10/24/2015 Breaking the Mold Creating a Blueprint for the Adult with ASD using an Occupational Therapy Approach Justin Lundstedt, OTR/L Objectives For Today • Brief introduction / reintroduction to autism • Understand the background of occupational therapy • Recognize occupational therapy’s role as a service for the general ASD population • Identify the need for continued services in clients with ASD through transition and adulthood • Provide further methodology and services under the OT umbrella for the aging client with ASD • provide case study descriptions of OT services Autism statistics • Currently 1/68 children are diagnosed with ASD • 1/42 boys ; 1/189 girls Center for Disease Control and Prevention 1
10/24/2015 Autism defined under DSM-5 • Persistent deficits in social communication and social interaction across multiple contexts: • Deficits in social-emotional communication • Deficits in nonverbal communication • Deficits in developing, maintaining, and understanding relationships (Severity is based on social communication impairments and restrictive repetitive patterns of behavior) Autism defined under DSM-5 • Restricted repetitive patterns of behavior, interest, or activities as manifested by at least two of the following: • Stereotyped or repetitive motor movements, use of objects or speech • Insistence on sameness, ritualistic • Highly restricted fixated interests of abnormal or intensive focus • Hyper or hypoactivity to or unusual interest in sensory aspects to the environment Autism defined under DSM-5 • Symptoms must be present in early development • Symptoms cause clinically significant impairment in social, occupational or other areas of functioning • Disturbances are not better explained by intellectual disability 2
10/24/2015 Autism defined under DSM-5 • Severity levels 1. Level 3: Requiring very substantial support 2. Level 2: Requiring substantial support 3. Level 1: Requiring support Occupational Therapy • Professionals focused on maximizing participation in all areas of life including but not limited to: ADL's (feeding, hygiene, • dressing) • Instrumental ADL's ( community, mobility, safety) • Education / work • Leisure / play / social interaction Tomcheck et al 3
10/24/2015 Domains of OT Areas of occupation • Activity demands ( physical, cognitive, • spatial, social, properties) Client factors (specific abilities, • characteristics, beliefs) Environment and context • Performance patterns ( habits, roles, • routines) Performance skills (communication, • interaction skills, motor and processing skills) (Autism: A comprehensive Occupational Therapy Approach 2nd ed.) Scope of OT for individuals with ASD • Support health and participation through engagement in life's occupations (AOTA, 2008) through: • Evaluation • Intervention • Assessment of outcomes • Providing of services to client and those in their lives Major life stages of OT intervention • Early intervention ages 0-3 • CPSE ( preschool) ages 3-5 • School age 5-21 • Transition age 14-21 • Adult ages 21 and up 4
10/24/2015 Outcomes of Autistic Adults • 81% of adults are living with their parents • Based on recent research • 34.75 of those studied attended college • 55% held paid employment during the first 6 years after graduation • More than 50% after 2 years of HS had no participation in ed or vocation (Shattuck et al.) Why? Services cease at the end of • schooling transition plans do not fully • plan for the future The client needs to self • advocate A difficult path to identify help • In the past a lot of help has • been private pay Outcomes Of Autistic Adults cont. It is important to look at data to • see what those with ASD and their caregivers need Focus on both self reporters and • legally represented sample There are recognized similarities • between those that self report and those with legal representation 2015 Gotham et al. 5
10/24/2015 What treatment is most utilized for adults with ASD • Medication • Behavioral / psychotherapy • Alternative medicine • Self help books • Support / social groups • Therapies (speech, OT, PT) What information is sought out most often? • Understanding and acceptance of adults with ASD • Employment • Health care access • Education • Current treatments Gotham et al. 2015 6
10/24/2015 Insurance reform N.Y. Insurance Law § 3216, § 3221 and § 4303 Require specified policies and contracts that provide coverage for hospital or surgical coverage to not exclude coverage for the screening, diagnosis and treatment of medical conditions otherwise covered by the policy solely because the treatment is provided to diagnose or treat autism spectrum disorder. The law was amended by 2011 N.Y. Laws, Chap. 595 (AB 6305) to also require every policy which provides physician services, medical, major medical or similar comprehensive-type coverage to provide coverage for the screening, diagnosis and treatment of autism spectrum disorder. The law prohibits any limitations on visits that are solely applied to the treatment of autism spectrum disorder. Treatment of autism spectrum disorder is defined to include behavioral health treatments, psychiatric care, psychological care, medical care, therapeutic care and specified pharmacy care. 2011 N.Y. Laws, Chap. 596 (SB 5845) amended these provisions to specify that coverage for applied behavior analysis is subject to a maximum benefit of $45,000 per year.Citation: N.Y. Isc Law §3216 Initiating a blueprint for "success" 7
10/24/2015 Occupational Therapy Evaluation of the Adolescent / Adult When does a client get • referred to an OT How does a client get referred • to an OT? Evaluate • Evaluation should be tailored to the concerns of the client and or guardian • Utilize skill based assessments to determine the client’s abilities in the areas of motor function, cognitive processing, sensory processing • Conduct a client centered assessment to identify interests, satisfaction, limitations, goals • Conduct an assessment of their life environments ( community, school, workplace) to identify limitations or needs for adaptations Evaluation Tools / Assessments • Function based: • Goal Oriented Assessment of Lifeskills (GOAL) • Pediatric Evaluation of Disability Inventory Computer Adapted Test (PEDI-CAT) • TEACCH Transition Assessment Profile (TTAP) • Canadian Occupational Performance Measure (COPM) • Leisure / interest check lists 8
10/24/2015 Evaluation Tools / Assessments cont. • Cognitive Assessments: • Behavior Rating Inventory of Executive Function (BRIEF) • Dynamic Lowenstein Occupational Therapy Cognitive Assessment (DLOTCA) • Behavioral Assessment of Dysexecutive Syndrome (BADS) • Executive Functioning Performance Test (EFPT) Evaluation Tools / Assessments cont. Sensory based: • Sensory Integration Performance Test (SIPT) • Sensory profile for Adolescent and Adults Assess and interpret Assess the client's strengths • and weaknesses and interpret how they impact their daily lives It is important to look at this • from a global standpoint. ASD presents with difficulties generalizing and transferring information from one area to the next. Do your homework about the • client! Access all the resources available to you! 9
10/24/2015 Communicate findings • Provide feedback as soon as possible • Identify client’s and parents’ understanding of results • Develop a document that identifies results and discussion (written evaluation) • Identify next steps with client and / or family (recommendations) Provision of Therapy • There is no "one size fits all" therapy. During first session create concrete goals • Client centered process using a Person Centered Planning Approach • This allows you to identify goals, strengths, weaknesses,etc. if a standard form doesn't work, BE CREATIVE (D&D) • Have client take ownership. • Identify REALISTIC goals • Identify time frame, but allow for some flexibility Provision of Therapy cont. • Maintain a structure or format for session, identifying daily goal and goal working towards • Identify progress along the way • Restructure goals as needed • Plan ahead for discharge or transition / transfer of services • Utilize the whole team 10
10/24/2015 Case Study 1 • 18 year old male • High IQ (test results identify high average) • Secondary to poor social skills, difficulty adapting to school environment dropped out of school, took GED exam • Current goals: to attend college and focus on life sciences and technology, to get a license • Limitations: foresight, organization, time management, social interaction, initiation and planning, IADL's, ADL's Case Study 2 • 53 year old gentleman of high intelligence • Recently diagnosed with ASD • Struggled with obtaining a new job • Struggles with marriage / relationships • Strengths: motivated, intelligent • Limitations: self reflection, empathy, flexibility, social awareness Case Study 3 • 15 y/o with mild to moderate cognitive deficits (expressive / receptive, working memory) • Sophomore in high school, aspirations of becoming a musician with a back up job of administrative assistant. Would like to be accepted by others • Strengths: dexterity, focus, intelligence • Weaknesses: initiation, organization, restrictive thoughts, poor social skills, working memory, problem solving 11
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