OCCUPATIONAL THERAPY: AN EFFECTIVE TREATMENT FOR AUTISM SPECTRUM DISORDERS INTRODUCTION Hardly a week passes these days, without

an article appearing in the media about Autism. Magazines, newspapers and television documentaries tell the stories of families dealing with Autism or provide information about new developments in brain research and early diagnosis. But how is the family of a child with an Autism Spectrum Diagnosis (ASD) to evaluate these articles or documentaries, since they have usually not undergone rigorous professional peer evaluation? Is all the information correct and unbiased and if not, how would a parent know? Rarely do these articles address what a family should do once they receive a diagnosis and if they do, the role of occupational therapy is never mentioned. In Canada, one in 165 children are thought to have Autism or an Autism Spectrum Disorder and while this figure is alarming it is consistent with current figures released from the US, Japan, France and the UK. In California, though there is some encouraging news suggesting that the recent autism epidemic may be on the decline. Autism and autistic spectrum disorders (included in the DSM-IV under the category of Pervasive Developmental Disorders) are lifelong neurodevelopmental disorders that affect an individuals ability to communicate and socialize effectively. It is called a spectrum disorder as symptoms can vary from mild to severe and the problem behaviours observed are as unique and individualized as the children themselves. Some children with ASD appear normal, have an average IQ but struggle in subtle ways with communication, while others cannot speak at all and may have a low IQ. What may not be clear to all families, when they read articles or see documentaries in the media, is that there is no cure for Autism. Researchers have not identified the cause or causes of the disorder and, as a result, no etiology-based treatment has been developed. Treatment, therefore, should be approached as a way to alleviate symptoms and help the child function better in the environment. Both parents and the professionals who work with these children, therefore, must carefully consider treatment options, once a diagnosis has been given because although children with ASD may have a similar diagnosis and sometimes even similar symptoms, each child is unique and needs an individualized approach. Professional practitioners and parents are urged to use evidence-based interventions but where to start? A recent review of some widely used interventions with ASD concludes that while some, particularly the behavioural techniques, do have empirical support, there is actually no consistent evidence favouring any one approach over another. Families must, therefore, use their own judgment and look for professionals who have appropriate training and expertise in the field. Early Intervention and Best Practices Guidelines in British Columbia recommend a comprehensive approach to treatment of these children that includes functional assessment and the use of multiple integrated therapies such as speech-language pathology, occupational therapy and physiotherapy as well as positive behaviour support techniques.

ROLE OF OCCUPATIONAL THERAPY So how exactly can an occupational therapist help? Children with ASD all have language deficits of one form or another but many of them, if not all, also demonstrate difficulties with sensory and motor regulation and could benefit from the intervention of a skilled occupational therapist. Problems with sensory regulation is now generally referred to as sensory modulation and has been identified in children with Fragile X Syndrome, Autistic Disorder, ADHD and can occur on its own, when it is called Sensory Modulation Dysfunction SMD. SMD includes both physiological reactions and behaviour responses and refers to the childs ability to regulate and organize his or her responses so they are appropriate to the situation demands. Problems with motor coordination are present in many disabilities, but a majority of children with ASD also experience delays in this area. ASSESSMENT Occupational therapy services typically begin with evaluation. A client-centered approach is used and the objective is to identify the clients most pressing concerns and personal strengths and deficits as they relate to the environments in which the child must function. Following assessment a plan of support and intervention can be formulated that addresses the specific deficits and supports the identified strengths. Children with ASD have a wide range of abilities and evaluation requires individualized attention. Assessing these children can be difficult if they do not have language skills, are unable to follow instructions or have significant sensory issues. Evaluation includes two steps: the occupational profile (for what purpose is the evaluation being done) and an analysis of occupational performance of the child (current performance skills at home, school, social participation, play and leisure). The type of assessment tools chosen also includes consideration of the childs age, language ability and whether he or she can follow instructions. Standardized measures, particularly norm-referenced tools, may not be appropriate with an ASD child, in which case the occupational therapist may use a combination of parent interview and standardized questionnaires. Parents regularly report difficulties with independence in dressing, rigid ideas about food, disruption at meal times, discomfort with many personal hygiene tasks, extreme difficulty with toilet training, reluctance to help with household chores and the need for constant supervision, for safety reasons. Current research suggests that children with an ASD experience more difficulties with basic and skilled motor activities than their typically developing peers. In school they may struggle with writing, establishing handedness, during PE and on the playground, as well as with following the normal daily school routine. Emotional outbursts are common. Their play and social skills are often considerably restricted. During an OT evaluation additional client factors may also be addressed, depending on the client and the presenting problems. These include areas of mental function such as sleep, attention, memory and perception; sensory function such as hearing, vision, smell, taste and proprioception; and neuro-muscular and movement

related functions such as the mobility and stability of joints, strength, muscle tone, reflexes and control of voluntary movement. Although the DSM-IV criterion for diagnosis of Autistic Disorder does not yet include sensory modulation dysfunction, difficulties in this area are extremely common in these children. Parents frequently report specific problems with tooth brushing, bathing and preference for specific colour or texture of fabrics. The child may exhibit unusual and very specific food preferences or only eat foods of certain texture, colour or taste. Loud, unexpected noises can be terrifying resulting in hyper-vigilance for potentially troublesome sounds. Constant sensory seeking behaviours and high levels of activity are often reported or seemingly obsessive needs for intense movement or repetitive behaviours like rocking, spinning or arm flapping. Occupational therapists who work with these children can examine all aspects of sensory processing with the family to determine which areas are typical and which are not. Once a comprehensive evaluation has been completed the information is analyzed and a plan of support and intervention is developed. INTERVENTION Occupational therapists have been working with children with Autistic Disorders for more than 40 years. Intervention with these children includes consultation as well as direct treatment models and the skilled occupational therapist will draw on different frames of reference to guide the intervention approach, dependent upon each child and his or her unique presentation of symptoms. Occupational therapists are uniquely trained to address the sensory and motor deficits that these children experience. Clinical occupational therapists are urged to use evidence-based interventions. At the end of this article a number of very useful texts, written by the experts in the field, are referenced which underwrite the efficacy of what occupational therapists, do. Sensory Integration: Dr. A Jean Ayres applied her theory of sensory integration to a variety of diagnostic groups including those with ASDs during the 1970s and clearly described the sensory disorders accompanying Autistic Disorder. These children frequently show early signs of deficits in sensory modulation (SMD), which can be seen as sensory defensiveness, under-responsiveness, gravitational insecurity or aversive responses to movement. Sensory defensiveness is the most common of the four and children who experience sensory defensiveness tend to respond negatively to normal sensations that other people consider harmless. Sensory defensive behaviours can be very challenging for family and friends, teachers and therapists as they result in fight, flight, and fear or freeze behaviours. Known more commonly as the 4Fs, these behaviours are also often much more pronounced in situations where there are additional motor, cognitive or social demands, such as school, birthday parties or PE. Increased activity level, gaze aversion, clowning around, pulling away, verbalizations (Im tired or This is stupid), crying, refusal or reluctance to try new things, angry outbursts (verbal or physical) and self-mutilation are examples of behaviours that fall into one of the 4F categories.

Because children with ASDs frequently present with disorders of sensory modulation, it is hard to imagine a comprehensive treatment plan that does not include sensory integration. This is because SI is gentle, child lead and provides an ideal way to develop the initial rapport and trust, which is so critical to successful treatment. Sensory integration is considered by some professions to be an alternative treatment but is used in the field of occupational therapy to describe both a theory to guide practice and a specific intervention approach. To be considered as classical sensory integration, treatment must meet some key principles and these differentiate SI from other types intervention used by occupational therapists. Classic SI includes: Evaluating and modifying the sensory environment Focusing on integrating tactile, proprioceptive and vestibular sensations Treatment in the context of play Active participation by the child Child-lead interactions Artful vigilance on the part of the therapist The Just right challenge Eliciting the adaptive response Tapping the inner drive of the child, with the childs engagement in the activity becoming its own reward. Classical sensory integration can really only be done effectively in a specialized setting, since it requires space and the use of suspended equipment. As such, it does not lend itself easily to the consultative model or the home, although it can be modified, if needed. The SI trained occupational therapist hypothesizes that neurological issues underlie problem behaviours and affect how the child experiences events during daily life. Therapy is directed at the level where the child can be successful, with the premise that the child intuitively knows what his or her body needs. Sensory integration facilitates ideation in play, encourages flexibility and adaptability and provides the child with consistent cues for understanding. With intervention embedded in play, sensory integration includes activities that are intrinsically rewarding and motivating for the child, and provides sensory experiences, which result in an adaptive response. In Canada, the occupational therapy community has, historically, viewed sensory integration with skepticism. This is because although many studies exist suggesting that the intervention is effective and the anecdotal evidence is overwhelming, there are also studies that suggest it does not work. Occupational therapists, specializing in SI, are the first to acknowledge that the research to date has had serious limitations but suggest there is not enough empirical data to come to any valid conclusions about its effectiveness. Based in the social sciences, the foundations for developing sophisticated, randomized clinical trials for sensory integration are still being developed and empirical data is yet to come. Lack of data supporting the effectiveness of SI does not mean it is ineffective and outright condemnation by both occupational therapists, who are not working in the field of Autism, and other professionals, is premature. In addition, most families cannot wait for definitive research evidence, before they start treatment they want help now.

Complementary sensory treatments Sensory defensiveness may have to be addressed first when a child presents with severe symptoms. Over-reaction to touch or tactile experiences may result in avoiding touch from others, dislike of crowds, irritation when having hair washed, refusal to bathe or have hair cut, avoidance of certain types of clothing and many other similar reactions. Treatment of these types of problems may include teaching the family the Wilbarger Deep Pressure and Proprioception Protocol. A review of recent research suggests, certainly on a case-by-case basis, there is emerging evidence to support the use of the protocol (DPPP) for individuals who present with over-responsiveness to non-noxious environmental stimuli. Oral defensiveness is seen frequently in children with ASD. Families describe avoidance of certain types or textures of food and dislike of things in and around the mouth, sometimes resulting in gagging or vomiting. One mother described her childs food preferences as a white and brown diet, which was totally devoid of fruit and vegetables. This is very common. Over-reaction to household smells such as shampoo, avoidance of tooth brushing and going to the dentist can also be signs of oral defensiveness and it is not unusual for parents of children with ASD to clean their teeth while they are sleeping. Often these children have to be admitted to hospital for major dental work, which is done under general anesthetic. The Wilbarger Oral Motor Protocol can be taught to the family to address these issues and can be extremely valuable. The Wilbarger Protocols are considered to be complementary or alternative treatments, within the scope of practice of occupational therapy. They should be used carefully, must always be taught by a trained therapist and only implemented within the broader context of ongoing occupational therapy intervention and a sensory diet. Motor coordination, praxis and play When compared to the other difficulties that a child with ASD is experiencing, motor coordination is often seen to be an area of relative strength. However, research suggests that these children, in fact, have more difficulty with their motor skills than do their typically developing peers. Frequently observed deficits include toe walking, gait disturbances, lack of hand dominance, slower motor performance and weakness of grasp, clumsiness and general motor impairment in such areas as manual dexterity, ball skills and static and dynamic balance. In a recent study of 6-8 year old children with autism, 75% were found to have a fundamental motor skill delay, which highlights the importance of examining the motor function of these children. Further examination often reveals that the childs neurological systems are also immature, with deficits in bilateral integration, reflexes, midline crossing, core strength, muscle tone and joint mobility. These children require early intervention and support to both develop ageappropriate skills and learn strategies to compensate for their coordination difficulties. Studies on children with Developmental Coordination Disorder (DCD), a motor skill disorder that interferes with a childs ability to perform many daily tasks, indicates that children with DCD can learn specific skills but still struggle with new motor skills. Children with ASD demonstrate similar motor difficulties to children with DCD and the current research indicates high levels of co-morbidity between the two diagnoses. In

other words, a high-functioning child with an ASD is also highly likely to have significantly poor underlying motor coordination. This is seen in delays in learning to do up small fasteners, use a knife, tie shoelaces, and ride a bicycle and slow, laborious, untidy writing. Occupational therapists think of play as a childs work since it is how they learn about themselves and the world around them. Play is such an integral part of childhood that improving play skills is often a primary goal of intervention with children with developmental delays. Play is also an important lifelong occupation and a very powerful tool for intervention. Children with ASD invariably demonstrate inadequate play skills. They are often attracted to objects because of a particular quality the object has, rather than for what they can do with that object in play. They demonstrate limited ideation, poor imitation skills, problems with social interaction and social language and inability to plan and execute the motor skills required for play. During therapy, occupational therapists engage in play with their clients in order to improve motor coordination, build skills and develop praxis, the ability to think, plan and do. Challenging the child to create ideas and formulate new plans in an integral part of therapy. Children who are non-verbal can be encouraged to be more creative when the environment is arranged so that it requires innovation. This could be as simple as covering the floor with obstacles and mats that must be negotiated or introducing familiar games such as tag or hide and seek to encourage motor planning and interaction with the therapist. Verbal children, once they trust the therapist, can be encouraged, with more guidance to increase their repertoire of activities and practice skills, while playing, that are needed during their daily lives. In a clinic setting there is also the opportunity for incidental peer modeling. Children in therapy may observe another child playing on a particular piece of equipment and be motivated to copy or play alongside. Speech, language and Social Interaction Occupational therapists and SLPs share a common interest in developing functional social communication but the needs of verbal and non-verbal children on the spectrum are very different and it is important for professionals to work together as interdisciplinary collaborative teams. During treatment the occupational therapist will talk to the child, give them directions and participate in imaginary play. During this interaction the therapist may become aware of possible underlying difficulties that may not have been noticed by the family or school. Referral to specialists, such as an audiologist, to confirm or rule out Hypercussis or Central Auditory Processing Disorder may be appropriate. Normal children experience difficulties with social skills, throughout their school careers. However, as they mature they are able to learn the social cues that guide interactions and react accordingly. Children with an ASD have trouble noticing the social nuances of successful interaction and are frequently unable to grasp the informal and sometimes formal rules of social communication. Assessing the social skills of children at home, school and in the community is not yet a routine part of an OT evaluation. Also there has been a recent trend for OTs to move away from the holistic practice of

intervention to that of addressing more discrete skills. However, the social skills that a child needs in order to cope with the demands of daily life can be addressed by occupational therapy intervention. Occupational therapists, working to develop social skills use a range on interventions including activity based social groups. It is important to note the resources are very limited and the therapists providing these services are often overwhelmed. In conclusion, occupational therapists are university-educated professionals who are licensed in each province across Canada and guided in their practice by a Code of Ethics. They have a unique set of skills that includes knowledge of anatomy, neuroantomy, psychology, child development and the grading of activities. Their approach to treatment is holistic, client centered and functional. The diagnosis of ASD includes a variety of disorders that affect functioning and skills development in multiple domains many of which can be addressed by occupational therapy. A myriad of treatment approaches can be used with these clients but best practice intervention by an expert occupational therapist is an evidence-based, global approach where the therapist seamlessly integrates different frames of reference dependent on the childs constantly changing needs. Occupational therapists also understand the need for collaboration between professionals and actively promote this team approach to intervention. REFERENCES: Bundy, A & Murray, E. (2002). Sensory Integration: A. Jean Ayres theory revisited in A. Bundy, S. Lane & E. Murray (Eds), in Sensory integration: Theory and practice (2nd ed. pp.3-33) Philadelphia; F. A. Davis Berkeley, S.L., Zittel, L.L., Pittney, L.V., & Nichols, S.E. (2001). Locomotor and object control skills in children diagnosed with autism. Adapted Physical Activity Quarterly, 18, 405-416 Early Intensive Intervention, Best Practices, BC Ministry of Health Guidelines. Eide, B. and Eide, F. (2006). The Mislabeled Child. Hyperion, New York. Francis, K. (2005) Autism interventions: a critical update. Developmental Medicine & Child Neurology, 47: 493-499. Frolek Clark, G, Miller-Kuhaneck,H & Watling, H (2004) Evaluation of the child with an Autism Spectrum Disorder. In Miller-Kuhaneck (Ed) Autism pp107-141. AOTA Press. Lemer, P S (2006) How recent changes have contributed to an epidemic of Autism Spectrum Disorders. Journal of Behavioural Optometry vol. 17, 2006 Number 3/p 72 Miller-Kuhaneck, H (Ed) (2004) Autism, A comprehensive occupational therapy approach, 2nd Edition. American Occupational Therapy Association, Inc.

Miller, L.J. (2003.) Empirical Evidence related to Therapies for Sensory Processing Impairments. Miller, L.J., & Lane, S.J. (2000). Towards a consensus in terminology in Sensory Integration theory and practice: Part 1 Taxonomy of neurophysiological processes. Sensory Integration Special Interest Section, 23(1), 1-4 Missiuna, C, (2003). Children with Developmental Coordination Disorder, At Home and in the Classroom. CanChild, Centre for Childhood Disability Research. Occupational Therapy Practice Framework: Domain and Process by American Occupational Therapy Association (2002), American Journal of Occupational Therapy, 56, p.611. Copyright 2002 by AOTA Smith Roley, S., Imperatore Blanche, E. & Schaaf, R.C. (Eds) 2001. Understanding the Nature of Sensory Integration with Diverse Populations. Therapy Skill Builders, Harcourt Health Sciences Co. Trecker, A. & Miller-Kuhaneck, H. (2004). Play and Praxis in Children with an Autism Spectrum Disorder. In Miller-Kuhaneck (Ed) Autism pp 193-211. AOTA Press. Fass A., Swinth,Y., McGruder J. & Tomlin G (2003). Sensory Modulation Dysfunction and the Wilbarger Protocol: An Evidence Review. AOTA Continuing Education article December 2006 About the author: Jane Remocker, BSROT has been an occupational therapist for nearly 40 years. She graduated in the UK and as a young OT worked in adult mental health. Going back to University in the 1980s she developed an interest in paediatrics, research and sensory integration. She has been in private practice in Vancouver for 15 years and now is the Director of a successful, but small group practice. The clinic uses sensory integration as part of its approach to treatment and sees an average of 60 children a week. More than half of these children have an ASD.