|AOTA: Integrating Methodologies and Team Efforts|
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Autism Spectrum Disorders: Integrating Methodologies and Team Efforts
Lynn A. Dell
Sherry L. Milchick
Coordinated team efforts are essential to ensure effective outcomes for children with autism and their families. But coordinating and implementing effective teaming often is daunting for providers because of team members' differing levels of knowledge about methodologies. This article highlights some key features of these methodologies and discusses how occupational therapy practitioners can be instrumental in the team process that supports thousands of children with autism across the country.
Early intervention occupational therapists often serve families with infants or toddlers whose initial diagnosis of developmental delay is later identified as autism. Because early intervention is crucial for ensuring successful outcomes, a multidisciplinary consensus panel assembled by the Child Neurology Society and the American Academy of Neurology formulated practice parameters for the diagnosis and evaluation of autism.2 The panel recommended that all professionals involved in early child care be sufficiently familiar with the signs and symptoms of autism to recognize possible indicators and determine the need for further diagnostic evaluation.
Several social and communication markers exist in 18- to 24-month-old toddlers, and their absence is an important diagnostic tool for early identification of autism. These markers include social interest, joint attention, showing objects to others, pointing, affective exchanges, pretend play, and imitation.3 Other research findings suggest the possibility of sensorimotor markers for autism in children as young as 9 to 12 months of age.4 These markers include poor visual orienting or attending in nonsocial situations, delayed responses to name, excessive mouthing of objects, and social touch aversions.
The Checklist for Autism in Toddlers (CHAT)5 screens for autism at 18 months of age. It can be used in a pediatrician's office as part of developmental surveillance procedures or by therapists conducting developmental screenings. It contains 14 items, of which 5 focus on joint attention and pretend play. The assessment takes about 10 minutes to administer and uses objects available in typical office or home environments. The Screening Tool for Autism in Two-Year-Olds (STAT) is being developed and likely will provide more sensitive identification than the CHAT.3
METHODOLOGIES: MATCHING FEATURES TO NEEDS
Autism spectrum disorder is a neurobiological disorder with no known cure. Instead, multiple methodologies and techniques use educational, behavioral, communicative, environmental, and sensorimotor approaches to minimize the functional difficulties created by autism and to facilitate improved performance in everyday life.6 Understanding the features of commonly used methodologies enables professionals to develop individualized supports that match each student's needs. This knowledge is important for avoiding methodologies that do not support children's particular needs.
Environmental Arrangements and Visual Supports
Children with autism rely heavily on consistent routines, structure, and physical arrangements to function. A program called the Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH)7,8 uses four key components of educational programming--physical structure, schedule, work systems, and visual materials--to arrange learning environments. Work areas consistently are organized with dividers, bins, clear visuals, and predictable work routines. After children learn their routines, they are better able to organize their behavior and attention to sustain work and learning tasks.
Occupational therapists can use environmental systems when designing home and school tasks that the child's team agrees are important. For instance, when teaching a new skill such as dressing, the occupational therapist collaborates with the team to arrange the bedroom and dressing area in consistent and organized ways that match the student's learning needs before the skill training is introduced.
Visual supports may be used to help the student sequence and organize the steps of a task and can include schedules, task organizers, transition and travel helpers, choice boards and menus, people locators, and communication aids.9 The occupational therapist contributes to the team's knowledge about the student's visuomotor readiness for perceiving pictures, icons or symbols, and print that might be used on the visual supports.
Many children with autism require augmented communication to facilitate receptive or expressive communication.10 The Picture Exchange Communication System (PECS)11 is effective for many students. It uses pictures or words on a card that is exchanged between communication partners. The PECS features that appear beneficial for children with autism include the visual representation of language, the exchange between communication partners, and the consistency and predictability of the approach. Other forms of support for the input and output of communication are signing, visual scripting, and high- and low-technology aids.
Social stories12 are a valuable tool that help many students to visually organize language related to important life experiences or challenging issues. Social stories are written by parents or professionals with the help of children with autism. Social stories include three sentence types: descriptive, directive, and perspective.13 Key considerations while creating social stories are using print size and vocabulary consistent with the child's reading level, explaining people's actions or motives that might be difficult for the child to interpret, writing flexibility into the story and mentioning changes that can happen in routines, using terms like usually or sometimes instead of always, and closely defining terms related to time.
Field trips, recess, lunch time, and special programs can be particularly stressful for children with autism because of their novelty and lack of predictability. Social stories can provide a valuable way to preview upcoming trips or programs with the student. I strongly recommend that readers become familiar with Gray's formula and review her texts to avoid designing stories that are too long or detailed. Opportunities to read and review the social stories should be built into the child's natural routines. With enough review, it is hoped that the student will be able to recall important aspects of the story, especially during stressful situations in which recall is challenged.
Applied Behavioral Analysis and Discrete Trial Training
Applied behavioral analysis (ABA) uses the scientific principles of behavior to build socially useful skills and to reduce problematic ones.14 Principles of ABA are used for children with autism to guide functional behavioral evaluations and to design intervention and instructional programs. ABA focuses on teaching small, measurable units of behavior through systematic practice, including specific cues, possible prompts, consequences, repetition, and generalization to other settings. Discrete trial training is one technique that may be used in ABA. Discrete trials refer to systematic, repeated practice for developing or strengthening specific skills.15 Positive reinforcement or motivators are used to reward children for desirable behaviors and may include social praise; attention or hugs; a favorite treat, drink, or toy; or the opportunity to engage in a desired activity.
Discrete trial training uses features that can match the child with autism's need for predictability, routine, consistency, and visuals. Occupational therapists can use discrete trial training to help children learn specific skills or subskills that can be chained to guide functional performance. For instance, to teach a student to make a sandwich independently, it may be necessary to teach discrete skills, such as how to retrieve the materials correctly; sequence the bread, mayonnaise, cheese, and meat; wrap the sandwich and put it into the lunch box; and clean up. Children may need specific reinforcers, cues, and prompts during the process. It is then crucial to teach these skills in different contexts so that generalization truly occurs.
Schneck categorized the research on sensorimotor intervention in autism using the following three distinctions: (a) to manage behavior through reinforcement; (b) to decrease self-stimulatory, stereotypic, or self-injurious behaviors; and (c) to decrease arousal and anxiety through the application of deep pressure, which may facilitate improved adaptive responses in the environment.16 Although the body of evidence for a sensorimotor approach remains less than optimal, it is consistent with the level of research on autism in most other professions and areas of investigation.17,18 Sally Rogers, a leader in the field of autism research, has reiterated that a lack of empirical demonstration of efficacy does not mean that treatment is ineffective but that "efficacy has not been demonstrated in an objective way" (p. 170).16
Occupational therapists may use sensory principles to help children and adults adapt the features of home and school tasks to better "match" the sensory thresholds and behavioral characteristics of the child with autism.19,20 Therapists also may design sensory or self-regulatory strategies that can be imbedded in the context of daily routines to help children maintain optimal levels of arousal and attention throughout the day.21,22 For children with autism, a sensory diet is most beneficial if "sensory meals" are woven into daily routines. These "meals" may include whole class activities involving moment breaks, snack breaks, or specific options designed during free-choice time. For many children with autism, calming or organizing activities do not involve high levels of sensorimotor stimulation. They may include being in a quiet part of the room and reading a favorite book or magazine in a bean bag chair or lying between two bean bag pillows, manipulating a favorite toy or ball of putty during waiting time, sucking a sugarless lollipop during a reading task, sitting on a move-and-sit cushion while writing or keyboarding, and following a visual script while a teacher demonstrates a science or art project.
Sensory activities that require students to leave classrooms or do things outside of typical routines may create more difficulties than expected. When movement tasks increase a student's level of arousal too greatly, therapists can work with teams to design methods (and scheduled time) to help the child recover and regain a state of readiness for learning and for shifting focus back to other forms of activity.
Other strategies to address functional concerns demonstrated by children with autism include accommodations, modifications, adaptations or instructional methods for fine and gross motor performance, feeding and self-care, writing and learning, and self-regulation. In school settings, occupational therapists are frequently involved in specially designed instruction to help children accomplish educational goals. For example, many children with autism struggle with the social skills that are critical for success in many aspects of the school curriculum--relating properly to peers and adults, playing appropriately on the playground, taking turns during group learning, or knowing the social rules of the cafeteria or school bus. The occupational therapist can use the features of various methodologies and the child's specific strengths and needs to help the team design effective instructional strategies. For instance, appropriate visual supports in the cafeteria and on the school bus and playground can help the student understand how to participate more effectively in the multiple tasks involved in each setting (e.g., where to sit, what activities to choose, in what order things are to be done, ways to interact with others).
Weak generalization of learning is one of the important characteristics of children with autism. Many of these children rotely memorize labels such as numbers or letters by using such methods as discrete trial training. However, outside of the training context many of these children have difficulty using the labels appropriately (e.g., to count the number of cookies on the table at snack time). Because generalization is so difficult, the team members must agree to concentrate on very specific areas of skill development and to design methods for teaching and practicing those specific skills in a variety of settings where they are likely to be needed.
Therapists working in different settings (e.g., early intervention, preschools, private practice, school systems) sometimes may provide families and educators with conflicting recommendations on techniques and strategies that are effective for a child with autism. These differences result from variations in therapists' experiences, frames of reference, continuing education, contexts, and methodologies. For example, a private therapist may be focusing on treatment to improve sensory integration, while the school-based therapist may be providing techniques and strategies to modulate sensory responses. All of the occupational therapists and occupational therapy assistants involved in a child's care must ensure that their interventions are complementary and not competitive. In addition, therapists should be spending some, if not all, of their treatment time with the children in natural contexts (e.g., meal times, in the bathroom, school settings, community outings) so that they can guide the family, teachers, and other providers in ways that are directly relevant to the child's performance.
John is a fifth grade student with high-functioning autism. He attends his community elementary school and divides his time between regular education classes and a learning support classroom. John's writing mechanics are strong, but he is inconsistent in his ability to write responses during testing situations or for school writing assignments. One day while taking a test in his learning support class, John's teacher asked him to erase his answers and try again. With no verbal warning, John slammed his fist onto the table in frustration. Afterwards, he struggled to regain his composure using the typical sensory strategies that are embedded in his school program.
Analyzing this situation together, the team members had different hypotheses about John's response. The speech language pathologist knew that John had difficulty using his language skills (internally or externally) to express his emotions and to tell his teacher when he disagreed with her requests. John's emotions had to be expressed in some way, so he banged on the table out of frustration. Later, when asked why he banged on the table, John could not provide a verbal explanation.
The behavior specialist saw John's physical expressions as a way to acquire increased attention and help from his teacher or to escape from the teacher's demand (that he erase his answer and try again). In this scenario, John did get attention from his teacher immediately after he hit the table, but she did not allow him to escape from the task demand. She required John to erase his response and to attempt to provide a better answer from the word bank. Although he did provide a different response, it was not the correct one.
The occupational therapist viewed John's response from a perspective that included sensory regulation and written skills. Throughout the school day, John worked very hard to maintain attention and appropriate on-task behaviors. He was typically well behaved and followed routines very well. He had a tendency to use repetitive movements to help modulate his central nervous system and maintain an appropriate level of arousal so that he could participate in the school tasks adequately. His very physical response to his teacher's request indicated his inability to tolerate the particular sensorimotor demands of that situation. He physically expressed his anger because he did not have sufficient opportunity to organize his body and mind for the demands of the test situation.
John's teacher struggled with John's cognitive discrepancies. John could be highly successful with tests one day and then very unsuccessful with the same testing format on another. She wondered whether her expectations were too high, although she knew that John's intelligence and achievement levels should allow him to manage the testing situations she was using. She wondered whether he had a memory or word retrieval issue that led to inconsistent behaviors and highly variable performance.
All of the team members had valuable insights about the nature of John's behavior. The key was to ensure that they collaborated during the course of their work to design effective solutions. If the teacher never conveyed her concerns to the other staff members, then she would be alone in her attempts to address his needs. However, if she actively pursued input from the team, or if the team members spent time in the classroom to observe these behaviors themselves, constructive solutions could be developed and tried.
The team developed an approach that considered the four performance areas known to be areas of need for John: pragmatic language skills, sensory regulation, cognition, and behavior. The speech language pathologist recognized the need for a visual system so that John had a way to access language when he struggled to verbalize his feelings. He was given a small card to keep in his pocket on which were printed key feeling words that he and his therapist identified as relevant for his needs in his various school settings. His occupational therapist recognized that this visual system also should include John's choices when he needed to ask for a break during a stressful situation or before or after testing (e.g., walk to the drinking fountain or office; perform one of his favorite relaxing activities, such as squeezing his putty ball, for 5 minutes). The teacher clarified with the school psychologist that the level of academic challenge was appropriate for John's ability then looked more carefully at the task demands to determine whether the task needed to be modified (e.g., fewer word choices in the word bank) to ensure John's success. The behavior specialist recommended that the teacher ignore John's banging to better determine whether he was using it as an outlet for frustration versus an attempt to get further attention or assistance. The behavior specialist also taught John (through coordination with the speechlanguage pathologist) how to solicit assistance more appropriately from the teacher by adding a visual to his low-tech word card.
Occupational therapists work with children with autism in many settings, such as homes, day-care facilities, schools, hospitals, outpatient facilities, and private practice clinics. For intervention to be successful, they must understand various methodologies, be able to select those that best address the child's needs, and work with other team members to ensure a consistent approach.
1. Huebner, R. A., & Lane, S. J. (2001). Neuropsychological findings, etiology, and implications for autism. In R. Huebner (Ed.), Autism: A sensorimotor approach to management (pp. 61 99). Gaithersburg, MD: Aspen.
2. Filipek, P., Pasquale, A., Baranek, G., Cook, E., Dawson, G., Gordon, B., Gravel, J., Johnson, C., Kallen, R., Levy, S., Minshew, N., Prizant, B., Rapin, I., Rogers, S., Stone, W., Teplin, S., Tuchman, R., & Volkmar, F. (1999). The screening and diagnosis of autistic spectrum disorders. Journal of Autism and Developmental Disorders. 29, 439 484.
3. Stone, W. L. (1998, June). STAT manual: Screening Tool for Autism in Two-Year-Olds. Paper presented at the National Institutes of Health State of the Science in Autism: Screening and Diagnosis Working Conference, Bethesda, MD.
4. Baranek, G. (1999). Autism during infancy: A retrospective video analysis of sensory-motor and social behaviors at 9 12 months of age. Journal of Autism and Developmental Disorders, 29, 213 224.
5. Baron-Cohen, S., Allen, J., & Gillberg, C. (1992). Can autism be detected at 18 months? The needle, the haystack, and the CHAT. British Journal of Psychiatry, 161, 839 843.
6. Richard, G. J. (2000). The source for treatment methodologies in autism. East Moline, IL: LinguiSystems.
7. Schopler, F., & Lord, C. (1994). TEACCH Services for preschool children. In S. Harns & J. Handleman (Eds.), Preschool education: Programs for children with autism. Austin, TX: PRO-ED.
8. Schopler, E., & Mesibov, G. (1994). Behavioral issues in autism. New York: Plenum.
9. Hodgdon, L. (1999). Solving behavior problems in autism. Troy, MI: Quirk.
10. Wetherby, A., & Prizant, B. (2000). Autism spectrum disorders: A transactional developmental perspective (Vol. 9). Baltimore: Brookes.
11. Frost, L., & Bondy, A. (1994). The picture exchange communication system training manual. Cherry Hill, NJ: Pyramid Educational Consultants.
12. Gray, C., Arnold, S., Burg, D., Goward, K., Hayes, S., Jension, L., Jonker, C., Lind, K., Smiegel, J., Wesorik, S., & Zuber, C. (Eds.). (1993). The social story book. Jenison, MI: Jenison Michigan Public Schools.
13. Gray, C. (1995). Teaching children with autism to read social situations. In K. A. Quill (Ed.), Teaching children with autism: Strategies to enhance communication and socialization (pp. 219242). New York: Delmar.
14. Cooper, J. O., Heron, T. E., & Heward, W. L. (1987). Applied behavioral analysis. Columbus, OH: Merrill.
15. Maurice, C., Green, G., & Luce, S. (Eds.). (1996). Behavioral intervention for young children with autism: A manual for parents and professionals. Austin, TX: PRO-ED.
16. Schneck, C. M. (2001). The efficacy of a sensorimotor treatment approach by occupational therapists. In R. Huebner (Ed.), Autism: A sensorimotor approach to management (pp. 139 178). Gaithersburg, MD: Aspen.
17. Lord, C., & McGee, J. P. (Eds.). (2001). Educating children with autism. Washington, DC: National Academy Press.
18. Rogers, S. J. (1998). Empirically supported comprehensive treatments for young children with autism. Journal of Clinical Child Psychology, 27, 168 179.
19. Dunn, W., & Sarracino, T. (1998, Fall). Sensory processing: Impact on the daily life of a young child. Pennsylvania Early Intervention, 10(1), 1 5.
20. Sarracino, T. (1997). Applying a sensory integrative frame of reference in school practice. Sensory Integration Special Interest Section Quarterly, 20(3), 1 2.
21. Wilbarger, P. (1995). The sensory diet: Activity programs based on sensory processing theory. Sensory Integration Special Interest Section Newsletter, 18(2), 1 4.
22. Williams, M. S., & Shellenberger, S. (1994). How does your engine run? A leader's guide to the alert program for self-regulation. Albuquerque, NM: Therapy Works.
FOR MORE INFORMATION
AOTA Practice Guidelines, Pediatrics Set
By the American Occupational Therapy Association. Bethesda, MD: Author. (Includes three titles: Cerebral Palsy, Attention-Deficit/Hyperactivity Disorders, Young Children With Delayed Development. $45 for members; $69 for nonmembers. To order, call toll free 877-404-AOTA.)
Autism: A Comprehensive Occupational Therapy Approach
By H. Miller-Kuhaneck, 2001. Bethesda, MD: American Occupational Therapy Association. ($62 for members; $74 for nonmembers. To order, call toll free 877-404-AOTA.)
Can Autism Be Diagnosed Accurately in Children Under Three Years?
By W. L. Stone, E. Lee, L. Ashford, J. Brissie, S. Hepburn, E. Coonrod, & B. Weiss, 1999. Journal of Child Psychology and Psychiatry, 40, 219 226.
A Comparison of the Performance of Children With and Without Autism on the Sensory Profile.
By M. A. Kientz & W. Dunn, 1997. American Journal of Occupational Therapy, 51, 530 537.
Making Assessment Accommodations: A Toolkit for Educators
By IDEA Partnerships--The Council for Exceptional Children. ($50 for members; $60 for nonmembers. To order, call toll free 877-404-AOTA.)
Occupational Therapy: Making a Difference in School System Practice (Self-Paced Clinical Course)
Edited by J. Case-Smith, 1998. Bethesda, MD: American Occupational Therapy Association. (Earn 33 contact hours or 3.3 CEUs. $363 for members; $463 for nonmembers. To order, call toll free 877-404-AOTA.)
Occupational Therapy Services for Children and Youth Under the Individuals With Disabilities Education Act (IDEA) (2nd ed., book only)
By E. Maruyama, B. E. Chandler, G. F. Clark, R. W. Dick, M. C. Lawlor, & L. L. Jackson, 1999. Bethesda, MD: American Occupational Therapy Association. ($40 for members; $50 for nonmembers. To order, call toll free 877-404-AOTA. Also available packaged with CD-ROM Discover IDEA '99.)
The Tool Chest for Teachers, Parents, and Students
By D. Henry, 2001. Bethesda, MD: American Occupational Therapy Association. ($20 for members; $30 for nonmembers. To order call toll free 877-404-AOTA.)
Tammy Sarracino, MEd, OTR/L, BCP, is an owner of TherAbilities, Inc., a pediatric occupational and physical therapy practice in central Pennsylvania. She is also an educational consultant for the Pennsylvania Training and Technical Assistance Network and a member of the AOTA ASPIIRE cadre. She can be reached at email@example.com.
Lynn A. Dell, MS, CCC/SLP, is an educational consultant/ program manager with the Pennsylvania Training and Technical Assistance Network. She is the statewide coordinator for Pennsylvania's Initiative on Serving Students With Autism Spectrum Disorder and the Statewide Speech Retraining Program. She can be reached at Ldell@pattan.k12.pa.us.
Sherry L. Milchick, MEd, CABA, is an educational consultant with the Pennsylvania Training and Technical Assistance Network. She coordinates Pennsylvania's School-Wide Effective Behavior Support training and provides training on autism. She can be reached at firstname.lastname@example.org.