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.