How occupational therapists are changing the field of treating autism in children
Occupational therapists strive to provide evidence-based practice to all their clients. For this ideal to become a reality, dedicated researchers with experience in the field are required to conduct studies on cutting-edge information.
Roseann Schaaf, PhD, OTR/L, FAOTA, is a professor and chair of the department of occupational therapy at Thomas Jefferson University in Philadelphia, and faculty for Farber Institute for Neurosciences at Thomas Jefferson University. She has worked in occupational therapy for over 30 years and has been researching the effectiveness of occupational therapy using sensory integration for children with autism.
Schaaf is currently conducting this research and training occupational therapists to treat this patient population. Her team includes members of Albert Einstein College of Medicine: occupational therapy coordinator Elizabeth Ridgway, OTD, and neuroscientists Sofie Molholm, PhD, and Jon Foxe, PhD. Molholm and Foxe oversee the multisensory integration EEG paradigm. The team is in the second year of a five-year study.
“Autism is a neurodevelopmental disorder, and it’s present before birth. People who have autism process information differently,” Schaaf said. “The approach that sensory integration takes, or that most of occupational therapy takes, is that we identify what challenges the child has in their daily activities.”
Schaaf calls these “participation challenges.” “Then, if we’re using a sensory integration approach or a developmental approach, we try to identify what the underlying sensory and motor factors are that are impacting their ability to perform in these everyday activities.”
This study, which includes 200 children over the five-year timeframe, will look at occupational therapy using sensory integration using comparison to discrete trial training to determine how these approaches impact functional skills.
“For sensory integration, we do a thorough assessment of their ability to process and integrate sensation and use it for movement and behavior. We then have to identify what’s difficult for them,” Schaaf said. These issues can range from tactile processing to vestibular processing, praxis or a mix of the above. Many times, equipment such as ball pits, foam shapes and wedges, swings, climbing walls and more will allow the therapist to design playful activities to make sure children receive the correct motor-sensory experiences to help with the child’s participation.
According to Schaaf, a behavioral approach works in a very different way. “Behavioral intervention targets the behavior itself. If the behavior [that needs to be addressed]is about eating a variety of foods for participation in dinnertime, a behavioral intervention is going to start with a functional behavioral assessment and identify which kinds of factors in the environment and in the task need to be shaped, taught or reinforced to the child so they can eat a wider variety of foods,” she said.
Since sensory integration and behavioral intervention are very different approaches to the same types of problems, it is important to understand why and how these treatments work for different children. “What we hunch is that some kids will do better with sensory integration, and some kids will do better with behavioral intervention,” Schaaf said. “We have such a large sample, so we’re hoping that we can find some answers about which kinds of children do better with which kinds of intervention, and which do best with a combined approach.”
Once the study is completed, Schaaf and the team will take the time to look at the brain functioning of the participants. For the sensory integration approach, their theory is that through working on these underlying sensory-motor factors, they will enhance neuroplasticity in the brain. This means that they will change the way the brain functions based on the experiences it has had.
“If in fact neuroplasticity does change, then this multisensory integration paradigm should show that,” Schaaf said. “The behavioral intervention isn’t working on the theory of neuroplasticity; it’s working on the theory that if you repeat and train a behavior enough times, it will become a skill.”
Schaaf believes this is a unique study not only because it is comparing two approaches, but because it is also looking to see whether there are brain biomarkers to determine which children will respond to which treatments.
Different Patients, Different Treatments
The therapy used in this study, according to Schaaf, is designed to target underlying factors as a basis for improving participation challenges. To achieve this individualized approach, parents are asked for their reasoning behind seeking occupational therapy and the challenges they have in regard to their child.
“There are no ‘typical’ goals for parents with their children,” Schaaf said. “Each goal needs to be individually created for each child. That’s really the hallmark of occupational therapy: It’s client-centered and individually tailored.” Schaaf and her team ask parents about their child’s strengths and identify some goals they would like to accomplish.
While treatments may not be exactly the same for each, each participant must meet a few requirements to be considered for the study. Each child is between 6-9 years old, must present sensory difficulties on assessment and must not be on certain types of medication. Children involved in the study have been randomly separated into three groups: sensory integration, behavioral intervention and no treatment.
Schaaf was able to see the need for a large study on this topic through a smaller study she ran in 2013. This study included 32 children and helped researchers “work out all the logistics and know whether this much larger study was warranted.”
Though small in size, the outcome of this study included a huge development: the first written protocol for occupational therapy using sensory integration. “Clinician’s Guide to Implementing Ayers Sensory Integration®: Promoting Participation for Children with Autism” was co-authored by Schaaf and her colleague Zoe Mailloux, OTD, OTR/L, FAOTA. “This is important because the thing that makes science accepted is if someone else can replicate your study and get the same findings,” Schaaf said. “In order to replicate the study, we have to be very clear and specific about what we do as occupational therapists that use sensory integration.”
Because of her direct influence on the protocol of the study, she has an insider’s view into the future of treatment for children with autism.
Bright Future for OT
“Occupational therapy using sensory integration involves active, individually tailored sensory-motor activities contextualized in play at just-the-right challenge,” Schaaf said, “[but]occupational therapy using sensory integration is only one of the tools in the therapist’s toolbox for treating children with autism. I would be remiss if I suggested that it was our only tool.”
According to Schaaf, it’s the occupational therapist’s job to perform a thorough assessment, get to know the child and the family and then conduct an assessment of what might be impacting the challenges the child may be experiencing. “The OT should then go into their toolbox and find which approach will work best for this child. They need to ask themselves how they’re going to use these approaches to help a particular child’s needs,” she said.
Regarding the future of treating children with autism, Schaaf believes that occupational therapists will be clearer about why they are choosing specific treatments for specific children, and will measure the outcomes of their interventions more consistently and systematically.
“What we’re not always doing as occupational therapists is being very explicit about why we’re doing what we’re doing. You don’t do the same thing with every child. You individually tailor it based on the child’s needs, and then you think about what you can bring as an OT to the table,” she said. “It’s also, importantly, about measuring outcomes throughout the entire process. Occupational therapy for children with autism is going to look like occupational therapists helping children with autism gain the highest level of independence and participating in their daily activities, and being very data-driven about which approach they take.”