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.