CONT-OT-Executive Function in Children with Autism ...€¦ · 11/21/19 2 Today’s Outcomes § 1)...

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Execu&ve Func&on in Children with

Au&sm Spectrum Disorder

Cara Koscinski, OTD, OTR/L The Pocket Occupational Therapist www.PocketOT.com

(c) The Pocket Occupational Therapist, 2017 1

(c) The Pocket Occupational Therapist, 2017

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Bright Brain Today’s Outcomes § 1) Describe executive function and its importance

to occupation of children with autism.

§ 2) Summarize the meaning of theory of mind and effects on daily living tasks.

§ 3) List five interventions for building executive function skills based on the Occupational Therapy Practice Framework, 3rd Edition.

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Mother to two children with autism.

Faculty at the University of Saint Augustine MOT and OTD programs

Advisor for OT and contributing author for Autism Asperger’s Digest Magazine and Autism Parent Magazine

Speaker across the US for Universities, Future Horizons Autism Conferences, state and local organizations

Co-Founder of Aspire Pediatric Therapy, Founder of Route2Greatness, LLC, & Owner of The Pocket Occupational Therapist, and OT2OT Program

Executive Vice President of Content for www.myHana.org


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EF and Autism Overview


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Autism Spectrum Disorders (ASD) §  1 out of every 59 children in the United States has autism

§  Autism undermines cognitive, social, emotional, and occupational capabilities

§  Insistence on routines and decreased ability to think outside

of the box to develop creative ways to solve problems

(CDC, 2018)

This Photo by Unknown Author is licensed under CC BY-SA

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ASD and Play §  Repetitive patterns of behavior, difficulties with transitions between

activities, (APA, 2013)

§  A hallmark issue for children with ASD includes deficits in pretend and symbolic play skills (APA, 2013)

§  Occupational therapy for children is rooted in the foundation that play is

the method of skill acquisition (AOTA, 2014) §  Play skills and EF deficits are linked and both contribute to delays in

occupational performance (Berenguer et al., 2018)

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EF Overview §  Important to know both order in which skills emerge AND

what each skill ‘does.’ §  Begin after birth and continue to adulthood. §  Frontal and Pre-frontal cortex §  Two ‘types’ of skills

§  Thinking (cognition) §  Doing (behavior)

(Berenguer et al., 2018; Sun et al., 2017) 11

EF definition/components in current literature §  Demetriou et al. (2017) completed a Level I study that

determined planning, concept formation, planning, mental flexibility, fluency, and response inhibition

§  Josman and Meyer (2019) completed a scoping review of fifty articles that found over thirty constructs in OT literature for defining EF

§  Cramm et al. (2016) determined OTs did not recognize the widespread effects of EF on occupational performance of children with ASD


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Often compared to air traffic control


This Photo by Unknown Author is licensed under CC BY-SA

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What is executive function? § Set of skills to manage tasks we complete every

day § What we will pay attention to and what we choose

to do § Manage emotions and thoughts so we can be

efficient § Regulate behavior when difficulties arise § Assist in ability to function with independence

(Berenguer et al., 2018; Sun et al., 2017) 14

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Two Types of Skills

•  Planning •  Organization

•  Time Management

•  Working Memory

•  Metacognition

Thinking

•  Response Inhibition •  Emotional Control •  Sustained Attention •  Task Initiation •  Flexibility

Doing

(Cramm et al., 2016; Demetriou, 2016; Josman & Meyer, 2019) 15

EF Neurology


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How Brain Connections Form

(Center for the Developing Child at Harvard University, 2014) 17

Regulation § Behavioral inhibition

ü Delay response vs. immediate gratification

ü Stop behaviors when they are not

working ü Manage distractions that could interfere

(Cramm et al., 2016; Demetriou, 2016; Josman & Meyer, 2019) 18

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Regulation § Our ‘optimal’ state of learning § We are engaged and ‘in tune to’ our environment § Not ‘too’ energetic and not ‘too’ tired. §  Just right state of BEING

(Jahromi, Bryce, & Swanson, 2013; Josman & Meyer, 2019) 19

https://www.kimbarthel.ca/ (c) The Pocket Occupational Therapist, 2017 20

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Upstairs vs Downstairs Brain Tantrum: §  Conscious choice §  Strategic and manipulative §  Can reason, make choices §  Emotions under conscious control §  STOP when demands are met

Sensory: §  Flood of hormones §  Over-ride conscious choice §  Loss of body control §  Can NOT be reasoned with §  Not capable of choices (Siegel & Payne Bryson, 2011)

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Neuroscience’s Star Patient

Phineas Gage: §  Injured by explosion §  Changed personality §  Impulsive §  Poor decision making

(O'Driscoll & Leach, 1998) 22

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Frontal lobe §  Rational thinking §  Future considerations §  Flexibility §  Matures at age 25 §  Mindfulness: Manage the internal environment

Interoception

–Manage Mood (to reduce intrusive thoughts) –Manage fatigue (pacing, regular breaks) –Manage physical comfort (pain, hunger, thirst)

(Henri-Bhargava, Stuss, & Freedman,2018) 23

Metacognitive process §  Internal awareness

§  How am I progressing §  Am I on track to meet the deadline §  Self-reflection

§  External awareness §  Am I on track with others §  See how they are doing it

(Jahromi, Bryce, & Swanson, 2013; Josman & Meyer, 2019) 24

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Quick Game § Repeat after me……SILK


Sub-cortical level §  Intense emotions

§  Impulse reactions

§ Rigidity

§  Lack of self-reflection

(Berenguer et al., 2018; Jahromi, Bryce, & Swanson, 2013) 26

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Theory of Mind"(ToM)


Theory of Mind § Theory of mind (ToM)—the specific ability to

attribute mental states to oneself and to others

§ Manage the external environment –Reduce distractions (auditory, visual) –Allocate sufficient time for tasks so less time pressure to distract –Structure and routine

(Berenguer et al., 2018; Chan et al., 2016; Jones et al., 2018) 28

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ToM and EF §  A child’s ToM is significantly associated with ability to engage in pretend

play. §  ToM include deficits in initiating play activities, object substitutions, and

making inferences (Chan et al., 2016). §  Decreased ability to communicate and difficulty putting yourself in

someone else’s shoes adds to struggles with EF (Jones et al., 2018). §  ToM relates to EF since it helps in social settings by limiting conflicting

behaviors during interpersonal interactions. §  It also includes intuitive social skills, understanding sarcasm, visual

perspective-taking, and social-emotional reciprocity (Jones et al., 2018).


Framework III"as foundation for evidence-based practice


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Evidence-Based Assessment Ideas §  Utilize the ToMI-2 Assessment (Hutchins, Prelock, &

Bonazinga, 2012) §  Use the BRIEF Assessment (Josman & Meyer, 2019) §  Complete an activity analysis during structured clinical

observations of adaptive behavior, social skills, regulation, caregiver-child interaction (AOTA, 2014; Gentles, Nicholas, Jack, McKibbon, & Szatmari, 2019)

§  Complete occupational profiles with caregivers to understand the child’s occupations at home and when considering challenging behaviors (AOTA, 2014; Gentles et al., 2019)


Evidence-based interventions §  Performance skills listed in Framework III in global and specific mental

functions provide the structure for OTs to create adaptions and modifications.

§  Utilize terminology from the Framework III such as chooses, gathers, handles, inquires, sequences, notices, adjusts, and accommodates.

§  Occupational therapists should gaze through an EF lens to view tasks commonly completed in OT sessions (Josman & Meyer, 2019).

§  Build performance skills in lesser-known categories of the Framework III such as approaches, times response, regulation, heeds, accommodates, and expresses emotion.


(AOTA, 2014)

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AOTA Practice Guidelines: § Video Modeling

§ Turn-taking games such as checkers, chess, Jenga


Games to Play §  Peek-a-boo §  Block copying §  Finger plays §  Hokey Pokey §  Simon Says §  Use inhibition such as: FREEZE….Ring around the Rosie §  Talking about mutually shared experiences §  Imaginary play


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Social and Theory of Mind Skills §  Consider effects of EF dysfunction on social skills and

pragmatic language, both of which increase smooth performance of ADLs (Berenguer, Miranda, Colomer, Baixauli, & Rosello, 2018; Sun et al., 2017).

§  Use riddles, Pictionary®, and Scrabble® to help improve performance skills and performance patterns in the social interaction (AOTA, 2014; Chan et al., 2016).

§  Target skills outlined the Framework III such as approaches, times response, regulation, heeds, accommodates, and expresses emotion (AOTA, 2014).


EF Components Metacognition •  Ask students to make predictions and to utilize rubrics to help

evaluate their own performance (Berenguer et al., 2018). •  Provide structured social play and scaffolding to support self-

reflection (Dawson et al., 2010).

Working Memory

•  Play games with patterns, sequences, and memorization such as Simon® (Dawson et al., 2010; Faja et al., 2016).

•  Reverse roles and allow the child to teach steps of the activity (Dawson et al., 2010).

•  Reduce working memory load by breaking down the steps of a task (Dawson et al., 2010).

Planning and Time Management

•  Encourage children to write down the plan, include each step, and review often to adapt for changes (Demetriou et al., 2017).

•  Encourage use of schedules (Josman & Meyer, 2019).


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CONCLUSION §  EF affects vast areas of occupation in children with autism. §  Play is greatly affected in both autism and EF dysfunction. §  ToM should be considered as a critical component of EF

and iADL performance. §  OTs need to complete an occupational profile to determine

areas ‘lesser known’ when considering EF. §  OT clinicians should consider working with older children on

EF skills.



This Photo by Unknown Author is licensed under CC BY-NC-ND

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Presentation"REFERENCES


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References: §  American Occupational Therapy Association. (2014). Occupational therapy practice

framework: Domain and process (3rd edition). American Journal of Occupational Therapy, 68, 1-48.

§  American Occupational Therapy Association. (2018). Vision 2025. American Journal of Occupational Therapy, 71,7103420010. https://doi.org/10.5014/ajot.2017.7130027103420010p1

§  American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

§  Berenguer, C., Miranda, A., Colomer, C., Baixauli, I., & Rosello, B. (2018). Contribution of theory of mind, executive functioning, and pragmatics to socialization behaviors of children with high-functioning autism. Journal of Autism and Developmental Disorders 48(2), 430-441. doi.org/10.1007/s10803-017-3349-0

§  Centers for Disease Control and Prevention. (2018). Retrieved from https://www.cdc.gov/ncbddd/autism/data.html

§  Center on the Developing Child at Harvard University (2014). Enhancing and Practicing Executive Function Skills with Children from Infancy to Adolescence. Retrieved from www.developingchild.harvard.edu.

§  Chan, P.-C., Chen, C.-T., Feng, H., Lee, Y.-C., & Chen, K.-L. (2016). Theory of mind deficit is associated with pretend play performance, but not playfulness, in children with autism spectrum disorder. Hong Kong Journal of Occupational Therapy, 28(1), 43-52.


References:


§  Cramm, H., Krupa, T., Missiuna, C., Lysaght, R. M., & Parker, K. C. H. (2016). Broadening the occupational therapy toolkit: An executive functioning lens for occupational therapy with children and youth. American Journal of Occupational Therapy, 67(6), 139-147.

§  Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., & Greenson, J. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The early start Denver model. Pediatrics, 125, 17-23.

§  Demetriou, E. A., Lampit, A., Quintana, D. S., Naismith, S. L., Song, Y. J. C., Pye, J. E.,…Guastella, A. J. (2017). Autism spectrum disorders: A meta-analysis of executive function. Molecular Psychiatry, 23, 1198-1204.

§  Faja, S., Dawson, G., Sullivan, K., Meltzoff, A., Estes, A., & Bernier, R. (2016). Executive function predicts the development of play skills for verbal preschoolers with autism spectrum disorders. Autism Research 9(12), 1274-1284.

§  Henri-Bhargava, A., Stuss, D. T., & Freedman, M. (2018). Clinical Assessment of Prefrontal Lobe Functions. Continuum, 24(3),704-726 .

§  Jahromi, L. B., Bryce, C. I., & Swanson, J. (2013). The importance of self-regulation for the school and peer engagement for children with high-functioning autism. Research in Autism Spectrum Disorders, 7(2), 235-246.

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§  Jones, C. R., Simonoff, E., Baird, G., Pickles, A., Marsden, A. J., Tregay, J.,… & Charman, T. (2018). The association between theory of mind, executive function, and the symptoms of autism spectrum disorder. Autism Research, 11(1), 95-109.

§  Josman, N., & Meyer, S. (2019). Conceptualization and use of executive functions in pediatrics: A scoping review of occupational therapy literature. Australian Occupational Therapy Journal, 66, 77-90. doi:10.1111/1440-1630.12525

§  O'Driscoll, K., & Leach, J. P. (1998). "No longer Gage": An iron bar through the head. Early observations of personality change after injury to the prefrontal cortex. BMJ (Clinical

research ed.), 317(7174), 1673–1674. doi:10.1136/bmj.317.7174.1673a

§  Siegel, D. J., & Payne Bryson, T. (2011). The whole-brain child: 12 revolutionary strategies to nurture your child's developing mind. New York, NY, US: Bantam Books

§  Sun, I. Y. I., Varanda, C. A., & Fernandez, F. D. (2017). Stimulation of executive functions as part of the language intervention process in children with autism spectrum disorder. Folia Phoniatr Logoop, 69, 78-83. doi.org/10.1159/000479586

References:

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§  “Helping Students Take Control of Everyday Executive Functions” by Paula Moraine

§  “Late, Lost and Unprepared: A Parent’s guide to helping children with executive functioning” by Joyce Cooper-Kahn

§  North Shore Pediatric Therapy, Inc. (2011) “Executive Functioning Skills Check-List”.

§  “Smart but Scattered Teens: The Executive Skills Program” for Helping Teens Reach their Potential by Peg Dawson (EdD) and Richard Guare (Phd)

§  “Smart but Scattered: The Revolutionary Approach to Helping Kids Reach their Potential” by Peg Dawson (EdD) and Richard Guare (Phd)

§  “The Parent’s Guide to Occupational Therapy for Autism and Special Needs” by Cara Koscinski (MOT, OTR/L)

§  “The Special Needs SCHOOL Survival Guide Book” by Cara Koscinski (OTD, OTR/L)


Resource books for therapists

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