AUTISM: An Occupational Therapist’s experience and perspective

Occupational Therapists work with individuals and groups in order to promote health through engagement in occupation (AOTA 2008). In this article, Margot Barry aims to highlight how the diagnosis Autistic Spectrum Disorder (ASD) can impact a child’s ability to develop and participate in activities of daily living and how occupational therapists assess and intervene with a child who has an ASD. It also gives some information on the services ‘Sensational Kids’ provides to children with ASD.

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Children in general learn through a variety of processes. They learn from observing others participate in activities of daily living and they also learn through trial and error processes. Trial and error learning relies on the child’s ability to try the same task in a variety of different ways. Children with an ASD often have limited interest in observing others, with the result that learning through the process of observation (a social process) is diminished. Similarly, the routines and stereotypical movement patterns associated with ASD can prevent a child from learning through a trial and error process. From my experience, the level of flexibility required for trial and error can be very difficult to achieve in the presence of the fixation on a routine. For a child with an ASD, natural development may not be an automatic process; assistance is required. As a result parents, teachers or professionals may refer a child to an occupational therapist. The occupational therapist’s main aim is to identify and work on the elements that hinder a child’s ability to develop and to participate in appropriate activities of daily living at home, at school and at play to the best of the child’s ability. Independence in activities of daily living develops as the child’s ability in various foundational skills develops.

These foundational skills include, but are not restricted to, motor skills, visual perceptual skills, sensory processing skills, work task planning skills, problem solving skills, social skills, play skills, independent work task performance and visual motor integration skills. If a child has difficulties with a particular foundational skill, all the activities of daily living within which this foundational skill is required will be affected negatively.

Children with an ASD often require occupational therapy intervention to assist them in acquiring proficiency and independence in activities of daily living, such as personal care activities, hairbrushing, toothbrushing, dressing, eating with utensils, school related skills, handwriting and cooperation in games and sport. Participation restrictions in these activities can arise from having delays or disordered foundational skills. An example of this is a child who is referred with difficulties and avoidance of participation in ball games, running games, physical education classes and team sport. In a child who does not have an ASD, the first foundational skill difficulty that is suspected is a gross motor skills delay or movement difficulty. However in the case of child with an ASD, movement difficulties are not inherently associated with the diagnosis and social skills and sensory processing skills are more likely to be the cause of their avoidance or inability to participate in sport. All the games and activities mentioned above have a large social skill component that requires a child to understand written and unwritten rules about games and conduct during these activities. A child has to use personal space appropriately during contact sport and also possess the ability to read situations flexibly in order to be able to respond appropriately. This is a very large challenge for the child with ASD. Social skills difficulties are an inherent feature of the ASD diagnosis (APA 1994) and they make it difficult for a child with the diagnosis to participate in team sport and social physical activity.

The social skills element involved in ball games and physical education is not the only difficulty commonly associated with an ASD that hinders participation; sensory processing ability is another. During participation, a child has to contend with noise, visual stimuli, touch and movement. None of these elements are predictable during games and sport. Many children with ASD experience sensory processing difficulties (Claveirole and Gaughan 2011; Kashman and Mora 2002). As a result they may tend to avoid participation in ball games and running games. This isolates boys, in particular, in the school yard, where soccer, running and tumbling are the preferred ways of interaction between peers. Occupational therapy plays a big role in facilitating the development of social skills through groups, where participation in group activities, games, turn-taking, joint participation and play activities is practised in a safe environment, thereby allowing friendships to be formed and social skills to be learnt.

Learning skills in a therapy group is important, but it is even more important that the skills are transferred into the everyday context of a home, neighbourhood or school. This may not happen automatically for a child with an ASD; it needs to be facilitated by integrating the new tasks into the child’s routine. A child with an ASD may have an urge to adhere to a specific routine. Routine can be used as a positive force to facilitate participation in newly learnt activities. Teamwork between the therapist, the parents and the teachers is essential in achieving success in the transfer of skills from one context to another. The context of an activity plays a very important role in achieving activity participation in the child with ASD.

A child with an ASD might display the ability to perform activities of daily living in one environment (e.g. home), but not display the same level of skills in another (e.g. school). In this case the occupational therapy intervention should focus on environmental strategies, rather than the child’s inherent ability. An assessment is carried out to investigate contextual elements of function. This is particularly important when the child transitions from one environment to another.

At times of transition, when the social environment changes for the child with an ASD, difficulties with previously mastered skills may arise. At these times, intervention is necessary to revisit and re-learn skills that may have been mastered in a previous context, but not implemented in the new environment. Occupational therapy is especially meaningful at these times of transition, e.g. from secondary school to university.

Transitions do not need to be as significant as a change from school to university. A transition that could cause difficulties could be as small as having to come back into class after break. Many social skills and sensory skills are necessary during times when there are changes in location and pace during the day and it is often at these times that a child with ASD needs assistance. It is essential that they are prepared for the transition and that the next task or chapter is evident to them. Transitions, no matter how small, need to be supported and this is best done through the creation of a predictable routine. The occupational therapy intervention may focus on assisting a teacher and parent to create such predictability.

The above information may give the impression that all skills which are addressed in occupational therapy are learnt. The reality is, however, that some children never progress from routines which require a lot of adult assistance and may remain at a basic developmental level. Their ability to adapt to environmental changes remains low and their need for sameness remains high. Where a child has a general learning disability and also an ASD, the two diagnoses make it difficult for the child to acquire skills (Claverole and Gaughan 2011). Occupational therapists take this into account in setting realistic goals together with teachers, parents and carers. In cases where it is clear that a child will never become an independent adult and will require support and supervision to be able to carry out a basic daily routine, it is essential that therapy is not unrealistically aimed at the norm of functioning for the child’s age group. It should be targeted at the level the individual’s capability. Teamwork between the therapy team, parents and teachers is essential in achieving the best outcome for the child. Occupational therapy provides one piece of the puzzle in a team approach to creating the best potential outcome for a child or adult with an ASD and a general learning disability and their family.

ABOUT SENSATIONAL KIDS

Sensational Kids is a registered charity set up by parents to provide accessible, affordable and high-quality clinical services, summer camps and groups for children of all abilities, including children with special needs. These services include occupational therapy intervention for children with an ASD. Sensational Kids runs a child development and learning store which stocks a range of skill building and therapy products. Sensational Kids is also committed to providing high.class training services for those who work with children with special needs.

Margot Barry is an Occupational Therapist who has worked with children with special needs in a variety of settings and countries since her qualification in 1996. She reached the level of clinical specialist and worked in an autism specific multi-disciplinary team of professionals for several years. Latterly, she worked as a lecturer in the University of Limerick, completed an MSc by Research and Thesis and also worked at Sensational Kids Ltd as the clinical manager. Margot is committed to working alongside parents and teachers to facilitate best outcomes.

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