Occupational therapist (OT) work with many individuals with varies mental illnesses and injuries through therapeutic interventions of everyday activities. They help patients develop, recover, improve, and maintain skills that are needed for daily living and working. Overall, helping them achieve a fulfilled and satisfied state of life. While OT’s work with a wide range of people, autism spectrum disorder (ASD) is becoming more prevalent within the past years. It is estimated that in 2007 about every 1 out of 150 individuals will be diagnosed with ASD (Centers for Disease Control and Prevention [CDC], 2007). With the increases in prevalence rate, comes a high need for services and programs that effectively promote and incorporate the participation of individuals with ASD as students, family members, and workers. OT’s are among one of the only professionals that are educated and design interventions to help individuals with ASD accomplished this lifestyle. Therefore, it is important that OT’s get the best evidence-based practice in the literature so they can develop programs and services that can help people with ASD most effectively.
ASD is a developmental disorder that affects communication and behavior. It has an onset that generally appears at around the age of two years old. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a guide used to diagnose mental disorders, they state individuals with ASD have three of these factors.
“Difficulty with communication and interaction with other people, restricted interests and repetitive behaviors, and symptoms that hurt the person’s ability to function properly in school, work, and other areas of life” (DSM).
Communication symptoms can include lack of eye contact, unmatching expressions to what is being said, listening problems, and not understanding others people points of view. While some behavioral symptoms can include sensitivity to light and sound, upset with slight routine changes, echolalia, and overly focused on particular subjects. An individual can be diagnosed with ASD by a doctor looking at the person’s behavior and development. This generally happens in two stages, the first beginning in general developmental screenings during checkups. This is where concerns can be noticed and risk can be assessed for ASD. An example of an individual with high risk may have a family member with ASD or was born with a low birth weight. The second stage is additional evaluation were a team of doctors and other health physicians who are experienced in diagnosing ASD. This team may include a child psychologist, neuropsychologist, and a speech-language pathologist which may even include blood work and hearing tests. This procedure may be more difficult with adults as some of the ASD symptoms may overlap with other mental health disorders. ASD is a complex disorder as it exists around a spectrum because there is wide variation in the type and severity of symptoms people experience. ASD also occurs in all ethnic, racial, and economic groups. It can be a lifelong disorder however, treatments and services can improve a person’s symptoms and ability to function. This is why it is key to understand the most effective interventions in the literature that an OT can implement in their practice as ASD is becoming more prevalent.
The best interventions and programs that help an individual with ASD are the ones that focus on the underlying problems. These interventions focus on the occupational and performance problems of social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. All of the symptoms are predominant characteristics that interfere with participation in schools and community activity. With young children, it is good to focus on enhancing the child’s sensory processing, sensorimotor performance, social–behavioral performance, self-care, and participation in play. This early intervention in these symptoms will help the individual develop cognitively and behavioral as they grow older. In adolescents, it is key to focus on social and behavioral performance, the transition to work, and independence in the community. This intervention will help them establish themselves in the working world as they begin to prosper and think on their own. It is important to understand that every individual is different and each individual falls differently on the spectrum. When implementing interventions and developing programs we can not go down the lift of them. We must incorporate the individual’s goals and their characteristics to develop their own personalized intervention program.
As stated above it is key to focus on sensory-based intervention with younger children diagnosed with ASD. Sensory information is what our body used to take in information from the outside world. This can include hearing, touch, and sight. Sensory-based intervention incorporates techniques such as massaging, brushing, and auditory integration.
“Sensory-based interventions, such as those that provide therapeutic touch, can decrease maladaptive behaviors, reduce hyperactivity, inhibit self-stimulation and stereotypic movements, and improve attention and focus” (Escalona, Field, Singer-Strunck, Cullen, & Hartshorn, 2001; Field et al., 1997).
The most evidenced-based intervention is massaging; when implemented daily it can improve attention and reduce stereotypic sensory behaviors. A study completed by Escalona et al. (2001) compared children with ASD who received massage administered by their parents every night for a month to a comparison group whose parents read to them every night. The children who received massage showed a reduction in hyperactivity, decreased impulsivity, and also an improvement for on-task behaviors. The best approach the therapy is to have a variety of interventions that try to accomplish the same goal. This allows options of interventions that best fit the patient. Auditory integration training (AIT) is another intervention that has some literature that backs it up. With AIT children listen to modulated music through headphones several times a day for an average of 10 or more consecutive days. Edelson et al. (1999) showed positive in a long-term randomized clinical trial; this trial found that participants who received the AIT improved more in aberrant behaviors, sound sensitivity, and eye contact. However, in more recent studies AIT was shown to be inclusive so when using AIT OT’s should closely monitor the patient’s behaviors. The goal of sensory integration intervention is to improve the child’s ability to modulate arousal, resulting in well-organized, adaptive responses. However, more research needs to be completed to show the exact effects.
Development Skilled-Based Programs are another set of interventions that OT’s need to be proficient in when dealing with patients that have ASD. These programs are played based; they use patients peers and focus on the strength of the children. The two main programs that are used are the Denver Model (Rogers & DiLalla, 1991) and Treatment and Education of Autistic and Communication Handicapped Children (TEACCH).
“Programs that emphasize a developmental, play-based approach that emphasizes positive affect, nonverbal communication play, social relationships, and classroom structure have small positive effects” (Rogers, Herbison, Lewis, Pantone, & Rels, 1986)
This intervention is typically used for younger patients and is implemented, hopefully, at the beginning of detection on the diagnosis. They can be found in preschool programs that emphasize on pretend and group play to help social development. While evidence may vary from studies, level II and III studies have shown positive effects.
Skill-Cognitive Training are interventions that are closely related to Developmental Skill-based as they too focus on social skills, however, they are less play based. Skill-Cognitive Training teaches the underlying cultural concepts of social interaction. For example, these could be turn-taking, joint attention, eye contact, and body language. A study showed after 7 months many individuals improved in social problem solving, emotional understanding, and social interactions.
While the use of all these evidence-based interventions are key in rehabilitation and therapy programs with people that have ASD, it is not the only thing. Parent education is a typical and key component not only for OT’s but any practitioners. These parent education programs are designed to meet two goals: The improvement of their child’s performance and the management of their child’s behaviors and decreasing maladaptive behaviors. This is important for parents to learn because it is only possible to be with the therapist a limited amount of times. So it is key for the parents to have the ability to create a consistent home environment for learning and it also helps ease the parents as most often parents want to be involved in their child’s health.
“Parent education about autism and behavior management can improve the parent’s confidence and self-esteem and can The American Journal of Occupational Therapy 423 improve the child’s behavior” (Sofronoff & Farbotko, 2002; Sorfonoff, Leslie, & Brown, 2004).
There is a limit to these training, while we would like the parents to do as much as possible they can not implement interventions themselves. Training parents to implement skill-based interventions has mixed evidence for its effectiveness in promoting the child’s performance. Overall, OT’s us a sensitive family-centered approach, this approach values the family’s priorities and allows members to participate in the intervention as much as possible by providing them with information every step of the way.
As ASD is becoming more and more prevalent each year it is even more important we as practitioners are staying up to date with the most current evidence-based practices that are out. ASD is a social and behavioral disorder interventions such as Developmental-Skill Based Programs and Skill-Cognitive Training focus on the social aspect of the disorder. Targeting the emotional and social interaction aspects on the spectrum of ASD. Sensory-based interventions such as massage and AIT help individuals with their problems of regulating sensory information. These can decrease maladaptive behaviors, reduce hyperactivity, inhibit self-stimulation and stereotypic movements, and improve attention and focus. Rehabilitation and therapy programs of ASD is a transdisciplinary act as it does not only rely on OT’s. We need to be able to talk to other occupations and even implement programs that teach parents how to help their children. We as a whole, coming together, can develop, recover, improve, and maintain skills that are needed for daily living and working in individuals that have ASD.
Audet, L.R., Mann, D.J., & Miller-Kuhaneck, H. (2004). Occupational therapy and speech-language pathology: Collaboration within transdisciplinary teams to improve communication in children with an autism spectrum disorder. In Miller-Kuhaneck, H. (Ed.). Autism: A comprehensive occupational therapy approach (2nd ed.). (pp. 275-307). Bethesda, MD: American Occupational Therapy Association.
Autism Spectrum Disorder. (2018, March). Retrieved April 10, 2019, from https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml
Case-Smith, J., & Arbesman, M. (2008). Evidence-based review of interventions for autism used in or of relevance to occupational therapy. The American Journal of Occupational Therapy, 62(4), 416.h
Edelson, S. M., Arin, D., Bauman, M., Lucas, S. E., Rudy, J. H., Sholar, M., et al. (1999). Auditory integration training: A double-blind study of behavioral and electrophysiological effects in people with autism. Focus on Autism and Other Developmental Disabilities, 14, 73–81.
Escalona,A., Field,T., Singer-Strunck,R.,CullenC., & Hartshorn, K. (2001). Brief report: Improvements in the behavior of children with autism following massagetherapy. Journal of Autism and Developmental Disorders, 31, 513–516.
Field, T., Lasko, D., Mundy, P., Henteleff, T., Kabat, S., Talpins, S., et al. (1997). Brief Report: Autistic children’s attentiveness and responsivity improve after touch therapy. Journal of Autism and Developmental Disorders, 27, 333–338.
Rogers, S. J., & DiLalla, D. L. (1991). A comparative study of the effects of a developmentally based instructional model on young children with autism and young children with other disorders of behavior and development. Topics in Early Childhood Special Education, 11(2), 29–47.