Abstract
Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s (AOTA’s) Evidence-Based Practice Project. This article presents a case example of a young child with autism spectrum disorder who receives occupational therapy evaluation and intervention in natural environments (home and child care center). Systematic review findings supporting enhancement of key life occupations through interventions to develop cognitive, motor, social–emotional, and self-care skills for young children were published in AOTA’s Occupational Therapy Practice Guidelines for Early Childhood: Birth–5 Years (Frolek Clark & Kingsley, 2020) and the March/April 2020 issue of the American Journal of Occupational Therapy (Gronski & Doherty, 2020; Kingsley et al., 2020; Tanner et al., 2020). Each article in the Evidence Connection series applies evidence from the published reviews on a topic to a related case. These articles are designed to promote application of the evidence to practice.
Case Background
Emma and Alejandro thought their son Jalen, age 2.5 yr, was developing a little more slowly than their older son did. They contacted their physician to share their concerns about Jalen’s limited play skills, temper tantrums, and inability to remain seated. After examining Jalen, the physician referred him to the local early intervention (EI) program. The EI team scheduled an appointment in the family’s home for the next week.
Two members of the EI team—an EI teacher and an occupational therapist—came to the family’s home to share information about the program. After Emma provided signed consent for Jalen to be tested, they administered the Bayley Scales of Infant and Toddler Development, 4th Edition (Bayley–4; Bayley & Aylward, 2019), to assess all areas of development (adaptive, cognitive, social–emotional, physical, and communication). Emma assisted by sharing information and encouraging Jalen to engage in the tasks. Because of Jalen’s low scores on several subtests (Table 1), he met the state’s eligibility criteria for EI services. The team suggested additional evaluations by the EI teacher, occupational therapist, and speech-language therapist, and Emma agreed with these recommendations. For the purposes of this article, the focus is on the occupational therapy evaluation and interventions for Jalen.
Jalen’s Performance on the Bayley Scales of Infant and Toddler Development
Occupational Therapy Evaluation and Goal Setting
Evaluation
The occupational therapist, Raven, used parent interview, structured and unstructured observations, and results from the Bayley–4 to generate an occupational profile for Jalen and his parents.
Observations
Raven began the evaluation in the family’s home, a fifth-floor apartment, by interviewing Emma and observing Jalen during unstructured opportunities to play with toys. Although Jalen participated in a few tasks with prompting from his mother, his preferred activity was flicking the light switch on and off for approximately 15 min. Raven asked about Jalen’s outdoor play skills, and Emma suggested they go to a nearby park. In the park, Jalen was observed running, climbing, and jumping off the equipment, spending only seconds on each activity. His mother had brought along a ball because that was an area of interest; however, attempts to engage Jalen in throwing or rolling a ball back and forth did not engage him. Sitting on a swing required maximum assistance; however, once the swing started moving, Jalen slid off, lay across the swing in prone, and spun himself.
Interview With Parents
History: Jalen was born 2 wk early and was discharged from the hospital with his mother after a routine delivery. His pediatrician has been monitoring him because Jalen missed a few language and fine motor milestones at the last checkup. In a recent medical evaluation, Jalen had been diagnosed with autism spectrum disorder. Illnesses include colds and ear infections approximately twice per year.
Concerns: Jalen’s parents thought he was “doing better.” He began to say “ba” (ball) 2 mo ago and now says “ma” and “da”; otherwise, he uses screaming to communicate his needs. Jalen tantrums if his parents ask him to sit in a chair for meals or to read books on their lap. He requires total assistance for dressing, toileting, and grooming, although he did pull off his pajama bottoms once. Staff at Jalen’s child care center indicated concerns about his play skills and interactions with peers (e.g., he showed minimal positive interactions).
Family routines: Emma works from home. One room is devoted to all of Jalen’s toys and is his “safe place” where he flicks the lights and throws his toys. He sleeps well through the night, and he eats a variety of foods but refuses to use a spoon, so only finger food (cut very small) is offered. He attends a child care center in the mornings.
Individualized Family Service Plan Outcomes
The Individualized Family Service Plan (IFSP) team determined that Jalen was eligible for EI services as a result of his developmental delays and, in collaboration with Jalen’s parents, developed three IFSP outcomes:
Jalen will play for 4 min with objects or equipment independently.
Jalen will stop having tantrums every day and will engage in daily activities.
Jalen’s clothing will remain dry during the daytime.
Occupational Therapy Intervention
On the basis of Jalen’s eligibility and need for services, occupational therapy sessions were delivered in Jalen’s natural environments of his home and the child care setting. Services were based on IFSP Outcomes and coordinated with parents and other EI professionals. Raven alternated weekly services between the home and the child care center.
Intervention 1
To address the first goal, “Jalen will play for 4 min with objects or equipment independently,” Raven provided education and training to Emma and child care center providers in play and developmental activities to enhance Jalen’s skills on the basis of strong strength of evidence supporting these intervention types (Bann et al., 2016; McManus et al., 2012; Wallander, Bann, et al., 2014; Wallander, Biasini, et al., 2014). Suggested activities included developmentally appropriate activities (e.g., sorting by color, playing make-believe games), shared reading with Jalen (e.g., parent–child interactions that may include naming or pointing to pictures), and joint play for 10 min every day (Tachibana et al., 2012).
Intervention 2
To address the second goal, “Jalen will stop having tantrums every day and engage in daily activities,” Raven focused on positive reinforcement for participation in short, structured activities, advising Jalen’s parents and child care providers to use positive behavioral supports such as providing reinforcements to Jalen when he expresses his frustration using his words, uses a strategy to calm down, completes activities, and follows directions (Solomon et al., 2014; Stanton-Chapman et al., 2016). Raven used the coaching model to support the parents’ use of Qigong massage techniques twice a day as part of their care routines to improve Jalen’s self-regulation and behavior (Silva et al., 2011).
Intervention 3
Regarding the third goal, “Jalen’s clothing will remain dry during the daytime,” Raven found low strength of evidence for toilet training for young children with ASD. To respond to this priority, Raven noted that the scenario in the study by Cicero and Pfadt (2002) resembled Jalen’s situation closely and decided to use practice-based evidence through progress monitoring to monitor the combined approach of habit training and positive behavioral reinforcement when Jalen was at child care. This approach included collecting data while taking Jalen to the restroom on a fixed schedule, analyzing the data to identify highly likely windows for voiding, and refining toileting to those times while reinforcing successes. Jaden’s parents requested additional support and were able to access a wetting alarm to be used both at child care and at home (Vermandel et al., 2009).
Occupational Therapy Outcomes
In preparation for Jalen’s transition out of EI at age 3, he was evaluated to determine eligibility for an early childhood special education (ECSE) preschool class. The multidisciplinary team evaluation found that Jalen had improved in many areas of development and had met many of the parents’ goals. His parents and the child care providers reported that he was now able to participate in structured play activities (e.g., playing at the day care center, playing ball during outdoor time, sitting with a parent during reading) for 4 min. Spontaneous, positive peer interactions (e.g., waving to a friend) were emerging at the child care center. His parents reported that he had fewer tantrums when given a request (e.g., “sit at the table,” “let’s take a bath”). The combined intervention approaches resulted in Jalen consistently using the toilet for urination and showing emerging skills with bowel movements on the toilet. The continued use of a schedule and positive reinforcement was recommended to further support toilet training.
Because Jalen’s cognitive and language skills were below age level and would interfere with his performance in preschool, an individualized education program was developed to address his needs. His cognitive and language needs would be addressed during ECSE preschool. The team agreed that direct occupational therapy services were no longer needed at this time because of Jalen’s progress and evaluation results.
Conclusion
This article illustrates how a specific case story is linked to findings from the systematic reviews of occupational therapy for children ages birth–5 yr to inform and guide practice (Frolek Clark, Fischbach, Crane, Corry, & Nadolny, 2019a, 2019b; Frolek Clark, Fischbach, Crane, Nadolny, & Corry, 2019a, 2019b; Gronski & Doherty, 2020; Kingsley et al., 2020; Tanner et al., 2020). For further evidence-based information on early childhood practice, see Occupational Therapy Practice Guidelines for Early Childhood: Birth–5 Years (Frolek Clark & Kingsley, 2020) or the AOTA Web site (https://www.aota.org/Practice/Children-Youth/Evidence-based.aspx).