Autism Spectrum Disorder (ASD) Overview

• The notes summarize information about Autism Spectrum Disorder (ASD).
• They cover diagnostic criteria (DSM-5), levels of severity, facts about autism, identification, assessment, roles of occupational therapy (OT), various intervention strategies, and family support.

DSM-5 Diagnostic Criteria

• Persistent deficits must occur in social communication and interaction across multiple contexts.
• Deficits in social-emotional reciprocity exists.
• Deficits occur in non-verbal communication behaviors used for social interactions.
• Deficits include developing, maintaining, and understanding relationships.
• Restricted, repetitive patterns of behaviors, interests, or activities must be manifested by at least two of the following.
• Stereotyped or repetitive motor movements, use of objects, or speech exists.
• Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or non-verbal behavior occurs.
• Highly restricted, fixated interests are evident, and are abnormal in intensity or focus.
• Hyper- or hyporeactivity to sensory input/unusual interest in sensory aspects of the environment is present.
• Severity is based on the level of social communication impairments and restricted, repetitive patterns of behavior.
• Symptoms must be present in early development.
• Symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning.
• The disturbances are not better explained by intellectual disability or global developmental delay.

Specifiers

• Specify if with or without accompanying intellectual impairment.
• Determine presence of absence of accompanying language impairment.
• Note any association with a known medical/genetic condition or environmental factor.
• Determine presence of catatonia.

Severity Levels for ASD

• Requiring support (Level 1): Deficits cause noticeable impairments, difficulty initiating social interactions, and atypical/unsuccessful responses to others.
• Requiring substantial support (Level 2): Marked deficits in verbal and non-verbal communication skills exist, with limited initiation of social interactions.
• Requiring very substantial support (Level 3): Severe deficits in verbal and non-verbal social communication skills cause severe impairments in functioning, with minimal response to social overtures.

Facts about Autism

• Prevalence:
  • Worldwide prevalence is 1.09 per 10,000, or 436 per 10,000.
  • Median prevalence is 100 per 10,000.
  • WHO estimates 1 in 100.
  • The Autism & Developmental Disabilities Monitoring Network (USA) estimates 1 in 44 children aged 8 years.
  • Identical twins: 36-95% chance of the other twin having it.
  • Non-identical twins: 0-31% chance of the other twin having it.
  • Child with ASD: 2.18% chance of the next child having it.
  • Median of 33% of individuals with ASD have ID (IQ<70).
• Common comorbidities include anxiety, epilepsy, ADHD, and sensory issues.
• 40% of children with ASD don't talk.
• 25% have some words at 12-18 months.

Identifying ASD

• Development surveillance may identify risk of developmental delay, deviance/abnormality.
• Early identification leads to early referral and intervention, which improve functioning.
• Screening:
  • No ASD-specific screening tool has been identified.
  • Checklist for Autism in Toddlers (CHAT) / Modified Checklist for Autism in Toddlers (M-CHAT) can be used.
  • High-risk populations should be screened at 18 months and 24 months.
• For children with 1+ of:
  • no babbling pointing or other gestures at 12 months of age
  • no single word at 18 months of age
  • no two-word phrases (spontaneous, non-echoed) at 24 months
  • any loss of language or social skills at any age
• should be referred for comprehensive developmental evaluation.

Assessment and Diagnosis

• Complex assessment by a trained multidisciplinary team will:
  • Obtain wider contextual and functional implications.
• Tools as needed include:
  • ASD-specific developmental history.
  • Direct observation..
• ASD-Specific developmental history
  • Autism Diagnostic Interview-revised (ADI-R)
  • Diagnostic Interview for Social Communication Disorder
• Direct observation
  • Autism Diagnostic Observation Schedule (ADOS)
• Purpose of assessment is to:
  • Review functioning in relevant domains.
  • Confirm diagnosis.
  • Create individualised intervention plan.

Roles of OT in ASD

• Occupational therapists can be part of a larger diagnostic team.
• They may be involved in direct diagnostic using ADOS and direct observation (ados/cars2).
• Clinical observations aids diagnosis.
• OT's will perform intervention in variable settings like school, home, childcare, clinic, playground
• OT evaluation involves reviewing:
  • Background of child.
  • Environment: physical & social.
  • Strengths and weaknesses.
• OT intervention incorporates a strength based interview.
• OT addresses occupational performance which may include:
  • routine based interview.
• Evaluate performance components such as:
  • fine/gross motor
  • sensory responses
  • visual perceptual
  • cognitive & adaptive skills
  • personal social skills

Core concepts for OT Intervention

• PEO model for intervention, which looks at:
  • Person
    • Affect all areas, especially early skills
    • Critically affects social interaction
  • Environment
  • Persons with ASD experience challenges in various environment
    • Especially when social demands are high or stimuli is novel
  • Occupation
  • Anticipation of routine
  • Social skill
  • Responsive smiles
  • Imitation
  • Bath time

AOTA Guidelines for Interventions

• Skills, communication, restrictive behaviours and play behaviours
• Social and activity group planning
• Facilitated communication
• Behavioral training and physical activity to limit repetitive behaviour

Services in SG

• Referral and diagnosis through:
  • KKH/NUH
• Then moving into early preventions programs:
  • EIPIC
  • DSP
  • ICCP
• Support at school at different levels:
  • AED
• SPED - Specialised schools

Evaluation of occupational performance

• Setting and context considerations should be accounted for.
• Utilize Multi-D/discipline specific assessment.
• Consider Standardized/non-standardized assessments.
• Play as an evaluation method.
• Consider the role of family.
  • Identify family & sibling concerns/issues
• Evaluation should include: ADL, IADL, Play, school performance (teen/adolescent: vocation)
  • Evaluate Specific components, (if relevant):
  • Gross/fine motor, visual perception & sensory processing.

Main intervention points

• Leisure participation: recess intervention, leisure group/social narratives
• Sensory regulation by:
  • Individualised goal area planning - use Ayres Sensory Integration (ASI)
  • Occupational performance & behaviour regulation improved by multi-sensory activities
  • Weighted vests should not be used
• Performance interventions:
  • Performance in work, ADL, IADL, education, rest and sleep
  • Work behaviours & performance improved using video-modeling & visual supports
  • ADL/IADL performance improved by using cognitive-behavioural techniques
• Parent and caregiver support
• Parents' self-efficacy, confidence & competence improved by behavioural interventions
  • Parenting skill & knowledge, family
• Consider resources available and potential harm

Intervention Models

• For Preschool child with Autism, use Comprehensive early intervention programme with:
  • Systematically planned activities
  • Individualised attention
  • Proactive management with neurotypical children

Key Interventions

• Early Intensive Behaviour Intervention
• Program of TEACCH
• More then words

Address family function

• Evaluate skills & participation to support their family function and quality of life
• Transition Planning

Communication development plan

• PECS - Picture Exchange Communication System
• AAC System

Addressing social skills and Challenges

• Work on cues and expressiosn
  • Direct and Explicit instruction
  • Modelling

Other key info to cover

• Unusual sensory response
• family and career support