Occupational Therapy

May people on the autism spectrum face motor difficulties. They may have gross motor difficulties, such as a clumsy way of walking or difficulty with large motor movements or difficulties with fine motor skills like writing, coloring in the line or using scissors. Some may have trouble coordinating movements between the right and left sides of the body making it difficult to skip, jump, hop or get down the stairs. Some others may have trouble with hand-eye coordination making it difficult to catch a ball, hit a ball with a bat etc.

In addition to these motor difficulties, children on the spectrum may also struggle with low muscle tone, sensory processing issues (too much or too little response to sensory inputs such as sound, touch, smell etc.), as well as difficulties with proprioception and interoception.

It has been estimated in a 2020 study conducted in the US that as many as 87% of children between 5 and 15 years of age on the spectrum face motor difficulties. Yet, only about 30% of the children were receiving any therapy for the same.

Motor issues may appear in infancy where 1-month old infants who are later diagnosed with autism move their arms less, they may struggle to keep their head in line with shoulders when pulled up to sit at 4 months and may struggle to stand at 14 months.

Poor motor skills may contribute to and accentuate autism traits as motor issues can delay babbling, gesturing, and acquisition of new vocabulary. Lack of motor skills may also elicit less interaction from caregivers and provide children less prompts for learning. Poor motor skills later in childhood may make children on the spectrum reluctant to participate in physical activities, limiting opportunities for social interaction. Bad handwriting can impact academic performance. Since visual-motor integration skills are important for imitation and learning from others, lack of these skills can hamper social development. Thus, motor difficulties might have cascading effects on cognitive, social, and emotional development.

That is why occupational Therapy is among the top therapies recommended for autism. The general focus of occupational therapy is to improve the client’s ability to participate in activities of daily living, which may include things like schoolwork to dressing and brushing teeth.

When an occupational therapist starts working with a child, they usually assess their support needs. They may use some tests like the school function assessment test (SFA), Children’s Assessment of Participation and Enjoyment/Preference for Activities of Children (CAPE/PAC), Assessment of Life Habits (Life-H), Children Movement Assessment Battery for Children Second Edition (Movement ABC2), Sensory Integration and Praxis Test (SIPT) etc. In addition, the therapist may observe the child in a range of settings to see if they are able to complete tasks of daily living. For example, they may watch to see if a child can button a jacket, cut with scissors, play appropriately in the playground, etc.

Once the tests and observations are complete, they develop an individual plan for the child. The plan is personal and may include academic goals like using scissors, printing letters, using a paint brush; daily living skills like brushing teeth, zipping jacket, tying shoes; social functioning goals like catching a ball, jumping on trampoline etc.

Occupational therapists usually work with the children in occupational therapy rooms or sensory rooms equipped with exercise balls, swings, jump ropes and other equipment. Therapists use techniques to strengthen the child’s hands, legs, and core, provide tools like weighted vests or large pencils to make some tasks easier etc.

The role of occupational therapists is not limited to working with children. They may work with adults to build living skills like cooking, cleaning etc. They may help with designing more comfortable workstations and equipment for adults working in offices. They can help in various areas of self-care, productivity, and leisure.

Sensory Processing and Occupational Therapy

We rely on the information coming from our senses (sight, sound, smell, touch, taste) to make sense of the environment around us. People on the autism spectrum may have difficulties dealing with the information coming in from different senses. A child may be distracted by the noise of a drill that you can barely hear. Another child may be feeling uncomfortable with the shirt label scratching on their neck. Yet another child might be getting overwhelmed with the perfume in the air. Too much sensory information can cause stress, anxiety, and physical pain. This can result in withdrawal, distressed behavior, or meltdowns.

Different sensory profiles

People on the autism spectrum can be under sensitive, oversensitive or both (at separate times) to any of their senses. For example, people who are under sensitive to sight may not have a good depth perception and may not be able to catch or throw. Those who are oversensitive may find it difficult to sleep even with a little light around. People who are under sensitive to sound may prefer crowded, noisy places or bang doors and objects. Those that are oversensitive to sound may not be able to filter our background noises, leading to difficulties in concentrating. People under sensitive to smell may sometimes lick things to get a better sense. Those that are oversensitive may have difficulties using toilets or may dislike people with distinctive, strong perfumes. People under sensitive to taste may like very spicy food. They may also eat or mouth non-edible items such as stones, dirt, soil, feces etc. This is known as pica. People with sensitivities to taste may end up with a restrictive diet. People under sensitive to touch may hold others tightly, enjoy heavy objects like weighted blankets on top of them. They may have a high pain tolerance and may self-harm. Those oversensitive to touch may not like to be touched and may have difficulties brushing and washing hair. They may also tolerate only certain types of clothing or textures.

Working with sensory processing

In general, people who are under sensitive to a sense seek out more of that sensory input to calm themselves, to relieve anxiety and sometime just for pleasure and relaxation. Those that are oversensitive try to avoid that sensory input for the fear of being overwhelmed. People on the spectrum may need help in handling these sensitivities. The general approach is to provide manageable alternatives to the under sensitive system and to slowly desensitize the oversensitive system through gradual exposure. For example, if a child is easily overwhelmed by sounds, she may close her ears every time someone speaks to her, losing out on useful information and learning opportunities. The therapy approach in this case would be to offer her earmuffs that can decrease the intensity of the noise, couple the sound input with a visual and gradually help the child be comfortable with the sound of spoken voice. A child who is under sensitive to touch may keep scratching walls or rough surfaces for stimulation, causing injury to fingers and nails in the process. In this case, the therapist may offer a manageable alternative by giving her a polystyrene sheet to scratch and get the sensory input.

Sensory Integration Therapy

Occupational therapists trained in dealing with sensory processing difficulties can help by providing interventions to target each sense, helping the child’s nervous system become more organized and regulated. Sensory integration therapy is one of the names given to such an approach. One of the options is to put a child on a sensory diet, a specially designed daily activity plan that provides the child with a variety of sensory activities. The focus is to help the child be regulated and improve attention and focus. When the child’s arousal level is too low, they can be given stimulating activities like dancing, singing, light exercise etc. When the arousal level is high, they can be given calming activities like going for a walk, reading, listening to music etc. It is important to choose activities that suit each child and provide the appropriate level of arousal or relaxation.

Sensory Circuits

Sensory circuits are another tool used by therapists to help children achieve a ready-to-learn state. Each session includes three elements.

• Alerting activities to stimulate the body's central nervous system in preparation for learning. For example, spinning, bouncing on a gym ball, skipping, star jumps

• Organizing activities which demand brain and body to work together. For example, balancing on a wobble board, log rolling, juggling

• Calming activities give an awareness of their body in space and increase the ability to self-regulate sensory input. For example, heavy muscle work and deep pressure like wall pushes, pushups, using weights.

In summary, some people on the spectrum may have sensory processing difficulties that make it difficult for them to process sensory information. Occupational therapists trained in sensory integration can help by designing sensory diets and other programs that can help children be more regulated, calmer, and focused, thereby reducing anxiety and increasing opportunities to thrive and achieve in the overwhelming environment in which we now live.

Beyond the five senses

We are all familiar with the five senses – sight, sound, touch, smell, and taste. However, there are three other senses that are not as well known. In the context of autism, it is important to know about these senses as people on the spectrum tend to experience processing difficulties related to these senses as well.

The three other senses are – Proprioception, Interoception and Vestibular system. Proprioception is our body’s intrinsic ability to sense and position itself in space. We have a set of sensory receptors in our muscles, joints, and tendons, that help us with full-body awareness. Interoception is our ability to sense our internal body states and emotional states, using the information we receive from receptors on our internal organs. The vestibular system is in our inner ear and helps us with our sense of balance and body control.

Proprioception

People on the spectrum can have proprioceptive difficulties that make it difficult for them to apply the right amount of pressure for a task. They also bump into things often and may have difficulties walking up and down stairs. They may struggle while feeding themselves, and frequently miss the mouth. They may also struggle with posture and movement fluidity when faced with a new motor task. They may underperform in sports and may struggle to remember the body posture associated with a new skill.

Proprioception difficulties can be addressed by occupational therapists using sensory integration techniques and practicing gross and fine motor movements with visual assistance like looking into a mirror while performing a task.

Interoception

Regarding interoception, people on the spectrum may be less aware of what is happening inside their bodies. The interoception center in our brains is called the insular cortex, which also plays a vital role in the perception of pain, primary emotions like joy, anger, awareness of bodily states like feeling of cold, and in the perception of being a self. Therefore, interoception difficulties may be responsible for emotional processing issues, problems in identifying and describing emotions, and difficulty with empathy and perspective taking. At an extremely basic level, people on the spectrum may not be able to recognize when they are thirsty, or hungry. They may not realize when they are full and may tend to overeat. They may find it difficult to self-regulate their emotions, attention, and behaviors. They may not be able to point to the source of their discomfort like where the pain is.

Interoception can be improved by practicing interoception awareness activities like guided self-body scans, deep breathing, guided progressive relaxation. Young children may need support with the help of timers for eating, drinking and toileting, portion control to help eat for balanced nutrition etc.

Vestibular system

The vestibular system refers to the structures in the inner ear that detect movement and change in the position of the head. This is the system that tells us if our head is upright or tilted, even with our eyes closed. Children who are oversensitive to this system can have fearful responses to ordinary movement activities like swings, slides, ramps etc. They may appear clumsy and fearful of moving in space. However, some children may actively seek intense sensory experiences such as excessive whirling, jumping, climbing heights, etc. Vestibular dysfunction can cause postural instability, gait dysfunction and impaired gaze. This can lead to delayed milestones such as sitting and walking and poor motor coordination. Vestibular dysfunction may be accompanied by auditory sensitivity and dysfunction.

Repetitive actions like mild rocking can help calm down an over stimulated vestibular system. Providing structured activities that satisfy an under sensitive system seeking stimulation can also help.

In summary, the sensory processing disorder, and related difficulties in autism go beyond the five better known senses and may impact proprioception, interoception and vestibular system. The impact of these dysfunctions is still being researched and understood. An occupational therapist can provide sensory integration therapy to help with these difficulties.