OT intervention for autism; case example - 1

At  4 years of age, Hari  was brought to  us with the complaints of  repeating words all the time, not able to speak in sentences, not mingling much with peers, not being imaginative in play, not showing hand preference yet, not eating all kinds of food, restricts many textures and touch of others, etc. He was diagnosed before to have speech and language delay and was treated by a communication therapist for a couple of months. On occupational therapy observation and evaluation, he was found to be markedly tactile defensive and had problems in bilateral integration and sequencing. Hari was an active, happy child with good comprehension and was intrinsically motivated to play.

Our immediate goal in working with Hari was to address tactile defensiveness in order help him maintain optimal arousal level even in the tactile rich environment as in play ground or in class room   activities involving peer touch and to address oromotor issues such as problems in suck- swallow- breath(SSB) synchrony, oral sensitivity shown through non acceptance to brush teeth, put water in and around mouth, eat fruits or any other sticky soft textured food, highly restricted choice of taste, etc.

He was under our occupational therapy intervention since two and a half months having three sessions per week.  Most of his sessions started with activities of his choice modified to give large amounts of deep pressure and proprioceptive inputs followed by enhanced tactile experiences. The latter half of the session focused on improving oral motor skills followed by a ten min work out on language and academic skills.

Within this period of intervention, Hari has shown good improvements in accepting to be exposed to and play with materials like clay, wet sand, oil, rough textured mats, etc, which used to evoke high defensive reactions previously  that as expressed through high pitched voice, tip toe standing, avoidance of touch, etc. Hari’s mother reported that he has started hugging his cousins and grandparents and playing with children in groups for 5 to 10 min. He still has problems in brushing teeth, washing face, wearing slippers instead of shoes, etc, which we are hoping would get better with further therapy.  

Focus of Discussion:

                Hari is brought into our discussion especially to share our views on his oromotor skill development.  Apart from oral sensitivity issues, he had problems in sucking food stuffs from within his cheeks, using his tongue appropriately to move food within his mouth, licking lollipops and sucking in the juice with proper lip closure, etc. These problems are the results of his inadequate Suck- Swallow- Breath Synchrony which seemed to interfere in his speech too.  We used a wash cloth dipped in juice to train suck-swallow pattern with lip closure. The juice dipped cloth was kept in his cheeks and he was taught to suck and swallow the juice from the cloth without taking the cloth out from the mouth. This was later generalized to eating, drumstick, sugar cane, etc. This helped him to learn to create a negative pressure inside his mouth which resulted in better sucking, chewing, and tongue lateralization within a week of intervention.

Note:     The same technique was tried in four other children with similar problem in SSB synchrony. All of them showed reasonable improvements which show that, using wet cloth to teach sucking might help improve oromotor skills in children with oromotor integration.  

Occupational therapy in autism

Autism Definition:

 Autism is defined as pervasive developmental disorder characterized by

     i. Qualitative dysfunctions of social interaction,

     ii. Qualitative impairment in communication abilities,

                 iii. Unusual restricted and repetitive ranges of play and interest

Prevalence: Estimated to be 1 in 88 children in recent studies with a male female ratio of 5:1.

Causes: Unknown; Other causes include genetic, biological, dietary, environmental factors such as family history of mood disorders, Sibling with autism, celiac disease, nuclear family, post natal complications, heavy metal deposits, high parental age etc.

Diagnosis: Done using Diagnostic and Statistical Manual IV for autism;

Other scales for diagnosis include: Childhood autism Rating Scale, Autism Diagnostic interview revised (ADI -R), Autism Diagnostic Observation Schedule (ADOS) etc.

Symptoms of autism:

Social interaction: Poor eye contact, Less attention to social stimuli, Difficulty with reciprocal social interaction, Limitations in emotional empathy, Less likely to exhibit social understanding and approach others spontaneously.

Communication: Poor eye contact, Poor or no response to name call, Diminished or absent verbal expression or gestures, Poor comprehension of others speech and body language, Impaired “pragmatics” of initiating/sustaining conversation, Stereotyped, “robotic” or idiosyncratic speech, Echolalia and rote repetition of words or dialogue, Unusual prosody of speech (sing-song, monotone), Pronoun reversals, Neologisms.

Restricted interests and repetitive behavior: Stereotypical movements such as hand flapping, head rolling, body rocking, finger gazing, etc, Compulsive behavior such as seriation, Sameness, Ritualistic behavior, Restricted behavior such has limited focus, decrease interest or preoccupation with single object or thought, Self injurious behavior.

Occupational Therapy in autism:

Occupational therapy treatment in autism is directed towards enabling the child to participate in three areas of performance such as

1. Daily occupations such as self care

2.  Contribution to society (work at home and school)

3. Quality of Life (Leisure and play)             

The participation in these areas is achieved through the following approaches in occupational therapy which focuses on either of the two domains. 1. Sensory motor development 2. General skill building.

Approaches:

• Play
• Sensory integration                                                                        
• Behavior modification therapy                                                              
• Task oriented approach

Occupational therapy Service delivery for autism:

3 types

1. Direct intervention --- Direct intervention with the child

2. Consultation --- help parents, teachers understand the condition and develop their own strategies to work with the child

3. Monitoring – develop programs and simple procedures and train parents, teachers or other care givers to conduct the same on the child

Intervention through play:

Assessment tool: The Play – Non play continuum is used to find the playfulness of the child.

Play is a transaction between individual and environment that is

• Relatively intrinsically motivated
• Relatively internally controlled
• Free of some constraints of objective reality

Intervention: It is focused on developing play skills in children in order to address the following performance components: Motivation, Imagination, Creativity, Peer participation, social skills such as eye contact, waiting, turn taking, etc.

The techniques include providing the opportunity to achieve playful as mentioned in the play – non play continuum along with setting up the environment for the same.  

Setting up environment:

• Arrange peers, toys and other materials of child’s interest
• Freedom to choose people or materials from the environment within the limit set in the environment
• Adult behavior that is minimally intrusive or directive
• A friendly environment that assures the child comfort and safety
• Schedules that reduces stress or fatigue to retain enthusiasm

Sensory integration:

Organize sensation from one’s own body and environment to use it effectively in the environment. Focus in occupational therapy is at understanding how and when a child is reacting poorly to a sensory experience and structuring the environment to accommodate or minimize such reactions.

SI = Sensory integration + Adaptive response in the context of play

  

Assessment:

Three ways:

•          Clinical observations
•          Standardized tools
•           Parental reports

Few among the group that are commonly used are Short and long Sensory profiles, Sensory integration And Praxis test (SIPT), Sensory processing measure

The three main systems addressed in SI are the tactile, vestibular and the proprioceptive systems. The common problems involved in children with autism in these three systems are discussed below

Tactile system =    1. Defensiveness

                               2. Discrimination deficits

Vestibular system = 1. Gravitational insecurity

                                  2. Intolerance to movement

                                  3. Poor registration or hypo responsive to movement

                                  4. Inadequate vestibule ocular responses

                                  5. Poor postural control

                                  6. Poor laterality, bilateral integration and sequencing

Proprioceptive system = 1. Excessive use of proprioception as a modulator

                                        2. Hyporesponsiveness to proprioceptive input

Praxis:  Two types ---- Tactile and proprioceptive contributes to Somato dyspraxia where as Vestibular and proprioceptive systems contribute to Bilateral Integration and sequencing

Performance components include

• Praxis (Includes ideation, motor planning that is requires for skill building in activities like writing, dressing etc)
• Self regulation
• Language and communication
• Oral motor/ Feeding
• Interaction style

Scaffolding: Intervention using sensory integration approach adapts the following steps to address the deficits in all the three systems mentioned above in order to achieve independence in the above mentioned performance components. The area of focus of the intervention that begins with arousal level and ends at organizing behavior of the child is called Scaffolding.

Area of focus                                                                                Outcomes

1. Arousal    ===      To improve attention to relevant objects and people, readiness to interact

2. Sensory Modulation === Improve self regulation of behaviors, emotions and interactions

3. Sensory Discrimination === Enhanced perception of broader perceptual field

4. Skill === ease learned interactions with objects and people

5. Praxis === more automatic and dynamic planning of adaptive & complex interactions with objects and people

6. Organization of behaviors === organizing sequences of multiple interactions both under current and future circumstances.

Behavior Modification Therapy:         

                                                                                          

  Behavior Modification Focuses on    

1. Decrease unwanted behavior

2. Increase skill development                

                                                                                                                                  

Techniques used in BMT in treating children with autism

Procedures	Behavioral effect Rewards               Aversive	Process
Reinforcement	Present                  Remove	Increase in likelihood of act
Punishment	Remove                 Present	Decrease in likelihood of act

      

• Positive reinforcement: the adding of an appetitive stimulus to increase a certain behavior or response.Example: Father gives candy to his daughter when she picks up her toys. If the frequency of picking up the toys increases or stays the same, the candy is a positive reinforcer

•      Positive punishment: the adding of an aversive stimulus to decrease a certain behavior or response.Example: Mother yells at a child when running into the street. If the child stops running into the street the yelling is positive punishment.

•       Negative reinforcement: the taking away of an aversive stimulus to increase certain behavior or response.Example: Turning off distracting music when trying to work. If the work increases when the music is turned off, turning off the music is a negative reinforcer.

•       Negative punishment (omission training): the taking away of an appetitive stimulus to decrease a certain behavior.Example: A teenager comes home an hour after curfew and the parents take away the teen's cell phone for two days. If the frequency of coming home after curfew decreases, the removal of the phone is negative punishment.

Task oriented approach:

Task oriented approach aims at teaching clients to accomplish goals for functional tasks by practicing motor behaviors and be motivated by the goal of task accomplishment. This method breaks a specific task into simple steps and the task is trained by repeated practice of each step.

Techniques: ( Applies for  BMT also in skill development)

Forward chaining: Break task into simple steps and teach the first step first followed by the other steps in the order. Eg in teaching to wear pants the first step taught would be holding the pants in and followed by inserting legs in the sleeves, pulling up. Buttoning and zipping..

Backward chaining: Involves breaking the task into simple steps and teach the last step first followed by the other steps in the order. Eg. In teaching to wear pants, the first step taught would be zipping, followed by buttoning, pulling up, inserting legs in the sleeves and holding pants independently.

Children With Autism May Benefit From The Introduction Of A Pet Into The Family

Children With Autism May Benefit From The Introduction Of A Pet Into The Family

Autism and tactile defensiveness

Tactile defensiveness is the most common sensory modulation deficit of tactile system and it is predominantly found in children with autism. Children with tactile defensiveness tend to react negatively to touch sensation that is considered otherwise non-noxious by most typical children. Most commonly it is the hyper-responsiveness to light or unexpected touch.

A child with tactile defensiveness may

·        Dislike changes in temperature such as going in or out of bathing

·        Dislike going barefoot or taking his/her shoes off

·        Pull away from light touch

·        Dislike eating messy foods with his/her hands

·        Avoid getting his/her hands in finger paint, sand, paste, clay, etc

·        Dislike having hair washed, teeth brushed or face washed

·        Prefer to touch rather than be touched

·        Seem irritated by fuzzy clothing

·        Have tendency to walk on his/her toes

·        Choose to weight bear on tip of the fingers

·        Get irritated when handled by others especially strangers

·        Resist wearing new clothes

·        Get irritated by tags on clothing

·        Prefer to stand at the end of the line to avoid contact with others

·        Prefers solitary play

Note:  Child should be observed for cluster of behaviors to be identified as having tactile defensiveness. These behaviors alone do not constitute to tactile defensiveness.  Detailed assessments using sensory profiles are important to arrive into a confirmation.

Tactile defensiveness is a problem, in large part, because of the inappropriate behaviors that accompany it. Defensiveness to touch potentially interferes with all occupations and roles. Basic self-care is affected when a child resists to food, clothes, washing hair, cutting nails, etc. Avoiding sand, refusing to walk barefoot on grass and sand affects play and aversive reactions to different textures or touch of other children disrupts class room behaviors in large which would in turn make learning difficult. 

Targets for intervention

•            Increase ability to maintain optimal level of arousal in the presence of tactile (or any over arousing) input
•               Decrease over reaction to tactile input
•               Improve emotional and organizational skills
•               Help the child cope with specific environments
•              Address fine motor skills

Intervention

          Sensory experiences can be started in each session with vestibular and proprioceptive input which will help the child calm down and feel a sense of control over the environment. It can be continued with deep pressure and gradual exposure to touch, if tolerated, can be given at the end.

Activities that provide the above mentioned sensory experiences include

•            Swing that can be used to provide slow and rhythmic movements
•            Hanging on to suspended equipments for proprioceptive input
•            Enable jumping, bouncing or pulling while on swing
•            Burrowing in large pillows and mats for deep pressure
•           Rolling large therapy balls over child’s back or legs for providing deep pressure
•           Activities that involve pulling or pushing heavy objects that would help in enhanced proprioceptive input
•        Pool of balls, beads or beans where the child can submerge and move around to bet enhanced touch input (allow touch input only until it is tolerated)
•         Playing with shaving cream, powder, lotion, paint, sand, water, glue, clay etc after providing vestibular,Proprioceptive and deep pressure input will help to decrease over reaction to touch
•         Chewy tubes, chewy snacks blowing activities, deep breathing can be encouraged throughout the day.

Guidelines for providing the above mentioned sensory experiences

·   Allow children to provide these inputs by themselves so that they have a control over input.

·     It is important to experiment different types of input which would be more effective in each child. Few children might enjoy and prefer deep pressure to heavy joint compression.

·   Children find tactile input more tolerable of they are applied in the direction of hair growth.

·        Proprioception is generally the most organizing type of sensation. When a child appears to be bothered by tactile sensation substituting proprioception or combining deep pressure with proprioception is often successful.

Modifying the physical and social environment

·       Reduce sensory over load in the environment

·       Avoid light touch

·       Avoid tight clothing

·        Lower voice, use natural light

·        Respect child’s personal space

·        Do not impose

·        Allow the child to have a control over the sense he/she receives and expect a response

SENSORY PROCESSING DISORDER - INTERVENTION STRATEGIES

Environmental modifications and initial sensory strategies :

Signs of atypical sensory processing	Environmental modifications and initial intervention strategies
Proprioception : Child may: •      Grasp objects too lightly or loosely •      Be un aware of changes in the body position •      Be clumsy and break toys •      Seek activities in which he has to jump, push, hit, pull, or bump. •      Grind his or her teeth •      Chew on non-food items such as toys •      Seems weak	•      Use heavy toys to provide more proprioceptive feedback •      Perform activities that require weigh tbearing, pushing and pulling, resistance joint traction and compression. ( playdoh, moving heavy objects, tug of war, weighted vest, heavy blankets, theraputty, theraband, backpack, etc.)
Tactile discrimination/ Hyporesponsiveness : The child may :         Like exploring through touch        Place object in his/ her mouth to explore it      Prefer to go barefoot       Have difficulty with tasks that require hand   manipulation        Have difficulty with gross motor coordination tasks        Have oral motor difficulties	•      Provide activities that require localization of tactile input and discrimination •      Suggested activities : ball bath, finding objects in sand or other textures, brushes, bubbles •      Observe motor skills – see motor planning
Tactile modulation : Child may :        Dislike changes in the temperature such as going in or out of the bathtub         Dislike going barefoot or taking his/her shoes off         Pull away from light touch         Seem irritated by fuzzy clothing        Prefer to touch rather than being touched         Resist wearing new clothing       Dislike eating messy foods with his/ her hands       Dislike having hair / teeth brushed , or face   washed         Avoid getting hands in finger paint, sand, paste, clay        Get irritated by tags on clothing         Have difficulty transferring to table food         Get irritated when being handled by people other than the primary caregiver ( cries during treatment)         Weight bear on finger tips         Have a tendency to walk on his/ her toes        Cry when hair is washed, nails are clipped         Avoid using hands or weight bear on open hands	Modify your social interaction with the child:         Respect personal space         Do not impose         Allow the child to have control over the tactile input he/ she receives – expect a response         Gentle and firm intervention style – a challenge Modify the physical environment:         Avoid activities that include light touch. Provide inhibitory input such as deep pressure and proprioception        Avoid tight clothing. Wash clothing before child wears it.         Provide a sensory diet : Pressing child between two large pillows, rolling down an incline, rolling a child inside a blanket or sheet, and brushing body
Vestibular system : modulation •      Be fearful of movement, going up and down stairs, playground equipment •      Get nauseous or vomit after movement experiences such as riding in a car •      Avoids having feet off the ground or balance activities such as walking on curbs •      Dislike being moved backward in space even when trunk support is provided •      Move very carefully •      Avoids jumping off a step or other surfaces •      Appear fearful when lifted up in space or when moved in space	•      Respect the child’s fears. Do not force movements •      Give the child control over his/her movements in space •      Treat near the ground •      Provide activities that require proprioception •      You may start by providing the child with the opportunity to experience linear vertical input (sitting on a wide based platform swing placed near to the floor) •      Start with antero-posterior movement of the trunk before you move to lateral and rotational movements
Vestibular - Hyporesponse: •      Seek large amount of movement experiences such as spinning, rocking, and twirling •      Not get dizzy when other children do •      Have difficulty with balance and protective reaction •      Tend to lean on hands when performing table top activities •      Have difficulty with tasks that require maintaining a stable visual field •      Have difficulty with activities that require bilateral motor coordination such as riding a bicycle or tricycle	•      Provide opportunities for movement experiences •      Provide activities that promote extension against gravity and proximal joint stability in the neck and the shoulder girdle area. Examples include swinging in prone while propelling on the floor or by pulling a rope, working in prone on the mat, etc. •      Work on maintaining stable visual field while moving(e.g., swinging and hitting a target) •      Activities that promote bilateral motor coordination •      While on the swing, pull on rope or providing an equipment to bump on, to change direction, speed and tempo of the swing’s movements.

Other daily activities (For propriocepion and vestibular hypo) :

}  Try having your child do some activities such as reading, playing a game, or coloring, while lying on his stomach and propping himself on his elbows.

}  Encourage activities that require balance, such as cycle riding, bike riding, kicking and so on.

}   Include “bilateral” or two-sided activities, such as jumping rope, swimming, rowing, playing a musical instrument and so on.

}  Try activities that involve coordination of movement of the eyes, head and hands, such as target games, catching, throwing, ping pong, tennis, and so on.

For hyper responsiveness

}  Adding weight ( for example, wrist or ankle weights or a backpack filled with bags of beans or rice) can help a child feel more secured when climbing or moving

}  If your child is fearful when walking up stairs, try holding him at the hips and applying gentle pressure. This may help him to feel more secured than when holding his hands.

}  Allow increased time for your child to explore and attempt activities that seems scary

For motor planning:

}  Play games like “ follow the leader “ help child to be able to plan actions based on watching and copying your/peer actions.

}  Encourage games that involve simple verbal directions to plan actions such as “Simon says” to help a child to plan actions without visual cues.

}  Ask child to help in activities like cleaning and arranging rooms, arranging items, unpacking, packing, wrapping a gift etc.