OCCUPATIONAL THERAPY

The World health Organization (WHO) defines Occupational Therapy as “the art and science of directing man’s participation in selected activities to restore, reinforce and enhance functions or performance or decrease disabilities and thus to promote health, quality of life and independency”.

Role of OT in Various Setup:

¢  Hospitals

¢  Institute based Rehabilitation

¢  Community based Rehabilitation

¢  Day care centre

¢  School based

¢  Psychiatry setup

¢  Old age home setup

¢  Industrial setup

¢  Vocational centers

Occupational therapy intervention for autism

Interventions based in sensory processing theory are very powerful, and often a component of a child’s OT intervention. Within OT, the changes in a child come not from the application of any specific technique or method but from the adaptive responses occurring during the therapeutic process. Adaptive responses range from scratching when you feel an itch, to learning to refine a bolster swing, to assertively dealing with a difficult or intimidating situation. They can happen automatically, with rehearsed patterns, such as driving a car on a familiar route, or can require split-second precision such as veering around a child who runs out in front of the vehicle. Adaptive responses develop using internal and external feed forward and feedback loops of sensation and thought, as in learning to drive a standard transmission for the first time. Challenging adaptive responses at the ‘just right’ level is fundamental to SI intervention.

Many education and intervention programs for children with autism include multisensory learning experiences with an emphasis on visual structure. This is because visual learning is strength in autism and in general a multisensory approach is thought to enhance learning. From an OT perspective, this is viewed as influencing the discriminative or learning sensory systems. However, having the right amount of stimuli without overload creates the ambience of learning and does just as much to enhance learning as opportunities for rich exploration. Sensory experience sets our nervous system’s capacity to attend and influences memory functions as well. With an appropriate amount of sensory input, the nervous system is organized and enhanced to motivate us to explore, interact, and learn. This drive toward exploration is directed at the environment, the task at hand, and the interaction occurring given the task and environment.

Occupational therapy intervention differs from perceptual motor training. Intervention is not comprised of working through a sequence of skills to be acquired and tricks to teach them, nor do the best treatment sessions follow a preplanned list of activities to be practiced. Rather, treatment evolves in a play context where the therapist manipulates variables in the sensory environment, activity, structure, and interaction to elicit more sophisticated postural responses, improved sensory modulation, and acts of praxis  These elements are at the core of best practices in sensory integration.

Therapists familiar with sensory integration treatment who are beginning to work with children who have autism are sometimes surprised to find that the remediation of underlying sensory processing and motor components often does not result in spontaneous acquisition of new motor skills. A burst in acquisition of untaught motor skills is not uncommon in sensory integration treatment of children with non-autism spectrum disorders. By contrast, in autism, remediation of deficits in skill components (i.e. equilibrium responses or vestibular modulation) may make a child more available for motor learning, but motor ‘teaching’ is necessary to realize that new potential for skill.

The experienced OT is careful to integrate this knowledge into their overall clinical reasoning, treatment is much more comprehensive than this. Children with autism have complex needs that are developmental, and therefore changing, as well as being situated in a family. These concerns should always be a part of an OT treatment plan. Because most children with autism present with strengths in visual learning, providing structure and routine with visual cues is fundamental to successful intervention for most of these children.

Getting ready for school case example: Pravi

This case example illustrates the combination of sensory integration, role development, and visual structure methodologies to support a child in natural and inclusive settings. The Table below summarizes examples of OT assessment and interventions for a 12-year-old middle school girl with autism, who is having difficulties getting ready for school and continues to have difficulty participating through the early part of her school day.

Functional manifestation of sensory integration disruptions and intervention rationale

Observations	Interpretation	Intervention principle	Strategies
Waking routine • Does not wake to alarm • Younger sister must shake her to wake her • Once awake, Pravi does not get out of bed without repeated coaxing • Wanders around bedroom, sometimes gets back in bed • Relies on verbal redirection from sister to start dressing	• Pravi’s sensory modulation is oriented toward low arousal states, especially early in the day when the level of sensory input is low. By late morning, amassed sensory input raises arousal level and participation is more spontaneous. • Praxis deficits make it difficult for Pravi to initiate her routine. She does not have a well-established routine of what to do first upon rising.	Build more proprioceptive and non-noxious tactile input into morning routine Rearrange bedroom to provide more physical structure cues for independent initiation and sequencing of activities	Add treadmill exercise to morning routine: cue to treadmill by moving alarm clock from sister’s bedside table to shelf beside treadmill • Use Pravi’s special interest in charts and maps to create a motivating wall chart on which Pravi will record each day’s mileage • Cue Pravi from treadmill to next task with cartoon coach drawing on lower corner of chart, saying ‘To the shower’
Shower routine • Spends excessive time in the shower • Washes hair several times, using every product in the shower • Omits some tasks	• Stays in shower to help her wake up • Difficulties with sequencing and organization	• Use physical structure to support understanding of the task • Use visual cues to support sequencing of tasks	• Place Pravi’s products in a plastic shower basket labeled with her name. Using marker label products with numbers to cue first, second, third, and last tasks.
Dressing routines • Cannot decide what to wear • Waits for sister to show her what to put on • May forget to wear some garments • Puts clothes on in wrong sequence; may put underwear on over outerwear	• Disruptions in arousal impact ability to persist with task • Praxis deficits result in difficulty putting garments on in logical order • Limited ability to choose appropriate clothing due to inability to anticipate day’s events and limited observation of peers	• Decrease reliance on cues from sister by developing visual supports for dressing sequence and making choices	• Provide photographs of complete outfits • At the beginning of the week, have Pravi and her mother select 5–7 photos appropriate for the season • Post 5–7 photos of appropriate outfits on bullet board beside • Have Pravi’s sister print cues on lower border of photos, e.g. ‘Good closet for a party’
Breakfast routines • Sits at built-in eating area • Lies down • Does not finish meal • Eats slowly	• Food choices and seating area provide minimal alerting sensations	• Provide seating that generates increased movement, postural challenge, and proprioceptive input • Expand breakfast food repertoire to include foods that provide alerting sensation	• Allow Pravi to eat at kitchen counter on tall stool with turning seat and foot rails • Teach Pravi to make breakfast smoothies in the blender
School behavior • Inconsistent participation in classes at school: better in afternoon Morning class observations: • Lies on desk • Completes little work • Wanders around room • Doesn’t respond to teachers’ questions • Doesn’t ask for help	• Sensory modulation challenges contribute to variability in arousal level. Pravi needs a greater intensity, duration, and frequency of sensory input, primarily movement, to remain alert and readily engaged. • After her late morning swimming class, when she has finally received sufficient sensory input, her attention is good and she is more responsive to teachers and peers and more organized with her materials	• Modify schedule and use part of study hall time for a school job that will incorporate alerting proprioceptive input • Develop visual supports for independent completion of work job	• Have Pravi travel to six classrooms on the second floor, collect library books and carry them to the first floor library • To limit reliance on teachers to cue and redirect • Provide clipboard with checklist to remind Pravi of the rooms she needs to visit • Outline the room number on the wall outside the designated classrooms with a band of blue electrician’s tape • To help pravi avoid becoming distracted and wandering the school, Pravi and her teacher make predictions each day of the exact time  Pravi will return to class. Pravi writes the predictions on the board and checks to see who was closest .

Conclusion

Among the cornerstones of best practices in autism are three principles that have been central in guiding the development of the discipline of occupational therapy:

·        The commitment to discovering and nurturing an individual’s strengths

·        The organization of intervention around preferred activities and interests of the individual

·        The commitment to maximizing health and quality of life by creating accessible, adapted environments that support meaningful participation in the occupations most valued by the individual.

Across all areas of practice, occupational therapists share in common principles of treatment based on the premise that engagement in purposeful activity valued by the individual enhances life. Occupational therapists have aimed high: at its best occupational therapy seeks to empower individuals coping with disability to identify their desired occupational roles and help them create activities that will develop the skills they need to succeed in those roles. Occupational therapists are now challenged again to themselves grow and adapt in order to join colleagues across disciplines in offering meaningful and effective services for individuals with autism.