Original Article

Effectiveness of Visual Schedule in Combination with

Sensory‑Integration Therapy for Developing Self‑Care in
Children with Autism
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Sailendri Dash1, Anurupa Senapati2

1
Assistant Professor, Department of Occupational Therapy, KMCH College of Occupational Therapy, Coimbatore, Tamil Nadu, India,
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2
Associate Professor & HOD, Department of Occupational Therapy, SVNIRTAR, Cuttack, Odisha, India

Abstract
Background: Developmental disorders like autism are heterogeneous and lifelong disorder which will have mild‑to‑severe limitations for which
they rely heavily on others for support in self‑care, daily living, employment, relation, and overall independent living. Objectives: The aim of
this study is to explore the effect of visual scheduling for developing self‑care in children with autism and to incorporate the visual scheduling as
a therapeutic intervention in combination with sensory integration therapy (SIT). Study Design: This was pretest–posttest control group design.
Methods: Convenient sample of 32 children with autism were screened with childhood autism rating scale (CARS) were allotted to experimental
and control group. The pretest score was taken using Wee‑FIM, after that, both groups underwent 12 weeks of intervention. Experimental group
followed conventional therapy (SIT) along with visual schedule protocol of self‑care and control group followed conventional therapy and
the culture‑based rearing techniques. The potential impact of the program on participation was assessed as post Wee‑FIM score. Results: The
present study aimed at knowing the effectiveness of the combined approach of visual schedule and SIT for increasing self‑care in children with
autism. Statistical analysis shows that there is a significant difference between both groups after posttest. Result shows the change in mean score
25.56–40.43. Moreover, the result is highly significant at the level of P = 0.00 (95% confidence interval). Conclusions: This study shows the
combined effect of visual schedule and SIT is an effective intervention to improve self‑care activities in children with autism.

Key Words: Autism, Childhood Autism Rating Scale (Cars), Pediatric Functional Independent Measure (Wee-Fim), Sensory Integration
Therapy, Visual Schedule

Introduction Difficulty in independent functioning impacts the overall

Autism spectrum disorder (ASD) is the most common variety
of developmental disorder which is characterized of impaired
verbal and nonverbal communication, and appearance of
repetitive stereotypical activities, behavior, and interest leads
to limitations from mild‑to‑severe for independent living in
a social situation.[1,2] ASD is more common in male children
than female, i.e., 4:1.
Self‑care is a major part of independent living, which is the
care taken by individuals toward their health and well‑being
and includes the care extended to their children, family, friends,
and others in the neighborhood and local communities which
seems concrete and self‑explanatory (UK Department of health
steering group. joining up self‑care in NHS 2003).[3‑6]
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outcomes for an individual with ASD and the burden of
care for the family. Thus, increased attention has focused
on teaching these children’s behavior such as daily living
skill (getting dressed) that attenuate the burden of parents
and caretakers.[4] Few techniques like pictorial management,
a visual schedule which is a supportive tool helps in
communicating the sequence of upcoming activities or events
through the use of objects, photographs, icons, word or a
Address for correspondence: Dr. Sailendri Dash,
Assistant Professor, KMCH College of Occupational Therapy,
Coimbatore, Tamil Nadu - 641 014, India.
E‑mail: sailendridash@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Dash S, Senapati A. Effectiveness of visual

10.4103/0445-7706.244553 schedule in combination with sensory-integration therapy for developing
self-care in children with autism. Indian J Occup Ther 2018;50:98-102.

Presented at 55th Annual National Conference of AIOTA, OTICON 2018, Nagpur, Maharashtra, India in February 2018.
Award: Won KEMOT Youth Talent Trophy for Best Scientific Paper.

98 © 2018 The Indian Journal of Occupational Therapy | Published by Wolters Kluwer ‑ Medknow

 Dash and Senapati: Visual Schedule for Self Care in Autism

combination of tangible supports to facilitate the independent
performance of a daily living skill in children with ASD.[4,5]
ASD children may also have a problem in integrating
appropriate sensory input which can disturb the independent
functioning but through the use of sensory integration therapy
(SIT) it is possible to make the child organized for the
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grooming, bathing, dressing upper body, dressing lower body,
toileting, brushing [Figure 1], bladder management, and bowel
management.
As it was for the home use assistance was given to the parents to
identify an appropriate physical location for various activities, creating
environmental structure and boundaries. The schedule was posted on
the wall or made available to the child in a book in vertical or horizontal

upcoming challenges.[7,8,9]
orientation as per the suitability. The schedule was demonstrated to
Hence, this study may serve as an attempt to validate the effect the parents and logbook was maintained separately for each child.
of visual schedule along with SIT in developing self‑care Postscore data was taken after the completion of 12 weeks.
in children with autism. The objective of this study was to
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explore the effect of visual scheduling in developing self‑care

in children with autism and to incorporate the visual scheduling Results
as a therapeutic intervention in combination with SIT. After completion of the post‑treatment evaluation, data were
collected and analyzed using Statistical Package for Social
Science version 23.0 (CRUM1ML Developers, USA). The raw
Methods score of pre‑intervention and post‑intervention data of outcome
The prospective pretest–posttest experimental study was having measure of both control and experimental group were added for the
the sample size of 32 children with mild‑to‑moderate autism final score. In this pretest post‑test experimental group design with
were screened by Childhood Autism Rating Scale (CARS) two‑tailed nonparametric study the change within the group were
and allotted to experimental and control group. The study analyzed by Wilcoxon signed‑ranks test, and between the groups
was conducted from January 2015 to April 2016 at Swami were performed using Mann–Whitney U‑test to know the difference
Vivekananda National Institute of rehabilitation training and in significance groups. After the data were analyzed, the results were
research, Cuttack and ASHA rehabilitation center Cuttack, shown in the following tabular form. Demographic characteristic of
Odisha.
Inclusion Criteria Table 1: Demographic characteristics of participants
• Children with mild‑to‑moderate autism (CARS) Baseline characteristic Group 1 Group 2
• Some abilities to get through the commands experimental control
• 3–7 years of age. Number of subjects (male/female) 16 16
Age range (months) 36‑84 36‑84
Exclusion Criteria Mean age (months) 52.75 46.8
• Severe mentally retarded *Demographic characterstics showing baseline characteristics of experimental
• Visual or hearing impairment and control group
• Physically challenged.
Table 2: Wilcoxon signed rank test of experimental
Tools Used
group
• CARS
• Wee‑FIM or pediatric functional independent measure. Number of Z-value Sign. 95% CI
subjects (P-value)
Procedure 16 −3.521 0.000 0.00‑0.08
All the participants in this study were screened by CARS. *Highly significant. CI: Confidence interval
Children fulfilling the inclusion criteria were selected, and
formal consent was obtained from the parents after explaining Table 3: The statistical analysis Wilcoxon signed rank
the treatment protocol. Convenient sampling (n = 16) was done test of experimental group
to alert the child either to the experimental or control group.
Number of Z-Value Sign. 95% CI
Pretest data for self‑care were measured using Wee‑FIM. subjects (P-value)
All children underwent 12 week of intervention protocol. 16 −3.417 0.001 0.00‑0.08
The experimental group received conventional therapy (SIT) *Highly significant. CI: Confidence interval
along with visual schedule and control group received
conventional therapy along with culture‑specific child‑rearing Table 4: Mann‑Whitney U‑test, comparing level of
techniques. difference between the groups
Both the groups received the intervention protocol for 1 h per Groups Mean Mean Z-Value Sign. CI
rank (P-value)
day and 5 days per week for 12 weeks.
Experimental 40.43 24.47 −4.816 0.000 0.00‑0.08
In this study, visual schedule included as three to five steps Control 26.31 8.53
of pictorial cues of the self‑care activities such as eating, *Highly significant. CI: Confidence interval

The Indian Journal of Occupational Therapy ¦ Volume 50 ¦ Issue 3 ¦ July-September 2018 99

 Dash and Senapati: Visual Schedule for Self Care in Autism

the patients are given in Table 1. Results obtained through statistical
analysis Wilcoxon signed rank test of experimental group, is
presented in Table 2 and for control group, it is presented in Table 3.
The Mann–Whitney U‑test score is given in Table 4.
Graphs 1 and 2 show the changes in mean score and the overall
change in self‑care activities.
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experimental group which is showing better improvement than
the control group in self‑care development in autistic children.
The difference in the result may be due to the application of
visual schedule in the experimental group.
Pervasive atypicalities in central nervous system and
deregulation in the autonomic nervous system, having a

high prevalence of comorbid anxiety, attention disturbance,

Discussion
The present study is aimed at knowing the effectiveness of
the combined approach of visual schedule and SIT increasing
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response inhibition, and social cognition is very common in
ASD which affects the adaptive behavior.[10]
According to Volkmar et al., the visual schedule can help the

self‑care in children with autism. students with ASD by reducing anxiety and unpredictability
in their day. They also provide emotional regulation while
The results show that there is an overall improvement in
reducing the challenge on short‑term memory. And also tells
self‑care in both the groups after 12 weeks of intervention as
about the events are going to occur, when they occur, the order
shown by the mean rank score in the Wee‑FIM. However, the
of activities and any change that are going to happen in daily
routines.[11]
Graph 1: Mean score change on Wee‑FIM
Ganz et al., 2007 noted that changing a student’s routine helps
to teach him to deal with changes if his schedule reflects those
changes, he will learn to follow the schedule instead of a typical
routine for the day.[11]
Schneider and Goldstein 2009, schedules can be used
as reinforcement strategies to keep frank of behaviors
during specific time interval using the individual chart
for students. This shows socially appropriate behaviors in
students with ASD and also shown that step by step visuals
includes multi‑sequential steps that support independence
in the completion of work and eliminate the need for adult
intervention.[12]
Graph 2: Change in the overall score for self‑care. Blue line‑control
group, Red line‑experimental group Other studies show schedules help in many ways to the children
with autism like helps the students to plan for the day or events,
Wee-FIM
provide a visual warning before transition.[13]
25
22 22 And improve student with ASD understanding of exceptions
20
18 18 18
17
(Mesibovi, Shea, Shopler 2005), this advance notice helps the
16 16
15 15 15 students to attend more to the material.[14]
13
11 11
10
9 9
According to effective practice for children with autism by
8 8
6 6 6
7 7 James, Dennis, Walter, 2008 in this book they showed any
5 5 5 5
3 3
2
3
4
2
static pictorial prompting that may be a single picture or in
0 0 a sequence form is an observational technique which helps
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Individual Improvement
in observational learning, the basic learning mechanism and
broadly applicable to teach new skills, used observational

Figure 1: Visual schedule for brushing (Opening the toothpaste, Applying paste on brush, Brushing the teeth, Cleaning teeth and mouth)

100 The Indian Journal of Occupational Therapy ¦ Volume 50 ¦ Issue 3 ¦ July-September 2018
 Dash and Senapati: Visual Schedule for Self Care in Autism
learning procedure to teach a variety of behavior to children
with disability inappropriate play, social interaction, attention
to and interaction with materials, activities, and people and
language skills.[15]
Grandin 1995, Hodgdon 1995, Quill1997 posted that visual
supports are especially effective in children with autism
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because their visual perception abilities are often seems as an
area of strength.[16]
The lack in strength in the area of rote memory, concrete
thinking, the ability to efficiently process visuospatial
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information (Quill 1997) compensated by using visual cue
as the primary form of instruction in children with autism.[17]
Adaptive behavior is the performance of daily activities
required for social and personal self‑sufficiency across a variety
of life situation including self‑care, community mobility, home
maintenance, establishing, and maintaining self‑relationship
and community needs and feelings.[18]
In many adaptive behavior measures, the test developers
operationalized adaptive behavior as independent performance
requiring that behaviors be performed without assistance. For
children’s and youth with ASD, environmental supportive
such as the use of pictorial schedules may improve
performance. Basic measures of adaptive behavior on
independent performance reducing their sensitivity to
change in adaptive function that is likely to occur when the
environment of children and youth with autism are modified
and supportive.[19-21]
Limitations
• The sample size was small. Thus, it is difficult to
generalize this finding
• Population sample was only confined to autistic children
with a very minimum age limit
• The duration of the study was also short
• Children have no alternate choice for exploration of
environment except home
• No follow‑up study has been done.
Recommendations
• Study with large sample
• Additional studies of long‑term benefits can be carried
out
• This type of study can be implemented to other
developmental disable population particularly developing
self‑care.
Conclusion
The result indicates that there is a significant improvement
in self‑care activities in autistic children by the use of visual
schedule along with SIT. So the experimental hypothesis has
been accepted, and the null hypothesis is rejected. Hence it
can be concluded that the visual schedule can be incorporated
to improve self‑care in children with autism as it strengthens
the visuospatial information to provide adaptive behavior.
The Indian Journal of Occupational Therapy ¦ Volume 50 ¦ Issue 3 ¦ July-September 2018
Declaration of Patient Consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the parent(s) has/have
given his/her/their consent for his/her/their child images and
other clinical information to be reported in the journal. The
parent understand that their child names and initials will not
be published and due efforts will be made to conceal their
identity, but anonymity cannot be guaranteed.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
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