Evaluation of activities of daily living accommodations for adults with intellectual and developmental disabilities

This study explores the role of Occupational Therapy in supporting adults with intellectual and developmental disabilities to lead self-determined lives. Developmental disabilities, which include intellectual disability and other conditions, are defined as “significant and persistent difficulties in learning academic skills” and often occurs in early school years (World Health Organization, 2025b, para. 1) with intellectual disability defined as “significant limitations in intellectual functioning across various domains” and “the presence of significant limitations in adaptive behaviour” with an “onset occurs during the developmental period” (World Health Organization, 2025a, para. 2–4). Finally, the concept of “self-determined lives” refers to individuals having control over their own lives, making choices and setting goals, to promote inclusion with support (Institute on Community Integration, 2005). Occupational Therapy practitioners can support adults with intellectual and developmental disabilities with “adaptive behaviour skills through teaching, remediating, or adapting the activities of daily living” (Blaskowitz et al., 2021, p. 2). Activities of daily living include taking care of oneself on a routine basis such as bathing, toileting, dressing, eating and swallowing, feeding, functional mobility, personal hygiene and grooming and sexual activity [American Occupational Therapy Association (AOTA), 2020].

Despite the recognized importance of supporting activities of daily living through Occupational Therapy, several challenges limit the current research landscape. Firstly, there is not an abundance of literature that is focused on individuals who have intellectual and developmental disabilities, rather it is focused on the comorbidities that often come along with intellectual and developmental disabilities, such as autism spectrum disorder and cerebral palsy (Brown, 2014). There are complexities to be considered in the conduct of research with adults with intellectual and developmental disabilities, whose right to participation and informed consent are enshrined in international law (United Nations, 2006). Through careful design and incorporation of adaptive communication strategies, continual consent negotiation and other supports (Dunn and Jeste, 2001; McFarland et al., 2023), it is possible for their research participation to be informed and meaningful.

There is limited research on the impact of Occupational Therapy accommodations focused on activities of daily living for adults with intellectual and developmental disabilities (Kottorp et al., 2003; Waldman‐Levi et al., 2019). Existing studies support the effectiveness of high-quality Occupational Therapy in enhancing independence and quality of life. Blaskowitz et al. (2021) completed a scoping review of 159 articles and found that 57 articles included activities of daily living, employment, leisure/social participation and community participation, with activities of daily living being the most addressed area (22 articles). Another study by Hallgren and Kottorp (2005) assessed six individuals with intellectual disabilities performance of activities of daily living after one to five accommodation sessions and found improvement in activities of daily living. Kornblau and Robertson (2021) found that several studies show the need for enhanced practices, supports and services through Occupational Therapy to increase access to life opportunities. Both reviews concluded that Occupational Therapy practitioners could help facilitate the development of activities of daily living through compensatory strategies, adaptive approaches and technologies to promote independence (Blaskowitz et al., 2021; Kornblau and Robertson, 2021). In this article, accommodation is defined as “an adjustment of policies, practices, or environments to ensure fair treatment and access for individuals with different needs, backgrounds, or characteristics” (Oxford Review, 2025, para. 2).

Focusing on activities of daily living training is justified by its potential to improve quality of life, community participation and achievement of life goals with support (DeCarsky et al., 2024). While not all individuals may desire or achieve full independence in activities of daily living, Occupational Therapy can tailor accommodations to individual preferences and capabilities (Cermak and Borreson, 2016). Generalization of learning is a key challenge, and strategies such as caregiver training and use of assistive technology are essential to support transfer of skills beyond the accommodation setting (Arvidsson and Jonsson, 2006; Burns et al., 2019; Cermak and Borreson, 2016; Crowe et al., 2015; McNicholl et al., 2021; Mechling, 2007; Wennberg and Kjellberg, 2010). Arvidsson and Jonsson (2006) found that only a few adults experienced increased autonomies and some preferred staff assistance instead but Burns et al. (2019) found that fostering educational opportunities for caregivers allows for increased likelihood of independence in different skills for adults with intellectual and developmental disabilities.

To quantify improvement in activities of daily living, research commonly used the Assessment of Motor Process Skills (Pan and Fisher, 1994). Three studies that used the Assessment of Motor Process Skills to assess activities of daily living performance are Hallgren and Kottorp (2005), Kottorp et al. (2003) and Mahoney et al. (2021). Hallgren and Kottorp (2005) and Kottorp et al. (2003) each used the Assessment of Motor Process Skills after each participant’s performance of two different activities of daily living. In a scoping review, Mahoney et al. (2021) identified the Assessment of Motor Process Skills as one of the most frequently cited observation tools to assess quality of activities of daily living and instrumental activities of daily living performance in addition to motor and process skills.

Previous studies have used various methods including questionnaires (Alonso-Sardón et al., 2019; Crowe et al., 2015; King et al., 2017), interviews (Arvidsson and Jonsson, 2006; Kottorp et al., 2003; Schijndel-Speet et al., 2014; Wennberg and Kjellberg, 2010) and caregiver education (Burns et al., 2019). There appear to be fewer accommodation studies focusing on activities of daily living skills training (Burns et al., 2019; Waldman‐Levi et al., 2019). These methods have provided insights into the effectiveness of Occupational Therapy accommodations and the importance of generalization of learning across contexts.

This study’s aim was to evaluate the effectiveness of Occupational Therapy accommodations focused on daily activities for adults with intellectual and developmental disabilities in an adult day programme. To address these gaps, this study investigates the following research questions:

Multiple assessment methods assessed this study. A small scale pre- and post-test survey, a quantitative evaluation of standard and specialized tools, and observations were used to assess students’ abilities and their perceived independence. Firstly, a pre- and post-project survey evaluated the site mentor’s knowledge of adaptation and her ability to adjust activities to keep it at the right level of challenge for students. The students’ perceived independence in two occupations was evaluated prior to receiving accommodations and again after accommodations were concluded. In addition, all participants were evaluated by the first author through observation throughout the project to allow for the collection of data to measure the change that occurred due to the project’s implementation. Accommodations for this study included individualized activities of daily training session, and creation of resources for the site and student participants’ families and caregivers.

This study was conducted in collaboration with a structured day programme in Wisconsin, USA, serving individuals with a range of disabilities and medical needs. Personnel from the adult day programme included a select number of students and their activities of daily living teacher. The site mentor was recruited as a convenience sample because of her role within the day programme. She was the activities of daily living teacher and had an existing relationship with the students, programme and teachers, which allowed her to serve as a local point of contact for all parties. Is it important to note that the site mentor was not involved in any direct data collection to limit potential bias. Student participants were recruited through collaboration with the site mentor and the students’ teachers. After students were identified by the site mentor and/or their teachers, direct communication for recruitment of student participants occurred through email and direct person to person solicitation. All identified student participants were given the opportunity during the recruitment process to decide if they wanted to participate in the one-on-one activities of daily living sessions or not participate in the study. Those who did wish to participate in the study received typical adult day programme services.

This project received approval from the authors’ affiliated university’s Institutional Review Board on 9 February 2024. After recruitment, written guardian consent was obtained for all student participants. Consent forms included benefits and risks to the student participants and acknowledgement they could leave the study at any time. The consent was written clearly with simplified language. Due to the students’ cognitive and physical abilities, a verbal assent was obtained from each student participant whose guardians signed the informed consent. The verbal assent ensured student participants wanted to participate in daily living sessions.

Recruitment started first with asking staff to identify students and the activities of daily living skills that students needed the most help with. The next step in recruitment was communication through an introduction email and direct person to person solicitation. Student participants were provided with consent forms that they provided to their guardians. All participants had the opportunity during the recruitment process to decide if they wanted to participate in the one-on-one activities of daily living sessions. The site mentor was also provided written consent to participate in the study.

The participants included 13 students – 8 males and 5 females. Student participants’ ages ranged from 20 to 41 years. Their diagnoses included autism spectrum disorder, Down syndrome, cerebral palsy, low vision, Angelman syndrome, leukodystrophy and intellectual disabilities. Inclusion criteria for students included a diagnosis of an intellectual or developmental disability, at least 18 years of age, and currently attended an adult day programme. Data collected from student participants was only analysed if students participated in at least six individualized life skill lessons. Reasons for attrition included frequent absences or students being on community outings during scheduled individualized life skill lesson time.

The site mentor also participated as they provided completed questionnaires to communicate their confidence levels in implementing the modifications for the activities of daily living. This participant was female and the only participant of this portion of the study.

The capstone project occurred over 14 weeks. Week 1 included an orientation to the site and recruitment. Observation and initial data collection occurred over Week 2. Implementation of activities of daily living lessons and observation occurred over Weeks 3 through 6. In Weeks 7 and 8, additional activities of daily living lessons occurred as well as receiving and implementing feedback. During Weeks 9 through 13, post-implementation data was collected. Weeks 10 and 11 included creating educational resources for the site and students. Data was analysed over Weeks 12 and 13. Information on the study was presented to the site and affiliated university on Week 14.

The data collection tools used in this study included a modified version of the Assessment of Motor and Process Skills and a series of questionnaires. The Assessment of Motor and Process Skills is widely cited as an observational tool for assessing the quality of performance in activities of daily living. Due to the practical limitations of administering the standardized Assessment of Motor and Process Skills – including time constraints, resource availability and training requirements – a customized observation template was developed, drawing on the foundational principles of the Assessment of Motor and Process Skills (Pan and Fisher, 1994; Zeltzer, 2010).

This modified template allowed for structured observation of student progress during individualized sessions and was directly aligned with the study’s first research question: “To what extent does observed independence among a sample of adults with intellectual and developmental disabilities improve following accommodations targeting activities of daily living?” The tool also supported equitable modification of tasks. After each session, the first author reviewed participants’ performance based upon several factors to inform adaptations for future sessions and promote generalization of learning. This supports the Assessment of Motor and Process Skills theory as it is designed to assess client factors, task demands and environmental factors to assist with generalization of skills across several contexts (Shirley Ryan Ability Lab, 2019).

In addition to the observational tool, three distinct initial questionnaires were developed to address the study’s second and third research questions. Each questionnaire was tailored to a specific group: student participants, site mentors and staff. The staff questionnaire was designed to gather baseline data on each participant’s level of independence in activities of daily living. These results informed the prioritization of tasks for instructional focus. Both student participants and the site mentor completed separate pre- and post-accommodation questionnaires. The mentor’s questionnaire assessed their understanding and ability to appropriately adjust the difficulty level of activities of daily living to meet student needs. Student participants responded to a single-question, verbal questionnaire administered during weeks one and six. This question gauged perceived independence using a six-point Likert scale adapted from the Visual Analog Pain Scale as seen in Figure 1 (De Knegt et al., 2013).

Time was spent observing 15 different classrooms, at least once, during the activities of daily living class to observe the overall student population’s abilities and introduce the first author to the site’s students and staff. Data from the measurement tools was collected electronically in a Microsoft Excel template. All observations were collected twice a week for six weeks and were written in the template. Observations included objective information, such as how many articles of clothing were folded and how long it took. The collected data by the first author was compared from the first and sixth individualized life skill lesson as all student participants completed at least six laundry folding lessons. For the site mentor’s survey, the pre- and post-data was collected in Qualtrics after the survey was distributed via email.

Student participants participated in individualized lesson plans that were modified for each student participant’s needs. The first task of folding laundry was chosen after discussions with the site mentor, classroom teachers and classroom observations. Folding laundry was a task that all student participants had difficulty completing. After student participants completed six sessions on folding laundry, they could choose a second life skill that was of interest or important to them. The second lesson was chosen in collaboration with the students, guardians and classroom teachers Activities of daily living that student participants chose included making a bed, washing dishes, driving a powered wheelchair, upper body dressing and grooming. Each skills’ lesson plan was designed to be completed six times for 15 min a session. These sessions included individualized modifications, adaptative devices and personalized instructions. There was not a consistent schedule of when the sessions were completed due to student participants being absent or being on an outing in the community during scheduled life skill lessons.

Next, through observation, interacting with the student participants daily and site staff feedback, ten activities of daily living were identified that needed modifications to make the tasks more challenging or simplistic. These activities of daily living included folding several types of laundry, making a bed, brushing and styling hair, washing face, brushing teeth and washing hands. Visual step-by-step instructions on how to complete each task were created and put into a shared virtual folder so all the staff at the site have access to the educational handouts and materials that were created. In addition, a chart was created that overviews the basic principles of creating more challenging or simplistic modifications that can be applied to a broader range of activities and therefore is more beneficial to the staff and students. These developed lessons can be implemented as needed in the activities of daily living classes and classrooms. The site mentor was oriented to the educational resources in the shared folder and was instructed on how modification options can be used within the activities of daily living curriculum.

After the student participants completed their final series of life skill lessons, their guardians and teacher were contacted via email. Included in this email was progress that their student participants made, how they seemed to learn best and any tools or modifications used to promote independence. Several guardians responded to this email expressing interest in continuing to practice these skills at home with the information and tools that were provided to them in the email. A post project implementation questionnaire was also distributed to the site mentor. Upon completion of the questionnaires, the site mentor’s and student participants’ learning experience were analysed.

Quantitative and qualitative data was analysed in Microsoft Excel. Quantitative data was separated into four distinct categories: Process Skills, Motor Skills, Observed Independence and student Participants’ Perceived Independence. Student participants’ process skills, motor skills and observed independence were rated based upon the type of assistance required (Open Resources for Nursing, 2021). For example, if they were independent in the skill, they were given a 0% because they needed no assistance. On the other hand, if they needed maximal assistance for that skill, they were given a 75% because they required 75% assistance to complete the skill.

To analyse the progression of student participants’ independence in process skills, motor skills and observed independence, the differences between the first activities of daily living lesson data and sixth life skill lesson data were taken. Then, the mean difference for each category was calculated. Finally, this data was put into tables to demonstrate the progress that student participants made. Table 1 illustrates the student participants’ observed mean percentage of improvement in folding laundry. For the student participants’ change in perceived independence, a similar process was taken; the mean rating of independence for each article of clothing prior to activities of daily living lessons and after the sixth activities of daily living lesson was taken and then both numbers were put into a representative graph. The first author gathered all pre- and post-implementation data from all students participating in the research. If students only participated in the pre-study data collection but did not participate in the implementation and/or post-study data collection, their data was excluded from analysis (n = 2).

The site mentor’s pre- and post-survey results were compared to one another. The site mentor’s survey used an 11-point Likert scale in which the site mentor was able to rate agreeability to six different statements. The number zero on the Likert scale represented “strongly disagree” and the number 10 represented “strongly agree”. The six statements were developed by the first author and reviewed before implementation by the third author and a high school special education teacher with thirty years of experience for clarity and relevance. Though each statement was different, they all had a common theme of highlighting the site mentor’s feelings toward available resources and their confidence in adjusting activities to adequately meet student participants’ abilities.

Results from qualitative and quantitative data were collected to assess observed and perceived independence among student participants following activities of daily living lessons, as well as staff experience with activities of daily living modification resources. Observational data was used to evaluate students’ improvements in motor and process skills during folding laundry tasks, while self-reported data displayed students’ perceptions of their independence based on the clothing item. Finally, staff perceptions of resource accessibility and effectiveness in supporting student independence were collected through Likert-scale responses. These results demonstrate activities of daily living accommodation’s impact on functional independence for adults with intellectual and developmental disabilities.

Observational data of students’ improvements in motor (n = 9) and process skills (n = 2) was collected and analysed. The two greatest categories for improvement in process skills for nine student participants were organizing timing and adapting performance categories. These student participants improved in initiating, continuing and completing folding different items of clothing in the correct sequence without prompting. Two of the participating student participants were evaluated based upon their motor skills rather than their process skills as they had significant physical limitations that kept them from adequately folding clothes. Their greatest improvements were in the categories of sustaining performance and moving self and objects. This means that these two student participants improved in maintaining a consistent tempo while folding; completing each folding task without pausing; coordinating body parts to effectively fold; lifting and transporting necessary objects for folding; and using appropriate force and speed in fluid movements when interacting with objects for the task of folding.

Each student participant (n = 11) used the six-point Likert scale to rate their perceived independence when folding each article of clothing. The mean change in perceived independence for each article of clothing is as follows: folding a t-shirt was 2.09; folding a sweatshirt was 1.7; folding pants was 1.6; and socks were 1.5. Figure 2 shows student participants’ progression in perceived independence of folding laundry. There was one student participant who only folded t-shirts; therefore, they were not included in data for other articles of clothing. Also, one student participant was not included in the data for folding sweatshirts because it was not included in their activities of daily living lessons.

Activities of daily living modification resources were provided following accommodation to assist staff with facilitating students’ independence throughout their day. Based upon an 11-point Likert scale, the site mentor demonstrated increased agreeability in feeling that resources for activities of daily living modifications are readily available and accessible; confidently modifying activities for students during activities of daily living groups; effectively educating staff on transferring activities of daily living into daily tasks; and modifying activities to improve students’ participation in activities of daily living. In addition, student participants perceived difficulty and the site mentor’s responses to the surveys were subjective to them.

This study aimed to evaluate the effectiveness of one-on-one activities of daily living accommodations with a sample of adults with intellectual and developmental disabilities by answering the three aforementioned research questions. Like prior research, this study demonstrates that task-specific training in activities of daily living supports not only motor and process skill developments but also fosters autonomy (Blaskowitz et al., 2021; Hallgren and Kottorp, 2005). In addition, this study highlights the need for occupational therapy practitioners to consider both complexity and individual preference when designing accommodations as participants demonstrated varying levels of improvement depending on the task. This supports DeCarsky et al. (2024) and Cermak and Borreson (2016), who advocate for individual accommodations that prioritize meaningful participation.

Hallgren and Kottorp (2005) and Kottorp et al. (2003), used the Assessment of Motor and Process Skills to evaluate observed improvements in activities of daily living performance among adults with intellectual and developmental disabilities. In the present study, observed improvements in process skills were identified based upon the student participants ability to initiate, continue and complete tasks without prompting, suggesting that structured accommodations facilitated learning in these areas. Similarly, improvements in motor skills for student participants with physical limitations support the role of adaptive strategies and environmental supports described by Kornblau and Robertson (2021). The observed improvements in this study answer research question one as they demonstrate the extent of improved independence following accommodations targeting activities of daily living.

As emphasized by the United Nations (2006), the inclusion of adults with intellectual and developmental disabilities in decision-making is both an ethical imperative and a best practice. The opportunity for student participants to self-rate their perceived independence adds dimension to the current literature as previous studies have relied heavily on interviews and caregiver reports (Crowe et al., 2015; Arvidsson and Jonsson, 2006). In addition, student participants responses answered the studies second research question as participants changes in perceived independence because of activities of daily living focused accommodations was analysed. The opportunity for self-reflection and perception reinforces the psychosocial impact of independence in activities of daily living.

Caregiver education, which included providing resource accessibility and confidence in facilitating activities of daily living focused accommodations, played a significant role in this study as it assisted with increasing the likelihood of generalization across several environments, like Burns et al. (2019) study. In addition, caregivers reported feeling more prepared to adapt tasks, educate others and promote independence throughout the day demonstrating the importance of training and resource development, which answers the studies third research question. Kornblau and Robertson (2021) also emphasize the need for systemic supports and accessible tools.

The findings of this study offer implications for Occupational Therapy practitioners in several areas including practice, education and training and research. The importance of task specific training and tailored accommodations for facilitation of independence in activities of daily living for adults with intellectual and developmental disabilities in everyday Occupational Therapy practices is highlighted in this study along with Blaskowitz et al. (2021) and Hallgren and Kottorp (2005) studies. In addition, education and training can support generalization across several contexts (Burns et al., 2019; Kornblau and Robertson, 2021). In practice, education and training should be used to further advance generalization with readily available resources and adaptive strategies. There are many implications for further research as the findings of this study can be used to inform future research on Occupational Therapy’s role in activities of daily living accommodation for adults with intellectual and developmental disabilities. Future research should further explore the role and effectiveness of individualized Occupational Therapy accommodation on adults with intellectual and developmental disabilities independence.

There were several limitations to this project. The primary limitation was participant attrition, due to the limited time allotted for activities of daily living lessons and the overall short project timeline. As a result, not all student participants completed the full series of six laundry-folding lessons, and their incomplete data was excluded from the final analysis. In addition, lack of space and resources posed logistical challenges. This led to the use of individualized session times to secure appropriate spaces or build adaptive equipment, which sometimes limited opportunities for students to engage directly in the targeted life skill practice.

The sustainability of the accommodation was another limitation, primarily influenced by staff turnover and the inability to consistently update individualized lesson plans. The limited availability of higher-level research on this specific topic also constrained the project’s foundation, as there is a lack of evidence to support accommodation strategies. Further research on this topic will support Occupational Therapy accommodation in programmes that work with this population and will create greater opportunity for Occupational Therapy to have an integral role in the lives of adults with intellectual and developmental disabilities.

It is important to note that there was an ethical limitation to this study as consent was obtained from parents or guardians rather than solely from adult participates, which does not fully align with current ethical guidance emphasizing participant autonomy (National Disability Authority, 2024). In addition, the study did not include a continual consent negotiation process, which could have strengthened ethicality of the study.

Furthermore, the study was small in scale, involving a limited number of participants from a single site, which restricts the generalizability of the findings. There is also lack of follow -up date, which limited the ability to assess long term outcomes. The data collected was largely subjective and could have potential observer and selection bias due to the study design and researcher involvement. In addition, the used tools in this study were non-standardized. This introduces potential bias and limits the reproducibility of the study in other settings or populations. Future studies with larger sample sizes, standardized protocols and multi-site involvement are recommended to enhance reproducibility, broaden applicability and build stronger evidence for accommodations in this area.

This study demonstrates Occupational Therapy practitioner’s role in promoting independence in activities of daily living for adults with intellectual and developmental disabilities due to their higher-level education and expertise in modifying occupations. It additionally emphasizes the importance of caregiver education and training to further support independence. Although limited by sample size, timeline and logistical challenges, the study supports the need for individualized, task-specific accommodations and highlights the essential role of Occupational Therapy in fostering independence and meaningful participation. Future research should continue to explore effective, evidence-based approaches that empower adults with intellectual and developmental disabilities to achieve higher level of independence, while embedding Occupational Therapy as a collaborative partner within adult day programmes and community services.

This study was conducted in accordance with institutional ethical standards. Ethical approval was obtained from the Concordia University Wisconsin’s Institutional Review Board under approval number FY24-220. All participants provided informed consent prior to their involvement in the study.