Visual Support: Daily Living Skills

-- by Sarah, Gaby's mom

We had all sorts of How-To Lists. We used them to teach her how to pack her lunchbox, how to pack her backpack, how to make a peanut butter sandwich, how to develop film in photography class, how to wash hands, how to get dressed, how to get to bed in time, how to use a sanitary pad or a tampon (that was fun), etc. They were generally illustrated lists (words + icons, sometimes with a more detailed social story) and were essential to promote understanding and independence.

We used a great book called "Taking Care of Myself" by Mary Wrobel. It has lots of good advice about teaching self-care, hygiene, etc. This is where I got the visual supports/ideas for prepping Gaby for her period. Invaluable.

Dentist

Gaby has severe oral sensitivity issues (which have a hugely negative impact on her diet to this day) and a hair trigger gag reflex. As you can imagine, the idea of a dental exam seemed like a non-starter. I know several kids with autism who have to be sedated and unconscious to even contemplate it. However, our dentist is a trooper and was willing to give it a try - and he also understood that we'd get as far as we could get and call it good. In fact, to get all the way through x-rays, a cleaning and the dentist's exam took years (it was really those stinking x rays that were the biggest problem). We would never have managed it without visual supports.

I called the office before Gaby's appointment and made sure I understood exactly what was going to happen, in what order, and what tools would be used. Then I made an illustrated check off list with all the steps and a picture of the selected reward on the bottom. As Gaby's anxiety increases, her ability to process language significantly decreases. For this reason, the visual support is critical in such a stressful environment. It also helps her keep track of how long she has to suffer before her ordeal is over. As we move down the list, checking things off, she can see the progress she's making towards being finished and getting her reward and this helps her control her behavior. It was also important to make sure the dentist and hygienist understood that they needed to show Gaby the tools they were going to use and how they worked before they stuck them in her mouth (assuming that they wanted to keep their fingers) and that they needed to use precise and simple language when they talked to her. For Gaby, it was critical that everyone be absolutely honest with her about what was happening and as specific as possible. Don't say "it won't hurt" if what you really mean is "it won't hurt much". We really had issues with this during the sealant process. I find it super awkward to interrupt and correct the dentist - after all, he's just trying to reassure Gaby in a way that's effective for most kids. However, with Gaby you just can't say "We're almost finished" when you mean "30 more seconds on this tooth and then 1 more tooth to go". Once you start telling her things like that, she won't trust you anymore and she's not going to let you anywhere near her.

Doctor

For Gaby, this was a much less stressful environment than the dentist - unless a shot was involved. Unfortunately, that wasn't saying much. Again, a visual support in the form of an illustrated check list with the selected reward at the bottom made the experience a lot easier. She understood what was going to happen to her, she could see that some of it was non-threatening for her, she was mentally prepared for the things that were stress provoking (like the blood pressure cuff - go figure) and perhaps most importantly, she could see that "shot" was not on the list (most of the time) and didn't go into unnecessary panic mode.

Swimming

Gaby loves to swim. She was a bit less enthusiastic about swimming lessons, unfortunately. The noise, the close physical contact with other kids, the waiting, and the dreaded "one hand on the wall" while waiting for your turn rule were all significant challenges for her. In the interest of full disclosure, I will admit that we started Gaby out with private swim lessons. But once she figured out that she couldn't continue to attempt to breathe normally while her head was under water (good grief), we were able to move on to group swim lessons. Unfortunately, in a group lesson, with a teenage instructor and an ever changing assortment of kids, it wasn't practical to come up with a check list of activities (although, in retrospect, I think we could have managed something if I'd been a little pushier). I did rely heavily on a laminated visual support that listed 3 important rules (quiet voice, listen to teacher, and "hand on wall") with Gaby's selected reward at the bottom. In that super stimulating, semi-chaotic environment, only that concrete visual reminder of the behaviors we wanted (none of which were on Gaby's preferred pool agenda) and the reward she would receive for compliance got us through what was often a very tense 30 minutes.

YMCA

In high school, we thought it would be good if Gaby could develop some kind of exercise routine. Gaby thought it would be good if I would drop her off at the Y and then go away. So we compromised. I made her an illustrated checklist of the activities that we had agreed together she would try. She followed the list and I sat off in a corner while she ignored me. Since independence is the ultimate goal, we were both happy. The list included the activities she chose, the amount of time she had to do them, wiping off each piece of equipment when she was finished and where to put the used towel. We ran through the routine together the first time (which she hated), to ensure understanding, and then she was good.

"As Gaby's anxiety increases, her ability to process language significantly decreases. For this reason, the visual support is critical in such a stressful environment."