Autism Spectrum Disorder (ASD) is a range of complex neurodevelopment disorders, characterized by social impairments, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior. There is no known cause (genetics & environmental) or cure.
What is Autism?
Highly Variable, no two people w/ ASD are alike.
CDC: 1 in 44 children dx. w/ ASD
Boys 4 x's more likely to be dx.
Signs
&
Symptoms
ASD begins before the age of 3 & can last throughout a person’s life, although symptoms may improve over time. Some children show ASD symptoms within the first 12 months of life. In others, symptoms may not show up until 24 months or later. Some children with ASD gain new skills and meet developmental milestones, until around 18 to 24 months of age and then they stop gaining new skills, or they lose the skills they once had.
Possible Signs
Social Communication & Interaction Skills
Repetitive or rigid language.
Narrow interests and exceptional abilities.
Uneven language development.
Poor nonverbal conversation skills.
Reduced eye contact/limited facial expression
Lack of response to name or indifference to caregivers
Prefers to play alone
Diff. w/ joint attention
Possible Signs & Symptoms
Behavior
Diff. w/ interpersonal play & imagination
Copied & pervasive rigidity with repetitive movements
Dislike unexpected change
Depend on ritualistic mannerisms, obsessional behaviors (stimming)
Motor tics
Diff. w/ new environment & change in normal routine
Low frustration levels, mood swings, & over stimulation results in agitation, anxiety or inattention
Delayed or impaired acquisition of words, word combinations, and syntax
Symbolic play deficits
Literacy deficits
Girls with ASD
stay in closer proximity to their peers and are better able to capitalize on social opportunity,
spend more time in joint engagement,
spend more time talking as a primary activity, and
appear to use compensatory behaviors to gain access into peer groups (e.g., swinging a jump rope near girls playing jump rope).
Boys with ASD
tend to play alone rather than participating in organized games,
spend more time alone, and
spend more time wandering as a primary activity.
Boys
vs.
Girls
sensory modality difficulties, including over-responsiveness, under-responsiveness, or mixed responsiveness patterns to environmental sounds, smells, light, tactile stimulation, movement, visual clutter, and social stimuli (e.g., social touch, proximity of others, voices)
preference for nonsocial stimuli leading to intense interests with sensory aspects of objects and events
patterns of food acceptance or rejection based on manner of presentation or food texture; and
consumption of a smaller variety of foods than the variety consumed by other family members.
Sensory
&
Feeding
gastrointestinal conditions
epilepsy
sleep disorders
neurodevelopmental disorders such as ADHD
psychiatric disorders
immune/metabolic conditions
Speech & language disorders
Co-occurring
Conditions
Evident in Prefrontal Cortex, temporal cortex & amygdala
abnormal cortical growth patterns, abnormalities in cortical thickness and disorganisation of neurons across the cortical layers & their connections to other regions of the brain
Neuro
1 Requires Support: Diff. initiating social interaction, organization and planning problems can hamper independence.
2 Requires Substantial Support: Social interactions limited to narrow self-interests, frequent restricted/repetitive behaviors.
3 Requires Very Substantial Support: Severe deficits in verbal and non-verbal communication skills, great distress/difficulty changing actions or focus
Eval by ASD specialist team (Psychologist, OT, SLP)
Must meet standards of the DSM-5
Must have problems w/ 2 categories to fall on autism spectrum (Challenges with communication/social interaction & restricted/repetitive patterns of behavior
Can be diff. to diagnose/missed by Dr. and take years for official diagnosis as waitlists for assessments exist
Terminology
There is variation among the ASD community about how to label individuals (person w/ autism vs/ autistic person) Ask their preference!
Also diagnosed as Asperger Syndrome and Pervasive Developmental Disorder
Strengths-based Approach: Shifts away from focusing on deficits, utilizes strengths and interests of child to develop emerging skills that are meaningful to the child & family
Part C covers birth-36mos. For eligibility, child must have 25% delay or show 1.5 SD below his/her age in one or more developmental areas. A child may also be eligible if he or she has a physical or mental condition known to cause a delay in development.
Part B covers school-aged children, if in EI must have transition plan by 3. At age 16 needs a transition plan post-graduation through IEP.
IDEA
Assessments
Occupational Therapists can perform formal and informal assessments with children who have ASD. The eval consists of a combination of observation, narrative and social assessment. used to better understand how the dx. is impacting their school, home life, and social situations. Assessments are important because OTs deliver valuable information to other involved professionals regarding a child's developmental status, which can inform the diagnosis of ASD. It also informs a plan for intervention.
Selecting
Should choose most relevant tool for the child & their challenges/abilities & setting
Variety of formal & informal assessments addressing multiple domains (sensory, motor, cognition, social etc.) w/ skilled observation & interviews for holistic picture
Non-standardized will provide more flexibility for adaptation and can highlight a child's strengths
Read manual & prepare/practice beforehand
Ensure all material is available
Set up the space for success (minimize distractions, only set out what you need to not overwhelm)
Practice giving clear directions
Make sure implementation is standardized or structured and if not document why it is/isn't
Use clinical reasoning/judgement when substituting testing items
Standardized assessments can be diff. to administer if therapist is unable to adapt conditions of the assessment to suit child’s needs
Implementing
Gives a clear score that can be used to give a picture of where child is in comparison to other children of the same age. This can be helpful information to create tx. plan.
Formal results on standardized assessments are often necessary when applying for funding or services.
Scores can also be used as a baseline for therapy & to show progress.
For a standardized test completed, child will receive at least one standard score & percentile rank based on normed data, some tests have multiple scores in different areas.
Scoring
Interpreting
All data must be synthesized and summarized using clinical reasoning by linking deficits to probable/possible causes
What do the findings mean in both medical and layman's terms?
Determines if child qualifies for services
Reporting
Be mindful of language used when reporting as family members will be reading. Highlight strengths/abilities not only deficits, exclude unnecessary low scoring comparative data (percentile ranks)...could be upsetting to family out of context. Use tables for easy reading.
Look for consistencies which are pervasive across settings & people
Is there a history of trauma to explain any behaviors?
When looking at restricted areas of interest/repetitive behavior, consider level of intensity, frequency & duration and how it interferes with everyday life.
Are social/emotional challenges, rigid patterns of thinking and/or behavior (etc.) affecting engagement in roles/occupations?
??? to guide clinical reasoning
Possible Interventions
Intervention
Focusing on sensory integration and sensory-based strategies.
Emphasizing mental health and wellness.
Implementing emotional development and self-regulation strategies and programs.
Organizing peer groups, social participation, and play activities.
Improving self-care routines to help with daily activities such as bathing, feeding, and grooming.
Working on motor development.
Supporting an adolescent’s transition into adulthood and helping them build skills to enter the workforce.
Using cognitive behavioral approaches to support positive behaviors.
There is no one-size-fits-all intervention
Individuals w/ ASD have unique patterns of difficulties, & strengths, choosing an intervention can be a complex task
Each child’s uniqueness should be considered in planning treatment or choosing an intervention
Each intervention views the treatment of autism from a different perspective & may focus on certain skills more than others
Intervention should have flexibility to meet the needs of each child/family at different times and also be based on scientific evidence
Selecting
What will a day be like for the child?
How will the intervention be adapted to meet each child’s unique needs?
Is this the best intervention for this child given his/her personality, temperament, and needs?
What risks are there to the child’s physical or emotional health?
Does this intervention meet the goals or needs of the family?
Will this intervention fit the family’s lifestyle?
How are families involved in the intervention?
Is there parent training included?
??? About child/family to guide reasoning
What kind of scientific research indicates the intervention is effective? (valid, reliable, generalizeable, replicated in setting)
Does the child share necessary characteristics with those in the research study (e.g. ability, age)?
Check for research articles about this intervention that parents can read
??? About Research to guide reasoning
??? About
Requirements
What equipment, qualifications, training, and knowledge do members of the intervention team have?
What is the involvement of the professionals in the intervention? Interprofessional collaboration?
Who is involved in the intervention on a daily basis? (aids, family)
Dosage protocol for best results?
??? About measuring outcomes
What goals or outcomes do you hope to achieve with this intervention?
How will this intervention help each child function better?
How will each child’s progress (skills and functioning) be evaluated?
Using what measurements & how often?
How will the program be adjusted according to each child’s progress?
Implementing
Entry into EI programs should happen as soon as an autism spectrum diagnosis is seriously considered
Family should be included in the intervention, esp. parent training
Find the "Just Right Challenge" by grading interventions
Evaluating
Ongoing assessment of child’s progress in meeting objectives should occur to further refine treatment plan
Needs of children with ASD will change with age & progress. Assessing progress will help set new goals to ensure progress continues. When child is not progressing, it is important to ask questions to discover why (cont. to ???)
Is approach to the intervention consistent among provider/s?
Do all interventionists have the training, knowledge, & skills for the intervention to succeed?
Would changes to any aspect of the intervention achieve more progress?
Are there significant events or changes in the family life that might be affecting the child’s progress?
Is there enough opportunity for the child to practice new learning?
Does the personality of the therapist/s fit with that of the child?
??? guide clinical reasoning
Goal
Setting
It is important to establish goals w/ specific predicted outcomes before the intervention begins. Goals should serve as the road map during intervention journey. Setting goals provides ways to measure the effectiveness of the intervention.
Goals should be measureable, relevant to child/family/setting, & regularly monitored
Parents play an important and active role in developing the goals for their child
??? to guide clinical reasoning
Is the goal developmentally
appropriate?
Is the goal meaningful to the family? Is the child motivated?
Has the goal been achieved in any setting? Is it achievable in current setting? What extra supports/adaptations could help child achieve goal and are they accepted by the client?
General Outcome Areas
Outcomes
Social Skills: enhances child’s participation in family, community, school activities (e.g. progress from imitation to social initiations & response to adults & peers, & from parallel to interactive play)
Communication: a functional communication system that might include non-verbal communication skills, receptive language, & expressive language
Interacting w/ Environment: increased engagement & flexibility in developmentally appropriate tasks of daily living & play, ability to attend/adapt to environment & respond to an appropriate motivational system
Motor Skills: fine and gross motor skills used for age appropriate functional activities, as needed
Cognition: cognitive skills, including symbolic play and basic concepts, as well as academic skills
Behavior: replacement of problem behaviors with more conventional and appropriate behaviors
Executive Functioning: independent organizational skills & other behaviors that underlie social and academic success
Collaboration
Interprofessional collaboration requires planning & cooperation, it also potentially enables better service coordination and may accelerate learner progress. Clinicians from each discipline bring their unique expertise and perspectives to develop a comprehensive approach to effectively address each child’s challenges. Consistency across treatments will maximize outcomes. Important to be cognizant of what services are already being provided by other professionals to not overlap services while also promoting the use of skills being developed in other therapies. Members of the team include:
Child
Family/Caregiver
Physician
Psychologist
Psychiatrist
Social Worker
Teachers/tutors
School Counselor/SPED Personnel
Physical Therapist
Speech Language Pathologist
ABA teacher
Evidence
Based
Practice
Instructional/intervention for which researchers have provided an acceptable level of research that shows the practice produces positive outcomes for children, youth, and/or adults with ASD
Autism Focused Intervention and Resources Modules (AFIRM) provides free modules designed to help learn process of planning for, using, and monitoring EBP for ASD from birth to 22 yrs old.
National Professional Developmental Center for Autism provides information for EBP
Parents may want to try a tx. not backed by evidence, communicate openly but remain supportive of the family and be willing to try what the family wants as long as there is no risk to the child.
Stay up to date w/ new and emerging practices by reviewing the literature and staying informed through AOTA
Sources of Evidence
Literature/Research
Textbooks
The child is an expert of his/her experience
Parents/caregivers/teachers may be experts of the child
Mentors who have experience and knowledge in the area