Autism Spectrum Disorder (ASD)

A developmental disability that can pose social, communication, and behavioral challenges for the client. This review is relevant also for Asperger’s Disorder, and PDD-NOS.

Signs and Symptoms

• Social communication and interaction skills (don’t worry too much about the ages, provided just FYI):
  • Avoids or does not keep eye contact.
  • Does not respond to name by 9 months of age.
  • Does not show facial expressions like happy, sad, angry, and surprised by 9 months of age.
  • Does not play simple interactive games like pat-a-cake by 12 months of age.
  • Uses few or no gestures by 12 months of age (for example, does not wave goodbye).
  • Does not share interests with others by 15 months of age (for example, shows you an object that they like).
  • Does not point to show you something interesting by 18 months of age.
  • Does not notice when others are hurt or upset by 24 months of age.
  • Does not notice other children and join them in play by 36 months of age.
  • Does not pretend to be something else, like a teacher or superhero, during play by 48 months of age.
  • Does not sing, dance, or act for you by 60 months of age.
• Restricted or repetitive behaviors or interests, e.g.,
  • Lines up toys or other objects and gets upset when the order is changed
  • Repeats words or phrases over and over (called echolalia)
  • Plays with toys the same way every time
  • Is focused on parts of objects (for example, wheels)
  • Gets upset by minor changes
  • Has obsessive interests
  • Must follow certain routines
  • Flaps hands, rocks body, or spins self in circles
  • Has unusual reactions to the way things sound, smell, taste, look, or feel
• Other characteristics include:
  • Delayed language skills
  • Delayed movement skills
  • Delayed cognitive or learning skills
  • Hyperactive, impulsive, and/or inattentive behavior
  • Epilepsy or seizure disorder
  • Unusual eating and sleeping habits
  • Gastrointestinal issues (for example, constipation)
  • Unusual mood or emotional reactions
  • Anxiety, stress, or excessive worry
  • Lack of fear or more fear than expected¹ 

Concepts and Clinical Reasoning

• What is the impact on function and occupations?
  • Communication
  • Social
  • Activity performance
• Are there and what is the impact of coexisting conditions, e.g., ADHD?
• What are client’s routines and patterns?
• How can structure help? What are some structured interventions?
  • Answer: Structure is often helpful for this Dx; Timers, routine, visual activity schedules, clear physical boundaries.
• How can the environment be more supportive (e.g., distractions, sensory stimuli)?
• What is the impact on the family?
• How can the family be included, e.g., parent training?
• How can your peer interactions be promoted?
• Main Points:
  • Observation is helpful for evaluation.
  • Interviews can provide additional information for areas of concern.
  • Promote inclusion in the classroom for behavioral issues.
  • Use a collaborative multidisciplinary approach to intervention, including the parents.
  • Utilize assistive technology as needed, e.g., AAC devices, to support communication. PECS = Picture Exchange Communication System
  • Incorporate planned breaks as needed.
  • Promote skill generalization in different settings.
  • Prepare for the client’s transitions between activities.
  • Utilize modeling and video interaction.
  • Provide interventions for sleep problems.
  • Facilitate transition to adult services.² 

Assessments

Interventions

1. Behavioral: most popular is Applied Behavior Analysis (some practices are controversial among OTs).
   • Discrete Trial Training (DTT)
   • Functional Communication Training (FCT)
   • Pivotal Response Training (PRT)
2. Developmental (Early Intervention): SLP, OT (Sensory Integration, Physical skills such as gross and fine movements.
3. Educational: in classroom setting, e.g., TEACCH approach (Treatment and Education of Autistic and Related Communication-Handicapped Children).
4. Social Skills Training: e.g., floor time, social stories, social skills groups.
   • Modeling
5. Pharmacological: for hyperactivity, anxiety, self-harming; also depression, seizures, sleep problems, GI problems.
6. Psychological: anxiety, depression, other issues, e.g., CBT.⁴ 
7. Visual Supports: e.g., schedules, structured work tasks.
8. Play Therapy: also important for social skills training such as with peers.
9. Sensory Integration⁵ 

1. CDC. (2023). Autism Spectrum Disorder: Signs and Symptoms. Retrieved from https://www.cdc.gov/ncbddd/autism/signs.html[↩]
2. Kendall, T., Megnin-Viggars, O., Gould, N., Taylor, C., Burt, L. R., & Baird, G. (2013). Management of autism in children and young people: summary of NICE and SCIE guidance. Bmj, 347.[↩]
3. Watling, R. (2010). Occupational therapy evaluation for individuals with an autism spectrum disorder. In H. M. Kuhaneck & R. Watling (Eds.), Autism: A comprehensive occupational therapy approach (3rd ed., pp. 285–303). Bethesda, MD: AOTA Press.[↩]
4. Hyman, S.L., Levy, S.E., Myers, S.M., & AAP Council on Children with Disabilities, Section on developmental and behavioral pediatrics. (2020). Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics, 145(1), e20193447.[↩]
5. Lindgren, S., & Doobay, A. (2011). Evidence-based interventions for autism spectrum disorders. The University of Iowa, Iowa, 206-1.[↩]