Effectiveness of the forward chaining technique in improving independent handwashing skills in children with autism spectrum disorder in inclusive kindergartens
Abstract
Handwashing is an essential self-care skill for children with Autism Spectrum Disorder (ASD); however, deficits in executive function and sensory processing impede its independent acquisition. This study aimed to analyze the effectiveness of the forward chaining technique in improving handwashing skills in children with ASD in inclusive kindergarten. A Single Subject Research (SSR) design with an A1–B–A2 format (baseline–intervention–post-intervention) was employed at TK ZAIS, Serang Regency. Three children with ASD aged 5–6 years were selected through purposive sampling. The instrument consisted of a task analysis-based observation checklist validated by two experts: a special education specialist and an early childhood education specialist. Data were analyzed through visual graph analysis encompassing level change, trend direction, data stability, and overlap percentage between phases. Interobserver Agreement (IOA) was calculated to establish reliability, and Tau-U was computed as a nonparametric effect size index. Results demonstrated that mean handwashing performance increased from the baseline phase (25%–40%) to 75%–100% during intervention, with a consistent ascending trend across all three subjects. During the post-intervention phase (A2), all subjects maintained skills at 91.7%–100%, indicating effective internalization and maintenance. Phase stability reached ≥80%, overlap between phases was <20%, mean IOA was ≥90%, and the aggregated Mean Tau-U of 0.86 indicated a strong effect size. This pattern indicates a strong functional relationship between forward chaining implementation and improved independent handwashing skills. The forward chaining technique proved effective and can serve as an evidence-based intervention model for kindergarten teachers in supporting self-care independence in children with ASD.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425787
Auld, C., Foley, K.-R., & Cashin, A. (2022). Daily living skills of autistic adolescents and young adults: A scoping review. Australian Occupational Therapy Journal, 69(4), 456–474. https://doi.org/10.1111/1440-1630.12806
Baylon, M. A., Parrish, J., & Smith, M. (2024). Parent and teacher involvement in self-care skill training for children with autism: A systematic review. Focus on Autism and Other Developmental Disabilities, 39(1), 45–57. https://doi.org/10.1177/10883576231189412
Bertolotto, N., Scarpa, A., & Canevaro, A. (2024). Toilet training interventions in children with autism spectrum disorder: A systematic review. Research in Developmental Disabilities, 145, 104671. https://doi.org/10.1016/j.ridd.2023.104671
Bottema-Beutel, K., Crowley, S., & Sandbank, M. (2023). Bias and problematic research practices in autism intervention research. PLOS ONE, 18(4), e0283340. https://doi.org/10.1371/journal.pone.0283340
Cooper, J. O., Heron, T. E., & Heward, W. L. (2019). Applied Behavior Analysis (3rd ed.). Pearson Education.
Eckes, A., Buhlmann, U., & Möbius, C. (2023). Comprehensive ABA-based interventions in the treatment of children with autism spectrum disorder — a meta-analysis. BMC Psychiatry, 23(1), 133. https://doi.org/10.1186/s12888-022-04412-1
Fuller, E. A., & Kaiser, A. P. (2020). The effects of early intervention on social communication outcomes for children with autism spectrum disorder: A meta-analysis. Journal of Autism and Developmental Disorders, 50(5), 1683–1700. https://doi.org/10.1007/s10803-019-03927-z
Hakobyan, L., & Harutyunyan, M. (2021). Caregiver-implemented interventions for children with autism: A narrative review. Review Journal of Autism and Developmental Disorders, 9(3), 323–336. https://doi.org/10.1007/s40489-021-00263-4
Hosseiny, S. F., Karamali Esmaili, S., & Akbarfahimi, M. (2023). Comparing predictive effects of sensory processing and executive functions on self-care activities in pre-school children with autism spectrum disorder. Iranian Journal of Psychiatry and Behavioral Sciences, 17(2), e128520. https://doi.org/10.5812/ijpbs-128520
Hume, K., Steinbrenner, J. R., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., & Savage, M. N. (2023). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: Third generation review. Review Journal of Autism and Developmental Disorders, 10(1), 1–20. https://doi.org/10.1007/s40489-020-00223-y
Landman, W., Bogaerts, S., & Spreen, M. (2024). Single case experimental designs in mental health: A critical appraisal of Tau-U. Research in Developmental Disabilities, 145, 104681. https://doi.org/10.1016/j.ridd.2023.104681
Leaf, J. B., Cihon, J. H., Leaf, R., McEachin, J., Liu, N., & Russell, N. (2020). Concerns about ABA-based intervention: An evaluation and recommendations. Journal of Autism and Developmental Disorders, 52(6), 2838–2853. https://doi.org/10.1007/s10803-021-04838-2
Leaf, J. B., Cihon, J. H., Leaf, R., McEachin, J., & Taubman, M. (2022). Applied behavior analysis and autism spectrum disorder: Evidence, ethics, and implementation. Behavior Analysis in Practice, 15(2), 558–573. https://doi.org/10.1007/s40617-021-00557-3
Leaf, R., & McEachin, J. (Eds.). (2023). Work in progress: Behavior management strategies and a curriculum for intensive behavioral treatment of autism (2nd ed.). DRL Books.
Ledford, J. R., & Gast, D. L. (Eds.). (2022). Single case research methodology: Applications in special education and behavioral sciences (3rd ed.). Routledge. https://doi.org/10.4324/9781315150666
Lord, C., Charman, T., Havdahl, A., Carbone, P., Anagnostou, E., Boyd, B., & McCauley, J. B. (2022). The Lancet Commission on the future of care and clinical research in autism. The Lancet, 399(10321), 271–334. https://doi.org/10.1016/S0140-6736(21)01541-5
Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55(1), 3–9. https://doi.org/10.1037/0022-006X.55.1.3
Parker, R. I., Vannest, K. J., Davis, J. L., & Sauber, S. B. (2011). Combining nonoverlap and trend for single-case research: Tau-U. Behavior Therapy, 42(2), 284–299. https://doi.org/10.1016/j.beth.2010.08.006
Romeiser-Logan, L., Hickman, R. R., Harris, S. R., & Heriza, C. B. (2017). Single-subject research design: Recommendations for levels of evidence and quality rating. Developmental Medicine & Child Neurology, 50(2), 99–103. https://doi.org/10.1111/j.1469-8749.2007.00099.x
Sandbank, M., Bottema-Beutel, K., Crowley, S., Cassidy, M., Dunham, K., Feldman, J. I., & Woynaroski, T. (2020). Project AIM: Meta-analysis of intervention effects for children with autism spectrum disorder. Psychological Bulletin, 146(1), 1–29. https://doi.org/10.1037/bul0000215
Sandbank, M., Bottema-Beutel, K., Crowley, S., Cassidy, M., & Woynaroski, T. (2023). Intervention effects on language in children with autism: A Project AIM meta-analysis. Autism, 27(3), 631–647. https://doi.org/10.1177/13623613221115252
Septiaji, A. (2024). Application of task analysis and chaining techniques in improving adaptive skills in autistic children. Jurnal Pendidikan Inklusi, 7(1), 34–44.
Shrestha, A., Anderson, A., & Moore, D. W. (2013). Using point-of-view video modeling and forward chaining to teach a functional self-help skill to a child with autism. Journal of Behavioral Education, 22(2), 157–167. https://doi.org/10.1007/s10864-012-9165-x
Slocum, S. K., & Tiger, J. H. (2011). An assessment of the efficiency of and child preference for forward and backward chaining. Journal of Applied Behavior Analysis, 44(4), 793–805. https://doi.org/10.1901/jaba.2011.44-793
Tarlow, K. R. (2017). An improved rank correlation effect size statistic for single-case designs. Behavior Modification, 41(4), 427–467. https://doi.org/10.1177/0145445516676750
Authors
Copyright (c) 2026 Dyah Sarie Endah N, Yuyus Suherman, Yoga Budhi Santoso, Budi Susetyo, Iding Tarsidi, Usep Saepul Ahyar
This work is licensed under a Creative Commons Attribution 4.0 International License.