Referral: Diagnostic vs. Intervention Planning Assessment
A referral initiated by a parent/caregiver, physician, or school personnel usually begins the occupational therapy process. Occupational therapy services are requested for individuals with an autism spectrum disorder (ASD) when functional performance limitations are present (e.g., in movement, sensory processing, or adaptive behavior). The reason for referral in many cases is dependent on the setting in which the practitioner functions. While in almost all cases the evaluation is ultimately requested to document the strengths and weaknesses of an individual for appropriate program planning, correctly identifying the reason for referral will help the practitioner define his or her role and assure specialized referral questions are answered.
In many cases, the purpose of the diagnostic evaluation process not only will be establishing or ruling out a diagnosis but also comprehensively assessing specific skill areas for individualized intervention planning. In comprehensive evaluations, team members often have well-defined roles and expectations because the individual skill areas assessed are interrelated with the skills assessed by other team members. Further, professionals of different disciplines approach assessment using different frames of reference and, as a result, may have different interpretations of observations made during the evaluation. Therefore, findings need to be integrated to develop a coherent intervention plan. This conceptual integration may provide a clearer understanding of the presentation of the individual with an ASD and lead to appropriate intervention.
Whether a referral is made for diagnostic or treatment planning purposes, the occupational therapy practitioner likely will be asked to document the strengths and weaknesses of an individual. Having the roles of each discipline clearly defined ensures that specialized areas are addressed and all referral questions are answered. Sharing of referral questions and teaming with the other professionals and the family of the individual with an ASD allows for appropriate diagnosis, program planning, and intervention development.
Given the social communication difficulties experienced by an individual with an ASD, the evaluation process usually begins with the occupational profile as reported by the parents of the child. This process varies according to the environment and context in which services will be provided but is generally completed in the initial session. During ongoing service provision, this information may be collected over several sessions as part of the therapeutic process.
The occupational profile identifies the child's occupational history and current occupations in various contexts and discusses typical routines and the child's interests and motivations. Additionally, the profile explores problematic daily routines. The current social supports (i.e., family and friend membership, peer relationships, community resources, intervention programs) are identified to guide information gathering related to functioning and engagement in childhood occupations. The profile also includes concerns, questions, and priorities. Interviewing the family using the Canadian Occupational Performance Measure (COPM) may assist this process. Additionally, instruments developed for use with children and appropriate for children with disabilities, such as the Perceived Efficacy and Goal Setting System (PEGS) and Children's Assessment of Participation and Enjoyment and Preferences for Activities of Children (CAPE/PAC), may be administered.
Information gathered in the occupational profile is used to guide the family-centered evaluation and intervention process. Using this information, the occupational therapist can identify the strengths and limitations of the child and family and, in turn, can identify relevant evaluation methods to assess the underlying components of the identified impairments. In collaboration with the team, the evaluation findings are used to establish goals and guide intervention planning.
When providing services to individuals with an ASD, occupational therapy practitioners work with families and a variety of professionals (e.g., educators, speech–language pathologists, behavior therapists) and paraprofessionals (e.g., instructional assistants, bus drivers, lunchroom personnel) in many settings. Factors that influence the evaluation process are briefly discussed in the following section.
Setting and Context Considerations
Occupational therapists may evaluate children in their home, school, diagnostic center, residential center, and/or community. This context in which the occupational therapist provides service influences the evaluation process.
A sampling of contextual considerations for assessment and intervention processes can be found in Table 3 in the original guideline document.
Multidisciplinary and Discipline-Specific Assessment
If an occupational therapist participates as a member of an evaluation team, it is important for the therapist to understand the team structure and his or her role as a member of the team. Multidisciplinary assessment is recommended. Multidisciplinary assessment implies that members of a team of clinicians from a variety of backgrounds are independently evaluating the child, deriving independent impressions, and coming together to formalize a consensus of diagnostic impressions and develop overall team recommendations. Evaluation findings then are analyzed as a team to develop consensus impressions and an integrated intervention plan. Team behavioral observations will have multiple interpretations that need to be assessed to determine the most appropriate intervention.
Oftentimes, however, an occupational therapist functions independently in the community to provide services. In this situation, the reason for referral, along with information gathered from the occupational profile, setting, and contextual considerations, will guide the targeted assessment and intervention planning.
Diagnostic Signs and the Selection of Methods: Standardized vs. Nonstandardized
During evaluation, testing is a social communication process. Inherent to the diagnosis of autism are impairments to social interaction and communication skills. Additionally, individuals with autism have been described as distractible, demonstrating variability in skill performance, having a low tolerance for incoming sensory stimuli, and impervious to the usual verbal and even tangible motivators that are used to support optimal performance during testing. Therefore, a standardized testing process does not play to the strengths of individuals with autism and, consequently, the testing process often is not well tolerated, nor does it result in an accurate reflection of the individual's abilities.
Many practitioners and researchers feel that evaluations should be conducted within the child's natural setting using nonstandardized ecological procedures (i.e., interviews, observation) rather than utilizing standardized instruments to obtain information on the child's functional performance. Other practitioners embrace the notion of testing in the natural setting with nonstandardized procedures but also acknowledge the need to adapt standardized instruments to clearly outline a child’s individual abilities.
Multiple measures are used in assessment. Whether using standardized or nonstandardized instruments, the focus of the assessment process should be on obtaining information on the individual’s occupational performance. A variety of strategies, including direct assessment, naturalistic observation, and structured interview, should be used to maximize information-gathering efforts.
Play as an Evaluation Method
Play can be a powerful evaluation method because it provides insight into a child's social, motor, cognitive, and sensory processing skills. Additionally, play often becomes the framework from which other areas are evaluated. From the onset of a direct assessment, a therapist observes the child's sensorimotor, social, adaptive, and communication behavior in play. These observations of play can be used to guide clinical decision making for evaluation methods and adaptation of standard measures, as well as allow the therapist to better understand a child's motivation to participate in testing and his or her apparent learning style.
Collaborative Role of the Family
Family-centered care and strong family involvement in evaluation and intervention programs are recommended for individuals with an ASD. In family-centered care, the family is recognized as a constant in the child's life and as having inherent strengths that serve as a foundation for growth and development. Therefore, it is crucial to include the family as an integral member of the interdisciplinary team.
The results of an evaluation are dependent on the setting and referring question. In some settings the findings provide diagnostic clarification, while in others, the goal is to establish a comprehensive intervention plan. In most situations, the overriding goal of an evaluation process is to clearly identify the child's strengths and supports that can be used to promote emerging skills and improve participation. Information obtained from the occupational therapy assessment is integrated with that of the other team members to provide a full picture of the individual. This integration results in a clear description of the individual's strengths and guides the development of interventions soundly grounded in the uniqueness of each child or adolescent.
Analysis of Occupational Performance
Evaluation of performance of individuals with disabilities often has been described as a linear process using either a "bottom-up" of "top-down" approach. Evaluation of individuals on the autism spectrum often takes on a different dimension and is not a linear process. Here, evaluation of both functional performance and component level performance often evolve simultaneously through play interaction. With the occupational profile and reinforcer assessment complete, the child's roles are more clearly defined, as are approaches to guide the process of evaluating participation in relevant occupations and contexts and environments. Participation of the child in family, school, and community roles will likely need to be addressed in this process. The following steps are generally included in analyzing occupational performance:
- Observe the client as he or she performs activities in the natural or least restrictive environment (when possible), and note the effectiveness of the client's performance skills (e.g., motor, praxis, sensory - perceptual, emotional regulation, cognitive, communication, social) and performance patterns (e.g., habits, routines, rituals, roles).
- Select specific assessments and assessment methods that will identify and measure factors related to the specific aspects of the domain that may be influencing the client's performance.
- Interpret the assessment data to identify what supports or hinders performance.
- Develop or refine a hypothesis regarding the client's performance.
- Develop goals in collaboration with the client and family that address the client's desired outcomes (e.g., activities of daily living [ADL] independence at both home and school).
- Identify potential intervention approaches, guided by best practice and the evidence, and discuss them with the client.
- Document the evaluation process, and communicate the results to the appropriate team members and community agencies.
Observations of Behavior in the Context of Play
During all aspects of a comprehensive evaluation, occupational therapists make observations of the behavior displayed by the client. Therapists use these observations in differential diagnosis and give insight into other components of the assessment (i.e., participation, motor performance, play, sensory processing, praxis). Additionally, they provide information about how a child responds to the varied contextual aspects of his or her surroundings and insight into the individual's unique learning styles.
Throughout the evaluation process, the therapist should note the quality of the social communication aspects of the individual's interaction with other people and the environment. Specifically, the therapist should make observations of social attention and responsiveness and monitor use of eye contact. Coordination of visual orientation and attention to people and objects is noted in relation to joint attention. The therapist documents the extent of language and characterizes it as spontaneous, imitative, or echolalic (immediate or delayed). The therapist also should document the use of compensatory nonverbal communication strategies (e.g., use of gestures or body proximity; using the hand of another person to request assistance, to indicate they want to do more of something, or to initiate/repeat an activity), if any.
Therapists also make specific observations about the extent to which the child interacts with his environment, with special attention directed to the types of toys and the nature of the interaction with these toys.
Identifying these factors provides the practitioner insight into functional play levels and allows him or her to draw upon common features that can be used in intervention.
Therapists should also document stereotypies. The presence, frequency, and/or triggers of repetitive motor stereotypies, unusual body posturing, object stereotypies, self-injurious behaviors, and vocal stereotypies are noted through observation or by report of caregivers.
Therapists should also document structured observations of externalizing behaviors exhibited during structured play and evaluation. The therapists should consider the child's ability to manage and express emotions, control impulses, and delay gratification within and between tasks.
Participation in Areas of Occupation
Individuals diagnosed with an ASD often have limitations in performance in one or more areas of occupation. Depending on the age of the individual being assessed, play performance, school occupations, adaptive behavior, and ADLs may be evaluated.
Children with an ASD often have a limited play repertoire, so play needs special attention as part of the evaluation. Assessment of play most often is accomplished through structured clinical observations (see Table 4 in the original guideline document) and occasionally in combination with a formalized measure (see Table 5 in the original guideline). Because a child's play performance is influenced by the surrounding environment, it is ideal to observe play across settings, both indoors and outdoors.
Therapists also should observe the child in both free and structured play situations and note similarities and differences in independent play versus play with peers. These observations should describe situations in which the child interacts with, socially references, and/or imitates others. Observations also should be made regarding how much structure and consistency the child requires for interaction.
In addition to the social responding aspects of play noted above, therapists should observe the child's interactions with objects and toys in the environment. The child's ability to initiate play with a toy, explore many toys, and/or sustain play with a toy for an extended period of time also should be monitored. With these noted, assessments may be made about what motivates the child in play and what types of play interactions he or she initiates. The purposefulness or functionality of the play with objects may be evaluated in relation to the overall level of play (e.g., symbolic, creative/imaginary, pretend).
Analysis of relevant school occupations will depend on a number of factors, including the grade level of the child, school type (e.g., Montessori vs. traditional model), and the classroom placement (i.e., self-contained vs. inclusion) in the school. Initial history gathering with the family and school personnel guides this analysis and prioritizes specific areas in which the child is experiencing difficulties. Observations of the child while participating in the activities in relevant contexts identifies the child's functional limitations, if any, and the types and level of support needed for successful participation. Observed and reported differences in participation in different settings (home vs. school) are noted.
To supplement observations, an evaluation tool also may be used. In early school-aged children, the School Function Assessment (SFA) can be used to measure a student's performance of functional tasks that support his or her participation in the academic and social aspects of an elementary school program (K–6). An alternative, the School Version of the Assessment of Motor and Process Skills (School AMPS) can be used for children ages 3–12 years to measure a student's schoolwork task performance in typical classroom settings.
Adaptive Behavior and ADLs
The child's level of performance in ADLs is another important area of assessment. Similar to the assessment of other areas of participation, both clinical observations and formal measures are used in this process, with the setting influencing the extent to which each of these methods is used.
Analysis of Performance Skills and Patterns
Gross Motor Skills
Gross motor assessment includes evaluation of postural stability, mobility, gross motor skills, and neurodevelopment. Neuromuscular status assessment is also a component of the child's gross motor status. Assessment of gross motor performance is often done within the context of play-based assessment or strictly through observation.
Occupational therapists assess developmental milestones and observe and analyze the quality with which they are accomplished. Standardized measures of motor performance, such as the Peabody Developmental Motor Scales - Second Edition and the Bruininks–Oseretsky Test of Motor Proficiency, Second Edition provide a foundation for determining the appropriateness of more specialized measures of motor performance.
Fine and Visual-Motor Skills
During fine motor assessment, grasp of objects, writing, block play, cutting tasks, and dexterity while manipulating clothing fasteners are evaluated. Stable positioning during fine and visual-motor tasks enhances optimal performance. Many of the foundational areas relating to fine motor task performance are assessed though observation of play. Table 6 in the original guideline outlines some example questions to guide these structured observations during fine motor assessment. Administration of standardized measures and observations of supplemental engagement in purposeful tasks are used to identify strengths, weaknesses, and developmental levels. If the child is unable to perform a fine motor task, activity analysis will allow the practitioner to determine related factors, including weakness, deficient muscle control, dyspraxia, cognitive limitations, or lack of motivation.
In conjunction with fine and visual-motor assessment, visual discrimination, visual memory, visual form constancy, visual-spatial relation, visual-sequential memory, visual figure ground, and visual-closure perceptual areas often are evaluated. Formalized assessment of visual-perceptual abilities in autism is usually reserved for children of school age and older who have adequate receptive-language abilities to allow the child to comprehend the required verbal instructions. Visual-perceptual instruments (see Table 5 in the original guideline) assess nonmotor perception, in that they do not require motor coordination for the completion of testing. Instead, the child can select his or her choice among the options by saying or pointing to the appropriate letter, form, or design that corresponds to his selection.
Supplemental clinical observations can be used to obtain informal information about perceptual abilities in children who cannot participate in formal testing. Practitioners can devise situations to assess specific areas or evaluate a child's work.
Another specialized area of evaluation for an occupational therapist is sensory processing. Similar to many other aspects of the evaluation process with an individual with an ASD, both formal and informal measures are used. Standardized caregiver or teacher reports include the Sensory Profile, Sensory Integration Inventory - Revised, and Sensory Processing Measure, Home Form and Main Classroom and School Environment forms. These inventories gather information regarding sensory processing within daily life situations, measuring the child's responsivity to varied sensory experiences (e.g., tactile, auditory, visual, vestibular, gustatory) and include assessment of behavior, praxis, and emotional lability. The scores can be graphed to depict the child's pattern of responses. In addition to a caregiver report measure, the Sensory Integration and Praxis Tests may be administered by a certified therapist to gather more specialized information. However, use of this instrument is rare and requires that the child has good receptive language.
Assessment of sensory processing includes structured clinical observations and response to sensory experiences. Because the environment and/or the contents of that environment can change how an individual responds to sensory input, these observations may support the caregiver report or provide contrasting information about the effects of an individual's sensory processing within different environments. It is important to note the sensory qualities of that environment (e.g., size and openness of the space, light quality and type, heating/ventilation noise, room temperature, visual qualities, smells) during the evaluation. These environmental conditions alone may impact an individual's ability to successfully participate in his or her daily occupations. Additional structured observations during evaluation of sensory processing and praxis in individuals with an ASD are found in Table 7 in the original guideline and may be guided more formally with use of Observations Based on Sensory Integration Theory.
Contexts and Environments
Occupational therapists acknowledge the influence of cultural, physical, social, personal, temporal, and virtual contextual factors on occupations and activities. Therefore, factors that support or inhibit performance should be identified during the evaluation process. Because the symptoms of autism are highly influenced by the environment, analysis of behavior in the natural environment is desirable. Observation in multiple settings can provide significant information about how a child functions and how the differences in settings change behavior and performance. Thus, the context in which evaluation of occupational performance occurs is an essential consideration. Table 3 in the original guideline summarizes activity demands and contextual considerations for assessment.
Determining whether a child may be able to complete an activity depends not only on the performance skills, performance patterns, and client factors but also on the demands of the activity itself. The demands of an activity are aspects of the activity that include the tools needed to carry out an activity; the space and social demands required by the activity; and the skills, body functions, and body structures needed to take part in a given activity.
The activity demands of childhood occupations require a child to have adequate cognitive, sensory, and motor control. Assessment of these client factors (e.g., body functions) can inform the occupational therapist about the client's ability to engage in occupations.
Interpretation of Evaluation Results
The evaluation process is not fully complete until the therapist interprets the evaluation findings. Ultimately, if deficits are noted in any of the underlying factors and aspects within the domain of occupational therapy, yet they do not impair occupational performance, services may not be warranted. After collecting the evaluation data, the practitioner integrates evaluation information to obtain a clear understanding of the individual performance and participation. After the occupational therapist interprets the evaluation data, these evaluation findings are integrated with the evaluation results of other team members. This integration provides a comprehensive description of the individual's strengths, identifies the underlying impairments that limit participation, and leads to an intervention plan. When conducting evidence-based practice, a third level of integration guides intervention planning.
Occupational therapy practitioners use the information about the child and his or her family gathered during the evaluation to direct client-centered and occupation-based interventions. The intervention process consists of the skilled actions taken by occupational therapy practitioners in collaboration with the child and other care providers to facilitate engagement in occupation related to health and participation. This intervention process is divided into three steps: (1) plan, (2) implementation, and (3) review. During the intervention process, information from the evaluation is integrated with theory, practice, frames of reference, intervention methods, and evidence from the literature. This information guides the clinical reasoning of the occupational therapist in the development, implementation, and review of the intervention plan.
Intervention Plan and Implementation
The occupational therapy practitioner develops the intervention plan collaboratively with the client; the plan is based on the client's goals and priorities. Depending on whether the client is a person, organization, or population, others, such as family members, significant others, board members, service providers, and community groups, also may collaborate in the development of the plan. The selection and design of the intervention plan and goals are directed toward addressing the client's current and potential problems related to engagement in occupations and/or activities.
The design of the intervention plan is directed by the (1) client's goals, values, and beliefs; (2) client's health and well-being; (3) client's performance skills and performance patterns; (4) collective influence of activity demands, client factors, and the context, which includes the environment, on the client; (5) context of service delivery in which the intervention is provided; and (6) best available evidence.
In addition to the above considerations, intervention planning for children on the autism spectrum often is complicated by the need to integrate occupational therapy interventions into the context of other interventions the child may be receiving. Typically, children with an ASD receive multiple, concurrent interventions within various settings.
Intervention Review and Outcome Monitoring
Intervention review is a continuous process of reevaluating and reviewing the intervention plan, the effectiveness of its delivery, and the progress toward targeted outcomes. This regular monitoring of the results of occupational therapy intervention determines the need to continue or modify the intervention plan, discontinue intervention, provide follow-up, or refer the client to other agencies or professionals. Reevaluation may involve readministering assessments used at the time of initial evaluation, a satisfaction questionnaire completed by the client, or questions that evaluate each goal. Reevaluation normally substantiates progress toward goal attainment, indicates any change in functional status, and directs modification to the intervention plan, if necessary. Additionally, this review of intervention may require revisiting available literature if occupational performance of the individual has changed.
Intervention review for individuals with an ASD is an ongoing process, with the setting and context again playing a significant role. For example, practitioners working in natural environments in early intervention programs conduct ongoing assessment as part of the intervention process. Here, family outcomes written on the individualized family service plan are monitored. In addition to these child-specific outcomes, the occupational therapist also contributes developmental reassessment components to the state-level child outcome reporting system for indicators within the State Performance Plan and Annual Performance Report required by the U.S. Office of Special Education Programs.
Intervention review and outcome monitoring in the public schools for children receiving occupational therapy services under the Individuals with Disabilities Education Act (IDEA) are completed formally on an annual basis when goals on an individualized education program (IEP) are reevaluated. Each year, the IEP team reevaluates the goals, establishes eligibility for continued special education and related services, establishes new goals, and outlines changes to specially designed instruction to address these goals.
Children transition throughout their schooling to different settings, grades, and situations. Under IDEA, children with disabilities are entitled to transition planning and services at two points in time: when the child moves from early intervention (Part C) into preschool and kindergarten (Part B) and when the student moves from high school to postsecondary education and community living. As part of the transition team, occupational therapy practitioners support positive transition outcomes to prepare the family and child for changes in roles and routines; facilitate academic and functional living skills for school participation; and facilitate community integration, including skills for employment, further education, and adult living. The occupational therapy practitioner also provides extensive information to the family about the new setting and program, explains how expectations for the child will change, and facilitates communication with the providers of the child's future program. Intervention(s) are reviewed and outcomes are monitored to develop new IEP goals and specially designed services for the child that are appropriate to the new setting and staff within that setting.
Discontinuation, Discharge Planning, and Follow-Up
Like transition, discontinuing and discharging services requires planning and should begin at the time services are initiated. During the annual review of services provided under IDEA, a practitioner as part of the IEP team may recommend discontinuation of services when the student either has met goals requiring occupational therapy collaboration and no additional ones are appropriate or has achieved maximal benefit from occupational therapy services. In addition, services may be discontinued if they no longer are needed; at the request of the family; or if the child is unable to participate because of medical, social, or psychological difficulties. As part of the discharge process, occupational therapists document the plan for discontinuing services to include a summary of progress and recommended follow-up, if any.
Occupational therapy services may be requested and required at different points in the development of the individual with an ASD. Therefore, additional intervention may be needed following discharge from services if the child’s developmental profile and/or the contexts (home, classroom) that affect occupational performance is changed.
Occupational therapists and occupational therapy assistants document their services and outcomes. This documentation should be completed "within the time frames, format, and standards established by the practice settings, agencies, external accreditation programs, payers, and AOTA documents."
The following types of documentation may be completed for each client, as required by law, the practice setting, third-party payers, or some combination of these:
- Evaluation or screening report
- Occupational therapy service contacts
- Occupational therapy intervention plan
- Progress report
- Prescription/recommendation for adaptive equipment
- Reevaluation report
- Discharge or discontinuation report
With multiple individual providers and agencies involved in the process, interdisciplinary and interagency collaboration becomes critical. Collaborative efforts can begin when professionals become aware of and gain an understanding of the myriad interventions in which children with autism may participate. The following section provides an overview of common interventions for children with an ASD. The overview will be organized with into five broad categories: (1) sensory-based interventions, (2) relationship-based interventions, (3) school-based programs, (4) social skills interventions, and (5) comprehensive behavioral interventions. While some of these interventions may not be specific to the domain of occupational therapy, likely many will be components of the overall intervention program for a child, and some may be interventions utilized within the occupational therapy intervention plan. Therefore, practitioners' understanding of these interventions is of vital importance.
Sensory Integration and Sensory-Based Interventions
Sensory Integration Intervention
The goal of sensory integration intervention is to improve the efficiency of the nervous system in interpreting sensory information for functional use. The therapist provides an environment rich in sensory experiences and offers activities that challenge the child to gradually engage in more challenging tasks and produce more complex responses. The activities developed by the therapist are developmentally appropriate, offer a "just-right" challenge to the child, and are designed to evoke an adaptive response. The adaptive response helps the child organize the sensory input and produce a functionally appropriate response to that input. The therapist supports the child’s adaptive responses by monitoring the child's functional behavior; giving verbal cueing or physical support during the activity; or modifying the activity if the child becomes frustrated, overstimulated, or unsuccessful.
Most sensory integration programs include two aspects: (1) clinic-based sessions, in which the child receives sensory-rich input through playful, goal-directed activities, and (2) sensory diets, daily programs implemented into the child’s routines at home and school.
The sensory diet is individually designed for the child by the therapist but may be monitored and reinforced by parents and teachers. The sensory diet is designed to help the child use sensory input to modulate his or her arousal levels and behavioral responses to sensation throughout the day. This program enables the child to participate in activities throughout the day by helping him or her maintain optimal arousal and avoid disorganized behaviors from overstimulation. Sensory diets most often involve specific alerting or calming activities or a retreat from sensory stimulation at regular intervals throughout the day.
Certain sensory-based techniques are initially passive and must be provided by the therapist, parent, or teacher. These techniques may include intensive sensory stimulation to one sensory system. The Wilbarger Deep Pressure and Proprioceptive Technique, with a surgical brush using a stroking motion on the arms and legs, followed by the trunk, has been used with children in the autism spectrum. The brushing is combined with joint compression and must be repeated throughout the day on a regular (every 2 hours) schedule. Massage is another touch-based approach that has been used with children with autism. This approach uses deep pressure and circular motions, and its recommended use is less frequent than brushing. As the child matures and improves, he or she is encouraged to independently access ways to maintain optimal arousal in socially appropriate ways (e.g., running in the morning, hot showers, weighted blankets, listening through headphones). Sensory-intensive interventions should be monitored vigilantly for immediate and long-term effects, adjusting intensity and duration of the sensory input as needed.
Therapeutic Listening and Auditory Integration Training
Occupational therapists sometimes apply sound-based interventions to children with ASDs. These interventions require specialized equipment and advanced training to apply and are generally considered to be an adjunct to occupational therapy services. Therapeutic Listening® is a home-based, therapist-directed program in which children listen to modulated music through headphones. The modulated music is selected specifically for each child based on an evaluation of his or her behavior and sensory system function. The music is carefully selected based on its rhythm and tones and has certain frequencies of sound removed to exercise the middle ear.
Therapeutic Listening is used with a sensory diet and is meant to complement a sensory integration program. The goal of therapeutic listening is to activate and organize the nervous system so that the child is more receptive to learning; therefore, the program must be combined with occupational therapy that targets specific skills. Specifically, the goals are to improve the child’s arousal, attention, focus, and organization.
Relationship-based Interactive Interventions
Relationship-based interventions aim to improve fundamental aspects of autism and to foster the child's social–emotional growth and learning capabilities. Because relationship-based interventions involve all or most of the child's social relationships, a team approach that includes the family, teaching, and therapy staff is needed. Occupational therapists frequently take leadership roles in these intervention approaches because the child-centered focus aligns with the approaches typically used by occupational therapists.
In developmental, relationship-based intervention, therapists model interactions that create problem-solving scenarios, encourage the child's sustained play, and support his or her responses. Parents are encouraged to increase their attentiveness to their child, improve their sensitivity to the child's communication attempts, and increase their positive responsiveness.
Occupational therapists often participate in comprehensive school-based programs. Their roles in these programs are supportive of the strategies designed by the team. At the same time, occupational therapists bring unique skills and perspectives to the program. Often the contributions of the occupational therapy practitioners relate to their in-depth understanding of the child's performance in the context of his or her developmental levels, unique strengths and concerns, the environment, and the activity (curriculum) demands.
In general, early childhood/preschool programs for children with autism are developmental and play based. Early childhood programs may use behavioral interventions with targeted children but not as a primary strategy for all children's learning. When students reach elementary-school age, programs emphasize functional and academic goals. In elementary school and beyond, developmental approaches are deemphasized and behavioral approaches tend to become the dominant teaching method.
Social Skills Interventions
Structured Social Interaction Groups
A defining characteristic of children with autism is minimal initiation of and difficulty sustaining social interaction. Their limited social skills do not necessarily reflect lack of interest in their peers. Occupational therapists assess a child's social skills to determine the individual factors that relate to social skill delays, including poor eye contact, difficulty in auditory processing, sensory processing disorders, and limited understanding of social cues and gestures. Assessment of sensory, cognitive, perceptual, and language performance as these factors relate to social function forms the basis for the child's individualized program.
Social Stories are individualized stories written to guide a child's social behavior. Social Stories are read to the child with autism prior to an event to give him or her directives for expected behaviors. The stories describe events in the child's natural environment and target particular undesired behaviors that need to be modified.
Comprehensive Behavioral Interventions
Behavioral interventions that use applied behavioral analysis with discrete trial training are popular approaches for children with ASDs. Occupational therapists may provide intervention to children who receive intensive behavioral intervention and consult with the psychologists and behavioral therapists directing the behavioral program. Occupational therapy practitioners are rarely primary in the development of behavioral programs and are rarely primary in the implementation, which is generally accomplished by paraprofessionals trained in the specific methods.
Intensive Behavioral Intervention (Discrete Trial Training)
Intensive behavior intervention is currently defined as a home-based 30- to 40-hours per week discrete trial training program. It is typically implemented by four to six paraprofessionals (often students) who are trained and closely supervised. In some programs, parents and relatives participate in the training. The primary strategy of the program is highly structured, one-on-one, discrete trial training. Developmental appropriate goals are established and skill components are identified to be taught step-by-step. The skills are taught by presenting the task, allowing the child to respond to the instruction or to imitate the action, and reinforcing the child's response. The task and reinforcement are repeated for 3 to 8 trials to ensure that the child has mastered the skill. Developmental skills across all domains are taught, with emphasis on language and cognitive skills, but including self-care skills and play competency.
Positive Behavioral Support
Positive behavioral support is a comprehensive intervention that includes (1) using the functional assessment to identify causative factors, (2) incorporating multiple behavioral interventions throughout the day, and (3) consistently applying the procedures developed by the team. Targeted behaviors include aggression toward others, self-injury, tantrums, and disruptive behaviors. A wide range of behavioral approaches are used, depending on how the child responds and what is most appropriate to the problem and the setting.
Recommendations for Practice
On the basis of the overall themes that emerged from the synthesis of research studies, the following practice recommendations are made:
- In addition to evaluating the child's performance in all areas of occupation, the occupational therapy evaluation of the child should include analysis of the physiological functions that may influence the child's behaviors (e.g., sensory processing disorders, sleep disorders).
- Evaluation of the child with an ASD should include assessment of the environment's influence on behavior.
- Regardless of the setting, occupational therapy intervention should be intensive (e.g., one-on-one, intensive time commitment, daily intervention). Both direct and consultative services are important. The occupational therapist's consultation should emphasize the individuals who interact with the child on a frequent basis.
- Given the pervasive nature of ASDs, occupational therapy services should be comprehensive (i.e., should address self-care, work, educational, and play occupations). They should also include underlying sensorimotor issues that relate to the child's performance and behavior. Intervention needs to focus on inhibiting certain behaviors that disrupt participation, such as on temper tantrums or inappropriate behaviors, as well as on facilitating self-regulation and performance that increases participation.
- Given the profile of children with an ASD, the focus of occupational therapy should be on facilitating active engagement of the child. Active engagement includes appropriate attention and arousal, sustained eye contact, joint attention to an activity and another person, appropriate affect, communication of needs, turn taking, gesturing as part of interaction, and initiation of social engagement.
Centrality of the Family
- Occupational therapy practitioners should acknowledge that the family is the decision maker for the child and needs to be fully informed about resources and systems.
- Occupational therapy services should support the family by listening, showing empathy, discussing the child in sensitive ways, educating the family about the disability, advocating for them, and promoting self-advocacy.
- Occupational therapy practitioners should give families information and guidance to enhance their child's participation across environments.
Levels of Evidence for Occupational Therapy Outcomes Research
|Levels of Evidence
||Systematic reviews, meta-analyses, and randomized, controlled trials
||Two groups, nonrandomized studies (e.g., cohort, case control)
||One group, nonrandomized (e.g., before-after, pretest and posttest)
||Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
||Case reports and expert opinions, which include narrative literature reviews and consensus statements
Source. Adapted from Sackett, D. L., Rosenberg, W. M., Muir Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence-based medicine: What it is and what it isn’t. British Medical Journal, 312, 71-72.