Transition to Adulthood

The strategy that I will use to promote independent living for Adam is focusing on basic social skills. Initially I will focus on the ability to identify his frustration before meltdowns, which usually means running away or self-injury. I will have Adam identify 1 activity he can do instead of running away. He can choose to hold a squeezable ball or other object. I would like him to squeeze the ball instead of running away. I will encourage his mother to carry this over at home. In addition, stopping and starting will be addressed by having him engaging in a grocery cart activity. I will have him start and stop so he begins to understand this concept more clearly. His family has learned to anticipate his breakdowns and have removed many issues. This appears good but environmental complexity is reduced and he does not have to deal with his all-or-nothing responses to stimulation. These are basic skills but will be necessary for the future when he will need to interact with others, participate in school, and pursue an occupation.

The strategy I will use to advance vocational awareness is empowerment to the family. Since this module I have discussed the importance of talking to Adam about having a career just like they do to their other 3 children. Adam’s mother was encouraged and open-minded when discussing these strategies. In addition, I will educate them on the importance of looking at vocation as a longitudinal goal. They can start to focus on extreme areas of interest and talk with the entire family about Adam pursuing a career one day. Talking to Adam in daily conversation about careers is another way to teach him and the family to have occupational expectations. In addition, this is a good avenue to reiterate the importance of social interaction development, since it is a skill needed for the work environment.

Thank you all to Adam’s supporters, your feedback, suggestions, and learning opportunities. I wish everyone the best with your future case studies!

Adam’s family’s well being is very good considering they have 4 children and 2 with the diagnosis of ASD. Church is a large part of their life. They describe their marriage as strong and supportive. They do have limitations in what they can participate in socially do to Adam’s poor modulation. Since reading this section, I began to talk to Adam’s mom about the social issues and how important they are for Adam and the family. She was a little fearful of change due to their busy schedule and factors involved in managing 4 children. My strategy at this time is to identify this issue as important with his mom. I requested she provide me with an activity we could address that the entire family would like to participate in, but is challenged to at this time. I could tell she was surprised that I addressed this issue, but acknowledged the importance of social interaction relating to the entire family. The next session she came up with a concern about their family home schooling conference in Indianapolis. She wanted all of her children to attend the children’s session so she and her husband could attend the adult sessions alone. After learning this, Noah and I sat down and wrote a social story of 6-7 pages. I asked Mom to read this everyday before leaving for the conference to prepare him. Adam’s Mom contacted me via email to inform me that the conference was a success! Adam attended the children’s sessions without difficulty and the parents attended their training alone. She stated she could not explain how thrilling it was to attend something for an entire weekend that the whole family enjoyed! Per the Quirmback article social stories were effective in improved game playing abilities with children with ASD. This is another option that may prepare and teach Adam about the upcoming family event.

Living with autism;Family's well being

Social Skills and Perspective Taking

Adam’s social referencing occurs toward his mother and father at times. He uses them as a safety net whenever there is something he does not want to participate in. He looks toward his mother for approval, but not necessarily to learn how to react or respond appropriately to others. Adam is very concerned with doing something right. If he feels he will do a task wrong he does not want to try or becomes angry immediately. If Mom has a calm, happy face in order to persuade Adam to participate, it is not very effective. She has more success than a therapist does, but Adam is rigid with this thoughts and feelings. This is a challenge because he is not able to understand on an emotional level that others have thoughts and it is important to consider others. This is a clear example of Adam’s deficit of Theory of Mind defined as the inability to understand that other people have thoughts, beliefs, and feelings that are different than their own (Miller-Kuhaneck).

Adam makes eye contact at times and recognizes individuals at the therapy clinic. Emotion processing and face processing challenge him. Adam is easily over stimulated. If I give praise or facially gesture that he has performed well, he covers his ears and says “no” while stomping his feet. He is sensitive to voice fluctuation. Adam typically avoids looking at my face or others when interacting. As I write this I can see how higher-level skills of emotional processing or Tom will be negatively impacted by avoiding eye contact. Adam’s challenges of face processing and emotional processing are over whelming for him. In fact, I will start at the basics for Adam and use Amy’s suggestion of labeling and matching emotional expression cards. As pictured above, I located this and will work on it with Adam. As I think of Adam’s future, I see where these skills will need to be incorporated in the treatment plan and his abilities will need to be challenged and expanded.

Motor Control and Motor Learning

Adam ambulates independently and transitions from floor to stand independently. He prefers to push up from the floor with his hands or attempts to hold onto something or someone else, indicating poor postural stability. He can run but isn't able to skip or gallop. He does not jump with 2 feet from the floor. He presents with impairments in motor planning evidenced by his tendency to have difficulty initiating a task, which leads to frustration. He has marked difficulty and anxiety with new tasks. Adam uses a palmer grasp when holding a marker and a spoon. When he engages in writing he likes to have tactile prompts when initiating copying letters but can finish on his own. Overall, he could be described as uncoordinated.

The first new concept I will incorporate from this module is a motor control concept of random trials. The Mass article identifies random order as more effective than using a block order. Specifically, this uses variable training of skills versus rote practice of the same skill. I am going to try to have Adam write letters in a random fashion and then increase to writing words. First, I will start with flashcards of letters and then change to verbal instruction to recall letters. They will not be in the same sequence as I usually use, "a,b,c...". Also, Adam enjoys various climbing activities such as climbing onto our mattress pad with assistance. Another concept that will be incorporated is decreased feedback. The Mass article reveals low-frequency feedback schedules facilitated better retention of skills. I will decrease physical assistance and feedback and then give him new challenges with climbing. For example, Adam will climb onto a large wooden box and then mattress pad or climb through tires, barrels and over other real-life obstacles such as pillows. The treatment strategies would incorporate motor control concepts of random trials and reduced feedback in a complex environment, tapping into intrinsic motivators in order to transfer skills to other environments.

Cognition, Perception, and Action

My initial evaluation was completed 6 years ago. I gave Adam the Peabody Developmental Motor Skills Test, used observation, and an interview with Mom. My comments indicate that he did not want to participate in some tasks on the Peabody. He received a score of poor for visual-motor and below average for fine motor, and was functioning at the 14-15 month level. It was recorded that he was ambulating, had not established hand dominance, used a palmer grasp for marking. Adam did not creep and used a wide base of support. He was following 1 step directions inconsistently.

His mother's biggest concerns were regarding his particular diet and sensory defensiveness. Noah was often in the high arousal mode. His mother's chief complaints now are eating vegetables, drinking from an open cup, and writing.

Perceptual: The treatments that I use to address these issues are writing tasks with concepts from Handwriting Without Tears. I need to break down the task as he copies alphabet letters. He often requires tactile prompts to initiate.

Movement: Adam works on climbing on different surfaces, creeping, and getting into various swings in order to address motor planning, coordination, and body awareness through proprioceptive activities. He enjoys this.

Cognitive: I work on incorporating cognitive skills into tasks. I encourage Noah to communicate his needs, recall previous information, and follow directions. I work on preparing him for the next activity such as drinking or eating. Since this class I have used the token system to complete drinking. Family is also using this system at home. He is now drinking 4 sips from an open cup at home, which is a huge success for him.

3rd post-enviornmental complexity

Adam has challenges managing environmental complexity. He becomes easily overwhelmed with noise, change in schedule, emotional responses, challenging tasks, and unpredictable situations and variables. He is accustomed to a fairly routine schedule with limited outside events due to home schooling. Adam manges novelty by self-stimulation such as hand-flapping, running away from the stimulation, or tuning into the TV. Adam's ability to process and respond to environmental complexity depends on his state of modulation. If he is attending to the situation and not in high arousal state he is better able to deal with changes in the environment. According to Miller-Kuhaneck(177) it was reported that children with executive functioning impairments have a great deal of difficulty with combination of activities, new activities, and changing activities. Looking at Adam, it appears relevant and explains why he may use his self-stimulation techniques. Due to his inability to predict, analyze, and adapt he resorts to comfort measures. Adam responds well with priming, which I have recently utilized to a higher level, so he knows what is expected and functions the best in a predictable routine world.

2nd post-behavioral strengths & challenges and communication strengths

Adam's behavioral strengths are that he responds well to reinforcement, the token system, prompting, and peer mediated intervention from his brother. He displays good perseverance when he engages in an activity he is interested in. He is able to follow simple 2-3 step directions depending on the request, displaying functional receptive language, has a good attention span, and cooperates approximately 75% of the time. He follows the rules unless over stimulated by therapy requests. In addition, Adam's verbal behavior from an OT perspective is that he has basic motor imitation, can mand for essential needs, intact echoic ability, able to tact, and has intraverbal skills on a concrete level of function. His behavioral challenges include inability to regulate between bothered and highly irate. He tends to become irritated and is unable to find the middle ground, resulting in a melt down. Adam is challenged by transitions and changes. These verbal behavior terms are from the the classroom lecture April 21, 2009.

Adam's communications strengths are that he is verbal, fluent, and articulate. He can express his basic needs. Adam often repeats phrases from the TV or video games even if they don't pertain to the current conversation. He does not require PECS or sign language to communicate his desires. He varies his intonation only when he is frustrated or really excited.

Case Study-Adam

Adam

Adam is a 9 year old boy who was diagnosed with Autism in May 2003. Adam has been receiving OT from me since age 2 1/2 with insurance coverage! He received PT for 3 years and behavioral services for 2 years at Indiana State University. Adam is home schooled. He receives Speech from school and PT on a consultative basis, even though he does not attend the school. Adam attempted PE but it was too stressful for him. Adam's parents have tried a variety of dietary interventions which have been helpful for his cognition, speech, and behavioral development per Mom's report.

Adam's strengths are his ability to memorize facts, complete puzzles, and recall all sports facts. Mom reports that he is very affectionate and responds well to affection from his family. He calls himself "joke boy" although his jokes aren't always funny. Eating at kid friendly restaurants such as McDonald's and Chuck E. Cheese are enjoyable. However, he becomes restless if he is expected to sit and wait for food. The family cannot go anywhere without his easy grip Gerby sippy cup. Adam's weaknesses include resistance to change, inability to deal with unpredictable situations, oral defensiveness, gravitational insecurity, fine motor delays, low tone, visual motor delays, and impaired ADL function and social interaction. All domains of his life have been impacted.

Adam's parents have been married for 12 years and describe their marriage as strong, stable, and loving. They are devoted to each other and working toward raising their children. Adam's older brother is 12 years old and has a diagnosis of PDD-NOS, a younger sister 6, and a younger sister 5 who was adopted at age 3. All 4 children are home schooled. Mom stays at home and Dad is an engineer. Adam attends church regularly with his family. He will go to Sunday School independently but stays with his parents instead of attending children's church. He really enjoys his Tae Kwon Do class which is 1 on 1. He has not played with his same age peers due to scheduling, but plays with his brother. They play Star Wars and the Wii. The majority of his time is spent playing the Wii or watching his brother play.