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Core Interventions for ASD are those developed specifically as treatment for behaviors and symptoms associated with ADS.
Related and additional therapies include those therapies not exclusive to Autism, but may also be used to treat many other disorders.
Given the communication problems inherent in ASD, speech-language therapy plays an integral part in the intervention program.
Speech Therapy can be provided in the home, school or clinic setting.
Speech Therapy is provided by a certified Speech-Language Pathologist or an SLP assistant under the supervision of a certified SLP.
Diane Sisk M.S. CCC-SLP, Mobile, AL working with Grace on speech.
Communication Deficits and ASD Children with ASD can present with communication skills ranging from non-verbal to verbal communication. Communication problems most associated with ASD include:
Perseveration (repetitive verbal and physical behaviors)
Echolalia (immediate and/or delayed “echoing” of words, music, phrases or sentences)
Hyperlexia (precocious knowledge of letters/words or a highly developed abilitiy to recognize words but without full comprehension)
Dactolalia (repetition of signs), pronoun reversals, inappropriate responses to yes/no questions, and difficulty with “wh” questions
Significant deficits in social skills and pragmatics
Assessment and Intervention
The Speech Pathologist will provide a comprehensive diagnostic assessment including: receptive and expressive language, articulation, oral motor skills, feeding/swallowing, social skills and play skills, pragmatics, fluency and vocal production.
Areas of Intervention
Receptive Language – the understanding of spoken or written language including naming objects, actions, adjectives, prepositions, and people.
Expressive Language – the production of language including sentence structure, verb tenses, regular and irregular plurals, and length of utterance.
Articulation/phonology – includes developing speech sound production.
Oral-Motor Skills – includes improving the range, rate, complexity, strength and coordination of oral motor movements.
Feeding and Swallowing – includes ability to close lips, manipulate food with tongue, chewing patterns, and safe swallowing, and toleration of differences in temperature, tastes, textures, smells and consistencies.
Social skills/play skills – includes appropriate social language, ability to read facial expressions, ability to understand social cues/body language, and play skills such as sharing, turn-taking, and playing independently and with others.
Pragmatics – the use of language in social context.
Cognition – the mental processes of knowing, including awareness, perception, reasoning, and judgment. (www.dictionary.com)
Alternative or Augmentative Communication- the use of any device, techniques, symbol system, or combination of these to support or enhance communication skills.
Communication options for the Non-Verbal ASD Child Sign Language – use of ASL alone or paired with speech Picture Exchange Communication System (PECS) – the use of picture symbols to communicate wants and needs. The student is taught to initiate communication using these symbols and then skills are expanded to the use of sentences. Many children who use PECS later develop some verbal skills and move on to the use of speech as the primary form of communication.
Communication Options Continued Communication Boards – developed with either picutures, photos or real objects that the child points to or removes from the board to communicate. Other communication devices – designed to allow the user to create longer messages. These devices can also act as a universal remote which allows the user to operate electronic devices in the environments such as TV, lights, etc. Total Communication – system that pairs simultaneous production of speech with manual signs, augmentative devices or symbol systems. The child is encourage to use words and phrases that he/she is capable of and to use the signs and symbols to communicate what too difficult to produce verbally.
Speech Therapy Resources Ohio’s Parent Guide to Autism Spectrum Disorders – www.ocali.org Ohio Speech-Language Association: www.oslha.org Arkansas Speech Language Association:www.arksha.org Speech and Hearing Association of Alabama: www.shaa.org
SLP Resources “Writing and Developing Social Stories: Practical Interventions in Autism” by Caroline Smith available at Amazon.com Little Pilgrims Labeling DVD Series Available at Amazon
Physical Therapy Physical Therapists(PT) are specialists in sensorimotor development, muscle and joint function, posture, balance and coordination, and gait and functional mobility. They are knowledgeable in the use of orthotic and prosthetic devices and assistive technology. PT’s identify movement problems and determine what may be interfering with the ability to develop age-appropriate gross motor skills.
Physical Therapy Continued Physical Therapists help young children with ASD by assisting them in walking, running, jumping, pedaling, and catching. They also assist preschoolers and school-aged children in becoming safe in their daily environments, such as using stairs and climbing. PT’s are very important in helping ASD children acquire the skills necessary to play on playgrounds or participate in physical education or sports. Physical Therapy may work closely with the occupational, sensory integration, or speech therapists.
Occupational Therapy Occupational Therapy focuses on an individual’s ability to perform daily life tasks or occupations that give life meaning. Performance areas include: *activities of daily living (grooming, hygiene, dressing), feeding, eating, socialization, functional communication and functional mobility *work and productive activities and home management (meal preparation, shopping, or clothing care) *play or leisure activities
OT Continued Following an evaluation, OT intervention is targeted towards those areas that are interfering with the child’s ability to function. Targeted tasks may include: handwriting, improving hand-eye coordination, buttoning, tying shoes, getting dressed, and eating. Intervention with autistic children often includes a sensory-integration approach. This focuses on controlling sensory input during specific activities. Sensory Integration will be discussed in more detail in the next section.
School-Based OT The focus of OT in the school is upon educationally relevant goals and associated with curriculum standards OT in the schools requires consultative approach in working with the entire educational team to ensure that accommodations and interventions will be implemented and effective.
OT Areas of Intervention Fine-Motor control/written output – fine-motor strengthening and coordination pencil-grips, specially lined paper, use of keyboard, extended time, shortened work load, use of note-taker or adapted software programs. Visual-Motor and Visual-Perceptual skills –
address the student’s ability to control eye movements
smoothly shift focus,
track objects across midline, and
perform the visual motor control needed to read text
Use of slant boards,
paper windows, and
guided and colored transparencies.
OT Areas of Intervention Continued Postural Stability and Control – Occupational Therapists may also help students in maintaining efficient seating postures (dynamic seating with therapy ball, camping pillow or a Move ‘n Sit Cushion.
Sensory Integration Sensory Integration was first researched by A. Jean Ayres, PhD. Sensory Integration is a process used by the brain to locate, sort and make sense out of incoming sensory information. Ayres described sensory integration dysfunction as a “traffic jam” in the brain. Some bits of sensory information get “tied up in traffic” and certain parts of the brain do not get the sensory input they need to function.
Examples of Sensory Integration Dysfunction Extreme sensitivity to noise, touch smell, or taste Need for bear hugs due to a hyposensitive proprioceptive system. These hypersenstive and hyposensitive reactions impact the child’s ability to function independently in many areas of life (peer interaction, attention at school, and daily living activities.
The Sensory Systems Proprioception – the sensation from joints, muscles, and tissues that lead to body awareness. These sensations occur when lifting, pushing and pulling heavy objects as well as engaging in activities that compress or pull apart the joints. This is the sense that allows a person to guide his arm or leg movements without having to observe the movement to make sure it is happening.
Vestibular – the sense of movement, centered in the inner ear, obtained by spinning, swinging, and any type of body movement or change in head position. This system coordinates the movement of one’s eyes, head, and body and tells the body where it is in space. The vestibular sense in central in maintaining muscle tone, coordinating two sides of the body and holding the head upright against gravity.
Tactile – the sense of touch, the sense obtained by providing a variety of input from textures, temperature and pressure. Auditory – the sense of what we hear. It is closely connected to the vestibular system. The auditory input is obtained by listening to various types of music or natural sounds. Some auditory input has been shown to have a calming and organizational effect. Music containing 60 beats per minute can have such an auditory response. Music with an irregular beat and contrasting volumes tend to be energizing.
Visual – the sense of sight can be used to calm or alert the nervous system. Visually busy or “cluttered” environments can interfere with some children’s ability to concentrate and learn. Olfactory – the sense of smell can also calm, stimulate or send a child into sensory overload. Taste – The sense of taste is obtained by the use of sweet, salty, crunchy, soft or chewy foods. This sense can also calm, alert, or organize the nervous system.
The Sensory Diet Following an evaluation of a child’s sensory processing abilities and needs, the OT will work with parents, teachers, slp’s and other professionals to develop a “sensory diet”. The sensory diet is a carefully designed program that provides the sensory input a child’s nervous system needs to stay focused and organized. Components of a sensory diet may include brushing, swinging, heavy work (lifting, carrying), swimming, wearing weighted vests, wrist or ankle weights, wearing earphones, tactile play, trampoline jumping, chewing hard and or crunchy objects.
Wilbarger Protocol The Wilbarger Protocol is a system of tactile and proprioceptive input using a soft bristle brush to provide carefully controlled sensory input, always followed by a deep pressure/joint compression system. While this protocol has been anecdotally reported as effective in regulating sensory processing for some, if done incorrectly, it can have harmful results. This procedure should only be used by professionals trained and under the supervision of a trained occupational therapist.
Occupational Therapy Resources “The Out of Sync Child” and “The Out of Sync Child Has Fun” by C.S. Kranowitz “Asperger Syndrome and Sensory Issues: Practical solutions for making sense of the world” by Myles, Cook, Miller, Rinner and Robbins Action Based Learning: www.actionbasedlearning.com The American Occupational Therapy Association: www.aota.org/index.asp Brain Gym: www.braingym.com Junction of OT Function: http://junctionof-ot-function.com/
OT Resources Continued The Kid Foundation: www.spednetwork.orgwww.spdconnection.com Occupational Therapy and Autistic Children: www.autism.ca/occther.htm Occupational Therapy Innovations: www.ot-innovations.com/sensorimotor.html. The Ohio Occupational Therapy Association: www.oota.org OT Exchange: www.OTExchange.com/ SI Focus magazine: www.SIFocus.com Ohio’s Parent Guide to Autism Spectrum Disorders: www.ocali.org
Vision Therapy Some children with ASD experience visual-perceptual problems. Visual Perception is the means by which a person becomes aware of his body’s relationship to external space, or the relationship in space between one object and another (Kranowitz, 1998). Vision Therapy is a process of retraining the visual-perceptual system so it functions with optimal efficiency.
The process of Vision Therapy follows a sequence of steps aimed at improving the visual system. Therapy activities are carried out in the office and frequently reinforced with home activities. There is some conflict between proponents of vision therapy and many ophthalmologists, who claim that vision therapy is not supported by scientific data. Vision Therapist contend that while ophthalmologists are experts in eye disease and surgeries, they are under-informed in the area of vision therapies and the benefits they can provide.
Interactive Metronome Interactive Metronome is an assessment and treatment tool used in therapy to improve the neurological process of motor planning, sequencing and processing. It can be used by OT’s, PT’s, SLP’s, educators, behavioral therapists and music therapists who are trained in Interactive Metronome
Interactive Metronome provides a structural, goal-oriented process that challenges the patient to synchronize a range of hand and foot exercises to a precise computer-generated reference tone heard through head phones. The client attempts to match the rhythmic beat with repetitive motor actions. A patented audio-visual guidance system provides immediate feedback measured in milliseconds and a score is provided.
Interactive Metronome Goals Increase focus attention for longer periods of time Increase physical endurance and stamina Filter our internal and external distractions Improve ability to monitor mental and physical actions as they are occurring Progressive improvement of coordinated performance www.interactivemetronome.com
Computer Based Interventions Fast ForWord I. Fast ForWord -Fast ForWord software helps with: early phonics difficulty, reading comprehension, dyslexia, learning difficulties, Autism, and auditory processing disorders II. The Fast ForWord program has been around for over a decade and has helped over one million students.
Computer Based Interventions www.gemlearning.com
Earobics is a powerful and transformative multisensory reading intervention for raising academic achievement. Earobics software provides individualized, explicit instruction in all areas of reading, plus writing. As students engage with the software, the program automatically adjusts based on each student’s Individual strengths and weaknesses. www.earobics.com Computer Based Interventions
Auditory Integration Therapy Auditory Integration Therapy is a sound therapy designed to retrain a disorganized auditory system and improves hearing distortions and sound sensitivity. Developed by Dr. Guy Berard Participants listen through headphones to modulated music therapy from an “AIT” device for 20 sessions of 30 minutes each for a total of 10 hours over 10-12 days. Sessions are provided under the supervision of AIT therapists or other AIT trained professionals. www.aitinstitute.org
Biomedical Interventions Biomedical Interventions for ASD include the use of medication, diets, and supplements to address behaviors, cognition, and sensory needs. There are many such interventions available. The following is an over-view of the more well-known biomedical interventions.
Medications A variety of medications have been prescribed for individuals with ASD. Of course, no one medication is effective for every individual with ASD Neurologists, Psychiatrists, and other doctors may prescribe medications to target the following symptoms: hyperactivity, sleep problems, obsessive tendencies, anxiety, aggression, and self-injury. As a rule, medications are prescribed on a trial basis with close monitoring of positive and negative effects. www.autism-society.org www.oscai.org
Nutritional and Dietary Interventions Individuals with autism may exhibit low tolerance or allergies to certain foods or chemicals. While not the specific cause of ASD, these intolerances and allergies may contribute to behavioral issues. As always, parents should not embark on any intervention without the guidance of the child’s doctors. Consultation with a gastroenterologist or nutritionist is also a important step toward implementing any dietary or supplementary program.
The Gluten-Free /Casein-Free Diet Proponents of this diet believe that some individuals are unable to completely digest the protein in cereals (Gluten) or in dairy products (Casein). The molecular structure of the partially undigested proteins, known as peptides, resembles opiates and are thought to have an opiate-like effect on the brain and nervous system. From this premise, it follows that long-term exposure to these peptides can have damaging effects on the developing brain and can also affect behavior, just as a narcotic would.
Beginning such a diet can be difficult because Gluten and Casein are found in many, many prepared and ready to eat foods. Gluten is most commonly found in wheat, rye and barley and some oats. Casein is found in dairy products. One obstacle is that the children who would benefit from this diet often crave foods with Gluten and Casein and are sometimes reported to experience withdrawal symptoms.
It may take up to six months for gluten and one month for casein to clear out of the system. Advocates of the diet recommend trying it for at least a year to give the best chance for improvement. Calcium supplements may be necessary on this diet Autism Network for Dietary Intervention: www.autismndi.com CFCF Diet Support Group: www.gfcfdiet.com www.ocali.org
Feingold Diet This diet is a food elimination program developed by Ben F. Feingold to treat hyperactivity. This diet is free of artificial colors, flavors, aspartame, three petroleum-based preservatives and certain salicylates. These additives, with the exception of salicylates are made from petroleum and digesting them uses up the PST enzyme, which is the main enzyme for detoxification of the body. Salicylates and phenols also depress the levels of PST enzyme.
Removing these artificial foods from the diet allows the people with marginal PST enzyme will have it available to detoxify the body including the brain. Proponents suspect individuals with ASD have a marginal amount of the PST enzyme. Feingold Association: www.feingold.org www.ocali.org
Specific Carbohydrate Diet This diet is a strict grain-free, and sucrose-free regimen. It was initially developed for individuals with celiac disease and other intestinal disorders, however, the diet may help individuals with ASD who experience gastrointestinal problems. The theory is that carbohydrates, being forms of sugar, promote and fuel the growth of bacteria and yeast in the intestines, causing an imbalance of bacteria and yeast.
Toxins and acids are then formed by the bacteria and yeast which injure the small intestine lining. Horvath,K.(1999).Gastrointestinal abnormalities in children with autistic disorder. Journal of Pediatrics, 135,533-535. www.ocali.org
Anti-Yeast Diet This diet was developed to address the overproduction of or allergies to a certain form of yeast: Candida albicans. While it is impossible to keep out of the body, it is usually harmless because it is controlled by beneficial bacteria. An imbalance in this bacteria causes the yeast to grow uncontrolled, releasing acidic toxins into the bloodstream. These toxins slow the brain down.
The anti-yeast diet consists of removing fermented foods from the diet. These foods may include: alcohol, non-alcoholic beer, vinegar, barley malt, chocolate, pickles, soy sauce, and aged cheese. Some believe that individuals with ASD are likely to have an allergy to or overproduce this yeast. Nutrition Institute: www.nutritioninstitute.com www.ocali.org
Supplements B6 and Magnesium – reported to help improve language, eye contact, brain electrical activity, behaviors, and immune system function. Vitamin B12 – a deficiency is characterized by the inability to absorb food. It is essential for metabolism of fats and carbohydrates and the synthesis of proteins. Vitamin B12 is also involved in the production of the myelin sheth, a fatty layer which insulates nerves in the brain.
DMG – Dimethylglycine is a food substance found in brown rice and liver. TMG- Tri-methyl-glycine breaks down into DMG and SAMe in the body. SAMe is a nutritional supplement sometimes used to treat mood disorders. Melatonin – a hormone made by a part of the brain called the pineal gland. It may help our bodies know when it is time to sleep and wake. Children with ASD often have sleep problems; melatonin has been shown to improve sleep patterns.
Vitamin A – high doses have been used to treat the measles virus. Using cod liver oil, Megson (2004) began vitamin A therapy with her patients and observed positive results in improved speech and language and eye-contact. Administering vitamin A should be under a doctors supervision, as too much can be toxic. Vitamin C – is a anti-oxidant that helps the brain utilize oxygen.
Without vitamin C, confusion and depression can develop. It can also help support the immune system, aid in detoxification, and fight viruses and bacteria. Folic Acid – a non-toxic B vitamin, and a nutrient essential to the brain’s health. It has been reported as helpful in treating autism. It is most effective when taken with vitamins B12 and C. Other supplements include essential fatty acids, zinc, probiotics, and cod liver oil. Autism Research Institute: www.autism.com Kirkman Labs: www.kirkmanlabs.com www.ocali.org
Defeat Autism Now! Protocol (DAN) This protocol is a guide for clinical assessment of individuals with ASD developed by participants in the DAN Conferences organized by the Autism Research Institute (founded by Dr. Bernard Rimland). The basic premise of the DAN! Protocol is that heavy metal toxicity in the form of thimerosal in vaccines, amalgams, or some other source is the cause of the symptoms of autism. Autism One: www.autismone.org Center for the Study of Autism: www.autism.org Defeat Autism Now!: www.defeatautismnow.com Generation Rescue: www.generationrescue.org www.ocali.org
Chelation therapy is the process involving the use of chelating agents to remove heavy metals from the body. Reality Check – The February 7th edition of the San Francisco Chronicle reported the following: “ in the case of autism, a sketchy study by British physician Andrew Wakefield in 1998 set the vaccine blame game in motion. He claimed that a combined measles, mumps and rubella inoculation given to infants was linked to the disease, and his findings were published by a prominent British medical journal the Lancet.
But follow-up research by other teams failed to match his results. In recent years, his study fell apart amid charges of dishonesty, violations of research ethics and a "callous disregard" for the 12 children involved in the research. The Lancet disavowal this past week capped the collapse. How does he feel about the wholesale discrediting of his work? The findings are "unfounded and unjust," he said. The damage will be hard to undo. Autism, a range of conditions that disrupts communication skills and social interaction, has grown in reported numbers as parents and doctors learned to recognize its symptoms. Nearly 1 in 100 American children is diagnosed with autism or a related condition.”
Recreational Therapies Recreational Therapy is a general term used to describe the practice of using leisure activities as therapeutic interventions. Such therapies provide opportunities for supporting and enhancing communication and social and motor activities, and may include, but are not limited to the following:
Aquatic Therapy Aquatic Therapy is the use of water and specifically designed activities to help restore, maintain, and increase function. Aquatic/swimming therapy focuses on therapeutic play activities that improve range of motion and increase balance, endurance, and body awareness. Swimming provides movement that can help enhance motor planning. Water pressure can be soothing and calming for children with ASD
Art Therapy Art therapy is an established profession that uses the creative process of art to improve and enhance the physical, mental, and emotional well-being. Art Therapy can increase fine-motor, visual motor, visual perception skills, organization, planning and artistic expression.
Art Therapy Resources American Art Therapy Association, Inc.: www.arttherapy.org Art Therapy Credentials Board: www.atcb.org Ohio’s Parent Guide to Autism Spectrum Disorders: www.ocali.com
Music Therapy Music Therapy is the prescribed use of music and musical interventions to work towards specific therapeutics goals and objectives. Goal areas include communication, academic, motor, emotional, and social skills. Music therapy can also have a positive effect on self-esteem and reduce anxiety while developing appropriate expression of emotions. Music is a form of non-verbal communication in that emotions and feelings can be expressed through melodies and lyrics.
Music is a natural reinforcer…immediate in time and provides motivation for practicing non-musical skills. Parallel music activities are designed to support the objectives of the child as observed by the therapist or as indicated by the parent, teacher, or other professionals. A music therapist might observe the child’s need to socially interact with others. Musical games like passing a ball back and forth to music or playing with sticks and cymbals with another person may foster interaction.
Eye contact may be encouraged with imitating clapping games near the eyes. Preferred music may be used contingently for a wide variety of cooperative social behaviors like staying in a chair or remaining with a group of children in a circle.
Music Therapy Resources American Music Therapy Association, Inc.: www.musictherapy.org Center for the Study of Autism: www.autism.org/music.html Ohios’ Parent Guide to Autism Spectrum Disorders: www.ocali.org
Therapeutic Horseback Riding Hippotherapy, or therapeutic horseback riding, uses horses as a source of treatment to improve balance, posture, and mobility. It can also improve the cognitive, behavioral, and communication functions of individuals of all ages. Horseback riding enables one to participate in a enjoyable activity while increasing attention span, independence, and self-esteem. While learning from the horse, riders often bond with the horse as well as the other riders, thus providing a good foundation on which to build relationships with others.
Therapeutic Horseback Riding Resources American Hippotherapy Association: www.americanequestrian.com/hippotherapy.htm North American Riding Association, Inc.: www.narha.org Ohio’s Parent Guide to Autism Spectrum Disorders: www.ocali.org
Hocus Focus Hocus Focus is a student centered experiential based education approach that utilizes the art of magic in the context of empowering relationships with the goal of student growth and development. It is a systematic approach by which students learn to focus and accomplish specific goals and objectives by learning magic tricks. These tricks are simple at first and then more complex tricks as they proceed and then exploring the benefits of each one.
Hocus Focus is presented in nine teaching models. Lessons are designed to address the eight areas of neuro-developmental function (Levine, 2002) using magic tricks to impact educational development. The activities combine education and imagination to help children improve skills in planning, sequencing, organizing tasks and movements, fine motor skills, gross motor function/coordination, memory skills and more. http://hocusfocuseducation.com
Summary As a parent or clinician, the sheer amount of supportive therapies for the ASD child is quite overwhelming. Careful consideration of the individual needs of the child along with input from doctors, therapists, teachers, and parents should be reviewed before initiating any new intervention.
Resources The Ohio’s Parent Guide to Autism Spectrum Disorders: www.ocali.org