Treatment strategies for OT's and SLP

What are 4 take home treatment strategies and rationale that SLP’s and OT’s can apply given the literature and discussion from the blog?  OT’s and SLP’s  can compliment each other’s therapy in many ways!  It is always nice to have an extra set of hands, ears,  as well as eyes!  Also, (as the old saying goes) “two brains are better than one”!  Our students with an ASD are complex people and never present the same.

1.       Categorization:   As we have learned and according to a study by Gastgeb (2006), person’s with autism have difficulty categorizing and this greatly impacts how information is processed. What a super way to incorporate language while sorting different items!  This adds an additional component to maintain attention while using an augmentative device or speech to communicate. 

2.       Attention: As studied in the article by Wang (2007), attention is the key factor in determining performance of tasks with individuals with ASD.  Wang suggests that while people with ASD are capable of global processing, they have a marked preference to local processing. (Wang, Mottron, Peng, Berthiaume, & Dawson, 2007).  Therefore, during co-treatment, therapists are able  to use language to encourage processing and understanding parts and the whole!  For example, while an OT works on dressing skills, a SLP may use an iPad to show and discuss ALL of the items needed to get dress for school.  This difficulty looking at the whole picture or weak central coherence results in a “disjointed internal social world” ( Miller-Kuhaneck ,3rd edition ).  A co-treatment could also include social scenarios’ to help socially while also addressing the need to process globally.   

3.       Sensory processing:  By co-treating with a SLP, you can simultaneously "attack" the sensory system to help organize and prepare a child for the components that a speech therapist is working on.  Providing appropriate oral motor stimulation helps to improve the ability to tolerate a variety of touches, textures, tastes and smells.  This can better  prepare for feeding and communication.   Appropriate sensory input also helps to increase or decrease arousal levels and puts a child in a more optimal state for learning.  This is needed to reach the goals of the OT and SLP (retrieved from: http://www.pediastaff.com/blog/tag/sensory-processing-disorder/page/3).

4.       Motor planning:  Perception is a major contributor to successful motor-planning.  Intersensory integration of visual, vestibular, and proprioception inputs guide motor execution ( Miller-Kuhaneck ,3rd edition ).  If a child has poor awareness throughout their body  they are going to have a much harder time coordinating their mouth muscles as well. To effectively communicate, a child needs to attend, maintain control of their body, and understand where their body is in space. Postural control is also regulated by the information that the vestibular and proprioceptive systems sends to our muscles. This can and does affect a child’s ability to use their breath support muscles for speech.   Providing movement can increase sound production and is frequently reported from the speech therapist I work with as a nice side effect with some children! While improving body awareness and motor planning (which includes the muscles of the face and mouth), the ability to imitate actions, sequences, and sounds will also improve. (retrieved from: http://www.pediastaff.com/blog/occupational-therapy-and-speech-therapy-why-we-need-each-other-2378).   Motor control as well as the ability to register an auditory event are affected by “the use of a feedback rather than a feed forward mode of control” (Schmitz,2005).  So by combining a motor event with auditory input may allow the child to better process the information and be able to feed forward  with the task in the future.   

Occupational and speech therapy are intimately linked as well as the  reasons for treatment strategies.  For example while bouncing on a therapy ball during a co-treatment and working on speech goals, a sensory component is being added, vestibular/proprioception input for better motor control, as well as improving attention.   Another wonderful benefit of co-treatments is the ability to incorporate the goals of the SLP as well as the OT.  This carries over into individual treatments as well!  

 

Motor Challenges and the impact on cognition and perceptual skills

Autism is associated with a wide range of motor challenges including:  difficulties with gait, postural control, balance, coordination, skilled movement, praxis, oral motor, and imitation. According to Miller-Kuhaneck (3rd edition), “motor symptoms are the earliest observable behaviors that currently are considered reliable in helping to diagnose autism” (pg165).   Children with autism frequently have trouble with pre-planning, planning, and programming which leads to difficulty with the movements listed above.  This is because of the difficulty perceiving and correctly processing sensations.

 In the article by Schmitz (2003), we learned how children with an ASD were slow to unload and used feedback rather than feedforward control to maintain postural stability. In the articles by Vernazza-Martin (2005) and Rhineheart et al (2006), we learned that children with an ASD have difficulty with motor planning.  Rhineheart (2006), also demonstrated the phenomenon known as kenesia paradoxa.   Kenesia paradoxa is increased motor impairments during tasks that require the least amounts of cognitive input.  This taught us to think differently about task analysis and breaking tasks into small parts as OT’s!

It is obvious that cognition plays a major role in motor actions because of not only the executive functions (planning) that are required for a successful task to be completed but also the ability to learn a new task.  This is another area where children with autism have had difficulties.  They also have difficulty retaining information from those new tasks so when the task is attempted again they have difficulty using that motor memory.  This is frequently why these children appear clumsy, unorganized, or inattentive.  If a child is cognitively motivated to participate in a task the performance and effort will also improve.

Perception is a major contributor to successful motor-planning.  Intersensory integration of visual, vestibular, and proprioception inputs guide motor execution.  When there are deficits in motor actions because of sensory processing we call children dyspraxic ( Miller-Kuhaneck ,3rd edition). 

Cognition and perception are closely related because to accomplish an action requires sustained attention.  This depends on the ability to maintain an alert state.   Sensory modulation and emotional responsiveness can impact whether a child responds hyper or hyporesponsivity.

Social aspects also play a role in motor execution.  We have all seen the positive response when using a peer to model a task and ask our students to then imitate the movement.  In Schultz article (2003), he stated that “repetitive behaviors are believed to have an important function in reducing the stress that results from the social deprivation” (pg.127).  

References:

·         Autism: A Comprehensive Occupational Therapy Approach 3rd edition Miller-Kuhaneck & Watling

·         Rinehart, Bellgrove, Tonge, Brereton, Howells-Rankin, and Bradshaw (2006) An examination of movement kinematics in young people with high functioning autism and asperger’s disorder: Further evidence for a motor planning deficit. Journal of Autism andDevelopmental Disorders. 36: 757-76.

·         Schmitz, Martineau, Barthelemy, and Assaiante (2003) Motor control and children with autism: deficit in anticipatory function? Neuroscience Letters, 348: 17-20.

I love the understanding this mother has of her son and how well she can articulate the difficulties he has.

Listen to this playlist: elaine1919's Playlist

Sensory challenges and the impact on perceptual skills

http://www.youtube.com/watch?v=AbeyIG7Fz8s&feature=related

Consider the sensory challenges in children with autism:  how may this impact perceptual skills?

Sensory processing is a challenge with many children who have an ASD. The study by Minshew (2008),  reports that a significant proportion of individuals with autism of all ages experience sensory sensitivities. This can lead to developmental, social, and academic delays.  Difficulty processing information, by parent report may be one of the first indicators of autism.  Unfortunately unless sensory  integration dysfunction is severe, people in the community and sometimes even parents mistake sensory processing difficulties with bad behavior, trouble learning in school, or just slow to process.  Four A’ have been developed to summarize and group sensory processing deficits in persons’ with an ASD (Miller-Kuhaneck 2010).  They include arousal, attention, affect, and action.  Arousal is the ability to remain alert and transition between sleeping and waking.  Attention is the ability to focus on something specific without becoming over or understimulated.  Affect is the behavior component and can lead to social adversion, fear, anxiety, emotional lability, or a flat affect.  The 4^th A is action.  This is the goal-directed behavior and when not carried out effectively can lead to clumsiness, decreased fine and gross motor skills, and praxis deficits (Miller-Kuhaneck 2010, page 137).  Each of the 4 A’s is influenced by the others and all interrelate.  If one area is affected therefore a person will demonstrate challenges in all areas.    

Perceptual skills involve an active process of discriminating sensory information, filtering out irrelevant information, and discriminating specific object and environment characteristics by actively exploring  Miller-Kuhaneck (2010 pg. 392).  Dr. Ayres described sensation as  ” food for the brain” (Ayers,J).  It is easy to understand if you are getting "too much or not enough food" and sensations are not being properly processed, that your perception of the world can be misconstrued.   The following is a clip developed by a person with autism to give us a glimpse into his world when he receives too much sensory  information: http://www.youtube.com/watch?v=BPDTEuotHe0&feature=related.   Once children with an ASD and their families understand sensory integration all aspects of their lives can be better managed, therefore improving the quality of life!

References:

Ayres,J.,& Robbins,J. (2005).  Sensory Integration and the Child:  understanding hidden sensory challenges. http://books.google.com/books?hl=en&lr=&id=-7NeFNFswo0C&oi=fnd&pg=PR9&dq=sensory+integration&ots=iJfqwfPaMi&sig=181VM3DTQARFhd0kXGkQLe6BMOY#v=onepage&q&f=false

Autism: A Comprehensive Occupational Therapy Approach 3rd edition Miller-Kuhaneck and Watling

Minshew, N. & Hobson, J. (2008) Sensory sensitivities and performance on sensory  perceptual tasks in high functioning individuals with autism. J Autism Dev Disorders, 38: 1485 – 1498.

selective attention test

Attention

Posting #3:  Consider attention challenges in children with autism.  How may this impact development of cognition?

People with, and without Autism vary in their cognitive abilities.  Human cognition involves the perception, processing, acquisition, retrieval, transformation, use and exchange of knowledge.  There are several differences that have been found in the way persons with ASD process information which affect cognition.  This includes categorization of information and local versus global processing.

  As we have learned and according to a study by Gastgeb (2006), person’s with Autism have difficulty categorizing and this greatly impacts how information is processed.  Categorization begins as an infant and becomes more complex as we learn to automatically sort through the extensive information our senses bombard us with.  If we are not able to filtering out irrelevant information it is hard to focus our attention on what is important or to even have a way to remember and therefore recall information. 

As studied in the article by Wang (2007), attention is the key factor in determining performance of tasks with individuals with ASD.  It was noted in the study that if the task was a locally oriented task (Embedded Figures Test, visual search, block design), then person’s with ASD did superior to controls (TD’s).  Unfortunately, it was more difficult to process and interpret information in a global perspective for person’s with ASD. Wang suggests that while people with ASD are capable of global processing, they have a marked preference to local processing. (Wang, Mottron, Peng, Berthiaume, & Dawson, 2007)

Local processing (or over select),  refers to an individual's tendency to focus on minute characteristics of an object or person, rather than the whole. For example, when looking at a car a child with ASD might not focus on the totality of the car (color, shape, individual parts), but instead will focus their attention only on one part such as the wheels. This  interferes with the understanding of what a car is because a car is obviously more than just its wheels. This tendency to focus their attention on specific features of an object or person rather than the whole hinders learning new concepts and interferes with the child's ability to interpret relevant meaning from information in their environment.

Another tendency often seen in individuals with ASD that can affect their ability to learn, is focused attention on a specific object or activity. This focused attention can last for a long time and can also be difficult to interrupt.  For example, if a child with autism has focused his attention on trains, he may continually choose to line up trains and resist playing with other toys. Focused attention may prevent a child from being able to shift attention to other people or other activities  such as a parent entering the room, a teacher giving instructions, or another child attempting to join in his/her play.

Here is a test of selective attention: (available on 4th post!).  If you have never tried it you will be amazed and really have a better understanding of why it’s so hard for children who have a difficult time with gestalt to really understanding the whole picture!

References:

Wang, L., Mottron, L., Peng, D., Berthiaume, C., & Dawson, M. (2007). Local bias and local-to-global interference without global deficit; A robust finding in autism under various conditions of attention, exposure time, and visual angle. Cognitive Neuropsychology, 550-574.

Gastgeb, H. Z., Strauss, M. S., & Minshew, N. J. (2006). Do Individuals With Autism Process Categories Differently? The Effect of Typicality and Development. Child Development, 1717-1729.

2nd posting concerning the concept of categorization

            Life could seem like a continuous 3 ringed circus without the ability to categorize!                     

Describe the concept of categorization. Categorization reduces the demand on memory and allows an individual to focus on the important information and ignore what isn’t needed (Gastgeb & Minshew, 2006). This brings to mind the u-tube of Carly where she describes how when she looks at someone’s face her brain takes hundreds of pictures and that’s why people with autism don’t make eye contact. All of those pictures are overwhelming.

How are categorization skills impacted in people with autism? If a person with autism has difficulty categorizing information , it could significantly impact their ability to communicate, their behavior, and their social functions. Obviously, if a child is unable to organize, and make sense of their world they could easily become over stimulated and overwhelmed. This could be why we see children with ASD want a routine that they can predict or why they may withdraw from others. They may even not understand what others are communicating because they can’t seem to filter out what isn’t important and what is (Gastgeb & Minshew, 2006).

What are the implications of impairments in categorization upon cognitive and perceptual skills? When categorization is difficult, a task must be broken down. This will make it less complex and therefore easier to processing. Once a child is able to process a task they can then be successful in learning the information! In our treatment sessions as therapist, we do this by aiming to present activities that are “just right”. This means that we present activities that challenge the child but allow them to also be successful. We need to consider the activity and how it can be broken down as well as other information the child may be taking in. If the child becomes easily over stimulated by any of his other sensory systems this also needs to be addresses as not to overwhelm his capacity to process (Bertone,et,al 2005).
　Resources:
Gastgeb, H.,& Minshew, N., (2006). Do Individuals With Autism Process Categories Differently? The Effect of Typicality and Development. Child Development, 77:1717-1729.
Bertone,A., (2005). Enhanced and Diminished Visuo-spatial Information Processing in Autism Depends on Stimulus ComplexityOxford Journals,128:2430-2441.,

Information processing in autism

      

Question #1

 Information processing in autism?

Information processing in autism is obviously different than a neurotypical.  Several theories have been proposed to explain why this is.  They include:

·         The large brain size in autism suggests that not just one location in the brain but a pervasive abnormality affects the way the way information is processed (Herbert & Kenet,2007).  There are also several specific structures of the brain that affect the way information is processed in individuals with an ASD (ie. the frontal cortex, gyrus, temporal lobe, limbic system, cerebellum).

·         Frith (1989), coined the term weak central coherence (WCC).  This style of information processing suggests that neurotypicals use central coherence to process and interpret information in a global or gestalt approach.  Meanwhile individuals with ASD process information in a peripheral coherence and as a result have only separate pieces of unrelated information available to use when processing. 

·         Gomet (2005), used an fMRI study and demonstrated that as a processing load is placed on children with autism the breakdown increases.  This may explain why there is a tendency with autism to ignore novel stimuli and be resistant to change.

·         Research has shown differences in the way the nervous system processes and responds to information through neurotransmitters and neuromodulators of persons with ASD and neurotypicals.  This is an integral part of the communication system and can have a huge impact on arousal level, GABA (responsible for information processing), motor activity, motivation, cognition, and sensory processing,  (Miller-Kuhaneck, 2010).  These areas affected will all contribute to altered behavior which directly tie into a persons ability to process information.

                                                           References

Frith,U. (1989). Autism:Explaining the enigma. Oxford:Blackwell

Gomot,M.(2006).Change detection in children with autism: An auditory event-related fMRI study. NeuroImage 29 (2006).475-484.

Herbert,M.R.,& Kenet, T. (2007).  Brain abnormalities in language disorders and in autism. Pediatric Clinics of north America,54(3),563-583.