April is OT Month and Autism Awareness Month!

Another apology is in order for the neglect of my blog. I’ve had several blog entries “in the works” for a long time, but have failed to finish developing them and getting them up here. I’ve made a promise to myself to get back into this, and my goal is to try to publish at least once a week! So if you’ve abandoned my blog because I haven’t updated in a long time, please come back!!! It seemed appropriate to come out of hibernation to blog during April, as April is the celebration of both Occupational Therapy, and Autism Awareness! I work with, and have worked with, many children and adolescents on the autism spectrum (about 1/3 of my current caseload has a diagnosis on the spectrum), so Autism Awareness is something that is important to me. In honor of both April celebrations, here is a general overview of autism and how occupational therapists work with individuals on the autism spectrum.

First, for those unfamiliar with autism, allow me to explain what I mean by “autism spectrum.”  This is an umbrella term that refers to a group of developmental disabilities that may cause significant challenges in the areas of social skills, communication, sensory processing and behavior.  The general term Autism Spectrum Disorder (ASD) [which can also be referred to as Pervasive Developmental Disorder (PDD)], refers to the following three disorders: Autistic Disorder (also called “classic autism” or just “autism”), Asperger’s Syndrome, and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS).

Someone diagnosed with Autistic Disorder generally has significant language delays, social and communication challenges, [unusual]* and/or stereotypic behaviors and interests, and atypical processing of sensory experiences. Often people with autism also have intellectual disability, but low IQ is not a diagnostic criteria. Within the classification of Autistic Disorder, there is variation in severity and functionality, though there is no “official” distinction, many people will often refer to different levels in terms such as “high functioning autism” or “severe autism.” Asperger’s Syndrome shares some symptoms with Autistic Disorder, such as social challenges and [unusual]* behaviors or interests, but symptoms exist in a more mild form, and there is no language delay. Typically those with Asperger’s Syndrome do not have intellectual disability and generally have average to above average intelligence. A diagnosis of PDD-NOS is given when an individual meets some criteria for Autistic Disorder but not all criteria. Signs of ASD in young children may include lack of, or delay in, spoken language; repetitive use of language and/or motor movements (example: echoing or scripting what another says instead of speaking spontaneously, hand-flapping , or twirling objects); little or no eye contact; lack of interest in peer relationships; lack of make-believe play; and persistent fixation on parts of objects.

*Author’s note: I bracketed [unusual] because these words are included in literature about diagnostic criteria for autism, however, I do not like these words. I do not feel as a “neurotypical” (the term that people on the autistic spectrum often use to describe those who are not) that I have the right to pass judgment on behaviors and interests of those on the spectrum, or anyone for that matter. To the person, it not unusual, so what right do I have to say it is?! Also, in my opinion often these interests aren't even necessarily so "unusual," often people with ASD just have very specific interests that can be quite intense (often referred to as obsessions or perseverations), such as Jason and his interest in the subway. Also, interests may seem "unusual" because people with ASD are often very detail oriented. The way one little girl I treat "plays" with toys is to line them up in various categories, such as organizing them by color, size and shape. To her, this is more interesting than using toys for their intended purpose. I suppose this may seem "unusual" but for her lining toys up into organized categories is meaningful and makes sense to her. It is the propensity for specific, intense, and often detail-oriented interests that can allow people with ASD to make important contributions to society. Temple Grandin (a woman with autism well-known for her work both in the autism community and her accomplishments in the field of animal husbandry), jokes that NASA is the largest sheltered workshop in the world! We should be thankful for these "unusual" interests!

What do occupational therapists do to treat individuals with ASD?  As discussed in previous blog entries, OTs assist when a person is experiencing barriers to successful participation in his or her daily occupations. OTs will work with clients diagnosed with ASD in many different areas of occupation. Interventions may target regulating emotion and behavior; processing sensory information that is needed for participation in occupation; developing social abilities, interpersonal skills and peer relationships; self-care skills such as dressing, feeding, hygiene, and sleep; skills for school success such as organization of task materials, independent work skills, group process abilities; using assistive technology to accomplish communication or other occupational needs; and developing motor skills that may be delayed.

I mentioned in previous blog entries that in December I attended the 2010 American Occupational Therapy Association (AOTA) Autism Specialty Conference in Baltimore, MD, which was an amazing opportunity to hear from the experts in the field, as well as convene with other occupational therapists who treat clients on the autism spectrum. At the conference, a point that was emphasized throughout the two days of presentations was that people with ASD are people first and a diagnosis second. They may have difficulty expressing and understanding feelings, but they certainly have them. Just because they lack social awareness and social skills does not mean they don’t long to be included. Research shows that children and adults on the autism spectrum want to have meaningful relationships, they just don’t know how. Additionally, people with ASD can contribute wonderful things to society. Sometimes, however, they just need to make their own way.  The norms of a society that is mainly made up of “neurotypicals” may not be how individuals with ASD find their path to success, and that is okay! As OTs, we have the ability to help individuals carve their own paths in the world and be able to make unique and important societal contributions. Occupational therapists are equipped with the skill set to look at a person’s strengths as well as challenges, analyze the tasks the person wants or needs to do, take into account the environment and extraneous factors that may support or inhibit participation, and collaborate with the individual to find a unique solution that allows for success!

At the conference, I had the privilege to attend presentations given by adults on the spectrum, and something they taught me that really made an impact on me was that many people with ASD do NOT consider themselves to have a disability!! They just accept that they are “wired differently” from neurotypicals. Most of these individuals have no desire to be neurotypical. They do not need to be “fixed.” They just want to be accepted, and assisted in order to be successful functioning in neurotypical society. Many adults on the spectrum have found the ability to celebrate their uniqueness and accept and embrace autism as a diversity. Now, if only neurotypicals would see it that way!

Sources for this blog entry include presentations from the 2010 AOTA Autism Specialty Conference, and “The American Occupational Therapy Association Frequently Asked Questions: What is Occupational Therapy’s Role in Supporting Persons With an Autism Spectrum Disorder?”

The Handwriting Lady

At the AOTA Autism Specialty Conference I attended last week (there will definitely be more about the conference in a later blog), Winnie Dunn, an amazing OT and researcher, said in her keynote address, "Don't let yourselves be pigeonholed. We are more than just the Handwriting Ladies!" (Followed by a comic nod  to the 3 male OTs in attendance). This is very true. In the world of pediatric OT, we are so often linked with handwriting to the point where other related service professionals, teachers, parents (and if we're not careful even us as OTs!!) can forget or never realize in the first place that OTs do so much more than just helping the kids we treat improve their handwriting!

Why is it that pediatric OTs so frequently address handwriting that it has become possible to pigeonhole us as “the Handwriting Ladies”? Why is it that poor handwriting is the most common reason for OT referral in school aged children (and poor pre-writing skills in pre-school children)? I believe it is because of a paradox that is a very real part of school for kids. And that is that handwriting is an essential part of a child’s occupation of being a student (for those non-OTs who may be reading, an "occupation" refers to the things people do in their daily life that are of necessity and/or of meaning to them, for children being a student is one of the primary occupations they engage in).  Children are required to produce written work in basically every school subject, because writing is how they communicate what they know and have learned.  Unfortunately for children with special needs, handwriting is also one of the most complex tasks children are expected to perform. It seems automatic for those without a disability, but handwriting actually encompasses an extraordinary amount of body systems and underlying component skills, and if a child has issues with any one or combination of these skills it will very often manifest as poor handwriting.

[Here’s something that will probably blow the minds of the non-OT readers. Take a deep breath in....ok, readysetgo: In order to write successfully, first one needs to be able to sit in a chair. Just that involves a lot, such as having the core strength and postural control to stay upright in the chair against gravity. Then there are also a lot of visual elements to handwriting. There's visual acuity (being able to see and see clearly), occulomotor skills (such as being able to move one's eyes to visually scan from left to right and top to bottom), visual perception (which includes being able to interpret series of lines and curves as different and distinct letters), and visual-motor integration (which includes being able to write in between the lines). Another key component to handwriting is fine motor skills. One needs to be able to grasp a pencil appropriately, and manipulate it using very small movements. This involves having good control over the very small muscles of the wrist, hand and fingers in addition to strength and endurance of these muscles. Also, there's praxis (motor planning), which is the ability to plan and execute the specific movements required to form each letter consistently and correctly. Then there's other neurological components, such as the ability to sustain attention to task. There’s cognitive components such as memory--one needs to remember which set of lines and curves represent which letter. There's sensory processing components involved, such as being able to feel the pencil in one's hands and judging how much force to use on it, and having the ability to filter out excess sensory stimuli from the environment. And a partridge in a pear tree, lions and tigers and bears oh my!!! This is just to name SOME of the many components and skills involved in handwriting!!!] 

I am an occupational therapist, not a handwriting specialist. However, as OTs, we have the knowledge base to break down the task and determine exactly which components are posing a barrier to the student's success in handwriting, and then determine an appropriate intervention to help that student. The reason why OTs so often address handwriting is not so much the WHAT (the student writes poorly), but the WHY (ie poor fine motor coordination and endurance, poor visual perceptual skills, ect), and most importantly, HOW it is affecting the student’s ability to be successful in school.

Our jobs are to help our clients with any and all things that prevent success in their occupations. Although handwriting is a big part of the childhood occupation of being a student, it is not by any means the only part. As Winnie Dunn said, it is very important to make sure that we are recognized as more than just "the Handwriting Ladies," and I do make sure to do my best to advocate for the many other things we do as pediatric occupational therapists to other professionals and those outside the related service field. However, that being said, I am also excited to be, for 45 minutes every Friday, just that: The Handwriting Lady! On Fridays at the clinic I run a handwriting group for 5, 6 and 7 year olds. I was so happy to see them today, because we did not have group the last two Fridays due to being closed the day after Thanksgiving, and then me being away attending the aforementioned Autism Conference.

The group I run is based on the handwriting program Handwriting Without Tears. I took the course to become trained in the program this summer and I absolutely adore it! It was developed by an occupational therapist, Jan Olsen, and encompasses underlying skills that support handwriting success as well as using techniques that target the way children learn best--through multi-sensory, experiential learning, as backed up by years of research. It's also fun, motivating, and easily adaptable for kids with many different special needs. OTs understand that there is so much more to writing than pencil meets paper, which is why when children have handwriting issues we tend to be the ones called in. The kids in my group came to me with a variety of different challenges and were at varying developmental levels, but they all have shown remarkable success in group so far. This, in my humble and professional opinion, is because I'm using a program that's fun, motivational, developmentally appropriate and multi-sensory, and I can tailor each group's activity to meet the needs of each of the five children in the group. We sing songs, color with crayons, use play doh, write on chalkboards, do activities using our whole bodies, and exercise our fingers all before sitting down and practicing letters with a pencil and paper.

I know the importance of not being pigeonholed as "the Handwriting Lady," but for 45 minutes on Fridays that is exactly what I love to be......just with a very "OT" spin!