Disability/Chronic Condition Assignment

Autism Spectrum Disorder

Part I: Description of Diagnosis/Condition

Autism Spectrum Disorder (ASD) is a new diagnosis included in the DSM-V that reflects four previously separate disorders, into one single condition with different levels of severity of symptoms (APA, 2013). ASD now includes the previous DSM-IV, Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder and Pervasive Developmental Disorder Not Otherwise Specified (APA, 2013). ASD is a neurodevelopmental disorder that is diagnosed based on behavior and developmental characteristics as opposed to medical, anatomic or genetic factors (Firth, 2008) It is necessary to note that there is not one specific behavior that is consistently seen in ASD and there is not a singe behavior that can disqualify someone from being diagnosed with ASD (Firth, 2008) ASD is a collection of social, communication and behavioral difficulties that create the disorder (Firth, 2008) There is also a wide spectrum of functional ability with ASD. The highest functioning individuals can score well above average of intelligence testing and the lowest functioning individuals can score well below (Firth, 2008). No two individuals are the same which is why the condition is considered to be a spectrum.

Prevalence

The prevalence of ASD is increasing at an exponential rate. According to the Centers for Disease Control and Prevention, ASD is the fastest growing developmental disorder in the United States with one out of every fifty-nine children being diagnosed someone on the spectrum each year (CDC, 2014). ASD is four times more likely to occur in boys than in girls (CDC, 2014). Studies have found that about one in fifty-four boys will be diagnosed and one in two-hundred and fifty-two girls will be diagnosed (Lord, et al., 2018). Researchers believe that there is an estimated 1.5 million children ages 3 to 17 in the United States living with ASD (Lord, et al., 2018).

Etiology

There is no known etiology of ASD (Porter, 2015). Throughout the years, many different hypotheses have been proposed, but none have been successfully proven. Within the past eighteen years, there have been many steps towards understanding the disorder, however, there is still a long way to go. There have been three general research areas that have emerged from looking further into the etiology of the disorder: genetics, neurological structure and development and environmental factors (Volkmar & Wiesner, 2009).

Genetics:

In 1977, it was found that identical twins were more likely to share autism than fraternal twins (Volkmar & Wiesner, 2009). It was also discovered that if one sibling was diagnosed with autism, the chance of the other sibling being diagnosed with autism increases. The instance rate for siblings increases from one in one-thousand to one in eighty (Volkmar & Wiesner, 2009). (Volkmar & Wiesner, 2009) found that to date, specific genes that play into this disorder have not been located. It has also been hypothesized that different severity of ASD has different genetic factors. Continued research in the area of genetics and ASD provides hope for future generations.

Environmental Factors:

Arguably the most controversial topic in terms of the cause of ASD is environmental factors. Theories such as immunizations and the use of pesticides contribute to the continued discussion of the disorder’s etiology. Most researchers are in agreement that there is little evidence that suggests an environmental cause is the reason for ASD (Firth, 2008). There are a large number of parents of children with ASD who claim that ridding their child’s boy of toxins, cures their autism (Porter, 2015). These theories have not been researched, therefore, they cannot be disputed (Porter, 2015). Researchers feel that it can be argued that environmental factors can impact the prognosis of an individual with ASD but cannot labeled as a direct cause of the disorder (Porter, 2015). Many longitudinal studies continue to be done, focusing on environmental causes of ASD.

Neurological structure and development:

One of the primary reasons for the belief that there is a neurological aspect to ASD is because of the increased likelihood that children with ASD will develop some form of epilepsy (Volkmar & Wiesner, 2009). Researchers have also found that around fifty percent of children with ASD have an abnormal electroencephalograms (EEG) (Firth, 2008). It is necessary to note that there is still no specific pattern of abnormality among those with ASD. (Firth, 2008) also found that individuals with ASD have fewer Purkinje cells in the cerebellum, which would be considered a neurological marker. Lastly, (Firth, 2008) found that individuals with ASD tend to have smaller and more compact cells in the frontal cortex of the brain. While all of these factors are beneficial in the effort to finding a concrete etiology for ASD, significant research stills needs to be completed in order to full understand neurology and a cause for ASD.

Diagnostic Criteria

The age on onset for ASD is very difficult to predict (APA, 2013). Children are typically diagnosed with an ASD between the ages of 18-36 months (APA, 2013). However, children who have higher levels of functioning may not be diagnosed well into their elementary school years (APA, 2013). While it may not have been caught earlier in life, symptoms were more likely than not present (Porter, 2013).

There are five specific diagnostic criteria for ASD as outline in the DSM-V. (APA, 2013).

“1. Persistent deficits in social communication and social interaction in three categories: social-emotional reciprocity; nonverbal communication behaviors used in social interactions and developing, maintaining and understanding relationships (Porter, 2015, pg. 41).”

“2. Restrictive, repetitive patterns of behavior, interests, or activities with the presence of at least two of the following four observation categories: stereotyped or repetitive motor movements, use of objects, or speech; insistence of sameness, inflexible adherence to routines, or ritualized patterns of behavior; highly restricted, fixated interests of hyper or hypo reactivity to sensory input (Porter, 2015, pg. 41).”

3. Symptoms are present in the child early on in development (APA, 2013).

4. Symptoms present cause a significant functional impairment (APA, 2013).

5. All other possible explanation for symptoms present have been ruled out (APA, 2013).

The DSM-V also divides ASD into three level of severity. The levels of severity are assigned based on the amount of support to the individual that is required (APA, 2013). The levels are as follows, level one, requires support, level two, requires substantial support and level three, requires very substantial support (Porter, 2013).

Treatment

There is no one best approach or treatment path for an individual diagnosed with ASD (Porter, 2013). Each case of ASD varies which means that treatment varies based on the individuals needs. However, professionals agree that early interventional for those diagnosed with ASD is critical (White et al., 2007). (White et al., 2007) found that individuals with ASD respond best to highly structured and specialized programs. In the past several years, the use of Applied Behavioral Analysis (ABA) has become increasingly popular (CDC, 2014). Years of research has showed the success that ABA has had with decreasing inappropriate social behaviors and increasing communication and learning (White et al., 2007). The goal of ABA is to reduce unwanted behaviors and reinforce behaviors that are wanted (Porter, 2013). While ABA has become one of the most popular forms of treatment, a 2009 study conducted by the National Autism Center found that there are 11 well established treatments with high levels of effectiveness for ASD (National Autism Center, 2011). Regardless of the treatment program used, it is stressed throughout the research that a cooperative group effort from all treatment teams is necessary for effective outcomes (Porter, 2013). The eleven treatments are as follows:

Antecedent Approach:

This intervention typically involves targeting the event that precedes a behavior that is looking to be increased or decreased (Porter, 2013). Examples include time delays and environmental enrichment (Porter, 2013).

Behavioral Package:

This intervention is designed to target a problem behavior and reduce it (Porter, 2013). Alternative behaviors and skills are then taught to be applied (Porter, 2013)

Comprehensive behavioral treatment for young children:

ABA therapy is considered to be this form of treatment. Typically these types of interventions are utilized when an individual in under the age of eight (Porter 2013).

Joint attention intervention:

This intervention focuses on teaching an individual (usually a child) to respond to nonverbal cues usually associated with social situations (Porter, 2013)

Modeling:

Modeling involves a peer or an adult figure demonstrating a desire behavior or action.

Naturalistic teaching strategies:

This intervention almost always includes providing a stimulating environment while reinforcing particular cues (Porter, 2013).

Peer training package:

This intervention teaches siblings or peers to engage in play with children who have an ASD. This, then promotes social interaction (Porter, 2013).

Pivotal response treatment:

This intervention is almost always used with a child and parent and focuses on areas such as social communication and self-initiation (Porter, 2013).

Schedules:

One of the most important interventions for individuals with ASD, this utilizes a list of tasks or sequences to meet an individual’s need (Porter, 2013)

Self-management:

This intervention is used to promote the independence of the client by teaching self-regulation of behaviors (Porter, 2013).

Story-based intervention package:

A recreation therapist can provide this intervention in many different formats for a variety of clients. Any desired task or behavior is demonstrating in a narrative or story (Porter, 2013).

Prognosis

There is no known cure for ASD. There is also no, “one size fits all” approach to treating the disorder. Professionals agree that early intervention is vital for more positive outcomes. It is likely that individuals with ASD will need services and support throughout the entire duration of their life (Lyall et al., 2017) However, with support services and interventions, individuals with ASD can live relatively normal lives. Most individuals successfully find jobs, form relationships and attend school. The DSM-V (APA, 2013) states that “the best established prognostic factors with individual outcomes with ASD are the presence or absence of associated intellectual disability, language impairment and additional mental health and health conditions.”

There are several secondary conditions that are commonly associated with ASD. Some of these conditions include, epilepsy, sleep disorders, hyperactivity, anxiety and depression (Lyall et al., 2017). Some more concerning secondary conditions include sensory processing dysfunctions, cognitive impairments and self-injurious behaviors (Lyall et al., 2017). As it has been stated before, ASD is a disorder with a wide spectrum. Where an individual falls on the spectrum will predict their prognosis. However, a positive quality of life is entirely possible and achievable.

Part II: Effect of Condition and Related Limitations on Functioning

Physical Functioning

Individuals with ASD can have difficulties with fine and gross motor skills (Everstole et al., 2016). This can limit activities of daily living. This can also impact the emotional functioning of an individual with ASD. It is often desired for one to be able to perform tasks on their own even though they have difficulty and need assistance. When an individual with ASD has fine or gross motor difficulties, this can impact ones ability to perform tasks in school or in a job.

Another area of physical functioning that is common in ASD is restricted and repetitive behaviors. This includes rocking, flapping, spinning, jumping up and down and rocking back and forth (Everstole et al., 2016). Other behaviors include spinning wheels, shaking sticks and pushing buttons (Everstole et al., 2016).

Cognitive Functioning

Around fifty percent of individuals who have an ASD have a below average intelligence while the other fifty percent have above average intelligence (Kuhlthau et al., 2010). (Volkmar & Wiesner, 2009) found that individuals with ASD think differently overall as compared to those without ASD. (Volkmar & Wiesner, 2010) explain that individuals with ASD think visually rather than linguistically. This is said to be one of the reasons that it appears that individuals with ASD process information at a slower rate. Overall, cognitive functioning will vary based on where an individual falls on the spectrum.

Social Functioning

One of the most common symptoms associated with ASD is deficits in the area of communication. Around 33 percent of individuals with ASD are considered to be nonverbal (National Autism Center, 2011). This means that they have difficulty using spoken language. Individuals with ASD may not understand or appropriately use eye contact, tone of voice, gestures, facial expressions and more. Generally, individuals with ASD are more interested in what is happening in the environment around them and in turn, do not interact with others (Kuhlthau et al., 2010). This leads to difficulty developing and maintain friendships (Kuhlthau et al., 2010). Another difficulty individuals with ASD may experience is socially inappropriate behavior because of the challenges recognize typical social cues. This may lead to difficulties in jobs, school and community settings.

Emotional Functioning

As discussed above, communication is a common difficulty among those with ASD. Communication is a key factor into social and emotional regulation and communication. Individuals with ASD often have difficult recognizing emotions and intentions in others, recognizing their own emotions, expressing their emotions and seeking emotional comfort from others (National Autism Center, 2011). The inability to regulate or communicate ones emotions can lead to stress, unwanted behavior and self-injurious behavior. This can impact and individual with ASD in schooling, with friendships and within the community. However, interventions can help to address these areas of difficulty.

Sample Client Description

Mike is a fifteen-year-old boy who was diagnosed with Autism Spectrum Disorder at the age of three. Mike is considered non-verbal and communicates by using Rapid Prompting Method. He attends his local high school and participates in regular outings with his therapists in the community. His favorite activities are watching music videos on YouTube, listening to music on his iPad, swimming and jumping on his trampoline. He lives at his house with his Mom and Dad, older brother and younger sister. Mike frequently expresses the desire to complete tasks and chores around the house (e.g. rolling trash to curb, walking the dog and setting the table). He is currently struggling to remain seated for a longer period of time. His repetitive standing and jumping up has begun to cause disruptions in the classroom, while on community outings and at home.

Part III: Client Needs and RT Service Providers

As was discussed above, there is not a standard treatment approach to those who have ASD. With that being said, there is also no standard treatment modality that is used in recreation therapy for those with ASD (Porter, 2013). There are many treatment considerations for recreation therapists to consider when working with those who have an ASD. It is important to be patient and firm, have a structured environment, promote activities that focus on client strengths, limit the use of physical guidance and be aware of possible self-injurious behaviors (Porter, 2013). Self-injurious behaviors, which include, biting oneself, scratching or hitting oneself, head banging and eye gouging, are one of the most important limitations in working with individuals who have an ASD (Porter, 2013). It is important to be mindful of specific client needs (as they change from person to person) and adjust your treatment approach based on your specific client.

Client Goals and Objectives

Goal #1

– To independently walk the dog (increase independent function)

Objective 1a

– Following  the first 20 min session with his recreation therapist, the client will demonstrate the ability to attach a leash to his dog’s collar.

Objective 1b

– Following the second 20 min session with his recreation therapist, the client will walk alongside the recreation therapist and dog for 10 minutes while holding a second leash.

Objective 1c

– Following the third 20 min session with his recreation therapist, the client will demonstrate the ability to independently hold a leash for a 5 minute walk with his dog.

Goal #2

– To reduce repetitive standing movement (reduce repetitive behaviors)

Objective 2a

– Following one 15 minute session with his recreation therapist, the client/family member will identify appropriate distractions to replace standing movement.

Objective 2b

– Following the second 20 minute session with his recreation therapist, the client will utilize distraction 2 out of the 4 times when prompted by his recreation therapist.

Objective 2c

– Following the third 20 minute session with his recreation therapist, the client will use distractions in place of standing movement without prompting during a 15 minute period.

Considerations

As always, precautions are necessary to take into consideration when working with any client, but especially those who have an ASD. Sometimes individuals with ASD will elope when overwhelmed in certain situations. This would be necessary to take into consideration if the recreation therapist were working with the client on goal number two in a public setting. Another safety precaution that should be considered is the physical, repetitive behavior movements such as flapping. If not paying attention, flapping or other physical repetitive motions could injure the therapist or the client.

Interventions

Two separate interventions will be utilized to meet the clients goals. These two interventions can be used in conjunction with one another which is the reasoning for having both. The first intervention is achieved through modeling. Progressing through each session, the client will watch the therapist engage in the task. The client will the follow, imitating what the therapist did. This can be utilized in the second goal as well by having the therapist model the appropriate behavior in the community outing. The client can watch and understand the appropriate behavior. The second intervention strategy that will be utilized for these two goals in self-management. Self-management promotes independence by training the client to regulate their own behaviors. The client setting their own goals helps to have success in these interventions. The client will be identifying their own motivational strategies for achieving both of these goals. The client will be identifying the distraction used in goal two as well as the reward for completing the task in goal one.

References

• American Psychiatric Association (2013)
  
  Diagnostic and statistical manual of mental disorders,
  
  fifth edition.
• Centers for Disease Control and Prevention. (2014) Autism spectrum disorders. Retrieved from http://www.cdc.gov/ncbddd/autism/index.html.
• Eversole, M., Collins, D. M., Karmarkar, A., Colton, L., Quinn, J. P., Karsbaek, R., . . . Hilton, C. L. (2016). Leisure activity enjoyment of children with autism spectrum disorders.
  
  Journal of Autism and Developmental Disorders
  
  , 46(1), 10-20. doi:10.1007/s10803-015-2529-z
• Firth, U. (2008)
  
  Autism: a very short introduction.
  
  New York: Oxford University Press
• Kuhlthau, K., Orlich, F., Hall, T. A., Sikora, D., Kovacs, E. A., Delahaye, J., & Clemons, T. E. (2010). Health-related quality of life in children with autism spectrum disorders: Results from the autism treatment network.
  
  Journal of Autism and Developmental Disorders
  
  , 40(6), 721-729. doi:10.1007/s10803-009-0921-2
• Lord, C., Elsabbagh, M., Baird, G., & Veenstra-Vanderweele, J. (2018). Autism spectrum disorder. The Lancet, 392(10146), 508-520. doi:10.1016/S0140-6736(18)31129-2
• Lyall, K., Croen, L., Daniels, J., Fallin, M. D., Ladd-Acosta, C., Lee, B. K., . . . Newschaffer, C. (2017).
  
  The changing epidemiology of autism spectrum disorders.
  
  
  
  
  Annual Review of Public Health
  
  , 38(1), 81-102. doi:10.1146/annurev-publhealth-031816-044318
• National Autism Center. (2011) National Standards Report. Retrieved from http://www.nationalautismcenter.org/nsp/.
• Porter, H. R. (2015).
  
  Recreational therapy for specific diagnoses and conditions
  
  . Enumclaw, WA: Idyll Arbor.
• Volkmar, F.R. & Wiesner, L.A. (2009)
  
  A practical guide to autism.
  
  Hoboken: John Wilen & Sons Inc.
• White, S. W., Keonig, k., & Scahill, L. (2007) Social skills development in children with autism spectrum disorders: A review of intervention research.
  
  Journal of Autism Developmental Disorders,
  
  37, 1858-1868. Doi: 10.1007/s10803-006-0320-x.