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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 individual’s 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.

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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 child’s 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 client’s 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 child’s 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

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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 1970’s 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 4F’s,

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

(“I’m 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.

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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 child’s 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.

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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 child’s

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 child’s 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 age-

appropriate 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 child’s 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

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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 child’s 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 SLP’s 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 inter-

disciplinary 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

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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 child’s 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.

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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 1980’s 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.