OT Clinical Conditions

Child Development

refers to how a child becomes able to do more complex things as
they get older. Growth only refers to the child getting
bigger in size

Developmental Milestones

are a set of functional skills or age specific tasks that most
children can do at a certain age Although each has an age
level, the actual age when a normally developing child reaches it
can vary quite a bit

Developmental Delay

term used to describe young children who reach developmental
milestones later than their peers impacts on some or all
elements of a child�s development

Developmental Milestone Categories

Gross Motor Fine Motor Language
Cognitive Social

Gross Motor

using large groups of muscles to sit, stand, walk, run, keep balance,
and change positions

Fine Motor

using hands to be able to eat, draw, dress, plan, write, and do many
other things


Speaking, using body language and gestures, communicating, and
understanding what others say


Thinking skills including learning, understanding, problem solving,
reasoning, and remembering


interacting with others, having relationships with family, friends,
and teachers, cooperating, and responding to the feelings of others

Transient Development Delay

slow to achieve milestones, but will do so in time and then
proceed to progress normally through life Examples of
causes: Premature birth, Illness, Immaturity or lack of opportunity
to learn some premature infants may show a delay in the
area of sitting, crawling, or walking but then progress on a normal

Persistent Developmental Delay

delay in achieving milestones continues over time If
the delay in development persists it is usually related to problems
in one or more of the following areas: Understanding and learning,
Moving,Communication, Hearing, Seeing

Developmental Disabilities

Disorders which cause persistent developmental delay are often

Developmental Disabilities

group of conditions due to an impairment in physical, learning,
language, or behavior areas. These conditions begin during the
developmental period, may impact day to day functioning, and usually
last throughout a person�s lifetime The scope and
definition encompass various developmental conditions, such as
Rhett�s syndrome, Tourette�s syndrome, Cerebral Palsy, Autism, and

Developmental Disabilities

officially established after the US Congress passed the
Developmental Disabilities Services and Facilities Construction
Amendments of 1970 Listed within the Developmental
Disabilities Assistance and Bill of Rights Act of 2000

Developmental disability

Mental or physical impairment or a combination of both
Is manifested before the person attains age 22 Results
in substantial functional limitations in three or more of the
following areas of major life activity: Self � CARE, Receptive and
expressive language, Learning, Mobility, Self-direction, Capacity
for independent living, Economic self-Insufficiency

Difference between Developmental Disability and Intellectual Disability

Developmental Disabilities refer to a broader spectrum of conditions
including some physical disabilities that do not have intellectual impairment

Developmental Disability Prevalence

An analysis of National Health Interview surveys indicated a
prevalence of developmental disabilities in 1 in 6 children in the
United States, and rates from 2006 to 2008 marked a 17.1% increase
from the previous decade (Boyle et al., 2011). Between 2014
and 2016, the prevalence of developmental disabilities among kids
ages 3 to 17 increased from 5.76 percent to 6.99 percent
Across all conditions, the CDC found that prevalence was
significantly higher among boys than girls. During
2014�2016, Hispanic children (4.69%) were less likely to have been
diagnosed with any developmental disability compared with
non-Hispanic white children (7.04%), non-Hispanic black children
(6.20%), and non-Hispanic other children (6.16%).

Who is affected by developmental disability?

Developmental disabilities occur among all racial, ethnic, and
socioeconomic groups. Recent estimates in the United States
show that about 1 in 6 or 15% of children aged 3 to 17 years have
one or more developmental disabilities. Some examples
Autism Spectrum Disorder
Cerebral PalsyHearing LossIntellectual
DisabilityVision ImpairmentOther Developmental Delays

Causes and Risk Factors

Developmental disabilities begin anytime during the
developmental period and usually last throughout a person�s
lifetime. Most developmental disabilities begin before a baby
is born, but some can happen after birth because of injury,
infection, or other factors. Most developmental
disabilities are thought to be caused by a complex mix of factors
including: Genetics Parental health and
behaviors during pregnancy Complications during birth
Infections the mother might have during pregnancy or
the baby might have very early in life Exposure of
the mother or child to high levels of environmental toxins
(lead, etc.) More often then not the cause
is unknown. Life expectancy of individuals with
developmental disabilities has increased from an average of 22 years
in 1931 to 66.1 years in 1993

Examples of what is known about specific developmental disabilities

At least 25% of hearing loss among babies is due to material
infections during pregnancy, complications after birth, and head
trauma Children who have a sibling with Autism are at a
higher risk of also having Autism Spectrum Disorder Low
birthweight, premature birth, multiple births, and infections during
pregnancy are associated with an increased risk for many
developmental disabilities. Untreated newborn jaundice can
cause a type of brain damage known as kernicterus. Children with
this damage are more likely to have cerebral palsy, hearing and
vision problems, and problems with their teeth.

Role of the Occupational Therapist

The role of the occupational therapy practitioner working with
children with developmental disabilities varies according to the
setting, client needs, and resources available.
Practitioners work in a variety of settings with individuals
with developmental disabilities including hospitals, schools,
clinics, vocational programs, residential settings, and other
community based programs. Occupational therapists are
skilled at assessing a child to establish what areas they are weak
in and what the reasons are for this. It is essential to break
activities down into their component skills needed to complete them
successfully. The role of an occupational therapist is to
identify the skills required for particular tasks and be able to
assess the level of these underlying skills in the child. The
therapist is then able to identify exactly which component of the
task is causing difficulty, and plan appropriate treatment to aid
development. Support the family

What are the needs of the family?

Family members experience emotions such as anger, grief,
disbelief, and isolation. These emotions are often intense
at the time of diagnosis and may reoccur over time.
Children with a severe delay may need a lot of assistance with
daily living skills such as eating, talking, and dressing. This can
place enormous stress on the family. Large number of
financial costs (visits to doctors appointments, special equipment,
extra supplies, and extra child care) Needs will vary from
family to family but most families will want:To have their questions
answeredSupport in understanding the nature of the child�s
delay.Information about services, and assistance gaining access to
them.Information and skills to help them assist their child in the
best possible way.
Having a break.

Early Intervention

Evidence shows that providing support and services for infants
and young children with developmental impairments can positively
alter the child�s developmental journey, and reduce the risk of
secondary health and psychosocial complications. Early
intervention services are best delivered in a coordinated, planned,
family centered manner that reflects a life course approach to
health and well being. Supporting the caregiver is a
crucial component of early intervention programs, as the caregiver
and family have a key role in fostering their child�s developmental
potential, and may experience additional stresses as they meet the
special needs of the child

Developmental Disability throughout Childhood

Depending on the child�s specific challenges, treatment options
may include:
Speech therapy
Occupational Therapy
Physical TherapyLife and Social Skills Training
Behavioral Therapy
Special Diets

When Children with Developmental Disabilities Grow Up

Children with developmental disabilities become adults with
developmental disabilities. Their level of functioning,
social, economic, and career success will depend upon a number of
Type of disabilityThe severity of the disabilityAmount
and quality of therapy they received as children
PersonalitySocial Network

Client Centered Practice

takes into account a person�s strengths, choices, and
preferences. Principles of self-determination and
self-directed support promote client inclusion in decision making
about services received and expenditure of allocated funds.
All efforts are made to include the client and the caregivers
throughout every step of the planning process.
Practitioners need to make every effort to include individuals
even if cognitive or behavioral barriers exist. General
goals for people with developmental disabilities are often aimed at
promoting positive social relationships, community participation,
and meaningful engagement.

Elements of Client Centered planning

Person-directed Capacity building Person
centered Network Building Outcome based
Community accountability


Includes client-directed services that change according to the
desires and needs of the client

Capacity building

Builds on the client�s strengths and capacities

Person centered

Places emphasis on client needs rather than the

Network building

Connects service providers and individuals integral to the client�s care

Outcome based

Focuses on outcomes that are meaningful to the client and promotes
enhanced relationships and functioning

Community Accountability

Provides adequate resources forsuccessful community engagement

Client Centered Approach

For the occupational therapy practitioner, a comprehensive
client- centered approach should include the client�s views and
attributes along with the environmental context and occupational
needs (Haertl, 2011). Multiple Occupational Therapy �
Occupation Based treatment approaches exist. Canadian
Model of Occupational Performance (Canadian Association of
Occupational Therapists, 1997) Model of Human
Occupation (Kielhofner, 2008) Person - Environment �
Occupation � Performance Model These models
emphasize the importance of the interface of the client, the
environment, and meaningful occupational engagement.

Quality of Life

Best practices in treating individuals with developmental
disabilities stress the importance of quality of life and personal
choice and decision making for clients. Quality of life
refers to personal satisfaction and well-being. Personal
choice denotes individual choice with relation to life conditions,
such as having input into place of residence, use of funds, and
choice of time use in daily occupations. Supports and
services have a significant impact on quality of life and on the
ability of people to take control and make decisions.
Decision making is emphasized through the concepts of
empowerment and self-determination.


refers to a consumer�s ability to choose services from a variety of
options and to participate in decision making, including that of how
resources are spent for care.

Self determination

emphasizes the importance of personal choice
Characteristics: autonomy,
self-regulation, psychological empowerment, and
self-realization Factors influencing include the
individual capacities and opportunities provided by services and
organizations to facilitate choice


The past few decades for people with developmental disabilities
have shifted from large institutions toward smaller, community-based
housing units. In the early 20th century people with
disabilities were often moved away from their families to large
state facilities. Trends have suggested an increase in the
number of people with developmental disabilities choosing to live in
their home communities or with parents and family members
Residential options for individuals with developmental
disabilities includes independent supported apartments, foster
homes, smaller group homes, and supported living with family
members. With expertise in evaluating the occupational
performance of clients and their capacity for the activities of
daily living and the instrumental activities of daily living,
occupational therapy practitioners can plan an integral role in
determining clients� housing needs.

Ohio History

Gov. John Kasich signed the Technology First Executive order on
May 24th, making Ohio the first state in the country to place an
emphasis on expanding access to technology for people with
developmental disabilities. �As we have worked in Ohio to
renew economic growth and prosperity, we have made it a priority to
leave no one behind � including those with developmental
disabilities,� � Gov. John Kasich said. While many Ohioans
with developmental disabilities face obstacles in their daily
activities, as well as in accessing education and jobs, this effort
to expand access to technology offers people an opportunity to
experience independence and personal freedom, while improving their
quality of life. Under the executive order, Ohio will work
with county boards of developmental disabilities to ensure
technology is considered as part of all service and support plans
for people with disabilities. People and their families can explore
how supportive technology can enable them to be more productive and
included in their community

Intellectual Disability

It is characterized by significant limitations both in intellectual
functioning and in adaptive behavior as expressed in conceptual,
social, and practical adaptive skills. This disability originates
before the age of 18

Intellectual Disability

a condition that is present from childhood (age 18 or younger), with
two standard deviations below the mean as measured on a standardized
test (IQ test) and significant limitations in adaptive skills

Adaptive skills

must also be two standard deviations below the mean on a standardized
test in conceptual, social, or practical skill areas.

Intellectual Disability in Children

a delay in their understanding of the world and take longer to
think and learn new skills such as talking and self help skills such
as dressing and eating independently. The age of acquiring
a specific skill depends on the rate of learning for that child.
Children with slower rates of learning acquire skills at different
ages and the delay often becomes more obvious as the child grows
older. There is a wide range in the severity A
child can still learn, but needs more time and practice than other

Diagnosis of Intellectual Disability

DSM The American Association on Intellectual and
Developmental Disabilities Classification (3-Step Process)

DSM � Classifies intellectual disability based on two criteria

Intellectual Functioning from IQ testing � labeled as mild
(85%), moderate (10%), severe (4%), or profound (2%).
Deficits in Adaptive Functioning � Individual has difficulty
with skills required to live independently in a responsible

The American Association on Intellectual and Developmental
Disabilities Classification (3-Step Process)

Administration of a standardized intelligence and adaptive
skills assessment Describe strengths and weakness across
dimensions of intellectual and adaptive behavior skills,
psychological/emotional considerations, physical/health/etiological
considerations, and environmental considerations.
Interdisciplinary team determines needed supports across the
above four dimensions

Etiology of Intellectual Disability

classified according to when they occurred in the developmental
cycle (prenatally, perinatally, or postnatally) or by their
origin. Hundreds of causes, but most are unknown
much less likely to be known with individuals who are mildly
intellectually disabled (IQ�s of 50 to 70) than with those who are
severely disabled (IQ�s of < 50) Up to 50% of the
individuals may have more than one causal factor.

Prenatal Factors (i.e. before birth)

� Chromosomal� Trisomy 21 (Down Syndrome)� Fragile X Syndrome
� Genetic� Tuberous Sclerosis� Metabolic Disorder (phenylketonuria)
� Maternal Factors� Poor nutrition� Smoking� Lack
of prenatal care� Herpes Virus (CMV)� Diabetes
� Hypertension
� Syndromes (some examples)� Williams Syndrome� Prader-Willi Syndrome
� Infections� Rubella virus� Cytomegalovirus (CMV)�
Toxoplasmosis� Syphilis
� Drugs/ Toxins� Excessive Alcohol� Narcotic
Exposure� Industrial Chemicals� Over the counter prescriptions

Perinatal Factors (i.e. around birth)

� Mechanical Injuries at birth
� Difficulties of labor because of malposition, mal presentation, or
disproportion or other labor complications
� Perinatal Hypoxia � reduced oxygen supply� Premature
placental separation� Massive hemorrhage from Placenta
Previa� Umbilical cord wrapped around the baby�s neck� Meconium Aspiration
� Premature infant�s can also have impaired respiration or
interventricular hemorrhage
� Trauma� Infections� Biochemical abnormalities such as
low sugar levels

Postnatal Factors (i.e. after the birth period)

� Traumas or infections that result in injury or lack of
oxygen to the brain�Near drowning or strangulation�Child
Abuse�Closed head injuries�Early severe psychosocial
deprivation�Infections � encephalitis or meningitis

Probable Causes of Intellectual Disability

No Defined Cause
Prenatal Conditions
Perinatal Conditions
Post Neonatal Events
CNS Birth Defects
Other Birth Defects

Prevalence of Intellectual Disability

Most frequently occurring developmental disability
Estimates range from 1-3% Boys are 1.5x more likely to
be diagnosed with ID then girls �Could be related to the sex linked
genetic disorders that result in intellectual disability
2/3rd of the children with severe ID have an additional
diagnosis; < 20% with mild ID were found to have additional
neurological diagnosis

How Common is Disability in Childhood?

Autism Spectrum Disorder
~ 1.6 / 100 Children
Intellectual Disability (mild)
~ 1 / 100 Children
Intellectual Disability (moderate/severe)
~ 3-5 / 100 Children
Cerebral Palsy
~ 1 / 1,000 Children
Hearing Impairment (hearing aids)
~ 1-2 / 1,000 Children
Blindness/ Severe Visual Impairment
~ 3 / 10,000 Children

Medical Management

� No Drug treatments for intellectual disability� Use to
prescribe psychotropics and antipsychotics to combat problem
behaviors� Now may be prescribed psychotropics if there is a
mental illness
Medication Type
Antipsychotic(Bipolar Disorder, Psychosis)
Antidepressants (Affective Disorder)
Antianxiety Agent

If left untreated, the child with intellectual delays may have
difficulties with

� Following instructions within the home, kindergarten, or school
environment� Learning to talk, speech intelligibility and
clarity� Managing a full school day due to poor endurance�
Participation in sporting activities leading to an inactive lifestyle
� Self-Esteem and confidence when they realize their skills do not
match their peers� Fine Motor skills/ Gross motor skills�
Completing self care activities� Self regulation and behavior issues
� Attention� Social Communication/ social isolation� Academic performance

OT Approaches and Activities

� Underlying Skills
� Confidence� Education� Task Complexity
� Just Right Tasks
� Simplifying Tasks
� Use Specific Language
� Brief Instructions� Non-verbal Cues� Backwards Chaining
� Chunking Information
� Developing Attention

Adaptive Behavior

focus of assessment and intervention is the
collection of conceptual, social, and practical skills that people
have learned so they can function in their everyday lives
Limitations impact a persons daily life and affect their ability
to respond to particular simulation or to the environment.

Adaptive Skills � Conceptual Skills

1. Receptive and Expressive Language
2. Reading and Writing3. Money Concepts4. Time Concepts
5. Number Concepts

Adaptive Skills � Social Skills

Interpersonal Social Responsibility
Self-Esteem Gullibility Naivete (Wariness)
Following Rules/ Obeying Laws Social Problem
Solving Avoiding Victimization

Adaptive Skills � Practical Skills

Personal activities of daily living such as eating, dressing,
mobility, and toileting Instrumental activities of daily
living such as preparing meals, taking medication, using the
telephone, managing money, using transportation, and doing house
keeping activities Occupational Skills Maintaining
a safe environment

Impact on Occupational Performance

All of the occupational performance areas and client factors
can be influenced by intellectual disability, however, those that
are affected will depend on factors such as the presence of
additional medical diagnoses and the severity of the diagnosis.
As an OT you need to be informed about the specific diagnosis
that accompanies the identification of intellectual disability and
the challenges that encompass that particular diagnosis.

Trisomy 21/ Down Syndrome

Chromosomal disorder usually resulting in mental retardation,
characteristic facies, and other features such as microcephaly and
short stature. Typically occurs spontaneously
Three types
� Trisomy� Translocation� Mosaicism
Incidence is 1 in 800 live births;� Mothers who are younger
than 20 years � 1 in 2,000 live births� Mothers who are older than
40 years � 1 in 40 live births

Trisomy 21/ Down Syndrome

Half of children have congenital heart disease and associated
early onset of pulmonary hypertension 66-89% of children
with down syndrome have a hearing loss of > 15 to 20 decibels in
at least one ear. The life expectancy has increased
dramatically in recent decades� from 25 years old in 1983 to 60
years old today�and people are graduating high school, going to
college, participating in social and recreational activities in
their communities, making up a vibrant part of the workforce, living
independently, and advocating for their rights.

Occupational Therapy and Down Syndrome

Occupational therapy practitioners work with persons to help
them master skills for independence through self-care like feeding
and dressing, fine and gross motor skills, school performance, and
play and leisure activities. Occupational therapy treatment
should begin in infancy and continue throughout an individuals
life. During infancy, a therapist may help a mother and child
who is having trouble feeding due to low muscle tone.
During childhood, a therapist may assist with the development of
motor skills. A school aged child may benefit from OT to
address self care skills or adaptations in the classroom
Adults benefit from OT in finding and retaining productive work,
learning independent living skills, and participating in active
recreational activities.

Fragile X Syndrome

Is the result of a mutation at what is known as the fragile
site on the X chromosome. The X chromosome has a
constriction near the end of the long arm, so that a section is
separated from the main portion of the chromosome by a thin stalk.
The stalk is referred to as a fragile site, thus the name.
Males are usually affected more than females Often
times children can be diagnosed as Autistic because of extreme gaze
aversion, lack of social connectedness, and sensory processing

Fragile X Syndrome Symptoms

Common features in males include long face, prominent ears,
macroorchidism, strabismus, larger than normal head, puffiness
around the eyes. Common features in females include
prominent jaw, prominent ears, long face, and overgrowth syndrome
present from birth Common to both males and females
learning disabilities, attentional problems, motor coordination
deficits, and sensory integrative dysfunction. Cognitive
abilities begin to decrease in childhood and continue to decline
through adolescence, but tapers off in adulthood Besides
Down Syndrome, is the second most common cause of Intellectual
Disability that can be specifically diagnosed

Fetal Alcohol Syndrome

A condition in a child that results from alcohol exposure
during the mother�s pregnancy. Causes brain damage and
growth problems Problems vary from child to child, but
defects caused by fetal alcohol There is no amount of
alcohol that is known to be safe to consume during pregnancy
Severity varies from child to child Signs and symptoms
may include a mix of physical defects, intellectual or cognitive
disabilities, and problems functioning and coping with daily

Physical Defects of FAS

Distinctive facial features including small eyes, an
exceptionally thin upper lip, a short upturned nose, and a smooth
skin surface between the nose and upper lip Deformities of
joints, limbs, and fingers Slow physical growth before and
after birth Vision difficulties or hearing problems
Small head circumference and brain size Heart defects
and problems with kidneys and bones

Brain and Central Nervous System Problems - FAS

� Poor coordination and balance� Intellectual disability,
learning disorders, and delayed development
� Poor memory� Trouble with attention and with processing
information� Difficulty with reasoning and
problem-solving� Difficulty identifying consequences of
choices� Poor judgement skills� Jitteriness or
hyperactivity� Rapidly changing moods

Social and Behavioral Issues - FAS

� Difficulty in school� Trouble getting along with
others� Poor social skills� Trouble adapting to change or
switching from one task to another
� Problems with behavior and impulse control� Poor concept of
time� Problems staying on task� Difficulty planning or
working toward a goal

Fetal Alcohol Syndrome causes

Alcohol enters the bloodstream and reaches your developing
fetus by crossing the placenta Alcohol causes higher blood
alcohol concentrations in your developing baby than in your body
because a fetus metabolizes alcohol slower than an adult does
Alcohol interferes with the delivery of oxygen and optimal
nutrition to your developing baby Exposure to alcohol
before birth can harm the development of tissues and organs and
cause permanent brain damage in your baby

FAS Complications

� Problem behaviors not present at birth that can result from having
this disability (secondary disabilities) may include:
� Attention Deficit/ hyperactivity disorder (ADHD)
� Aggression, inappropriate social conduct, and breaking
� Alcohol or drug misuse
� Mental health disorders, such as depression, anxiety or eating disorders
� Problems staying in or completing school
� Problems with independent living and with employment
� Inappropriate sexual behaviors
� Early death by accident, homicide, or suicide

Treatment for FAS

� There is no cure or specific treatment � Intervention
services may involve the following:
� A team that includes a special education teacher, speech
therapist, physical and occupational therapists, and a psychologist
� Early intervention to help with walking, talking, and social skills
� Special services in school to help with learning and behavioral issues
� Medications to help with some symptoms
� Medical care for health problems, such as vision problems or heart abnormalities
� Addressing alcohol and other substance use problems, if needed
� Vocational and life skills training
� Counseling to benefit parents and the family in dealing with the
behavioral problems

Transition Process

In the United States, the transition from secondary school
occurs between ages 16 to 21 yeas and is regulated through the
mandates of the Individuals with Disabilities Education Improvement
Act (IDEA) of 2004. The following definition of the
transition process focuses on achievable outcomes for students with
disabilities, although it is based on expectations that all families
have for their children as they reach the end of their secondary
school experience. IDEA mandates that a transition plan be
in place beginning at 16 years (many states address it beginning at
14) and that supports and services be provided through age 22.

According to IDEA, the Transition Process in the US is a coordinated
set of activities for a child that

Is designed to be within a results-oriented process that
focuses on improving the academic and functional achievement of the
child with a disability to facilitate the child�s movement from
school to post school activities, including postsecondary education,
vocational education, integrated employment (including supported
employment), continuing and adult education, adult services,
independent living, or community participation; Is based on
the individual child�s needs, taking into account the child�s
strengths, preferences, and interests; and Includes
instruction, related services, community experiences, the
development of employment and other post school adult living
objectives, and when appropriate, acquisition of daily living skills
and functional vocational evaluation.

The Rehabilitation Act of 1973

�the right of individuals to live independently, enjoy
self-determination, make choices, contribute to society, pursue
meaningful careers, and enjoy full inclusion and integration in the
economic, political, social, cultural, and educational mainstream of
American Society�.

Transition Planning

includes both 1 year goals but also long term goals that
incorporate the community in which the student will be transitioning
into. Parental involvement is critical for youth with
developmental disabilities to become successful adults It
is also important to keep the health professionals involved in order
to keep the plan person centered and strengths based rather than
problem focused

Individualized Planning

A process that can occur throughout secondary school whereby
team members assist youth with learning about their own strengths
and interests, developing goal statements that address their future,
and identifying specific steps to reach those goals.
Research suggests that improved employment outcomes and
successful transition to adult living situations are dependent on
youth learning effective problem-solving and decision-making

Community Planning

Involves linking to community resources that support successful
employment and community living, requires orchestration and is a
critical step in transition planning. The school system is
a single agency that provides coordinated services and supports, but
when the transition to the community occurs, adult services are
varied, and each has its own eligibility criteria. A
variety of public and private agencies can be tapped to provide a
mix of supports and services, depending on several factors,
including the student�s needs, family resources, eligibility
requirements of the agency, and availability of openings


Transition programs that focus on community integration and
developing social relationships are important for persons with
developmental disabilities. Strategizing for meaningful
participation for youth with developmental disabilities includes
activities that facilitate friendships and relationships with
others. Relationships are critical for developing a sense of
belonging within the community to be accepting of individual

Supports and Services

A customized array of support and services should be part of a
transition plan for youth who are exiting the secondary school
environment. Although parents and caregivers have an
important role in identifying and articulating the interests and
choices of transitioning youth with developmental disabilities, the
complexities of community living require creativity and the
involvement of people from the school and the community.
Occupational therapists have unique knowledge and skills that
can be used to facilitate team planning and optimize available

Community Participation

Participation in meaningful activities that involved giving
back to the community through volunteer or work experiences is an
important part of becoming an adult in society. Equally
important are opportunities to develop friendships and social
relationships while engaging with others in exploring satisfying
leisure pursuits. The role of the occupational therapist in
this analysis and planning process is based on knowledge of
occupational performance and enablement

Interagency Collaboration

Collaboration between and within agencies is integral to
comprehensive services for persons with developmental
disabilities. Public and private agencies that support adults
with disabilities include vocational rehabilitation services,
centers for independent living, local recreational or YMCA centers,
social service agencies, career centers, and local businesses that
provide employment experiences

11 Key Strategies for Schools and Agencies to Enhance interagency
collaboration to support Transitioning Youth

� Flexible scheduling and staffing� Follow up after
transition� Administrative support for transition� Use of
a variety of funding sources� State-supported technical
assistance� Ability to build relationships� Agency
meetings with students and families� Training of students and
families� Joint training of staff� Meetings of agency
staff and transition councils� Dissemination of information to a
broad audience

Post Secondary education

Many youth with developmental disabilities experience positive
outcomes in high school and want to continue to participate in age
appropriate post-secondary education. Many college campuses
are developing programs that allow young adults to participate
without being matriculated, offering them valuable learning
experiences. Occupational therapists can offer guidance and
recommendations for accommodations, collaborating with the college
disability services office.

Post Secondary Education

� Some universities offer opportunities with internships and work experiences.
? This type of program has shown good outcomes related to employment
at the end of the program
� A good resource practitioners can use to help support families in
transition is Think College!
? Organization continually explores options for adults with
developmental disabilities who are interested in pursuing education
beyond high school.
? Resources are available for middle and high school students,
family members, and professionals, and may residential and services
options are offered.

Collaboration for Employment and Education Synergy

CEES is designed for high school students with intellectual and
developmental disabilities ages 14-21. CEES offers 12-week
individualized transition curriculum to help young adults with
intellectual disabilities determine how their interests and
abilities can be applied in the workplace as they also learn the
necessary life skills that enhance their ability to live and work
more independently. CEES aims to create community
integrated employment experiences that incorporate meaningful social
interactions with peers and employers and provide families with the
support to develop high expectations and actively engage in the
transition process. The anticipated impact of CEES is to
change the Quality of Life (QoL) for individuals with intellectual
and developmental disabilities. Specifically, through CEES, students
will develop the following skills opportunities associated with QoL:
? Employment skills necessary for integrated community work? Social
communication skills necessary for social interactions and soft
skills for employment

Transition and Access Program

Since its inception in 2012, TAP provides a four-year college
experience for individuals with mild to moderate intellectual or
developmental disabilities (ID/DD). Students live in the residence
halls, attend classes, engage in vocational internships and
participate in an active social life. TAP�s mission is to enhance
the quality of life of students through advocacy, access, and
research. TAP aims to provide a post- secondary experience for all
persons who desire it. Each TAP student is enrolled in at
least one UC course and 4 TAP courses each semester.
Academic tutors collaborate with the Academic Coordinator, who
is a trained intervention specialist, to implement modifications and
accommodations needed, develop a weekly academic work plan, and
support completion of weekly assignments. � The TAP students meet
with the academic tutors two times per week in our academic lab
supervised by our Academic Coordinator.

Impact Innovation

IMPACT Innovation offers adults significantly affected by
autism a year-round program that includes lifelong learning, healthy
living, and vocational exploration through an inclusive experience
on the UC campus. IMPACT Innovation was created in response
to state and federal government initiatives to increased integrated
employment opportunities forindividuals with disabilities.
With the dedicated support from Impact Autism, waiver funding,
and private pay options, IMPACT Innovation is able to provide adults
22 years of age and older meaningful employment opportunities and
quality life experiences in inclusive settings which ultimately
leads to more independent and fulfilled lives.

Living Arrangements

Every human being desires to be as independent as possible no
matter their diagnosis or disability. There are many
options for individuals with disabilities besides living with family
including options such as privately owned apartments or house to
supervised group homes. Factors to consider are the level
of required supervision, personal preferences, safety issues, and
housing availability within a community. Housing
considerations are often left for future decision making when young
adults have had time to adjust to work or postsecondary education

Community Participation

Integration into the community after completion of secondary
school requires opportunities for community participation in
recreational and leisure activities. Community Mapping is a
strategy used to identify resources within a community that are
related to particular interests of and are available for the
transitioning youth adult. ? Analyze the community environment in
which a person lives, including transportation options, religious,
recreational, and cultural programs and resources; and local
businesses for volunteer or employment opportunities. Once
the community is mapped, community participation opportunities can
be explored using individual preferences, abilities, and

Community Participation

Also includes life skills within the community such as grocery
shopping, purchasing clothing and other items, and developing safety
habits and social skills. Offering youth with developmental
disabilities a variety of opportunities to practice appropriate life
skills and social behaviors in community settings while still in
high school enables them to be more successful when they transition
out of the school setting. Social competence and the
ability to maintain friendships and other relationships can
determine successful transition to adult leisure, community living,
and employment situations


Transitioning from the education system to the adult services
system requires collaboration with community organizations that have
unique rules, regulations, eligibility guidelines, and procedures
which is particularly when considering employment options.
It is critical to involve local or national vocational
rehabilitation agencies or organizations in the transition process
to ensure interagency cooperation and efficient service
delivery. Career planning begins in elementary school, with a
focus on assessing students� interests, aptitudes, work habits, and
skills In middle school, identifying the types of supports
students will need When in high school, the focus should be
on obtaining work experiences with the goal of future long term


Luecking (2009) described specific types of experiences related
to work activities that can provide opportunities for transitioning
youth, including career exploration, job shadowing, work sampling,
service learning, internships, apprenticeships, and paid
employment. By observing and participating in a variety of
settings while in high school, students can experience aspects of
the job that cannot be simulated. A customized employment
approach is currently considered best practice, as recommended by
the US Department of Labor�s Office of Disability and Employment
Policy. ? The department defines customized employment as �a
flexible process designed to personalize the employment relationship
between a job candidate and an employer in a way that meets the
needs of both�


� In a report by the Maryland Commission on Autism (2012), a
customized employment model was summarized as having the following characteristics:
? Has a proven employment strategy that emphasizes sustainability of
employment, in addition to employment placement that meets the needs
of both the employer and the job seeker
? Follows a flexible process that considers the needs of both
the employee and the employer ? Matches employees to jobs
in which natural supports are easily integrated into the employment
scenario and external supports can be phased out quickly ?
Promotes competitive employment in the community


A chronic disorder in which children are unable to pay
attention, control their activity, and restrain impulsive behavior.
These problems can interfere with a child�s ability to hear
or read instructions,complete school assignments, participate in
games, and perform tasks at home. It is the most common
neurobiological disorder that manifests in childhood and often
continues through adulthood. in the DSM-5 under
neurodevelopmental disorders which is a change from the previous
edition in which it was listed under disruptive behavior
disorders. Research suggests that a majority of kids who
have also suffer from depression, anxiety, obsessive-compulsive
disorder, oppositional defiance disorder, a learning disorder,
autism, sensory processing disorder, or some other psychological or
neurological problem.

ADHD History

Medical science first documented children exhibiting
inattentiveness, impulsivity, and hyperactivity in 1902.
Since that time the disorder has been given numerous names
Minimal brain dysfunctionHyperkinetic reaction of
childhoodAttention deficit disorder with or without hyperactivity
With the DSM- 5th Edition classification system, the disorder
has been renamed attention-deficit/hyperactivity disorder or
ADHD. The current name now reflects the importance of the
inattention aspect of the disorder as well as the other
characteristics of the disorder such as hyperactivity and

Incidence of ADHD

In 2015, The total number of American children having it
totaled nearly 6 million. The CDC reports that 11% of all
children in the US aged 4-17 have been diagnosed by 2011.
The CDC estimates that 9.5% of school age children are
affected. The National Institutes of Health estimate that it
affects 4-5% of adults More than 2/3rds of children have a
least one other psychiatric, developmental, emotional, and/or
neurological disorder sometime during their lifetime. Boys
are 4x more likely than girls to be diagnosed, although the rise has
been higher in girls and women then in boys and men over the last
few years.

ADHD Diagnosis

No test alone can diagnose It is a nuanced condition
with three distinct sub types- Primarily Inattentive- Primarily
Hyperactive-Impulsive- Combined Type Symptoms appear along
a continuum of severity often overlaps with other comorbid
conditions that often complicate diagnosis and treatment
symptoms typically arise in early childhood

ADHD Diagnosis

An in-depth evaluation critically analyzes many aspects of the
child�s life including learning, memory, cognitive functioning,
executive functioning, reasoning, social functioning, verbal
communication, and non-verbal communication. Testing should
also include an intelligence test and may also gauge math, reading,
and writing skills. Child and family medical history
Various teacher/parent rating scales Neurophysiological
testing Observation of daily life routines An
in-depth evaluation looks for comorbid conditions such as learning
disabilities, depression, and anxiety.

ADHD Diagnostic Criteria

A child can be diagnosed if he or she:
Exhibits 6 out of the 9 following symptoms
If the symptoms have been noticeable
for at least 6 months in two or more settings.
The symptoms must interfere in the
child�s functioning or development
At least some of the symptoms must have
been apparent before age 12
The DSM-5 now requires professionals diagnosing to include the
severity of the disorder. Clinicians can designatethe severity as
�mild,� �moderate� or �severe� under the criteria in the DSM-5

ADHD - Primarily Inattentive

A person will fit at least six of the following nine descriptions.
Often fails to give close attention to details or makes
careless mistakes in schoolwork, at work, or during other
activities. Often has difficulty sustaining attention in
tasks or play activities Often does not seen to listen when
spoken to directly Often does not follow through on
instructions and fails to finish schoolwork, chores, or duties in
the workplace Often has difficulty organizing tasks and
activities Often avoids, dislikes, or is reluctant to engage
in tasks that require sustained mental effort Often loses
things necessary for tasks or activities Is often easily
distracted by extraneous stimuli Is often forgetful in
daily activities

ADHD � Primarily Hyperactive- Impulsive

Often fidgets with or taps hands or feet or squirms in
seat Often leaves seat in situations when remaining seated is
expected Often runs about or climbs in situations where it is
inappropriate Often unable to play or engage in leisure
activities quietly Is often �on the go�, acting as if
�driven by a motor� Often talks excessively Often
blurts out an answer before a question has been completed
Often has difficulty waiting his or her turn Often
interrupts or intrudes on others

ADHD � Combined Type

an individual must meet the guidelines of both ADHD Primarily
Inattentive and ADHD Primarily Hyperactive-Impulsive.
Children younger than 17 must exhibit at least six inattentive
and six hyperactive-impulsive symptoms. Children older than
17 require only five symptoms in each category due to the
understanding that a reduction in symptoms often occurs with
increasing age.

ADHD � Other Specified or Unspecified

Individuals who show some symptoms characteristic of the disorder,
but who do not meet diagnostic criteria

ADHD Etiology

The specific underlying cause is unknown. Like other
neurological disorders, it most likely results form a combination of
genetic factors and environmental factors with nutrition, brain
injuries, or characteristics of the social environment being
possible contributing factors. Many regions of the brain,
and chemicals (neurotransmitters) within the brain, have been
implicated, with the neurotransmitter dopamine receiving the most
attention. The prefrontal cortex, which serves many
cognitive and executive functions (attention, concentration,
inhibition), has a high concentration of dopamine, and it has been
hypothesized that individuals may not produce sufficient levels of

Co-Occurring and Comorbid Conditions

often comorbid with motor, sensory, learning, mood, anxiety,
and disruptive behavior disorders in children and adults. (
80% of children diagnosed are at risk of having at least one
other disorder such as learning disorders, developmental
coordination disorder, oppositional behavior disorder, depression,
and/or anxiety Motor disorders have been reported in as
many as 40-60% of individuals representing all three subtypes, with
slightly more representation in the combined clinical
presentation Disorders of attention and learning have also
been associated with sensory processing disorders or sensory
integration dysfunction A number of mental health
disorders are also commonly seen in children and adults including
mood, anxiety, and disruptive behavior disorders

ADHD Prognosis

lifelong disorder, although only 50% of children continue to
meet the criteria into adulthood Clinical presentation
changes over time. Overt behaviors associated with hyperactivity
tend to subside with age, while difficulties with attention and
sustained focus and disorganization more often continue into
adulthood Education outcomes of older children is
discouraging with 30-50% children receiving special education
Children have higher school dropout rates 23-40% and lower grade
point averages Adults engage in more risk taking behaviors,
have poorer driving records, and have more problems in the

Pharmalogical and Medical Interventions - ADHD

The majority of children who use medication report having
increased self- esteem, fewer disruptive behaviors, and improved
relationships with parents, siblings, and teachers. The
clinical practice guidelines recommend medication as the first line
treatment in school age children, citing a formal review of 78
studies on the treatment, which �consistently supported the
superiority of stimulant over non-drug treatment.� �A
pharmalogical intervention is more effective than a behavioral
treatment alone.�

ADHD - Stimulant Medication

most recommended form of ADHD treatment. According to
the American Academy of Pediatrics, 80% of the children who use
stimulant medications, either alone or combined with behavior
therapy, increase focus and decrease impulsivity. �work by
increasing levels of dopamine andnorepinephrine in the brain, and
the medication has a calming effect, which improves inattention,
impulsivity, and over activity come in different forms
including pills, capsules, liquid, or skin patches. All medications
have the same active ingredients, but deliver the medication
differently. Some side effects are decreased appetite,
sleep problems, anxiety, mild head ache or stomach upset, and

ADHD - Non-stimulant Medication

viable alternative for children who can�t tolerate or don�t
experience the desired effects of stimulant medications.
These medications do target neurotransmitters, but not dopamine
specifically, like the stimulants do. Different side
effects than stimulant medications � upset stomach, less appetite,
nausea, dizziness, fatigue, headache, and mood swings do
not tend to cause agitation, sleeplessness, or lack of appetite.
They also do not post the same risk of abuse or addiction
medications include Strattera, Intuniv, and Kapvay

Diet and Nutrition for ADHD

Research shows that diet and nutrition impact cognition,
attention, sleep, and mood. According to Harvard Health
Blog, studies show that people who eat clean or whole diets high in
vegetables, fruits, unprocessed grains, and lean meats, are more
likely to experience better emotional health and 25 to 35% less
likely to experience depression. Studies have shown that
protein triggers alertness � inducing neurotransmitters, while
carbohydrates trigger drowsiness. This supports the popular belief
that people do better after eating a protein-rich breakfast and
lunch. For optimal brain performance, children should eat
more unprocessed foods, complex carbohydrates, proteins, vegetables,
and fruits. That means avoiding artificial colors and flavors,
chemical preservatives, and over-processed foods� all shown to
exacerbate symptoms in some individuals.

Exercise for ADHD

Exercise turns on the attention system, the so-called executive
functions� sequencing, working memory, prioritizing, inhibiting, and
sustaining attention. On a practical level, it causes kids to be
less impulsive, which makes them more primed to learn.
Exercise causes the brain to release several important
chemicals, one of which is endorphins which regulate mood, pleasure,
and pain. The same burst of activity elevates the brain�s
dopamine, norepinephrine, and serotonin levels. These chemicals
affect focus and attention. �When you increase dopamine
levels, you increase the attention system�s ability to be regular
and consistent and reduces the craving for new stimuli and
increasing alertness�. A 2015 study found that 30 minutes
of exercise before school can help kids focus and manage moods. In
can decrease the need for stimulant medications used to treat

School and Learning - ADHD

The symptoms of inattention, impulsivity, and executive
functioning deficits often mean kids don�t perform well academically
or have trouble focusing on schoolwork. 1 in 4 students
have other serious learning disabilities in one or more of the
following areas:
Written expression
Oral expression
Listening Skills
Reading Comprehension
Individuals with Disabilities Education Act (IDEA) � covers
children with very specific conditions, including intellectual
disorders, emotional disturbances, hearing impairments, learning
disabilities, and speech and language difficulties. Section
504 covers children who do not qualify for special education
services under IDEA, but who need extra help in the classroom

What can OTs do for ADHD?

While medications work on a neurological level to regulate the brain,
occupational therapy addresses specific problem behaviors by
structuring time at home, establishing predictability and routines,
and increasing positive attention.

What can OTs do for ADHD

Evaluate a child at home and at school to determine how ADHD is
affecting the child�s ability to perform assignments and participate
at home Recommend a program that addresses the physical,
behavioral, and emotional effects of ADHD and identifies goals to
help the child succeed Use the intervention of sensory
integration to modify the environment to decrease noise and
distractions caused by visual, auditory, and tactile stimulation
Occupational therapists can assist children by working on
social and organizational skills, executive and other cognitive
functions, coping skills, and sensory-motor and/or language skills,
as well as, teach problem solving skills, and implement strategies
and accommodations for managing the challenges of everyday life at
home, work, and school

Autism Spectrum

�Neurodevelopmental disability
�Not a mental illness
�People first language
Child or individual with autism
NOT autistic child
��Hidden� disability � no identifying physical characteristics

Austin Spectrum

� group of lifelong, brain-based, developmental disorders, usually
diagnosed in early childhood, affecting
�language and social behavior
�restrictedor repetitive behavior/
unusual interests
�The prevalence is 1/59 people in the US; 4:1 males to females
�There are varying levels of severity: from nonverbal to high-functioning

Why are there more children with ASD

�Increased awareness
�More uniform criteria for diagnosis
�Broader range of diagnosis
�Actual increase in the number of children with ASD

Definition ASD: DSM-5

�Qualitative impairments in social communication and interaction
�Persistent pervasive deficits not
accounted for by general developmental delays, manifested by all 3of
the following:
�social-emotional reciprocity
�nonverbal communicative behaviors
�relationships appropriate to the
developmental level

Defining ASD: DSM-5

�Restricted/repetitive behaviors/interests�Restricted, repetitive
activities as manifested by at least 2 of the following:
�stereotypedor repetitive speech, motor
movements, or use of objects
�Excessiveadherence to routines
�Highly restricted, fixated interests
that are abnormal in intensity or focus
�Hyper-or hypo-reactivity to sensory
input or unusual sensory interests

Defining ASD: DSM-5

�DSM-5 also requires clinicians to specify:
�Other diagnoses that may be present
such as cognitive or language impairment, known medical or genetic
conditions, other neurodevelopmental or behavior disorders
�Clinician rates the severity of the
ASD: level 1 requires support; level 2, substantial support; or level
3, very substantial support

ASD DSM-5 Revisions

�Autism Spectrum Disorder
�Formerly Autism, Asperger Syndrome, and PDD-NOS
�Consolidated required features
�Social/communication deficits
�Restricted, repetitive patterns of
behavior, interests, activities
�Addition of sensory criteria
�Increases specificity while maintaining sensitivity
�Important to distinguish spectrum from
non-spectrum developmental disabilities
�Improves stability of diagnosis
�Addition of new diagnostic category - SCD

Social Communication Disorder (SCD)

Diagnosed when an individual has deficits in the social use of
language but do not demonstrate the restricted interests or repetitive
behavior typically observed in ASD

Previously Established Diagnosis (ASD)

The DSM-V text states �Individuals with a well-established DSM-IV
diagnoses of autistic disorder, Asperger�s disorder, or pervasive
developmental disorder not otherwise specified should be given the
diagnosis of autism spectrum disorder�

Absolute Indications for ASD

�No babbling by 12 months
�No gesturing (pointing, waving bye-bye, etc.) by 12 months
�No single words by 16 months
�No 2 word spontaneous phrases by 24months(not echolalic) �ANY loss
of ANY language or social skills at ANY age

Signs of Autism: Social communication and interaction

�Expressive and/or receptive language delay
�Limited use of communicative gestures, ie. Pointing, waving
�Use of atypical ways to communicate, ie. Leading by the hand
�May have history of regression of language skills at average age of
21 months
�Atypical social interaction
�Poor eye contact

Signs of Autism: Restricted/repetitive behaviors and interests

�Repetitive behaviors
�Repetitive physical movements, ie. hand flapping, spinning, finger flicking
�Sensory difficulties, ie. sound or tactile sensitivities
�Behavioral concerns, ie. tantrums, hyperactivity, poor compliance

Screening for ASD

�American Academy of Pediatrics (AAP) Policy Statement, 2006 & 2007
�Developmentalsurveillance at all well visits
�Administer standardized developmental
screening tool at 9, 18, and 24 or 30 month visits
�SpecificASD screen at 18 and 24 months

Routine Screening for ASD

�MCHAT R/F� modified checklist for autism in toddlers
�Ages and Stages Questionnaire: Social Emotional (ASQ-SE)
�Social Communication questionnaire (SCQ)

AAP Policy Statement 2006/2007 ASD

For those at-risk/positive screening results�
�PCP to refer developmental concerns to early intervention orearly
childhood programs
�Recommend developmental evaluations

Difficulties with ASD diagnosis

�No blood test or brain scan
�No �medical� tests
�Most reliable diagnosis - Multi-Disciplinary Team Evaluation
�Developmental Pediatrician
�Speech Pathologist
�Occupational Therapist

ASD Possible Causes

�No one cause
�No one type
�Early onset
�Both genetics and the environment play a role in early brain
development leading to autism
�Much research is being done to learn more

Care team for children with ASD

�Developmental and Behavioral Pediatrics
�Occupational Therapy
�Physical Therapy
�Speech Therapy

ASD Genetics

�Risk of any sibling of child with autism is 2 - 18% (2011)
�Relatives may be affected by difficulties that are conceptually
related to autistic behaviors (broader autistic phenotype)

Genetic syndromes ASD

�Some known genetic syndromes can be associated:
�Tuberous Sclerosis Syndrome
�Fragile X Syndrome
�Rett Syndrome
�Down Syndrome

ASD Vaccine Controversy

�No evidence-based studies have supported a relationship between
vaccines and autism
�Retraction of Lancet article reporting link between MMR vaccine and autism
�Ongoing family concerns fueled by reports in the media that
contradict research

Strengths Associated with ASD

�Attention to detail
�Lots of energy
�Methodical habits
�Nonjudgmental attitude
�Passionate about their interests
�Strong mechanical skills
�Visual learning

Challenges Associated with ASD

�Language and communication difficulties
�Thinking differences
�Social deficits
�Difficulty waiting
�Sensory challenges
�Motor skills challenges (more noticable in older children)

Variability in ASD

�Every individual on the Autism Spectrum is unique
�What works for one individual may not work for another individual
�The saying goes� �If you have seen one person with autism, you have
seen one person with autism�

ASD Continuum

Intellectual Disability-----------------------------Gifted
Social Interaction
Withdrawn------------------------Inappropriately Social
Activity Level
Self Stimulatory Behavior
Challenging Behavior
None--------------------------------------------High Rate

ASD Communication Difficulties: Speaking

�Be non-verbal or have limited verbal skills
�Be very verbal but still struggle communicating
�Have difficulty expressing basic wants,
needs, or feelings
�Have difficulty asking for help, for a
break, for attention
�Have difficulty asking and answering questions
�Have difficulty making choices (yes,
no, last option)
�Repeat your words and phrases
�Confuse pronouns (Mine and yours, I and you)

ASD Communication Difficulties: Listening and Understanding

�Seem like they can not hear
�Not respond to name, instructions, or questions
�Seem to understand more than they
actually do
�Seem like they don�t understand when
they do
�Have difficulty with abstract concepts
�Time concepts (�wait�, �later�, �in a
minute�, �after while�)
�General terms (�share�, �be nice�, �be
a good boy�)
�Idioms (�shake a leg� for hurry up)

ASD Tips for communicating

Keep it simple Speak slowly Allow extra
time Be specific Repeat & rephrase
Listen! Allow them to repeat you Use visual
Talk too much Talk too fast Be in a
hurry Use abstract or vague language Talk �over�

ASD: Possible Thinking Differences

�Extreme focus on narrow topics
�Attachment to certain objects
�Rigid or literal thinking patterns
�Desire for sameness/order/repetition
�Need for preparation
�Slow to process information and respond
�Difficulty with complex instructions

ASD Tips for Thinking

Be predictable Provide structure Prepare
them Consider all styles of learning Use visual
Be unpredictable Be disorganized Rush
them Just rely on words Stop repetitive
behaviors Take away items of interest

ASD Visual supports

�Assist in understanding
�Provide clear expectations
�Reduce anxiety
�Establish trust

ASD Possible Social deficits

�Difficulty with social interaction
�Difficulty understanding perspective of others
�Preference for objects or interests over people
�Difficulty reading & using nonverbal social cues
�Difficulty understanding �unwritten� social rules
�Poor eye contact

ASD Tips for interaction

DO: Reassure them of safety Be patient
Be consistent Be positive Be flexible
Model calm behavior Be aware of sensory needs�Offer
choices Use visual supports
Make them hurry Be unpredictable Be
defensive Be overly rigid Touch unless
permitted Demand eye contact Raise your voice
Misinterpret behavior

ASD Sensory Processing

�Extreme reactions or lack of reaction to certain sensory input
Auditory Visual Tactile
Olfactory Gustatory Vestibular

ASD Auditory: what they may do..

Constantly make sounds Seek out sounds Put
hands over ears Try to escape from noises Get
upset by loud noises (toilet flushing, hand dryers, buzzers,
vacuum) Not respond to certain sounds or name

ASD Auditory: what you can do..

Be aware of difficulty with crowd sounds Anticipate
that an individual may bolt from distressing sounds Be
aware of acoustics in room that may be irritating Lower
voice if appropriate Consider use of headphones

ASD Visual: What they may do..

Look off to the side or use peripheral vision
Squint/close eyes Stare at bright lights Flick
objects or fingers in front of eyes Be drawn to shiny
objects Be agitated around bright fluorescent lights or
sunlight Be agitated around excessive visual input

ASD Visual: What you can do..

Allow the person to use peripheral vision Not expect
eye contact Present material at eye level Allow
sunglasses or hat to block light Soft natural light is more
calming Decrease visual distraction as much as possible

ASD Tactile: What they may do..

Seem uncomfortable about being touched Insist on
wearing certain fabrics or types of clothes and avoids others
Take clothes off May not like to get hands dirty or
touch certain things Seem to have a high pain
tolerance Touch people and objects Seek out certain

ASD Tactile: What you can do..

Don�t touch the person without asking them Warn them
if you have to touch them Give personal space Stay
calm Be aware of problems that can be caused by things like
having shoes off Be aware of need to wash hands immediately
if dirty Don�t be alarmed if they try to touch you

ASD Olfactory: What they may do..

Avoid smells Gag with certain smells Smell
everything or everyone Smell everything before they eat

ASD Olfactory: What you can do..

Explore this information with families Consider smells
in the environment Avoid wearing lotions, perfumes,
etc. Don�t panic if children want to smell your clothes

ASD Gustatory: what they may do..

Have a very restricted diet Avoid using utensils
Mouth/chew on objects Gag easily with non-preferred
foods Pocket foods in mouth

ASD Gustatory: what you can do..

Explore concerns with family Provide individualized
and focused treatment Oral motor input
normalize mouth�s ability to interpret
input (decrease sensitivity or increase awareness)
Oral motor exercises to improve one�s ability to manage
food Visual and tactile exploration of new foods

ASD Vestibular: what they may do..

�Seek movement/body in constant motion
�Take risks
�Display gravitational insecurity
�Have difficulty tilting head to look down
�Get car sick

ASD Vestibular: What you can do..

Allow for safe movement Provide frequent movement
breaks Educate caregivers on the impact of movement
- Spinning (rotation) is alerting
- Linear (rocking, swinging) is calming

ASD Proprioception: What they may do.. Under-Responsive most often

�Oftencrash into objects, walls or people
�Use excessive force
�Move quickly and often
�Toe walk
�Don�t seem to know where their body is in space

ASD Proprioception: what you can do..

Provide deep pressure touch input Allow opportunities
for safe crashing, jumping, climbing, etc. Educate family
on challenges related to decreased body awareness

ASD Possible attention problems

�Attention difficulties
�Off-task behavior due to distractions in their surroundings
�Lack of inhibition

ASD Safety

�Many children lack the ability to understand danger
�Data suggests that children are at increased risk for serious
injury and even death due to accidents
�Many children will require safety supervision much longer than
other children
�Top safety risk: Wandering/Bolting

ASD Possible Emotional difficulties

�May laugh or giggle for no apparent reason
�May cry �out of the blue�
�Excessive fear of harmless objects or situations
�Lack of fear in response to actual dangers
�High anxiety & stress level in �normal situations�
�May become upset if others interrupt what they are doing

ASD Common challenging behaviors

�Property Destruction
�Self-Injurious Behavior (SIB)

ASD: how we contribute to challenging situations

�We are inconsistent and unpredictable�
�even when we don�t mean to be
�We place the individual in confusing, disorganized environments
�We misunderstand the difficulties of people with ASD
�We are sometimes stressed/anxious around individuals and they pick
up on it

ASD: OT role in treatment

�Enhancing participation and performance
�activities of daily living,
instrumental activities of daily living, education, work, play,
leisure and social participation
�Evaluation to assess individual skills
�strengths and challenges
�individualized techniques and
procedures directed at the individual, environment or activity
�Use of Self-Management skills to encourage, empower and equip
patients and families
�Measuring outcomes
�occupational performance
�client satisfaction
�role competence
�health and wellness
�prevention of further difficulties
�quality of life

What is it like to have DCD

For those with DCD, most tasks feel like novel tasks every
time The motor plan does not become integrated as it does
fortypical children Imagine tying your shoes... but every
day brings a new shoe,new fastening devices, some days you wear
gloves, etc.

DSM 5 Criteria for diagnosis for DCD

Impaired planning, learning, and execution of motor skills
Impacts various areas of the child�s life Onset in
the early developmental period Not explained by
intellectual disability, visual disturbance, or other neurological
All criteria must be met and a diagnosis provided by a physician

Why DCD is important

Under-diagnosed disorder�5-6% of school aged children
Historically ambiguous terminology Continuity and
consistency of care Continues throughout lifespan
Global health concerns Misunderstood students affecting
perceptions of competence and self-esteem

Co-occurring conditions with DCD

� ADHD (approximately 50% co-occurrence)� Specific learning
disabilities (esp. reading and writing)
� Speech and language disorder
� Autism Spectrum Disorder� Conduct disorder

Characteristics of DCD

Motor skill delay ADL limitations School
challenges Social implications Communication
issues Poor fitness/obesity

Characteristics of DCD - ADL limitations

� Difficulty sequencing and completing tasks
� Inability to fasten buttons, zippers, or tie shoes� Require
assistance with cleaning up/getting ready
� Lunch time difficulties
�coordinating use of utensils
�frequent spills�positioning self
at the table
�carrying a tray

DCD ADL challenges in school

�Fine motor:
Issues with handwriting and keyboarding Using
scissors, folding paper, completing artwork Opening locker
or combination lock Opening lunch items
�Gross motor:
Problems keeping up with peers at recess or in gym class
Donning/doffing coat and shoes, gym clothes Getting
off/on the bus Achieving appropriate posture for circle
time, class seating

DCD ADL challenges in school

Executive functioning:� Organizing and finishing work on
� Sequencing tasks� Efficiently
opening locker� Retrieving and opening lunch items
� Attending and behaving in class

Social implications for DCD

�Social implications:
Lower self-esteem Behavioral issues Anxiety
and depression Higher levels of frustration
�Communication issues:
Verbal and written Receptive and expressive

Test and Measures for DCD

�Screening tools
�Developmental Coordination Disorder
Questionnaire (DCD-Q)
�Movement Assessment Battery for
Children � checklist
�Standardized movement assessments
�Movement Assessment Battery for
Children � version 2
�Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2)

Test and measures for DCD

�Screening tool:�Used to determine
the overall impact on the child�s life
�Cannot be used alone to diagnose
DCD�Developmental Coordination Disorder Questionnaire (DCD-Q)
�Movement Assessment Battery for
Children � Checklist- version 2
DSM Criteria:
1) Impaired planning, learning, and execution of motor skills
2) Impacts various areas of the child�s life
3) Onset in the early developmental period4) Not explained by
intellectual disability, visual disturbance, or other neurological diagnosis


�Developmental Coordination Disorder Questionnaire (DCD-Q)
�15 question parent questionnaire
(likert scale)
�5-15 years of age�Time: 10 minutes
�Free and can be found
online�Sensitivity = 85%; overall specificity = 71%
�Little DCD-Q: ages 3-4 ($50 fee)

MABC Checklist (DCD)

�Movement Assessment Battery for Children � Checklist- version 2
�5-12 years of age
�10 minutes/30 items
�Completed by parent or teacher
�Approximately $38/pack of 50
�Three sections:
�Movement in a static and/or
predictable environment
�Movement in a dynamic and/or
unpredictable environment
�Non-motor factors that might affect movement
�Sensitivity = 41% (low); specificity = 88% (acceptable)

Test and Measures DCD

�Standardized tests:
�Identifies motor delays, does not
diagnose DCD specifically
�As always, interpret with
caution�Movement Assessment Battery for Children � version 2 (MABC-2)
�Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2)
DSM Criteria:
Impaired planning, learning, and execution of motor
skills Impacts various areas of the child�s
life Onset in the early developmental period Not
explained by intellectual disability, visual disturbance, or other
neurological diagnosis


Movement Assessment Battery for Children-version 2
� Age Range: 3:0-16:11 years�
Time: 20-40 minutes� Content:
� 8 tasks cover the following 3 areas:
� ManualDexterity�
BallSkills� StaticandDynamicBalance
� A score below 16th percentile, indicates need for treatment
� <5th percentile: represent children
with DCD
� 5-15th percentile: children at risk
for DCD� Also has a checklist for teachers/families


Bruininks-Oseretsky Test of Motor Performance - second edition
� Age Range: 4:0-21:11� Time to complete
� Short Form - 15-20 minutes�
Complete Form - 45-60 minutes� Fine Motor - 25-30 minutes�
Gross Motor Form 25-30 minutes
� Content:� 8 sections (4 fine motor, 4 gross motor)
�FineMotorPrecision,Fine Motor
Integration,Manual Dexterity,Bilateral Coordination, Balance, Running
Speed and Agility, Upper-Limb Coordination, Strength
� No specific cut-offs for DCD designation at this time

Intervention types for DCD

� Process-oriented
Addresses the body functions required to perform an
activity Sensory integration, kinesthetic training,
perceptual training, strength training Bottom up
� Addresses the motor task itself
� Can be whole or part training
� Top down approach

Process-oriented DCD

OT example: handwriting� Work on putty for proprioception
and hand strength, coloring for speed and endurance, Where�s Waldo
for visual perception.... eventually work on handwriting
� PT example: classroom transitions
� Work on balance, endurance, strength
for stairs, proprioception... eventually work on classroom transitions

Task-oriented DCD

OT example: handwriting
Have the child write, assess where the breakdown in
performance is. Coach the child through making a goal and
plan, then gaining awareness into what went wrong and helping them
discover new solutions. Work on handwriting the entire
PT example: classroom transitions
Have the child navigate the hallway, determine the breakdown
in performance Coach the child through making a goal and
plan, then gaining awareness into what went wrong and helping them
to discover new solutions. Work on transitions the entire

Task-oriented approaches DCD

� Task-oriented approaches are recommended for treating DCD as
compared to process-oriented techniques
� Working on handwriting improves handwriting!
� Working on transitions improves transitions!

Task-oriented Training DCD

Three primary interventions in the literature:
� Neuromotor task training� Cognitive Orientation to
Occupational Performance
� Motor imagery

Task-oriented: NTT (DCD)

� Neuromotor Task Training (NTT)
� Combination of theories
� Motor learning theory:
� Task structure
� Repetition
� Ecological theory:
�The task and environment can be modified
� Assessing the interaction between the
child, the task, and the environment
� Tailored to the child because it uses neuromotor assessment &
task analysis
� Steps:� Determine the child�s
goal� Perform task analysis & identify barriers� Adapt
the task/environment� Train to overcome barriers & promote learning
� Consider types and frequency of feedback provided

Task-orientated training: MI (DCD)

� Motor Imagery (MI)
� Mental rehearsal of a skill without
the motor component
� Can be used in a group setting
� Use of videos to assist with problem
solving and preparation
� Keying them into thinking about how
the activity feels

Task-orientated training: CO-OP (DCD)

� Cognitive Orientation to Occupational Performance (CO-OP)
� �A client-centered, performance-based, problem solving approach
that enables skill acquisition through a process of strategy use and
guided discovery,�
Goals of CO-OP:
1. Skill acquisition2. Strategy use3. Generalization to
other settings4. Transfer to other tasks
� The client�s goals are really a means to an end, which is
effective use of metacognitive strategies
� The real goal of CO-OP isproficient use of strategies

Task-orientated training: CO-OP (DCD) Pre-requisites

Pre-requisites - Client
� Ability to identify goals� Sufficient language� Basic
cognitive ability� Behavioral responsiveness� Basic awareness
Pre-requisites - Therapist
� Client-centered� Understanding of disability per ICF
(participation level)� Effective communication� Activity
analysis� Learning theory

CO-OP: strategy (DCD)

Global strategy:
Goal>plan, do, check> skill acquisition
Domain specific strategies:
� body position� attention to task� task
modification� knowledge supplementation
� feeling the movement� verbal mnemonics� scripting

CO-OP: Guided Discovery (DCD)

A means of providing both instruction and feedback
Encourages learner to problem solve independently
Guided by knowledgeable instructor who provides coaching and
hints Basic premise (Mayer 2004) is that meaningful learning
occurs when the learner makes sense of material by
selecting relevant information organizes it
integrates it into other organized knowledge
� One thing at a time � Ask, don�t tell� Coach, don�t
adjust � Make it obvious


Modify task � size of the tool, time to complete, technology
use Alter expectations � consider the ultimate goal, be
flexible Teach strategies � break down the task, give clues
to problem solve Change the environment � noise, visual
distractions, furniture, tools Help by understanding �
educate others, emphasize successes