Rehab Services for the Autistic Child

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• Rehab Services for the Autistic Child
• October 20, 2009

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Services

• Occupational Therapy
• Physical Therapy
• Speech Language Therapy
• Audiology
• http//www.snhmc.org/medical/rehabilitationservice
  s.htm

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Locations

• Hudson
• Pediatric Rehab Center, 5 George Street
• 300 Derry Road
• Nashua
• 460 Amherst Street
• 280 Main Street
• 5 Merrit Parkway
• 10 Prospect Street (Audiology)
• Merrimack 696 DWH
• Milford 10 Jones Road
• Inpatients

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Specialty Programs

• Hearing Aids
• Diagnostic Auditory Brainstem Response
• Hand Therapy
• Lymphedema
• Wound Care
• Aquatic Therapy
• Vestibular
• Wheelchair Management
• Womens Health/Incontinence

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Pediatric Specialty Programs

• Sensory Integration
• Feeding Team
• Therapeutic Listening

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FYI

• 100 of all SNHRC patients/parents who
  completed a recent patient satisfaction survey
  would refer others to our Rehabilitation Centers!!

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Pediatric Rehab Center

• 5 George Street, Hudson, NH
• 603-579-3601

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Pediatric Rehab Staff
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Speech Language Pathology ServicesBrenda L.
Lynch MS, CCC-SLP/L
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Pervasive Developmental Disorders in the DSM-IV
Autistic Disorder Retts Disorder
Aspergers Syndrome Childhood
Disintegrative Disorder
Pervasive Developmental Disorders-Not Otherwise
Specified
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Role of the Speech-Language Pathologist

• Children are often referred to SLPs due to
  concerns regarding delays or differences in their
  language, social interaction skills and overall
  play/behavior.
• An SLP alone cannot diagnose Autism Spectrum
  Disorders at this time. This should be done by a
  multidisciplinary team of professionals
  (developmental pediatrician, speech-language
  pathologist, occupational therapist,
  psychologist, etc.).

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Role of the Speech-Language Pathologist

• A child is not required to have a formal
  diagnosis of ASD before we can start therapy.
• Any child can be referred for an evaluation by
  their pediatrician and/or family if there are any
  concerns regarding overall communication skills.
• Following the initial assessment at the Pediatric
  Rehabilitation Center, treatment can begin to
  address the childs communication weaknesses and
  build upon their strengths.

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Role of the Speech-Language Pathologist

• The SLP will complete a comprehensive
  assessment on the childs communication and
  symbolic play skills via observation, parent
  interview, and administration of standardized
  and/or non-standardized assessment tools.

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Red Flags for ASD

• Significant impairments in a childs ability to
  use non-verbal communication (eye contact,
  pointing, gestures, or facial expression) to
  regulate social interaction.
• Significant delay/difference in spoken language
  not compensated through alternative modes of
  communication.
• Impaired spontaneous seeking of shared interests
  or enjoyment with others (i.e., lack of
  bringing/showing or pointing out objects of
  interest to others).
• Does not respond to name when called.
• Often will not initiate social turn-taking games
  as a toddler (peek-a-boo, patty cake, etc.) .

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More Red Flags for ASD

• Delay or absence of pretend or symbolic play
  prior to age three.
• Stereotypical or scripted language use
  significantly challenged ability to initiate and
  sustain conversational exchanges.
• Restricted or repetitive interests or patterns of
  behavior (i.e., hand flapping, significant
  difficulty adjusting to changes in routine).
• Preoccupation with parts of objects or
  inappropriate use of objects.

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Communication Skills

• Communication is the process by which information
  is exchanged between individuals. It involves a
  shared understanding of gestures, body language,
  sign language, vocalizations (laugh/cry), and
  spoken language.

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Receptive Communication

• Response to sounds or voices
• Understanding of words and concepts
• Ability to follow commands/directions
• Ability to respond to Wh questions (what,
  where, who ,why, what isdoing)

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Expressive Communication

• Involves both verbal (sounds/words) and nonverbal
  ways (eye contact, pointing, nodding, gestures)
  in which we interact with others and regulate
  attention
• Language Refers to words, vocabulary, and
  grammar development
• Speech Refers to the articulation or production
  of speech sounds

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Play Skills

• Children with ASD often display delays or
  differences in their symbolic play skills,
  imitation, and attention, as well as a limited
  range of interests.

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Social Communication Skills (pragmatic language
skills)

• Social Disability is the core and defining
  symptom in all ASDs.
• Often children with ASD use their language for
  limited communication functions including
  requests, protests, and label.

• The goal is to expand the range of communicative
  intents/functions that a child uses to decrease
  tantrums, increase reciprocal communication with
  peers, parents and teachers.

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Some Important Things to Know Before You Get
Started

• Your child begins to communicate when
• S/he learns to pay attention to you
• Finds enjoyment in two-way communication
• Learns to copy the things you do and say

• Learns to understand what others say
• Learns to interact with others, especially other
  children
• Structure and routine are part of the
  communicative process

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Treatment

• Individual therapy is designed to address each
  childs specific communication needs using a
  social communication approach.

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Treatment

• Naturalistic routines and preferred play
  activities are incorporated into each session.
• Sessions will focus on providing support,
  education, and information for parents.
• Caregivers are taught how to use everyday
  meaningful activities to facilitate optimize
  their childs communication and interaction
  skills.

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More Treatment

• SLP will utilize a total communication approach
  utilizing words, gestures, pictures, and print to
  maximize the childs comprehension and use of
  language.
• Augmentative communication systems may be
  utilized using digital photos, Boardmaker images,
  the use of Picture Exchange Communication
  Systems (PECS).

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Social Stories

• Children with ASD often struggle to read,
  interpret, and respond effectively to their
  social world.
• Social stories describe how people act and feel
  in difficult situations give some ideas about
  what to say or do in those situations.

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Social Stories

• Social stories are helpful in teaching children
  about unpredictable or novel situations
• Going to the dentist
• Thunderstorms
• Riding the bus
• Fire alarms

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Occupational TherapyKara Myers MS, OTR/L, SIPT
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Whats my role as an Occupational Therapist?

• Promote skill development and independence in all
  daily activities
• Analyze all internal and external factors that
  are necessary for individuals to perform
  activities
• Evaluate a childs skills abilities- self care,
  play skills, fine motor skills, motor planning,
  visual perceptual, sensory integration, etc.
• Assess environmental factors
• and community supports

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Role of OT

• Perform a comprehensive evaluation based on
  clinical observations, parent interview and
  administration of standardized and/or
  non-standardized test.
• Develop an appropriate plan of care to facilitate
  the individual needs of each child.

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Treatment Four Key Principles

• Just Right Challenge
• The child must be able to successfully meet the
  challenges presented to them.
• Adaptive Response
• The child adapts their behavior with new and
  useful strategies in response to the challenges
  presented.
• Active Engagement
• The child will want to participate because the
  activities are fun.
• Child Directed
• The childs preferences are used to initiate
  therapeutic experiences within the session.

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What is Sensory Integration?

• Our bodies and the environment send our brain
  information through our senses. We process and
  organize this information so that we feel
  comfortable and secure. We are then able to
  respond appropriately to particular situations
  and environmental demands.

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I Thought There Were Only 5 Senses!

• Vision
• Hearing
• Touch
• Smell
• Taste
• Vestibular
• Proprioception

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What is Sensory Integration Dysfunction?

• Inappropriate and inconsistent responses to
  sensory stimulation
• Difficulty organizing and analyzing information
  from the senses
• Reduced ability to connect or integrate
  information from the senses
• Difficulty using sensory information to plan and
  execute actions

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Hyper-Reactivity

• Distress with certain sounds
• Sensitivity to light
• Discomfort with certain textures
• Aversion to certain smells tastes
• Irrational fear of heights and movement
• Frequent startle reactions
• Extreme discomfort with grooming tasks

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Hypo-Reactivity

• Excessive need for movement, climbing, jumping
• Disregard of sudden or loud sounds
• Unaware of painful bumps, bruises, cuts, etc.
• Absence of startle reactions
• Lack of attention to environment, persons, or
  things
• Lack of dizziness with excessive spinning

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Sensory Activities Used in Treatment

• Tactile Activities
• Massage
• Texture box- texture balls, lamb wool, sponges
• Rice bin treasure search
• Finger-painting
• Play-doh, Clay, Therapy Putty
• Foam soap, shaving cream
• Thera-Pressure Protocol
• Mystery box- Labeling objects by touch alone (no
  vision)

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More Sensory Activities Used in Treatment

• Proprioceptive Activities
• Wheelbarrow walks, Animal walks
• Playing tug of war
• Squishing between large pillows
• Therapy ball activities
• Scooter board activities
• Joint compressions
• Wearing a weighted vest or lap pillow
• Hanging from a trapeze bar
• Hot dog bun pillow with weighted ketchup
  mustard

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Sensory Activities Cont.

• Vestibular Activities
• Jumping
• Swinging
• Spinning
• Rocking
• Climbing
• Riding toys
• Bouncing on therapy ball

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More Activities

• Oral Motor Activities
• Bubbles
• Blow toys
• Straw drinking
• Vibrating toothbrush, Jigglers, z-vibe
• Chewing gum
• Sour/bitter snacks

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Sensory Diet

• A planned and scheduled activity program designed
  to meet a childs specific needs.

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Sample Sensory Diet
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Environmental Accommodations and Modifications

• Offer a hide out place to retreat to when
  over-stimulated
• Decrease visual and auditory stimuli to minimize
  distraction
• Use body pillows, weighted blankets, heavy
  quilts, to offer calming input
• Use timers to alert your child to the beginning
  and end of an activity
• Have heavy work jobs available for your child
• Establish routines and be consistent in following
  them
• Use touch to get your childs attention if
  calling them doesnt work
• Whenever possible, give visual cues when giving
  directions

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Therapeutic Listening

• A program that uses specially modified music
  along with sensory integration stategies to
  promote the emergence of involved time space
  organization, handwriting, visual motor skills,
  motor control, timing social interations.
• Combines the musical elements of tone, rhythm,
  melody, harmony, timbre/texture, space
  instrumentation modulation to create a unique
  listening program that is individually tailored
  to each child.

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Fine Motor Skills

• Pencil grasp
• Handwriting
• Cutting
• Pasting
• Tool use- stapler, hole punch, tape dispenser
• Sequencing
• Organization

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Self Care Skills

• Dressing
• Shoe tying
• Fastening buttons, zippers and snaps
• Self feeding and utensil use
• Hygiene tasks

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Physical Therapy ServicesLinda Peterson, PT
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PT and Autism

• According to the National Autism Association a
  child with autism spectrum disorders may benefit
  from PT if they have the following indicators

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These Indicators Are

• Increased muscle stiffness or tightness
• Delay in obtaining motor milestones
• Poor balance and poor coordination
• Difficulty in moving through the environment
• Muscle weakness
• Pain

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According to the American Physical Therapy
Association

• Interventions for autism spectrum disorders
  traditionally have been the functions of
  pediatricians, OTs and SLPs.
• However decreases in muscle tone and strength,
  decreased balance and coordination and general
  lack of physical fitness relative to autism
  spectrum disorders are not as minor as once
  believed.

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According to Shelley Goodgold, PT, ScD, Professor
of PT at Simmons College

• If you take a child with impairments in verbal
  and social skills, and then, on top of that, they
  have motor problems, they are really at a
  disadvantage when it comes to physical play, in
  sports and on the playground, that can be the key
  to making friends and learning to participate in
  social activities.

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What Does a PT Do for Children With Autism?

• We work as a team including communicating with
  early intervention specialists, school based
  therapists, therapeutic riding specialists, and
  aquatic based therapists.
• We work as a team in our facility with
  significant input from OT and SLP and will
  facilitate co-treatments as needed.
• If a child is referred for PT but has significant
  fine motor or sensory processing issues, we
  facilitate an OT referral.

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Children With Autism May Have Difficulty With the
Following Gross Motor Activities

• Ascending or descending stairs reciprocally (one
  step and then the other)
• Kicking a stationary or rolling ball
• Balancing on one foot
• General motor planning including transitioning
  between activities
• Uneven gross/fine motor skills such as not being
  able to kick a ball or jump but having the
  ability to stack small blocks

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What Are Some of the Techniques We Use?

• We break tasks into small chunks. To bike ride,
  we work on pedaling first with feet secured, no
  steering component or need to concentrate on
  keeping feet on.
• We use structured activities including a picture
  board.
• We know from research in motor learning that we
  need to integrate skills in multiple settings for
  carryover. For example, stair climbing may be
  practiced coming into the clinic, walking up the
  clinic stairs and walking up the practice stairs
  in the treatment area.

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Therapy Techniques

• We use verbal cues, physical prompts,
  demonstration and lots of repetition.
• We try to separate behavioral issues from how a
  child is moving. Sometimes if behavioral
  problems are severe, people may not notice how
  the child is actually moving.
• We tailor the environment to the child. Do we
  need a busy room or quiet room?

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In the End

• PTs try to develop therapeutic programs for
  strengthening core muscles and improving motor
  planning, balance, and ball skills that enable
  children with autism spectrum disorders to
  participate in activities that are crucial to
  social integration.

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Johnny

• Cried throughout his initial evaluation.
• Signed and verbalized bye bye to end PT.
• Did not tolerate any tactile input from this PT.
• Did not follow single step directions.

• Internally distracted

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Johnny 6 weeks later

• Enters the building smiling.
• Signs and verbalizes more for specific tasks.
• Allows tactile input from PT.
• Follows one step directions.

• On Zip Line

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Johnny continued

• Would initially sink in ball pit.
• Cried as he was unable to stand up or get out of
  ball pit.
• Now stands and gets out of ball pit independently
  or with a few cues.

• Independently transitioning

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Johnny Continued

• Did not perform any activity on command
  initially.
• Now kicks a ball, at times with a slight delay,
  two of three trials.
• Now transitions between activities and treatment
  rooms with a picture schedule without tears or
  bye bye.

• Getting ready to kick

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Questions ?????