Transcript Occupational Therapy and its role in treating children

Occupational and Speech
Therapy: Treating children with
ASD
Emily Rasco, OTR
Mindy Granberry, MA, CCC-SLP
June 12, 2010
Pediatric Speech Language
Pathologists:
• Evaluate and treat children for speech, language,
cognitive, social communication and feeding or
swallowing deficits.
• American Speech Language and Hearing
Association (www.ASHA.org)
Autism: Implications for
Language Intervention
• Therapy attempts to adapt input and support
output to accommodate information-processing
differences.
• Therapists’ call is to determine specific
information-processing limits, interferences with
learning, and most helpful input/output
modalities for each individual with ASD.
Williams, D. & Minshew, N. (2010, April 27)
Speech-Language
Evaluation
• Standardized assessments:
- Language assessments (e.g. Preschool Language Scales – 4th Edition,
Clinical Evaluation of Language Fundemantals, etc.)
- Pragmatics/Social interaction (Communication Symbolic Behavior
Scales)
- Speech/articulation/oral motor (e.g. Goldman-Fristoe Test of
Articulation-2)
• Clinical Observation
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Spontaneous Language Use (language sampling)
Spontaneous Speech Use (speech sampling)
Verbal and nonverbal communication assessment
Joint attention, eye contact, reciprocity, turn taking, initiation
Language-based cognition: play skills, problem solving
Evaluation cont.
• Parent Interview
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Behavior
Play
Social Relationships
Checklists of behaviors/language observed at home
• Goal setting
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Developmental
Short term goals
Long term goals
Treatment Models
• Individualized sessions
• Group Therapy
• Co-treatments
Treatment Overview
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Social Communication
Speech
Language
Language-based cognition
Play skills
Social Communication
• For children with ASD, challenges in orienting to
social stimuli and acquiring joint attention skills
are evident from a very early age and provide
barriers to the development of early
communicative intent, social functions of
communication, and language acquisition.
ASHA, 2006
Hierarchy of Social Communication
Goals – Floortime Approach
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Attention
Engagement
Intentionality
Initiation
Circle of communication
Problem solving
Generalization
Greenspan & Wieder, 2006
Social Communication Treatment
• “Because difficulty with attention and
engagement are the first core deficits of autism,
working with the child on these should be the
first goal of parents, educators, and other
caregivers.” (Greenspan & Wieder, 2006)
Social Communication
Treatment - Attention
• Joint attention
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social orienting
recognizing another’s visual line of regard
establishing shared attention
monitoring emotional states
considering another’s intentions
ASHA, 2006
Social Communication
Treatment - Attention
• Attend to the child’s
• Slow down and observe where their attention
• Why?
• Guide them into a more functional task
Social Communication
Treatment - Engagement
• Engagement: “entering the child’s world and
helping her enter into a shared world with
others.”
• social and emotional development
• self-regulation
• purpose or direction in actions
• leads to shared problem solving
Greenspan & Wieder, 2006
Social Communication
Treatment - Engagement
• Join
• Observe
• Attend
• Follow
• Respond
• Distress?
• Relevant toys
Greenspan & Wieder, 2006
Social Communication Treatment Intentionality, Initiation, Social
Reciprocity
• Intentionality
• Initiation: Initiating bids for interaction
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Maintaining interactions by taking turns
Providing appropriate responses to communication initiated by others
• Circle of communication:
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Child initiates/Caregiver initiates
Caregiver responds/Child responds
Child responds/Caregiver responds
Greenspan & Wieder, 2006
Social Communication
Treatment – Problem Solving
• Small changes to the play interactions.
• Communication and language intentionally to seek
emotional responses from others
• Gauge social impact
ASHA, 2006
Social Communication Treatment
• Social Stories
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Needs based
Visual picture story
How event “should” go
Review story
Execute story
• Group therapy
• Practice for success
• Generalizations of skills
Speech
• Speech: the faculty of expressing thought by
spoken words or sound symbols that are
understood by another.
• Speech Disorder: unacceptable variations from
the common form of speech creating negative
impressions on the listener, lowered intelligibility,
and personal disturbance in the speaker.
Palmer & Yantis, 1990
Speech
• Approximately one-third to one-half of individuals
with ASD present with significant difficulty using
speech as a functional and effective means of
communication.
Speech Disorders
• Articulation
• Delays in developmental acquisition of sounds (common
in ASD)
• Phonology: the rules and customs of phoneme use
• Apraxia/Dyspraxia of speech: a disturbance in normal
volitional muscle movement patterns (common in ASD)
• Fluency and prosody
Palmer & Yantis, 1990; ASHA, 2006
Speech: Treatment
• Speech analysis
• Target errors
• Therapy techniques
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auditory bombardment
modeling
imitation
tactile cues
• Therapy
– structured tasks
– free play
Speech Treatment
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Single sound production
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Consonant-vowel (syllable shape)
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Increase complexity of syllable shapes
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Transference to meaningful words
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Words in sentences
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Multi-sentence production
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Conversational speech
Language
• Language and related cognitive skills: underlying
capacity to symbolize and learn a rule-governed
system, enable an individual to request, protest,
share experiences, and exchange ideas with
others through modalities of communication that
have shared meanings.
• Language Disorder: a problem involving the
linguistic aspects of oral communication.
Meaning, communicative intent, and linguistic
code of an utterance may not be conveyed
successfully.
Palmer & Yantis, 1990; ASHA, 2006
Language
• Receptive Language: the understanding of
spoken or written messages
• Expressive Language: communication through
spoken or written form, or other forms
• Verbal and Nonverbal
Language
• Children with ASD’s ability to recall detail
information (often non-relevant) is really a failure
to form schemata or paradigms spontaneously to
organize information into categories that make
information meaningful.
• Language in ASD often involves holistic storage
of information with a failure of analysis and
integration.
• Most children with ASD capable of verbal
communication but significantly limited for some.
Williams, D. & Minshew, N. (2010, April 27)
Language
• It is common for children with ASD to develop
problem behaviors to communicate (e.g.,
screeching, hitting, and/or fleeing from an
undesired activity) in lieu of acquiring more
conventional gestures or symbolic communication
as effective strategies for protesting, exerting
social control, and emotional regulation.
ASHA, 2006
Language Treatment
Children with ASD:
• Limited range of conventional gestures (showing, waving,
pointing, shaking head) and vocalizations in early stages of
communication development.
• A reliance on presymbolic gestures (leading, pulling
another’s hand)
ASHA, 2006
Language Treatment
• Language therapy with nonverbal children may
include teaching of conventional gestures to:
• Help get basic needs met
• Expand underlying cognitive concepts of symbolic
communication which is required for meaningful word
development
Language Treatment - Picture
Exchange Communication (PECS)
Language Treatment
• Children with ASD may have difficulty with any
component of language development:
• Semantics: system of meaning
• Morphology: rules of word formation
• Syntax: rules of sentence formation
• Pragmatics: use of language
• Literacy
Language Treatment Semantics
• Children with ASD:
• Restricted semantic development and difficulties with
development of more creative and generative language
• Emerging language: often limited to nouns or object
labels
• Delays in developing word form referents other than
nouns: action words, modifiers, and relational words.
ASHA, 2006
Language Treatment Semantics
• Total vocabulary
• Variety of classes word forms
• Semantic roles
• Multi-word relations
• Wh- questions (What? Where? Why? When?)
• Use of conjunctions
Language Treatment Morphology
• Children with ASD may hear a word or “chunk” of
language and associate it with a specific
experience or event rather than understanding
the conventional meaning of a word or phrase
and how it may be applicable across similar
contexts. ASHA, 2006.
• Children with ASD may have difficulty
understanding and using morphemes (smallest
units of language that carry meaning).
Language Treatment Morphology
• Morphemes:
• plurals (e.g. dogs)
• possessives (e.g. “the dog’s”)
• verb tenses (e.g. “the dog jumped", “the dog is
jumping”)
• verb contractions (e.g. “it’s”, “he’s”)
Language Treatment Syntax
• Grammatical concepts:
• modulation of simple sentences (e.g. verb tensing:
present, past, future, regular vs irregular; subject-verb
agreement)
• embedded and complex sentences (e.g. prepositional
clauses, infinitives)
Language - Pragmatics
• Using Language
• Changing Language
• Following Rules for conversation
www.asha.org
Language Treatment Pragmatics
• Using language for different purposes
• greeting (e.g., hello, goodbye)
• informing (e.g., I'm going to get a cookie)
• demanding (e.g., Give me a cookie)
• promising (e.g., I'm going to get you a cookie)
• requesting (e.g., I would like a cookie, please)
www.asha.org
Language Treatment Pragmatics
• Changing language according to the needs of a
listener or situation:
• talking differently to a baby than to an adult
• giving background information to an unfamiliar listener
• speaking differently in a classroom than on a playground
www.asha.org
Language Treatment Pragmatics
• Following rules for conversations and storytelling:
• taking turns in conversation
• introducing topics of conversation
• staying on topic
• rephrasing when misunderstood
• how to use verbal and nonverbal signals
• how close to stand to someone when speaking
• how to use facial expressions and eye contact
www.asha.org
Language - Literacy
• Due to strengths in visuospatial perception and
rote episodic associations, individuals with ASD
may learn phonological rules and detect patterns
in words, thereby allowing for the acquisition of a
sight word vocabulary, often without
comprehension of the printed words: hyperlexia.
ASHA, 2006
Language Treatment Literacy
• Language therapy may address:
• Figurative language
• Mental states in written narratives
• Varying grammatical forms to clarify their intentions to
an unfamiliar reader
• Inferences
ASHA, 2006
Cognition: Language-based
• Impact across cognitive domains including
• difficulty managing complex information
• difficulty deriving new problem-solving strategies within novel
situations.
• manifested in day-to-day functioning
ASHA, 2006
Cognition: Language-based
treatment
• Functional and symbolic play
• Problem solving in play
• Formulation of thoughts or ideas
• Executive functions
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Planning
Preparing
Executing
Negotiating
Treatment Modalities
• Relevant information obvious/explicit.
• Words paired with environmental referent
• Large number of examples
• Extreme examples for abstract concepts.
• Limit amount of information
Williams, D. & Minshew, N. (2010, April 27)
Treatment Modalities
• Platform of routine/structure
• Multimodality input:
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Visual: picture schedules and cues
Tactile: sensory input based on child’s needs
Auditory: concrete; repetition
• Structured tasks and free play
• Behavioral considerations
Treatment Modalities
Treatment Modalities
Augmentative/Assistive
Communication
Overview
• What is Occupational Therapy?
• Occupational therapy services focus on enhancing
participation in and performance of activities of daily
living (ex. Feeding, dressing), instrumental activities of
daily living, education, work, leisure, play and social
participation.
Evaluation
• Occupational therapy evaluation includes:
• Standardized assessments
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Peabody Developmental Motor Scales – 2nd ed.
Bruinnicks – Oseretsky Test of Motor Proficiency – 2nd ed.
Sensory Profile Caregiver Questionnaire
Beery VMI
• Clinical Observation
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Functional Play
Sensory Processing
Engagement
Evaluation cont.
• Parent Interview
• Self Care Skills
• Behavior
• Social Relationships
Treatment Overview
• Sensory Integration
• Play Skills
• Self Care
Sensory Integration
• Sensory Integration is defined as “the process by
which people register, modulate, and discriminate
sensations received through the sensory system
to produce purposeful, adaptive behaviors in
response to the environment” (Ayres, 2005)
Sensory Integration
• According to research findings it is estimated that
the rate of sensory processing dysfunction may
be as high as 90% in individuals with Autism
Spectrum Disorder. (Baraneck et al., 2006)
Sensory Integration
• Children with ASD can often have deficits in the
following:
• Sensory registration – the way a child's awareness of
sensory stimuli is associated with attaching meaning to
situation. (Kuhaneck-Miller, 2004).
• Sensory modulation – the interaction between internal
processing and the external environment.
Sensory Integration
• Children with ASD can often have deficits in the
following:
• Sensory perception – Being able to discriminate between
sensory stimuli.
• Praxis – the ability to do.
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“ A uniquely human skill requiring conscious thought and enabling
the brain to conceptualize, organize and direct purposeful
interaction with the environment.” (Ayres, Mailloux, & Wendler,
1987, p. 94).
Sensory Integration
• When children are not adequately registering,
modulating and perceiving their sensory
environment it limits their ability in these areas:
• attend to tasks
• perform coordinated motor actions
• plan and sequence tasks
• manage demands of the classroom
• perform self care tasks
• participate in family activities
Sensory Integration – Goals
of treatment
• Improve adaptive responses of sensory input
• Develop postural responses and proprioception
• Develop praxis
• Improve cognitive skills, language acquisition and
academic achievement
• Improve social-emotional skills
Sensory Integration Treatment
• Focused sensory environment and activities
including those that highlight the proprioceptive,
vestibular and tactile sensory systems.
• Focused on regulating the sensory system in
order to achieve increased attention, organization
of behavior and motor planning.
Sensory Integration Treatment
• Sensory diet
• “Feeds” the underlying sensory needs of the child
Sensory Integration Treatment
• Wilbarger Protocol
• Focuses on treating the touch and proprioceptive
systems – decreases tactile defensiveness and can assist
in self-regulation
Sensory Integration Treatment
• Repetitive or negative behaviors
• Incorporate new and more appropriate behaviors that
continue to meet the child’s needs
• Transitions
• Add sensory activities
• Create a schedule/routine
• Educate parents
Sensory Integration Treatment
• Accommodations for School
• Adding extra movement breaks
• Fidget toys
• Shortening assignments
• One to one attention
Play Skills
• Functional use of objects
• Using play skills to develop praxis
Play Skills
• Functional use of objects
• Demonstrate difficulty interacting appropriately
with individuals and their environment
• Tend to play with objects that have a specific
sensorimotor property and character toys
Play Skills
• Developing praxis
• Praxis goes beyond to include the act of thinking about
doing rather than acting
Play Skills
• “A disorder in the drive to engage, coupled with
poor imitation and deficits in sensory processing,
creates a high likelihood for poor praxis abilities
(Kuhaneck-Miller, 2004).
Play Skills
• “Children lacking adequate ideation do not
recognize the potential play possibilities of
therapeutic equipment, lacking concepts for
complex body-environment interaction, they
tend to use equipment in a simplified way”
(Ayres, 1985)
Play Skills
• Activities that are motivating and challenging
• Used to increase engagement, interaction and
allow praxis to emerge.
Play Skills
• Imitation
• Acts as a building block for conceptualizing ideas and for
effective motor plans.
• Facilitates new learning
Self Care
• Studies suggest that due to decreased motor
planning and sensory processing deficits, children
with ASD often have difficulty performing self
care activities. (Kuhaneck-Miller, 2004).
Self Care -Treatment
• Dressing
• Putting on and taking off clothing
• Adapting clothing
• Grooming
• Building routines
• Adapting activities
Self Care
• Feeding
• Establishing diets
• Oral Hyposensitivity - overstuffing
• Using Utensils, including cups
Self Care
• Toileting
• Readiness for toilet training
• Sensation of “having to go”
• Establishing a routine
Tools for Parents
• Become a team member with your therapists:
observe and implement strategies at home
• Provide structure using picture schedules and
social stories
• Within structure, meet child at current level and
providing modeling to next level
• Model simple, concrete language: use repetition
Tools for Parents, cont’d.
• Require some type of response to get needs met
(providing model if needed)
• Make social markers obvious (eye contact, taking
turns)
• Provide sensory activities throughout the day to
assist in maintaining an appropriate arousal level.
• Imitate the child and allow opportunities for the
child to imitate you.
Tools for Parents, cont’d.
• Provide appropriate assistance to allow success
• Provide opportunities for turn taking
• Be interested in what the child is doing; if
necessary, “get into his world.”
• Set up environments that are attractive to the
child and invite interaction.
ST and OT Outcomes
• Maximal independence in communication in
academic and social settings
• Functional social skills to participate in group
oriented activities
• Independence in self care
• Being able to self regulate and modulate sensory
information to more successfully interact in one’s
environment
How to refer a pt for ST/OT
• Who would benefit from a referral: Children aged
18 months to 18 years
• Concerns with delays in speech, language, social
interaction, sensory processing, self care, fine and visual
motor skills
• Types of facilities:
• Hospital based, private practice, school programs, ECI,
Home health
Early Intervention
• Effective interventions for children with ASD are
characterized by early intervention, intensive
instruction, and individualized objectives.
National Research Council (2001)
References
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American Speech-Language-Hearing Association (2006). Principles for
Speech-Language Pathologists in Diagnosis, Assessment, and Treatment
of Autism Spectrum Disorders Across the Life Span [Technical Report].
Available from www.asha.org/policy.
Ayres, A.J. (1985). Developmental Dyspraxia and adult onset apraxia.
Torrence, CA: Sensory Integration International
Ayres, A.J. (2005). Sensory integration and the child. Los Angeles:
Western Psychological Services. (Original work published in 1976.
Ayres, A.J., Mailloux, Z., & Wendler, C.L. (1987). Developmental
Dyspraxia: Is it a unitary function? Occupational Therapy Journal of
Research, 7, 93-110.
Baranek, G.T., David, F.J., Stone, W.L, and Watson, L.R. (2006). Sensory
experiences questionnaire: discriminating sensory features in young
children with autism, developmental delays, and typical development.
Journal of Child Psychology and Psychiatry, 47. 591-601.
References
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Fombonne, E. (2005). Epidemiological studies of pervasive developmental
disorders. In F.R. Volkmar, R. Paul, A. Klin, &D. Cohen (Eds.), Handbook
of autism and pervasive and developmental disorders (pp 42-69).
Hoboken, NJ: John Wiley & Sons.
Greenspan, S., & Wieder, S. (1998). The child with special needs:
Intellectual and emotional growth. Reading, MA: AddisonWesley/Longman.
Kuhaneck-Miller, H. (2004). Autism; A comprehensive occupational
therapy approach. Bethesda, MA: The American Occupational Therapy
Association, Inc.
National Research Council (2001). Educating children with autism.
Washington, DC: National Academy Press.
Palmer, John M. & Yantis, Phillip A. (1990). Survey of Communication
Disorders. Baltimore, MD: Williams & Wilkins.
Willams, D. & Minshew, N. (2010, April 27). How the Brain Thinks in
Autism: Implications for Language Intervention. The ASHA Leader.
ST/OT Resources
• American Occupational Therapy Association:
www.aota.org
• American Speech-Language-Hearing Association:
www.asha.org
• www.spdfoundation.net
• The Out of Sync Child: Recognizing and Coping
with Sensory Processing Disorder by Carol
Kranowitz