skills of the child. Environmental factors such as division of labour division of family members for child's care, safety issues in physical environment and cultural habits and social routines of family may be registered. Task analysis is made to define activity demand, activity is divided into steps and reviewed, steps are listed and requirements are defined. The Functional Independence Measure for Children (WEFIM), Waisman Activities of Daily Living (W-ADL) Scale, The Paediatric Evaluation of Disability Inventory (PEDI), The Vineland Adaptive Behaviour Scales, The Assessment of Motor and Process Skills (AMPS),

society, game playing, leisure, social participation and work occupations [65].

**4.1. Assessment**

172 Autism Spectrum Disorder - Recent Advances

Occupational therapists may refer to different approaches to improve ADL and IADL per‐ formances in children, including 1) establishing and maintaining performance, 2) activity adaptations or compensatory methods [78].

#### *4.2.1. Establishing and maintaining performance*

At the initial stage of intervention, therapist uses an activity analysis to define which steps of activityprocess areproblematic anddefinesbehavioural andeducativemethods tobeused[78].

Behavioural approaches has been used, often in combination with other approaches, to obtain a baseline of the child's behaviours and as a way of establishing clear goals. Behavioural methods like reinforcement and token systems are useful in attainment and sustainment of skills in individuals with autism. Furthermore, besides guiding learning, they may facilitate visual (showing), verbal (speaking or written information), tactile (guidance or using a part of body) or environmental (colour coded materials) cues. Cues are important to improve the quality of performance and to brief individual on what to do in the next step. As individuals with autism may experience difficulties in understanding natural cues and verbal communi‐ cation, context or activity demands such as use of prompting can be modified [86].

One of the important training methods used in ADL training is chaining. Training of complex skills generally requires chaining steps of the task. Three chaining options are available for functional task training: a) Backward chaining in which the last step of the task is trained first, followed by the second to last step and the last step, and so on, progressing backward through the chain, b) Forward chaining in which the first step of the chain is trained first, followed by the first and second step, and so on, progressing forward through the chain c)Whole task method in which each step of the chain is trained on each presentation [87]. Another method is time-delay procedures. The time-delay cueing system typically involves two training stages: 1) A cue designed to elicit the next step in the chain is delivered so as to coincide with the stimulus (i.e., the completion of the previous step in the chain). 2) A defined interval is inserted between the occurrence of the stimulus and the response-eliciting cue [88]. These educational methods include strategies that occupational therapists can use in skill training. Repetition and development of habits and routines are required to sustain the skill after it is learned and to reduce environmental supports. Furthermore, generalization of skill in different environ‐ ments should be emphasized [78].

#### *4.2.2. Activity adaptations or compensatory methods*

Compensatory strategies may include modification of task or task method, use of assistive technology or modification of environment. Therapists may also refer to the combination of these methods [78]:

#### **• Adaptation of task methods**

"Grading" is a method commonly used by therapists. Grading is adaptation of task or parts of a task according to the capability of child. Activity is divided into subtasks with task analysis and task is modified depending on the difficulty or easiness level for the child [78].

#### **• Visual Strategies**

Individuals with autism can process visual information easier than auditory information [89]. Visually based interventions include visual (e.g., picture, written) schedules, visually organ‐ ized tasks, written or pictorial scripts, rule reminder cards, and visual task analyses [90]. Such interventions are reported to be effective in individuals with autism [90, 91]. These activities may be used for individuals with autism to learn activities of daily living skills, to foresee daily routine and to become independent from various environments [92].

#### **• Assistive Technology**

In literature, technologies like video modeling, video prompting, handheld devices, structured computer games and virtual reality environments are used for training purposes. Research incorporating technology has consistently demonstrated good effects to daily living skills for children with autism. Additionally, assistive technology requirement of occupational thera‐ pist, which technological tool is applicable and proper assessment of factors related with accessing technology such as economical status of family are important [92-95].

#### **• Sensory Strategies**

Creating sensory-friendly environments and implementing adaptive sensory strategies are important for effective ADL and IADL performance in children with sensory modulation problem. For instance, environment should be structured to be silent when an activity is performed with a child who has auditory-hyperresponsiveness responses. Use of earphone is recommended in environments that cannot be controlled. Another example is that preparation of a child with deep pressure and organized, rhythmical touches might be facilitating before starting a dressing activity with a tactile defensive child [23].
