AUTISM - AN OCCUPATIONAL THERAPY PERSPECTIVE The Pervasive Developmental Disorders (PDDs) are a group of neuropsychiatric disorders, characterized by specific delays & deviance in social, communicative & cognitive development, with an onset typically in the first years of life. Although commonly associated with mental retardation, these disorders differ from other developmental disorders in that their developmental & behavioral features are distinctive & do not simply reflect developmental level (Rutter, 1978). The Diagnostic & Statistical Manual (fourth edition) (DSM-IV, APA, 1994) includes the following disorders in the diagnostic category of PDDs: 1. Autistic Disorder 2. Rett’s Disorder 3. Childhood Disintegrative Disorder 4. Asperger’s Disorder 5. PDD – NOS Of the various PDDs, Autistic Disorder is the most common, most widely recognized & intensively studied. Dr. Leo Kanner first introduced the term autism in 1943. He identified behaviors such as extreme aloneness, failure to assume anticipatory postures, delayed or deviant language, excellent rote memory & a limited range of spontaneous activities. Earlier theories regarding the origins of autism placed fault with parenting strategies. Mothers of children with autism were labeled “refrigerator mothers” & were blamed for cold, unfeeling relationships leading to social withdrawal of their children. By 1970s, research indicated that autism is a spectrum disorder of neurological origin. Prevalence: The incidence of Autism Spectrum Disorders (ASDs) has been reported to be as high as 1 in every 500 births (Ritvo et al., 1989). The DSM-IV-TR reports prevalence in the range of 2 to 20 cases per 10,000 individuals (APA, 2000). Diagnostic Criteria: The four main categories identified by the DSM-III-R (APA, 1987) include the following: 1. qualitative impairment in reciprocal social interactions, 2. qualitative impairment in verbal & non-verbal communications & imaginative play, 3. a markedly restricted repertoire of activities & interests, & 4. onset during infancy or childhood.
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The DSM-IV criteria for Autistic Disorder (299.0) is as follows: DSM-IV Criteria for Autistic Disorder (299.0) A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3) (1) Qualitative impairment in social interaction, as manifested by at least two of the following: (a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction (b) failure to develop peer relationships appropriate to developmental level (c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) (d) lack of social or emotional reciprocity (2) Qualitative impairments in communication as manifested by at least one of the following: (a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) (b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others (c) stereotyped and repetitive use of language or idiosyncratic language (d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level (3) Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least two of the following: (a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (b) apparently inflexible adherence to specific, nonfunctional routines or rituals (c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) (d) persistent preoccupation with parts of objects B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play C. The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder. Etiology: A. NEUROANATOMY: Bauman & Kemper (1985) reported that the brains of individuals with autism are generally bigger & heavier than most brains of typical subjects. 2
1. Cortex: Reversed asymmetry & abnormal lateralization of the cortical hemispheres has been noted by researchers (Lotspeich & Ciaranello, 1993). 2. Limbic System: In individuals with autism, cells in the limbic system, where emotions are processed, are a third smaller than normal & are found in excessive numbers (Bauman & Kemper, 1985). 3. Cerebellum: Deficiencies have been found in the numbers of Purkinje cells & granule cells, neuron shrinkage has been found in the inferior olive, & the vermal lobes VI & VII have been found to be smaller as well (Bauman & Kemper, 1985, 1986, 1993, 1994; Courchesne et al.,1988,1989; Ritvo et al., 1986). 4. Brain stem: Bauman & Kemper (1985) found brain stem abnormalities, such as decreased cell size of individuals with autism. MRI studies of the brain stem, particularly the pons, revealed smaller sizes in autistic subjects (Gaffney et al., 1988). B. NEUROPHYSIOLOGY: 1. Cortical Physiology: There is some evidence of diminished hemispheric lateralization in subjects with autism (Ornitz, 1987). EEG differences have been noted in the frontal & temporal regions when autistic children were compared to control subjects, & these differences were more marked in the left than in the right hemispheres (Dawson et al., 1995). 2. Subcortical Physiology: When compared with control subjects, autistic subjects demonstrated metabolic reductions in the anterior & posterior cingulate gyri (Haznedar et al., 2000). C. NEUROCHEMISTRY: Autistic individuals exhibit significant increases in peripheral blood levels of serotonin. Serotonin influences mood, aggressive behaviour, repetitive movements, sleep, memory, pain & anxiety. D. GENETICS: Studies have demonstrated a genetic component to the etiology of autistic disorder. There is a greater concordance for autism in identical versus fraternal twins. E. ENVIRONMENTAL: • Pre- & perinatal factors such as maternal history, abnormal presentation in labour, low birth weight, low apgar score & post-maturity may play a minor role in the etiology. 3
• Potentially serious neurotoxins include hormone disruptors, such as pesticides & polychlorinated biphenyls (PCBs). These chemicals that mimic estrogen have the potential to alter the typical development process. • Regression can be explained by those who believe that autism is caused from childhood vaccinations. Wakefield found a relationship between the measles, mumps, rubella (MMR) vaccination, inflammatory bowel disease & autism. • Bernard et al (2000) suggest that vaccinations may be providing significant exposure to mercury. They theorize that autism may be a form of mercury poisoning that is caused by receiving too many vaccinations as an infant & young child.
Clinical Features: Children with autism exhibit the following signs & symptoms that characterize all ASDs to a great degree: o Expressive & receptive communication & social deficits. o Insistence on routine & resistance to change. o Appearing to be “off in their own little world”. o Resistance to physical closeness such as hugging. o Attachment to “odd” toys such as kitchen utensils. o Parallel play (playing beside other children rather than interactively with them) & lack of imaginative play. o Sudden & apparently unexplainable anger & tantrums. o Repetitive behaviours & OCD. o Splinter skills (excelling in a particular skill that is above the apparent IQ level). o Appearing to have sensory overload in normal environments. Individuals with autism demonstrate a variety of behaviours & difficulties across each of the following domains: A. Socialization: Individuals with autism demonstrate deficits in three areas of socialization : the purpose of socialization, the frequency of socialization & the readability of the social act. Behaviours that reflect socialization deficits include: • A decrease in the frequency of attempts to initiate or respond to communication. 4
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Use of isolated means such as gestures only (i.e. leading others by the hand). Crying/ laughing that is not apparently related to obvious needs. Use of unconventional behaviours such as hitting & biting oneself or others. Difficulty anticipating future events, tendency to tantrum. Problems with transitions. Difficulty being soothed by others. Problems understanding figurative language. Problems engaging in play with others (getting into play, remaining focused on play, joint attention to play).
B. Communication: Receptive & expressive communication deficits include: • Failure to vocalize, babble or engage in jargon. • The typical development of vocalizations or speech that then stops & regresses. • Decreased ability to imitate. • Decreased use of eye gaze shifting between people & objects (joint attention). • Oral-motor problems. • Problems attending to the speech of others. • Problems understanding object labels. • Problems understanding directions. • Infrequent / no use of words. • Decreased use of conventional gestures. • Use of unconventional gestures. • Echolalia. • Unusual speech tone & speech-rhythm. • Pronoun confusion. • Difficulties responding to questions. C. Restrictive-Repetitive Acts: Types a. Rocking b. Hand flapping c. Moving objects close to & away from the eyes d. Spinning objects or self e. Mouthing objects f. Being fascinated with one’s hands g. Being attached to an object or part of an object 5
h. Creating very specific routines that are difficult to modify D. Cognition & Intelligence: Autistics can have levels of intelligence that range from profoundly mentally retarded to genius. Often, it is difficult to accurately assess the intellectual ability of individuals with autism. Individuals who possess a Gestalt learning style tend to learn about the world in chunks or whole. This may possibly lead them to be rigid in their thinking & have difficulty with abstraction. Research indicates that individuals with autism prefer to engage in construction play rather than representational or pretend play (Mundy et al., 1987). Also, autistics may appear to prefer solitary play to the social domain of play.
E. Sensory Processes: Fisher & Bundy (1991) presented a conceptual model that described the possible relationship between sensory processing, perception & adaptive behaviour. Impairments in integrating sensation can result possible deficits in cognition, socialization & motor behaviour. Indications of problems with sensory perception & processing include: • Behaviours such as rocking, flicking objects, spinning, hand-flapping, fascination with hands • Sensitive startle response • Lack of response to sensory stimuli • Unusual sleep patterns • Decrease activity level or lack of response • Increased activity level • Decreased attention for that which is salient • Problems shifting attention • Problems with the textures or smells of foods • Unusual or exaggerated fears • Avoidance of eye contact • Difficulties being soothed • Acts of dropping oneself onto or into objects • Clothing sensitivities • Preference to sleep without covers • Preference to sleep between mattress & box spring 6
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Preference to sleep in small areas such as drawers, boxes or shelves Lining up of objects Periods of staring at lights or shadows
F. Motor Skills: Autistics have gross & fine motor difficulties related to motor planning issues, muscular weakness or sensory issues. The motor deficits include:
Gross Motor Delayed development
Fine Motor Delayed development
Low muscle tone
Low muscle tone
Oral Motor Mouthing Apraxia Decreased tolerance for foods Limited oral exploration or play Excessive drooling Prone to choking or gagging
O T Evaluation of the child with Autism: Children with autism demonstrate global developmental delays & behavioural challenges that necessitate a different evaluation approach than might otherwise be used. An individualized & Transdisciplinary approach is imperative. Children with autism demonstrate difficulties with reciprocal social interaction, verbal & nonverbal communication, selective attention, imitation & sensory processing. All these make evaluation challenging, particularly if standardized tests are used. Standardized tests, especially norm-referenced ones do not allow the autistic child to demonstrate his/ her abilities in a typical environment. Specific methods or tools (interviews & observations) are used in assessing different components & contexts such as:
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A. Level of Participation: The level of the child’s current ability to participate as a family member (chores, being included in family events, mealtimes), fulfill the role of student (getting to & from school, learning & completing academic work, interacting & communicating with peers & school staff) & participation as a member of a larger community (neighborhood playmate) must be assessed. B. Self - Care & Adaptive Behaviour: This is best assessed through informal observation & interviews. E.g.: The Pediatric Evaluation of Disability (PEDI) (Haley et al., 1992) may be used with children ages 6 months-7.5 years & is completed by means of a parent interview (Not developed specifically for use with autistics). C. Play: Examples of tools that can be used to assess play include: 1) Test of Playfulness (ToP) (Bundy,1997) - A 68 item observational tool for children ages 2 to 10 years. It incorporates the elements of intrinsic motivation, internal control & the freedom to suspend reality. 2) Preschool Play Scale (Bledsoe & Shepherd, 1982; Knox, 1974) – It measures four domains in children from birth to 6 years old: space management, material management, imitation & participation. Unstructured observation of play may provide information about the child’s developmental level, sensory preferences, social & communication skills, imitation & motor planning as well as gross & fine motor abilities. D. Behavioural Issues: Functional assessment is used to analyze the meaning of behavior. It is a way to understand the child’s strengths, preferences, & ways of communication & it also examines the influences of the environment on the child’s behavior. The contexts in which behaviors (hitting, screaming, self-injurious, self-stimulatory, etc.) occur must be examined. These include the physical & social settings, the tasks, predictability & choice making. E. Sensory Processing & Sensory Integrating: 8
Deficits in sensory processing skills, especially in children ages 0-3 is one of the greatest hindrances to relating & communicating (Greenspan, 1996). Most children with autism have difficulty registering, filtering & organizing incoming sensory input, which results in difficulty interpreting & organizing responses to people around them & the environment (Williamson & Anzalone, 1997). Typically, autistics have difficulty modulating sensory information; they may be hyperresponsive, hyporesponsive or fluctuating between the two. Sensory histories are interviews or checklists that help identify behaviours that are thought to indicate sensory processing dysfunction. Commonly used by occupational therapists include: 1) Sensory Profile (Dunn, 1999) – The parent/ caregiver is asked to rate on a scale of Always to Never how often a child engages in a particular behaviour. It has 125 items that are grouped into three main sections: sensory processing, modulation, & behavioural & emotional responses. 2) Evaluation of Sensory Processing (ESP) (Parham & Ecker, 2000) - The ESP assesses seven sensory systems: auditory, gustatory, olfactory, proprioceptive, tactile, vestibular & visual. It also asks caregivers to rate the frequency of occurrence of behaviour on a Likert scale of Always to Never. 84 of the items on the ESP distinguish between children with & without S I dysfunction (Johnson-Ecker & Parham, 2000).
O T Intervention in Autism: The Sensory Integration (S I) F.O.R is increasingly relevant to occupational therapists working with individuals with autism. When occupational therapists working with children within the autism spectrum were surveyed, 95% to 99% reported using the S I F.O.R (Case- Smith & Miller, 1999; Watling et al., 1999). S I is the neurological process of organizing sensations from one’s body & the environment, so that the body can be used effectively in the environment by making an adaptive response (Ayres, 1972). An adaptive response occurs when environmental challenges are successfully met. Certain concepts to be considered include:
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1) Sensory Registration- This term has been used clinically to describe the behaviour of noticing sensory stimuli in the environment (Miller & Lane, 2000). Ayres (1979) hypothesized that some children with autism have deficits in sensory registration. Poor registration may account for some of the behaviours observed in autistics. Lack of registration may be the result of having unusually high thresholds for receiving sensory information & may cause problems related to attention. 2) Sensory Modulation- It refers to the capacity to regulate & organize the degree, intensity & nature of responses to sensory input in a graded & adaptive manner. Autistics vary widely between extreme hyporesponsivity & extreme hyperresponsivity, sensory seeking & sensory avoiding, and unusual patterns of sensory play. Common patterns of hypersensitivity are auditory & tactile defensiveness (Keintz & Dunn, 1997) & visual fixations. A common example of hyporesponsiveness is a high pain tolerance. Praxis- It is the ability to have an idea & plan about a future novel activity that involves deciding what to do & how to do it. Thus, dyspraxia is difficulty in planning & carrying out skilled, non-habitual motor acts in a correct sequence. Specific aspects of praxis such as timing, sequencing, initiating & transitioning are common difficulties for autistics, although motor execution is frequently intact. Ideation is a problem. One of the diagnostic features of autism is resistance to change & avoidance of novelty. Poor ideation is likely to be associated with this feature of autism. Assessment of S I dysfunction & praxis abilities is a critical aspect of occupational therapy evaluation in children with autism.
Key constructs that guide therapy when using S I principles include: • Use of structured sensory environment that highlights the Proprioceptive, Vestibular & Tactile systemsProprioception- It has been described as the cornerstone of S I intervention (Blanche & Schaaf). Proprioception is both alerting & calming, & hence, a key sensation that alters levels of arousal & enhances self-regulation. Proprioceptive sensations are achieved through traction, compression, movement of the joints & muscles, or the use of muscles against resistance. Jumping, climbing, hanging, pushing & pulling activities all provide proprioception. Equipments commonly used to provide proprioception include mats, mattresses, trampolines, tires, bungee cords attached to swings, trapeze bars & climbing structures. 10
Vestibular- A variety of swinging equipment is used so that rotary, linear, orbital movements or a combination of these movements are available for sensory play, often in conjunction with proprioception. Examples include single & dual suspension swings, gliders, rockers & spinning seats. Tactile- Deep pressure is a prime organizing sensation. Use of weighted vest has been found to result in increase in attention to task & decrease in self-stimulatory behaviour (Hinojosa et al., 2000). Activities & equipment that provide deep pressure are made available often in conjunction with proprioception. Heavy pillows, mats, large bolsters, beanbag chairs & cushions are used to provide deep pressure. Items with a variety of textures are used for play, such as clay, beans, rice or water. Commonly used equipment includes ball baths, Theraputty, Playdoh, beans/ rice, brushes, vibrators, cloth samples, water & items that are hot or cold. •
Tapping the Inner Drive-
The inner drive in many autistics may lead to engagement in unhealthy occupations like obsessive, ritualistic, or repetitive behaviours; self-injurious actions or socially inappropriate habits or patterns. Using carefully selected sensory-based activities can be helpful in enhancing abilities such as initiating action, transitioning from one activity to the next, sustaining participation & finding meaning & purpose in tasks & activities. •
Delivery of intervention in the context of Play-
The inner drive of the child can be tapped through play (Mailloux & Burke, 1997; Parham, 1997). In S I, it is perceived that the therapist & the child have the intent to play together & that the child is a well-respected playmate. The child’s current capabilities guide the play. •
“Artful Vigilance” on the part of the therapist-
The therapist must maintain “artful vigilance” as he/ she watches for opportunities to engage the child adaptively while altering the sensory & motor challenges (Parham & Mailloux, 1989). Vigilance is required to ensure the child’s successful engagement. The autistic child can shift from sensory-seeking during an activity, to a disorganized state, to sensory avoiding behaviour in a short period of time. The therapist must be alert to signs that the child is becoming over-or-under-responsive to the various qualities of 11
sensation . Watching the child’s reactions, including subtle cues like body language, eye gaze, or minor gestures; determining what is “just right” for the child & anticipating what should come next are all important elements of using artful vigilance within the S I framework. •
Child-Centered Approach-
For a children with autism, this approach is often challenging because they may have difficulty with organization of their behaviour. The philosophy of S I theory & practice believes that children will generally seek the types of experiences they need to grow & develop, even if they do not have the skills to go about engaging in activities in an appropriate way. Clinicians follow the lead of the child while providing the activities & structure that are necessary for him/ her to make appropriate responses to people & things in the environment. The therapist must provide an adequate balance of freedom & structure so that the child benefits from the therapeutic interaction. •
Elicitation of the Adaptive Response-
Adaptive response is defined as “an appropriate action in which the individual responds successfully to some environmental demand” (Ayres, 1979). This is the single most essential feature that guides the direction of the therapy. Adaptive responses are identified when the child interacts in a slightly new & more complex way to a challenge. Ayres (1972) identified one of the most basic adaptive responses as holding on & staying put. •
Delivery of the “Just-Right level of challenge”-
Therapists who use the S I approach constantly seek the “just-right level of challenge”. The just-right challenge is a point in therapy where the conditions are right for the child to make an adaptive response. The child & the therapist work together until the appropriate level of challenge is reached. • Emphasis on Active versus Passive participation where the engagement in the activity is its own reward (Ayres, 1972; Parham & Mailloux, 1989, 1996; Koomar & Bundy, 1991)The S I approach has always stressed the importance of active, purposeful & meaningful participation. 12
Certain passive sensory experiences such as swinging the autistic child in a slow, rhythmic manner, providing deep pressure by pressing the child between cushions, might be calming, alerting or organizing to the child. These kind of passive activities might be used to help get a child ready for participation in more challenging tasks. The emphasis on active participation is especially important for the child with autism, who, because of the nature of this disorder, may have significant difficulty with initiation & self-direction.
Social Skills Intervention for Children with Autism : Social skill deficits in autism include impairment in the use of nonverbal behaviours such as eye-to-eye gaze, facial expression, body postures, & gestures to regulate social interaction; failure to develop peer relationships appropriate to developmental level; a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people; & a lack of social or emotional reciprocity. Social skills intervention can start as early as 2 ½ - 3 years in many cases soon after a diagnosis is made or after social deficits are suspected. Social skills groups & activity groups are safe environments that allow children with autism to learn & practice new skills within a normal social context of a small peer group. Intervention to address social skill deficits in children with autism generally can be based on the following principles: a. Structure & predictability- routines that allow a child to foresee beginnings & ends of social activities, timing of demands, breaks & rewards, & likely behaviours of other people. b. Active engagement of the therapist & opportunities for the active engagement of the child - during developmentally appropriate tasks, therapist is actively engaged & child is socially responsive; during activity that is too difficult, child remains passive & has to be prompted frequently. c. Involvement of parents- parents engage in consultation with the therapist so they can carry on the intervention at home; clinician helps parent interact with the child in a positive way, which may entail helping the parent come to terms with past negative social interactions they may have had with their child. d. Inseparability of cognition, affect & social development.
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e. Individualization of goals & techniques- treatment goals take into account the child’s level of cognitive, affective & social development. f. Work within a natural environment- natural aspects of social situations used as much as possible. Social Stories (Gray, 1986): One social skills program, Social Stories (Gray, 1986), is developed specifically for children with autism. This program has a variety of stories related to everyday life activities, for example, riding a school bus or going out to recess. The story sequentially describes a situation & the appropriate responses to social cues within the situation. The stories are written from the perspective of high-functioning autism & Asperger’s Disorder. Behavioural approaches for children with Autism: Behavioural approaches use strategies to systematically change behaviour, to teach new skills & to use rewards to reinforce behaviour change. The process of systematically applying consequences to bring about change is governed by principles of reinforcement, which can be either positive or negative. Behaviouralists observe human behaviour while considering three interrelated components that are based on the work of Skinner (1953): antecedents, behaviours & consequences. Applied Behaviour Analysis (ABA) is the term commonly used to describe a behaviouralist orientation & the many behavioural intervention methods available. Within an ABA model, clinicians systematically manipulate antecedents & consequences. Thorough analysis of behaviour is critical prior to the design of a behavioural intervention plan. After a thorough analysis of all the three factors, clinicians determine to what extent the plan will manipulate antecedents & to what extent consequences will be manipulated. Behaviouralists influence what the child experiences as a consequence using three different methods- positive reinforcement, negative reinforcement & punishment (Alberto & Troutman, 1995).
Educational Intervention approaches for children with Autism: Some of the educational strategies commonly used with children with autism include: 14
A. Discrete Trial Training: Discrete trial methods are behavioural in nature. The child is engaged in repeated teaching trials in which he/ she has multiple opportunities to learn the correct response to a given stimulus. The teacher determines which skills to teach according to the child’s areas of deficit, breaks down the individual skills & goals into small parts & then teaches each part using a fixed stimulus. When the child has learned an individual part, the teacher chains together the other parts to produce the whole. When needed, the child receives a prompt to encourage an appropriate response. After the teacher rewards each correct response with positive reinforcement, the next cue or instruction is given. B. Pivotal Response Training (PRT): PRT is an intensive behavioural intervention specifically designed to enhance the development of skills such as language & play skills that are necessary for broad areas of functioning (Koegel et al., 1989). The pivotal skills this method was designed to teach are motivation & responsivity to multiple environmental cues. These procedures may be used in a one-to-one teaching environment or in the child’s natural environment. Skills are taught in a developmental sequence. For example, language skills training begins by teaching prebabbling (cries, laughs) & then progresses to babbling (ba, dada), spontaneous sounds, sound pairing (child’s vocalization follows teacher’s vocalization), verbal imitation, spontaneous word approximations, spontaneous phrases & finally concepts. C. Structured Teaching: This approach was developed through Division TEACHH (Treatment & Education of Autistic & Related Communication Handicapped Children) at the University of North Carolina Chapel Hill in 1966. This approach is designed to help people with autism better understand the world & function more successfully in it. The structure in this approach includes environmental modifications, concrete & visual presentation of information & proactive use of routines to teach skills. The five distinct elements of this approach are: 1. Physical structure- to define the layout of the classroom environment so each area has a distinct meaning & purpose. Boundaries are created with furniture, tape on the floor, & other visual means to help the child understand where each area begins 15
2.
3.
4.
5.
& ends, & what happens in each area of the environment. Visual & auditory distractions are kept to a minimum. The daily schedule- It is a visual representation of what activities will occur & in what sequence (Mesibov et al., 1994). This schedule fosters anticipation, provides predictability, eliminates demands on memory, & reduces anxiety about unknown events. Schedules may include very few activities or cover the span of an entire week & may use words, pictures or both. Work systems- They provide structure that helps autistic children develop independence in routine tasks. They may include jigs or visual maps that outline the placement of objects used for each task. This emphasizes the concepts of where to begin a task, what & how mush to do, what comes next & what the completed task looks like. Routines- They help to establish order & provide understanding & security for children with autism. Children are taught to approach visual information from left to right & from top to bottom. Thus, children know where to start & how to proceed with a task. Visual structure- It has three key elements: visual instructions (showing the student information about how to complete a task), visual organization (organizing materials & space in the child’s work environment) & visual clarity (highlighting key materials or elements of objects through colours, pictures, numbers).
D. Priming: It is an adult-supported strategy developed to help parents provide learning opportunities that might improve a child’s success in the classroom (Koegel et al., 1992). It gives the child a preview of a new skill or task that he/ she will be required to do but is likely to find difficult. This familiarizes the child with the materials & expectations prior to the demand for performance. Typically, priming is done to prepare a child for learning a new topic or skill in school. Often, the parent conducts a priming session at home just before the skill will be taught in school. The purpose of priming is to increase a child’s familiarity with an area of potential difficulty before those difficulties arise. E. Picture Exchange Communication System (PECS):
The PECS is an augmentative communication system that requires the exchange of pictures rather than words between the communicating parties (Bondy & 16
Frost, 1994). Children are taught to exchange small picture cards with adults & other children to express their desires, answer questions & make comments. Pictures can be line drawings, photographs or pictures from magazines/ computers. An adult is responsible for making sure the picture source is available to the child at all times. F. Token Systems: It is a concrete, visual method to incorporate predictability & positive reinforcement into a teaching session. The child earns tokens for each task that he/ she performs or answers correctly. G. Peer Modeling: It is a strategy to benefit a child with autism by pairing him/ her with a typically developing peer who is able to act as a model. The peer’s role is to lead the autistic child from one activity to the next during transitions, help the child to successfully engage in play & work activities, demonstrate the appropriate use of materials, & assist the child with management at snack times. H. Transition Objects: These are items that clearly represent the different activities that make up the child’s day. This technique closely parallels the PECS method; however, objects rather than pictures are used. Assistive Technology for Students with Autism: Assistive technology devices are any simple or complex tools that enhance learning, communication, leisure pursuits or socialization. The occupational therapist’s knowledge base in activity adaptation & task analysis allows him/ her to function as an integral member of the technology team. The therapist here may take on the role of task analyzer, equipment modifier, problem solver, student, staff trainer or consultant. Deciding if technology is required/ appropriate, determining appropriate technology, determining whether the equipment should be obtained on a temporary or permanent basis & funding & obtaining the technology are the areas where occupational therapists contribute. Assistive technology can be grouped into:
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1. Hardware- It is the machinery itself. It includes alternative keyboards, mouse emulation devices, word processors, switches, augmentative & alternative communication (AAC) devices & even computers themselves. 2. Software- It is the program that creates the activity or function performed by the hardware of the computer. Software technologies include moue training programs, voice recognition, word prediction, AAC software & virtual reality software. 3. High technology- They are relatively sophisticated. Most of the computer-based augmentative software falls into this category. 4. Light or no technology- This includes: a. PECS b. Visual displays such as language boards, language books or word displays containing symbols, pictures or words that indicate the intended meaning. c. Facilitated Communication (FC)- It is a form of communication whereby a Facilitator (usually an adult) lends physical support to the communicator either by supporting the hand in a pointing position or by providing physical support at the wrist, elbow or shoulder. While the Facilitator is providing the support, the communicator will then point to a letter display (e.g., keyboard) & “spell out” a message, pointing to each letter consecutively to complete a message. FC is based on the notion that people with autism may have a form of apraxia whereby they have difficulty initiating certain moor movements (Biklen, 1990).
Interactive Guiding: The Affolter Approach:The Affolter treatment approach, or “interactive guiding”, uses nonverbal manual cueing to assist people in completing daily living skills. The emphasis is on helping the tactile-kinesthetic system to receive & process information that can then be combined with other sensory systems to perceive events appropriately. This approach has been used with a variety of diagnoses like CVA, TBI, coma & Alzheimer’s disease, as well as PDDs. The Affolter approach, developed by the Swiss speech & language pathologist Dr. Felicie Affolter, focuses on the perception of tactile & kinesthetic input & uses these sensations in intervention as movement is guided. While using this approach, the therapist’s hands are placed directly over the hands or body part of the person. If hand-to-hand guiding is used, hands should be placed fingertip to fingertip (as if the hands were a pair of gloves). The amount of pressure 18
used depends on the amount of resistance the person needs to interpret the tactile input appropriately. Thus, the pressure varies from maximal to very minimal resistance. Perception being a whole-brain experience, alternating input between the left & right sides of the body to provide input to both the cerebral hemispheres is important. Any bilateral activity should be guided bilaterally.
Alternative & complimentary approaches in the treatment of autism: Medications: These include stimulants, antidepressants, hypertensives, anticonvulsants & antipsychotics. 1. Dietary modification- This has shown benefits for children with attention, learning & behaviour problems. This incorporates: Eat a diet that is Unrefined, Varied & Free of Artificial Colors, Flavors, Additives, & Naturally Occurring Salicylates Eat a diet that is Gluten & Casein Free (GFCF) Eat a diet that is Yeast, Mold & Sugar Free Filter Water Nutritional Supplements 2. Immunotherapy- Parents of some children report an onset of autistic symptoms & hyperactivity after an immunization. A technique called intravenous immune globulin (IVIG) therapy is currently being used in children with a PDD.
Treatments that affect sensory processing: These include1. Auditory Integration Training (AIT)- One type of AIT was developed by Dr. Guy Berard in France, who believed that autistic children hear some sound frequencies more clearly than others. This hypersensitivity to sound in turn affects the development of phonological awareness & language. Although music therapy is not a form of AIT, it works by enhancing both the auditory & vestibular functions. 2. Vision Therapy (VT)- Eyesight is the act of seeing; vision is the ability to focus on & give meaning to that which is seen. VT includes varied activities individualized for each child. It begins with simple visual arousal activities (like visually directed games with balloons or flashlights in a darkened room) because improved awareness of the peripheral visual 19
world is a prerequisite to good eye contact & social skills (Rose & Torgeson, 1994). Next, more difficult visually directed tasks such as completing mazes are performed as the child learns to use his/ her eyes more efficiently.
Floor time Model (Stanley Greenspan) One-on-one intensive engagement Parents and school personnel trained to be facilitators Meets child at his/her own level Recommend 15+ hours per week of interaction Focuses on the social and affective development of the young child Child centered but not passive watching Natural learning contexts are utilized Builds on natural interests of child Open and close circles of communication Extend and broaden circles and interests Cues are the critical unit of observation Cues indicate the child’s enjoyment, tolerance or displeasure Obvious cues: frowning, moving away, eye contact, smiling Subtle cues: rigid posturing, pausing, allowing intrusion/interaction Assessment Unique Comfort Zone (CZ) activities Functional Developmental Levels (FDL) Sensory Profile (SP) Flexible curriculum based on child’s individual profile. Floortime Intent of Intervention Alertness Awareness Initiative Flexibility Affect Communication Problem-solving
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Functional Developmental Levels 1&2: Engagement and shared attention 3&4: Two-way communication 5: Shared meanings and symbolic play 6: Emotional thinking Can be used in diverse contexts within the daily routine Floortime Attention/Engagement & Two-way communication (FDL 1-4) Humor, suspense, surprise One & two step commands Make child work Reward/reinforce Use playful obstruction Floortime Shared Meanings & Emotional Thinking (FDL 4-6) Pretend play Outings Multiple circles of communication Model, rehearse, expect Express empathy and feelings Social stories Floortime “Comfort Zone” of preferred actions used to define play sequences to engage child. Engagement begins with sensory motor play. The play turns into games. Language is added. Imagination is next. Establishes relationships, simple to complex. Solomon, 2002 Floortime The Good Floortime facilitator: Provides supportive body posture Reads the child’s cues Follows child's lead, then expands in playful, encouraging, non-directive manner Knows when to talk and when to pause Treats what the child is doing as purposeful
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