Module 5 Motor Planning

Jake struggles with motor planning tasks everyday and his ability to anticipate performance. He can be described as having overall good muscle tone, but lacks initiation to engage in simple activities. Jake needs much prompting to brush his teeth, sometimes with hand over hand assistance of his mom. There is not a whole lot of rebellion when mom does this, but it would be better if he completed the task on his own. Even when he stands in front of the sink he does not initiate motor planning to get a toothbrush, toothpaste and brush his teeth.

One tx we can try using will be categorization skills. We will place two contrasting pieces of paper on the table and begin categorizing items. One paper will be yellow(playground), the other blue (bathroom). Jake will be given 5 pictures of toothbrushes and 5 pictures of a ball. he will need to categorize the ball with the playground and toothbrushes with the bathroom. After he masters this skill we will 1-2 more objects (i.e. toothpaste, comb, etc) for him to complete his hygiene with little to no prompts. Knowing that Jake likes Mickey Mouse we will make sure he is using a MM toothbrush and MM toothpaste.

Knowing that motivation will increase his attention and level of alertness, he will be more likely to complete the task with Mickey Mouse. Increasing his motivation will increase his initiation. Less initiation from mom = less prompting.

Module 4: Modulation

Jake does demonstrate some sensory overload, or modulation, with going to the mall or toy store. His mother often requires him to hold her hand. Jake does not like this control and tries to break free and will run without direction or without fear of getting hurt (sidewalks, open parking lots, etc.). At the end of each tx session, Jake is provided a lollipop after he puts on his coat. He is then walked to the waiting room where healways persists on mom to let go of his hand. If he breaks free he runs aimlessly. IF she does not let him free, he drops like a noodle to the floor and has an tantrum. We are working on this behavior, still trying to discover the stimulus causing the reaction. I am thinking of the lights, or some other object in the waiting room. We do have a "holiday tree" that he seems to be drawn towards...hmm

Cognition/Action/Perception/Modulation

Module 4: Cognition/Action/Perception

Jake is a very bright individual, and functions a high level. However he struggles with abstract processes. i.e. if he is presented with pictures representing a frog or muffin and followed with the question of "what would you eat?" he freely chooses the frog. Jake does not understand that we are talking about meals, perhaps he is thinking of playtime. Miller-Kuhaneck (Chapter 5) describes occupations as a set of actions performed with intent. These occupations must be motivating to Jake, if they are going to be pursued. Our next tx session would be to find out what Jake like to eat for breakfast and present him with a picture of "breakfast food he enjoys" versus a frog and see if he makes a better choice. If we can identify and share an occupation that is meaningful to Jake, then we should be able to decrease many of ASD behaviors.

Individuals with ASD process information differently then typically developing children (Miller-Kuhaneck 2004). This difference makes us as therapists change the way we look at occupations and design tx on a more understandable level. Discrete Trial Training (Miller-Kuhaneck 2004) could prove as one intervention style. Jake struggles with dinner time and eating. This is assessed daily through mealtimes at home. His tx is to begin table setting activities during clinic. Jake also has a behavior of attachment to objects(fishing poles, candy canes, etc). We have him set the table with one plate, one cup, one napkin etc. for each person. He is making progress with this. Initially he wanted all the cups and plates for him. He will share when prompted. This behavior could also be effecting his limited social building skills. The attachment to objects could be seen as selfish and other children may not want to play with him or engage in social activities. Jake does enjoy constructional play (blocks, puzzles).

ASD individuals struggle with occupational reframing (p. 94). If Jake is better able to balance the need to have all the toys, with the social action of sharing and turn taking, then he stands a better chance at increasing his social acceptance by peers. If Jake is presented with an occupation that is more motivating to him, or we can increase his level of arousal (Lynch PPD, 2009) then there is a greater likelihood that he be able to attend to task longer. Increased attention to tasks will increase communication skills and social interactions and decrease many of the behaviors we have been describing in class.

Module 3: Environmental Complexity:

Jake does not like busy environments, or compelx one. He does not do well when at the mall or going out to eat. If mom takes him to store, he will not stay in cart or hold her hand. Jake wants to run, not atypical for 4 y.o. boy with energy. It is his behavior afterward that needs improvement. He will long sit on the floor, cross his arms across his chest tightly and close his eyes. He will not not verbalize or communicate why he needs to run. Mom keeps a structured plan at home, and avoids taking him out for fear of him running into a congested area. She is also fearful that he will someday run in front of a car.

Module 3: Attention and tokens:

It has been difficult to hold the attention of Jake. Knowing that motivation and decreased interferance could help us, I talked to mom and found that he likes Mickey Mouse. We were able to locate some Mickey Mouse Dominos and use them as a token system. The goal of today's intervention was to build sentences verbally using words. Each word he produced verbally would yield one MM domino. If he completed 10 words, he could change in his tokens and play a board game. The Mickey Mouse dominos motivated him to say an 8 word sentence by the end of the tx session, and we played the board game.

Interference:

not wanting to watch her son struggle, mom would always interject and prompt Jake on what to say, or how to repsond. Politely we asked mom to hold back on her interjections and see how he performs for the entire session. Her compliance, although not 100%, was satisfactory.

Module 2: Understanding Behaviors in Autism

Discrete Trial Training (DTT) is a highly structured and systematic teaching mechanism used for behavior modification. Jake enjoys hugging people at inappropriate times and sitting on my lap. These behaviors need to be more socially acceptable with his peers. During our tx plan Jake is allowed to sit in a separate chair by me, but not on my lap. He is also allowed to hug people at the end of his session and if he is able to identify why he wants to hug them. We are practicing picture cards for behaviors that would be acceptable for a hug or vice versa.

Jake will be 4 y.o. next month and we can't wait to celebrate with him. His lives with his biological parents and 5 y.o sister. He is a very pleasant boy, often smiling, yet avoiding eye contact. He will greet you with a cheerful "hello" even after the first meeting.

It was just around his 2nd birthday that Jake was diagnosed with Pervasive Developmental Delay (PDD). Even at an early age, Jake didn't achieve milestones like his older sister, or other infants similar in age. Jake did not walk until he was 19 mos., pointing at 18 mos. with much prompting, and had great difficulty with his diet. At 2 y.o. Jake could not point to his body parts.

Jake enjoys stacking blocks, counting, and Mickey Mouse. His new interest is in puzzles and toys with buttons.

Diet: We had difficulty advancing Jake past stage 1 baby food until 18-19 mos. Early in his infant years there was issues with frequent constipation. He continues with an aversion to all vegetables, eating only when "hidden" in other foods. Other food that he avoid include macaroni, potatoes and fries. He was strictly a chicken and beef eater until 6 mos ago. Now he eats some fruit-mainly apple sauce, but still no veggies. He also expanded his diet to include rice, pasta and cheese-but in small portions. His parents have been informed of many diets, but none have been recommended by his health care team (SLP, pediatrician, developmental pediatrician, school OT). They are not currently following any diet guidelines other than trial and error.

Communication: Jake avoids eye contact, does not initiate conversation or verbal behaviors, will not respond when called by his name, does not engage in gestures of hand waving, lack of imitation with gestures. Jake still struggles with comprehending body expressions and facial expression. He did not begin pointing until 18 mos. His verbal expression is limited to less than 20 words at 3 y.o. He has recently been improving with help of his SLP. He does not use verbal language to mand with consistently, but will use word approximation if he wants something. Sometimes he will bring his mother's hand to an object. He is able to communicate needs through American Sign Language.

Behavior: Jake is not very verbal, uses less than 20 words. he spends much of his time at home with mom. As an infant he did demonstrate some repetitive hand gestures that seemed to calm him down, but they are no longer present. Jake struggles with 2 step commands, however using a token reward system has yielded some positive changes (not generalized yet). There are no outbursts, tantrums, self injury or disruptive behaviors. He does not demonstrate anxiety disorders. He does walk on his toes when he is excited.

Motor skills: late crawling, walking-initially toe walker, somewhat clumsy running- tripping over own feet and flailing arms. Jake never elicited any hyperactivity. he can use eating utensils to feed himself appropriately and with good accuracy.

Sleep: Jake was colicky for the first several months, but then calmed down. Thought this was a milk sensitivity as mom is lactose sensitive. He eventually started sleeping through the night. He would wake up on occasion with discomfort. His limited verbal skills make it difficult to identify the source of discomfort (i.e. constipation). He did not exhibit any increased activity with his sleep patterns as witnessed by parents. When he does wake up, he is able to fall back asleep on his own.

Immune System: parents describe Jake as overall being healthy, but when he gets a 'cold' it lasts a little longer. No history of ear infections.

Cognition: difficulty with imitation of gestures

Functional/Occupational based challenges: Jake struggles with functional play, establishing peer relationships, communication and language skills to express emotions and feelings.

Areas for improvement include: communication skills both expressive and nonverbal, social interaction, attention and listening skills, functional play.