ARTICLE - There is more to TWI than applications in our jobs. In this article, a creative mother shares the moving story of how she used Job Instructions to help her 5-year-old son with Asperger Syndrome.

Words: Nienke van Berkum

Autism has many faces. One of them is Asperger Syndrome, a developmental disorder characterized by impaired social interaction, repetitive patterns of behavior and restricted interests, and normal language and cognitive development. This condition represents a big part of my life: both my husband and my son are diagnosed with it, and many of our friends also experience Asperger’s in their daily lives.

A few years ago, through my work as a lean management advisor to the Dutch government, I saw an opportunity to apply Training Within Industry techniques to teaching my child new tasks, jobs and behaviors. When I realized there was an interesting connection there, I searched for articles on autism and lean management, but couldn’t find any. Someone at the Lean Management Instituut then challenged me to write the first one, so here I am. 

TWI was never meant to be a method to help people with Asperger’s, but one to empower an organization’s employees to perform tasks in the right way and with great results. It was developed as a way to let people excel. And people with Asperger’s, like any person with a disability, can excel too, so long as they are challenged in the right way.

Because I have found that TWI works so well with them, I decided to share my experience. This way I hope to contribute to the empowerment and emancipation of autistic people and their close family members, and to the improvement of the care they receive.

First of all, let me spare a few words on this condition. People with Asperger’s notice details, but find it hard to see the whole picture. Because their brain functions in a different way (they collect sensory information differently), their interpretation of what is happening can be different too. Every day life and the world can be overwhelming for them: social situations with all their variants are complex, and emotions are even harder to understand. Change is stressful for most autistic people: that’s why learning routines can help Asperger patients to cope with their daily lives and to create behavioral patterns that bring stability to their existence. Lean thinking can teach them how not to struggle so much with daily activities.

Lean’s main remit is to improve the life of the customer. In hospitals, the customer is the patient, and we have learnt we can improve their lives by supporting the caregiver’s journey to providing better service. In a similar way, lean has helped me to figure out how to better care for my child, how to empower him and allow him to improve his own life and to take control of the opportunities he is presented with. In other words, it has helped me to educate him so that he will help himself.

A BIT OF INFORMATION ON TWI

Training Within Industry was developed in the United States between 1942 and 1945. It consists of four elements: Job Instructions, Job Methods, Job Relations, and Program Development. The elements have different focuses: Job Instructions are used to learn new jobs and Job Methods to improve jobs. Job Relations tackle interpersonal relations between team members and their impact on the work. Program Development focuses on what and when to train every member of a team.

TWI was devised to improve the performance of American industry during the war, when men were called to the front and factories needed new employees that could fill in for them quickly and effectively. In a time when experienced staff and materials were scarce, TWI brought a quantitative and qualitative increase in productivity to many companies. After the war, this type of training was introduced to Japan. It’s still provided in Toyota factories.  Job Instructions is one of the four elements of TWI. They teach how to learn new habits and tasks, and consist of these principles:

• First see the whole, then the little steps;
• Learn by seeing it, then understand it, then do it yourself and experience it;
• The structure helps to focus first on the routine of the steps, then on their key points and finally on the reasons behind those key points;
• First focus is on doing the task right, then speed up the action

One of the premises of Job Instructions is that every task or job can be learnt, by anyone. The supervisor becomes an instructor and teaches the new task to the new employee. To support the instructor the task is written down in a Job Breakdown Sheet.This describes the task in three columns: what steps in the right routine, how you like each step to go (in key points), and why the step needs to be done in this specific way.

LEARNING HOW TO SHOWER

Our 5-year-old son with the syndrome of Asperger was always happy to take a bath. But whenever we wanted him to shower he would start to panic, kicking and screaming. My husband and Ihad no idea why this happened or how to end it. Adding to our stress, the following year at school our son would have to shower after PE, by himself. I began to think of how I could help him to deal with something that to most of us appears so simple but that to him appeared so terrifying: taking a shower.  

When I decided for TWI, and realized it was all about teaching, I got prepared. I looked at the task at hand and broke it into steps. I then drew a picture of each of the steps.

To my own surprise, the task of taking a shower alone had 18 steps. My husband and I both had a different routine and, furthermore, that too changed from day to day. No wonder our son started to panic!

We had to approach this challenge as one united front. It took some time, but having one approach as parents is important in learning scenarios for kids (even more so for autistic children). We agreed to communicate one message until he got the job “taking a shower” right.

First of all, we determined the situations in which he would have to take a shower:

• In the event of a little accident (toilet training);
• When he is visibly dirty (hands, knees, head);
• When he is smelly;
• After sports;
• Once every two days, so that he wouldn’t have to perform this dreaded task every day and, at the same time, he wouldn’t have a way to avoid showering by simply avoiding any of the activities that might lead to it (my son is that clever!).

Together with my husband, we defined the showering routine, the key steps in the routine, and the reasons why those steps were important.

Teaching had to happen in a place where both my son and I felt comfortable. I chose not to teach him in the bathroom, fearing it would be far too stressful. Instead, the next day I sat him down in the living room and explained to him that, growing older, he would need to be able to perform a number of tasks by himself, such as making a sandwich or taking a shower. I told him that the following year he would be able to take a shower with the rest of his class after physical education, suggesting that perhaps it’d be useful if he learned that now. He agreed.

Day one of the “training” was dedicated to explaining the reasons for taking a shower, which my son was curious to know about. I told him that people take a shower for personal hygiene and to stay healthy. A clean body allows you to check for bruises and how they are healing. There is also a social aspect to it, I said to him: people like clean people, and after playing and getting dirty it’s necessary to clean ourselves up. I talked of this as of a normal rule in our household.

The next day I showed him the 18 cards with pictures of the steps necessary to take a shower. By watching and then laying the pictures down in a row in the right order, our son saw the complete process for the first time.

There were moments of laughter, too, as the routine started to sound more and more logical in our minds. Wash your hair first and behind after. You wouldn’t want to do it the other way around, would you? We then discussed the key steps of showering: how to wash your hair, the movement of a washcloth on your arm, and so on. The third time we went through it, we took time to explain the complete routine, its key steps, and the reasons why those steps were important.

We agreed to hang the cards in the shower as a reminder, and that evening we went for it.

The shower was prepared, the cards hanging to a line (visual management at its finest, wouldn’t you say?). I was of course there to provide assistance. Our son stepped confidently in the bathroom, and then in the shower. This time, there was no screaming. He knew what to expect. He glanced at the cards, named the first step with its key points and the reasons for them, and then performed it. After completing the first task, he turned the card and went on to the next step. 

According to the routine, he closed the shower curtain. From that moment, I could not see anything any more, but I could hear him. I asked him the coaching questions. I encouraged him and complimented him because, for all I could hear, things were going well. Then he asked, "Mom, why do I have to rinse the foam off my body now? There is no foam."

We had forgotten one step.

We missed the step "Put soap on your washcloth." Normally, our son would get very upset if anything unexpected happened or he made a mistake. But this time he just laughed. I, the instructor, had forgotten something and he had done nothing wrong. He turned the cards without complaining, and then started again from the point when he washed his neck with soap, this time putting soap on his washcloth.

An hour later, a clean boy was standing, proud, in our bathroom.

The next day, an extra card hung on the instructions line, carrying the step we had originally forgotten. The struggles, frustration and stress related to our inability to help our son with his shower ended that night: within a month, he could shower by himself. Six months later, the instructions line disappeared from the shower. In the next six years (he is 11 now), he developed his own shower routine, with four different ways of showering:

• A long shower of at least 15 minutes;
• A short five-minute shower;
• An after sports shower;
• A shower to relax.

While he learned to speed up the process, he also maintained the routine. Today he is doing everything in less time, still completing the key steps. He improved his routine himself with some help from us parents (one way to do it was giving him less time to complete the routine, as in the 'Oh No!' method off Taiichi Ohno, as described in Freddy and Michael Ballé's The Goldmine).

WHY DOES IT WORK?

People with Asperger don’t just pick up routines or tasks; they need to be taught explicitly. Using job instructions is a way to do it. This method is based on the assumption that if a worker (or pupil) does not learn a job, it means that the instructor has not taught it properly. This gives the pupil maximum freedom to learn at his or her own pace.

The reason why job instructions work is because they are meant for anyone, including someone with Asperger, who needs to learn repetitive tasks (like using a phone, packing a schoolbag, cleaning a room, or taking a shower).

As a starting point, they use the knowledge of the worker (or in this case of an autistic person). Most autistic people know how to do many things, and by building on that knowledge we can empower them to learn new tasks or behaviors. In the case of our son, his knowledge of taking a bath or of individual steps, like “washing your hair,“ helped with teaching him how to take a shower.

The structure of job instructions and job breakdown sheets helps autistic people to grasp the task at hand. First they tell them when to do a certain job and why (most of the time people forget). The pictures also help, because they are so simple the person does not get lost in the details.

Key steps give answers to general questions (who, what, where, when?) so that there are clear instructions about each step. For people with Asperger this is a crucial, and when the setting up is clear, the how can also be addressed.

The “why” is most of the time obvious to non-Asperger people, but for those with the condition the reason for something happening can be completely new. Reasons are addressed to justify why a certain task is completed in a certain way.

Adding general concepts, like health or socially accepted behaviors, to the third column of the sheet can help autistic people even more. These are extra reasons why a task is the way it is. Connecting tasks to these big “values” helps to create a broader focus on the actions required to complete them, which in turn helps autistic people assess new situations more quickly.

With the success of TWI and of our shower experiment in mind, we taught our son other “normal” routines like packing his schoolbag, going to the store by himself, and cycling to school. Today, at 11, he has three projects in place: cleaning his room and sorting LEGO bricks; taking the train alone; and learning to learn new skills.

It was him who wrote the Job Breakdown Sheet, with our help. This had the additional benefit of telling us parents how he likes to do things and why. Ultimately, TWI has increased mutual understanding in our family.

There is another element to TWI: Job Relations training. Social relations can be extremely complex to deal with for a lot of people with Asperger. As Donald A. Dinero tells us, Job Relations training in a firm allows employees to solve personal problems using an analytical, non-emotional method combined with some basic foundations of human relations.

When he is ready, Job Relations may help our son in his social interactions just like Job Instructions helped him with his personal hygiene. And who knows, maybe in a few years he will be the one writing an article on how people with Asperger can help themselves and others using TWI principles and techniques.

To see a fragment of the Job Breakdown Sheet click {loadlink}here{/loadlink}

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_{THE AUTHOR}

Nienke van Berkum works as a Senior Lean Advisor at Rijkswaterstaat, which is part of the Dutch Ministry of Infrastructure and the Environment (and responsible for the design, construction, management and maintenance of the main infrastructure facilities in the Netherlands). As part of her job, Nienke supports the lean transformation within Rjkswaterstaat. Her main passion is to connect people to improve together. She holds a Masters degree in Landscape and Planning at the University of Wageningen, Netherlands.