ASD in Pediatrics

• impacts 1 in 152 children in the US - consistent with world-wide estimates

• some children (32%) experience a regression in skills (e.g. child develops normally walking and talking, but randomly stops)

  • avg regression on set is just before 2 yrs old

• impacts individuals in different ways 

ASD Diagnosis

• 4+ social communication & social interaction deficits

  • social emotional reciprocity - includes abnormal social approach & failure of normal back-and-forth conversation; to reduced sharing of interests, emotions or affect; failure to initiate or respond to social interactions

  • non-verbal communicative behaviors - includes poorly integrated verbal & nonverbal communication; to abnormalities in eye contact & body language or deficits in understanding & use of gestures; to a total lack of facial expressions & nonverbal communication

  • difficulty with relationships

• 6+ restricted, repetitive patterns of behavior, interests, or activities

  • repetitive, stereotyped motor patterns (stimming)

  • resistance to change (e.g. transitioning especially from a preferred activity to non-preferred activity)

  • highly restricted, fixated interests

  • hyper- or hypo-responsivity to sensory input or unusual interest in sensory aspects of the environment

    • People who have Autism almost always have sensory processing disorder but people with SPD do not always have ASD

• must be present across multiple contexts and symptoms are present in the developmental period

• *PDD-NOS & Aspergers (now referred to as Social Pragmatic Disorder) were eliminated in the latest iteration of the DSM and are no longer given

• Diagnosed using scoring from:

  • Vineland Adaptive Behavior Scales (Vineland-3) - typically done by a psychologist

  • Childhood Autism Rating Scales (CARS)

  • **OTPs do not diagnose -- may complete or assist in completing parts of the testing

    • more likely can be a part of an educational diagnosis for ASD but not in the medical diagnosis process

Key Characteristics of ASD

• Echolalia: repeating speech that is said

• Hyperlexia: intense fascination with letters & numbers (do not have the phonemic ability - cannot understand to perform more higher level processing)

• Coregulation: need for others to assist in regulation

• Hypervigilant: heightened monitoring that impacts socialization

• Stereotyped behavior: rigid or repetitive actions that provide satisfaction

• Twice expectational: extraordinary learning abilities coexisting with other pathology

Impact on Mental Health

• ASD has a higher occurrence of:

  • depression & anxiety

  • bipolar disorder

  • obsessive-compulsive disorder

  • schizophrenia

  • suicide attempts

Role of OTP

• dependent upon the individual's age, level of symptoms, area of testing

• OTPs use a variety of assessments to evaluate functioning in different areas

• Common evaluations:

  • Sensory: SPM, SP-2

  • Motor: BOT, PDMS

  • Adaptive Behavior: Vineland-3

Intervention Settings

• Home

  • EI

  • group home or residential

  • home care

• School

  • pre-school

  • elementary, middle, high school

  • transition services

  • post-secondary

• Community

  • outpatient 

  • work/employment assistance

  • adult day programs

  • therapeutic leisure pursuits - aquatic, hippotherapy

General Intervention Focus

• focus on occupational performance

• utilize a mix of research-based strategies & approaches

• no 'one-size fits all'

• understand the contextual supports/barriers

• inter-professional understanding & methods

• training/coaching/consultation to support carryover

Possible Interventions:

• ADLs

  • sleep hygiene/routines

• play/leisure

  • participation & exploration

• social participation

  • social pragmatics

  • self-advocacy skills

  • social stories

    • descriptive sentences

    • directive sentences

• work

  • exploration

  • work-readiness skills

• others

  • motor planning skills

  • fine motor skills

  • sensory integration, processing, sensory-based tools & strategies

  • accommodations & tech

  • sleep

Specific Interventions

• ABA 

  • external experiences shape behavior; manipulation of environmental consequences (reinforcers); classical/operant conditioning; compliance w/ adult demands

  • Discrete trial training (DTT): repetitive trials of antecedents -- behavior -- consequence

  • positive behavioral support (PBS): seek to understand the purpose or function of the behavior; more proactive

• cognitive approaches

• Ayres' sensory integration (ASI)

• Floortime & the developmental individual differences, relationship-based model (DIR)

  • naturalistic & play-based

  • child leads, adult joins child's world, expand interactions

• Animal assisted therapy (AAT)

Educational Interventions

• academic alterations

• visual supports

  • pictures (schedules, communication boards, choice boards)

  • written directions, checklists

  • signs, maps

  • timers, clocks, watches

• technologic supports 

• social supports

  • social groups

  • peer mentoring

  • play groups

  • 5-point scale (inside out, angry birds, emojis)

  • emotional regulation programs

• behavioral supports

• sensory supports

• motivational supports

Teaching Strategies

• forward chaining - begin with the first step

• backward chaining - begin with the last step

• reinforcement - 

  • positive - give something they live

  • negative - remove something aversive - does not mean give something negative

  • continuous - reinforce each correct response

  • partial - fixed or variable

• fading of prompts

• modeling - observational learning or imitation

• visual (and/or picture) schedules

• whole body listening programs 

Family-Centered Care

• occupational alienation: family cannot do things they want/need to do because of the impact of ASD (e.g. can't go to the grocery store, can't do holidays or family parties, transportation)

  • may no longer be able to do things they used to do

  • may have to leave work or educational pursuits

• dependence upon routine impacts entire family's routines

• caregivers may "divide & conquer" siblings during social outings

• benefit from access to respite care & financial resources