News - Occupational Therapy for Autism

An article on"Autistic children's ability to perform everyday tasks improved by occupational therapy" was released by Medical News Today on 27th November 2013. The following URL will link to the original article. http://www.medicalnewstoday.com/releases/269371.php

How to teach colours to children

Colour recognition is the ability to identify and name basic colours. Colour recognition is important in recognizing objects around us and it is a precursor to language in the context of naming and using adjectives. Recognizing colours or other general concepts like shapes, numbers, alphabets, etc. develops in a child in the order of sorting / matching, identifying, naming and generalizing, where, in the context of colour concepts,

·        Matching denotes the ability to match similar coloured objects

·        Identifying denotes the ability to identify a colour when it is named

·        Naming denotes the ability to name a colour when asked

·     Generalizing denotes the ability to understand the similarity of colours in varied objects

Matching:

Initially, in teaching colour concepts, only one or two primary colours must be taught at all levels of matching, identification naming and generalization. To begin with teaching colour concepts, the child is given activities that involve matching. For example, collect objects of similar shape or size but different colours like yellow and red beads or yellow and red coins. Take two cups, one in yellow and one in red. To teach matching, the child is expected to drop the red coin in the red cup and the yellow coin in yellow cup. Encourage positive responses and correct the wrong attempts. Once the child masters this, include more colours like blue, green, black, white etc.

Generally, children tend to easily achieve this level of matching and parents would begin to proceed to next level- identification. But practically, the transition between matching and identification must be including another phase which involves matching of same colour with objects that are varied by size and shape. We, in our centre, took 15 children with varied cognitive abilities to teach colour concepts. Among them, 11 children could do matching of all primary colours efficiently but could not progress directly to identification.

After matching red and yellow coin in red and yellow cup respectively, the children (individually ) were instructed to pick red coin when named and drop in the red cup (this is identification). All of them were able to leave yellow coins and pick up red coin and drop in the red cup. But when red and yellow coins and red and yellow beads were mixed and presented, children were able to pick up red “coins” but not the red “beads” when instructed to pick up red. This implies that children paired the word “red” for only “red coins”. They could match colours for only those objects that are similar in shape or size. So, before moving to identification children must be trained to match colours of both similarly sized or shaped objects and differently sized or shaped objects.

Hence, the steps in matching would be:

1.     From a group of red and yellow coins, match only red coins to the red cup

2.     From a group of red and yellow coins and red and yellow beads match only red coins and red beads to the red cup

3.     From a group of red and yellow coins, red and yellow beads, red and yellow balls, match only red coins, red beads, red balls to the red cup

4.     Follow the above steps to all other colours

Identification:

Once matching is achieved for all basic colours with varieties of objects, identification of colours can be taught. Here children will be presented with objects of varied colours and varied shapes/size and asked to identify the named colours. 

Eg. 1. Present yellow bead and red ball and ask the child to pick up red

          Eg. 2. Present red ball and yellow block and ask the child to pick up yellow.

          Follow the same for all other colours. In identification, parents/teachers must name colours and child must be asked to repeat the naming during identification. This is the precursor of the next level – naming of colours. For example when the parent says “pick up red”, the child must say “red” when picking up red object. Here the child is learning to pair the name of the colour to the object.

Naming:

          In this level, the child must be asked to name the colour of the object for example when the parent says “what is the colour of the ball”, the child must say “red”. If this is not achieved, the child must again be taught identification.

Generalization:

          This involves naming of colours that are fixed colours of objects. Example generalization involves the understanding that red is common for apple, tomato, pomegranate, blood, rose, etc. in this the child must be asked to list objects that are of red colour, yellow colour and so on.

  

Article on echolalia

Autism and Echolalia (Repetitive Speech) – Questions and Answers - Craig Kendall, the author of The Asperger’s Syndrome Survival Guide

Your child is repeating movie and TV scripts all day, and showing all the signs associated with autism and echolalia. What should you do? Should you be worried? Not quite, says some language and autism experts who discuss the topic.

First of all, what is echolalia? This is when a child with autism will either repeat back to you what you have just said, or what they heard someone say earlier, or they will repeat seemingly random lines from kid’s TV shows or movies that they have heard.

This may seem, at first glance, like totally non-functional communication to you. It may seem very frustrating, because you’re trying to talk to your child and all you’re getting back is seeming nonsense. It probably will have you worried for your child’s development.

Scripting, Autism and Echolalia

But actually, if you look closer, these seeming nonsense statements are actually quite full of meaning. Kids with autism who have echolalia will often do something called “scripting,” which is repeating scripts from TV shows or movies. They do this because they don’t have the language skills or ability, yet, to come up with their own language. But, they have learned that they can express a need or a feeling by matching it to the thousands of statements they have stored in their head from watching things like Blue’s Clues, Dora the Explorer or other such things.

Emotions are easier to understand on exaggerated kids’ shows. Therefore, kids with autism may be able to understand the language easier and due to their great memories, save it for a time when they need it. This is what happens with autism and echolalia.

So, if you hear a bizarre statement that doesn’t seem to quite fit, see if you can recognize it from one of the shows your child watches. For example, one mother gave the example of a kids’ TV show where one character is tired of the other and says “I’m going to go read in the bathroom!” Her son uses it to express the feeling of “I’m done with this; I want to be by myself.”

The actual words in an echolalic statement don’t really matter. They are just placeholders for the emotion being expressed. So her son doesn’t actually want to read OR go to the bathroom – he wants to go off on his own. You kind of need to know the original show it’s from to understand what’s being said, but it’s far from nonsense language. You can ask “Where is that from?” to try to get more clues about the origin and meaning.

Autism and Echolalia – Should I Discourage this Behavior?

Many parents wonder, Should I be trying to stop my kid from using echolalia? Should I ignore him and try to coach him out of it? They want their child to be more “appropriate” and more easily understood by the outside world. But the answer is no – no, you shouldn’t. Language does not come easy for many kids with autism. Any attempts at all at language should be rewarded and appreciated.

It has actually been shown that echolalia is a positive indicator that the child will gain functional language. But, like all other things for a child with autism and echolalia, it will just come much later than their peers.

Echolalia is part of a “gestalt” system of learning language. That means language is learned gradually and absorbed from the environment, until one day it all just seems to coalesce and make sense, or at least more sense. This is as opposed to the more analytical, word by word form of language learning that most typical kids turn to by the time they’re of school age. This doesn’t work nearly as well for most kids with autism.

Autism and Echolalia – Echolalia as a Developmental Step in Building Language

Echolalia can come in two forms, immediate and delayed. Immediate echolalia is when the child repeats something you just said instead of giving a response. If this happens, be patient. At least there is an attempt to communicate. You may want to reinforce verbal skills by having pictures of different choices and feelings for them to point to. Know that if you say something like, “Do you want juice or milk?” and the response is “Or milk,” it doesn’t necessarily mean they want milk. They’re just repeating the last part they heard. Try turning it around and asking it the other way. Sometimes you’ll just have to guess.

Delayed echolalia is when the child repeats something from movies or TV, or something they heard earlier.

Eventually they get better at choosing the right script for the moment so that you might not even know they were scripting if you weren’t already familiar with the scripts. Then that turns into “modified echolalia,” where they will sometimes keep the basic structure of the script but replace it with words that are more appropriate to the situation. Names will be swapped out for the people actually in the situation; descriptions will be closer to what is actually going on.

After more time goes on, this will usually lead to some sort of spontaneous language. It will start with only a few words at a time, but eventually it will evolve into several word sentences. Scripting provides a good base for the child with autism to learn about the structure of and use of language until they have acquired enough skills to use it on their own, according to many accounts of autism and echolalia.

When Does Echolalia Occur?

Even after there has been some language development and ability to use language independently, kids with autism may still script when they’re feeling particularly stressed out or anxious. The scripts are comfortable and familiar and it takes some of the stress off of them. Also, they may be used when the kid just plain doesn’t know the answer or how to answer.

A lot of kids with autism don’t know how to say “I don’t know.” Sometimes this is teachable. Gather together a series of questions that may be commonly asked in daily life but that you don’t think they will know the answer to. Model to them how to say “I don’t know.” Prompt the “I don’t know” after each question. You may even want to reward them with a small token after each “I don’t know,” and then graduate to rewarding only when it is spontaneous. This will, at the least, make communication about some things a little easier and also more comprehensible to those not familiar with the scripts.

Typical kids and babies coo and babble when they are toddlers and just beginning to learn how to speak. They are trying to imitate what they hear and what is going on around them before they can put it all together. The only difference is, with autism, it can take longer – much longer – for this to happen.

But for many kids it WILL happen, and using echolalia is a natural step to learning language. If you are patient and reward their efforts, if you try to get into their world and respond to them, you will find that autism and echolalia doesn’t have to be quite the volatile mix that you might have thought it was going to be. 

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