OT and Music Therapy: An interdisciplinary approach to improving handwriting in children on the autism spectrum
By: Meg Ladyman, MS, OTR
In creating an evidenced based treatment plan, one needs to start with an evidenced-based intervention. This author is using the Handwriting Without Tears (HWWT) to facilitate writing progress in pre-writers on the autism spectrum. According to the findings of authors Lust and Donica (2011), HWWT significantly improved kindergarten readiness scores as compared to treatment as usual (p. =.0058 with a large treatment effect of d=1.05). This study was a two group nonrandomized control trial with a pre and posttest design with HWWT in one preschool classroom and a typical Head Start curriculum in the other.
After defining the treatment plan, next one must look to the room itself where the intervention is to take place and build from there. According to the American Occupational Therapy Framework: Domain and Process, 3rd Ed. they ask, “What are the physical space requirements of the activity, and what are the social interaction demands?” (pg.S8). The evidenced- based client-centered treatment plan this author created consists of a HWWT Saturday class that is facilitated at Indiana State University (ISU) with three ISU occupational therapy (OT) students. This class is a ten-week interprofessional course with OT and Music Therapy. Five of the six children attending this class are on the Autism Spectrum. The physical space requirements (or context and environment) were first examined to prepare for the children to be successful. A masking tape oval was created for the children where they could sit or stand so that they did not have to try to figure out where to go. This allowed for specificity with wording of directives, such as “put your toes on the circle” if we were doing a standing activity, or “put your bottoms on the circle” when it is time for a sitting activity. The Framework III states, “Physical environments can either support or present barriers to participation in meaningful occupations” (pg. S8). It was found that this part of the intervention was most critical to the success of the lesson. The room set up was modified from 4-desk cluster, to the desks in one straight line pushed up close to the wall with chairs for the students on one side and chairs for the helpers on the opposite side. This arrangement facilitated the helpers so they were able to quickly re-direct the student, hand them the materials, and enthusiastically praise attempts at participation. This method also easily facilitated joint attention; one of the building blocks of social interaction according to the Joint Attention Symbolic Play Engagement and Regulation Model, JASPER (2012). The JASPER study found in their randomized control trial (RCT) that there was a significant difference in play diversity skills p=0.04 at the exit with a large effect size of d=0.81. after intervention on the Mullen Scales of Early Learning. The implication for this author is that this study employs techniques that can be incorporated into interventions with young children with autism to increase play diversity.
When reflecting on client factors from the Framework III one needs to address the body functions of the children with autism by starting with sensory functions. Occupational therapists should take into consideration sensory processing when seeking to promote the child’s ability to engage in their desired occupations. In a randomized trial by Schaaf and Colleagues (2013) with 32 children on the autism spectrum they found that there was a significant difference on the Goal Attainment Scales (GAS) ( p=.03, d= 1.2) and in socialization (p=0.04, d=.07) after 30 sessions of sensory integration as compared to treatment as usual. Their study described the feelings of isolation that families report due to difficulty with their children processing sensory input. Those authors expounded on some of the tactile and proprioceptive activities they used in their treatment sessions. Although our intervention site does not afford a fully equipped clinic, a sensory component was integrated into the seated portion of the treatment plan during desk time. It was quickly observed that two or three of the students were having difficulty attending to their seat work even after other adjustments occurred, such as picture schedules. Therefore, therapy bands were included and wrapped around the desk legs to add a heavy work component and a move-n-sit for each chair to provide some vestibular movement even while seated. A tactile experience was added – shaving cream on the desk to reinforce letter skills.
The Framework III addresses performance skills. Two areas of performance skills for a child on the spectrum for us to examine are motor skills and social interactions skills. In planning the flow of the class, motor skills are a big part of handwriting. HWWT includes several motor skill demands. However, we wanted to capitalize on this area by increasing the motor piece such as having the children take turns to point to the ABCs on the white board as they lead the ABC song instead of sitting to sing. We wanted to capitalize on social interaction skills by including the Say Hello dance and promoting friendships by strategically placing students next to each other on the circle and at the desks.
In a typical intervention plan, goal writing would include collaboration with the parent and also the child if he/she was old enough. In this group setting, where the curriculum is predetermined, it is still important to seek out parental advice and information on the child such as their reward preferences and make changes accordingly. After parent feedback and observation, some changes were made for the next class. The activities remained of short duration, approximately 3-5 minutes long. Music therapy was strategically placed in the first fifteen minutes and the last fifteen minutes of the class. The first fifteen minutes we see the music therapy introduction as part of the preparatory process helping to enable the children to focus on more academic tasks. A sample intervention is below:
1:00-1:15 – Music Therapy
1:15-1:20 – ABC Song (children pick wood pieces from bag to use to point at letters on white board)
1:20-1:25 –“A” worksheets (Goal: Learning to form the capital A with chalk and crayon).
1:25-1:30 – “M” worksheets (Goal: Learning to form the letter M with emphasis on grasp).
1:30-1:35 – “N” worksheets (Goal: Learning to form the letter N with playdough and wooden pieces). Incorporating “Where Do You Start Your Letters” and “The Crayon Song” during worksheet time.
1:35-1:40 – 10 Little Fingers (Goal: Finger dexterity and fine motor control).
1:40-1:45 – Wood Piece Hokey Pokey (Goal: Identifying wooden pieces used to make letters).
1:45-2:00 – Music Therapy and closing songs.
Although circles of interaction were facilitated with the children, the intervention piece occurred through use of the table top activities with focus on correct pencil grip, correct letter formation, and attending skills.
One of the biggest reasons for success is the therapeutic use of self through relation to our students and the use of compassion toward the parents. The Framework III describes empathy as, “ …the emotional exchange between occupational practitioners and clients that allows more open communication, ensuring that practitioners connect with clients at an emotional level to assist them with their current life situation” (pg. S12). The compassion component led to initiation of a parent support group. After training ISU counseling students on ways to support parents who have a child affected by autism, this author introduced them to the activity time suggestions included in the book “Autism Breakthrough” by Raun K. Kaufman (2014). Those chapter assignments include how to approach control battles, the communication ladder, the eye contact chart, and the creativity exploration. Due to time constraints the present support group is completely parent directed and student facilitated, with plans of introducing Son-Rise techniques next semester. These activities support parents in their quest for increased joint attention, diversified play, and quality of life issues.
To promote home carry over, a take home activity is printed out and given to the parents during the last class to reinforce concepts that the children have learned over the ten-week period. This activity includes items easily found in the home, an oven rack, paper, and crayons. The parent can place the oven rack over the butcher paper and have the child use it as their writing lines. That will reinforce concepts of starting the letter at the top, crayon grasp, letter formation, and using lines.
Although this intervention plan has an alternative delivery method from one on one therapy, it beautifully incorporates many of the occupations described in the Framework III such as play exploration, play participation, leisure exploration, social participation, community, and, of course, handwriting. The class also naturally allows for the emphasis on social skills and social cognition which we incorporate into each group activity by a variety of activities including taking turns to play the drum, allowing each student to pick another child for us to sing to, and dancing together in the Shake Hello song. Crooke et al. (2008) states that, “…social cognition is the complicated process whereby individuals acquire, understand and use social knowledge to respond quickly and accurately to verbal and nonverbal social information”, (pg. 582). Their single subject design study examined the effects of a social cognitive intervention on six boys with autism ages 9-11. They found significant gains in Expected and Unexpected verbalizations (p= .03) using the Wilcoxon signed-rank. Many of the strategies discussed by Crooke and colleagues (2008) such as listening/thinking with your eyes, whole body listening, politeness, and introducing oneself can all be incorporated into the group described in this study. This study has provided the unique opportunity to address social cognition because it is a community setting with children on the autism spectrum, neuro-typical siblings, and caring adults. Due to high parent demand after this 10-week program, it was requested that the course occur again. This experience was an extreme honor, and it is hoped future opportunities will serve the autism community within the local community and city.
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About the Author
Meg Ladyman, MS, OTR is an assistant professor and AFWC in the OT department at Indiana State University. She received her Masters of OT in 2010 from Concordia University Wisconsin and is currently working on her OTD from Rocky Mountain University of Health Professionals. As an AFWC Meg has a passion for placing her students in amazing FW opportunities. Her other passions include understanding the most effective interventions for autism and using her skills in developing countries. She will be returning to Haiti again this year and bringing 5 ISU OT students to work with orphans with disabilities.
- American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and Process (3rd ed.). American Journal of Occupational Therapy, Vol. 68 (Supplement 1)
- Crooke, P., Hendrix, R., Rachman, J. (2007). Brief Report: Measuring the Effectiveness of Teaching Social Thinking to Children with Asperger Syndrome (AS) and High Functioning Autism (HFA), Journal of Autism and Developmental Disorders, 38, 581-591.
- Good, K., Ishijima, E., Chang, Y., & Kasari, C. (2013). Preschool Based JASPER Intervention in Minimally Verbal Children with Autism: Pilot RCT. Autism and Developmental Disorder, 43, 1050-1056.
- Handwriting Without Tears® All Rights Reserved -Jan Olsen, OTR. Retrieved on 11/20/2015 http//www.hwtears.com
- Kaufman, R. K. (2014). Autism Breakthrough: The Groundbreaking Method That Has Helped Families All Over the World. St. Martin’s Griffin
- Lust, C.; Donica, D. (2011). Handwriting Readiness Program in Head Start: A Two-Group Controlled Trial. American Journal of Occupational Therapy, 65, 560-568.
- Schaaf, T. B. (2013). An Intervention for Sensory Difficulties in Children with Autism: A Randomized Trial. Journal of Autism and Developmental Disorders, 44,1493-1506.