AUTISM SPECTRUM DISORDER: A CASE STUDY OF MIKEY

A CASE STUDY

Presented to
The Faculty of Social Sciences and Humanities Department
Caraga State University-Main Campus
Butuan City

In partial fulfilment
Of the Requirements for the Degree
BACHELOR OF ELEMENTARY EDUCATION

RICARTE C. FERNANDEZ

APRIL 2019
 INTRODUCTION:

With a rise in Autism Spectrum Disorder (ASD) diagnoses (Centers for Disease Control

and Prevention, 2015) it is important that clinicians are acquainted with strategies to enrich client’s

lives and increase their occupational performance. With regards to the holistic occupation based

treatment of individuals with ASD, there is not an abundance of research that provides evidence-

based solutions, aside from sensory-based approaches. There is also a lack of research describing

the large role of occupational therapy treatment in ASD care.

I have decided to pick this topic because this gives me curiosity of what is an Autism

Spectrum Disorder (ASD) looks like. Also I want to improve my learning about autistic person and

their kind of lifestyle and behaviors.

This case study aims to describe diagnostic criteria for ASD, suggested causes, prevalence

and incidence, impact on client factors, comorbidities, and will end with a case study that describes

a typical pediatric client with common characteristics of ASD and includes insight on evidence-

based evaluation and treatment to improve functioning for the client, caregivers, and family.
 Autism Spectrum Disorder Background

Suspected Causes of Autism Spectrum Disorder

The exact cause of ASD is currently unknown, but there are many theorized causes.

These causes range from genetic factors to environmental factors to neurological abnormalities.

This paper will discuss some examples of the hypothesized theories, but it is not an all-inclusive

list, and will not fully explore each topic.

Genetics. Numerous studies have found links between ASD and genetics. Genetic etiology

is supported by the statistic that every twin study focused on ASD found that monozygotic twins

have a higher co-occurrence of ASD (Geschwind, 2011). This cause is also supported in a study

by Bolton and his colleagues, who found that relatives of individuals with ASD have a significantly

higher risk of also having the disease than the general population (Bolton, et al., 1994). Although

there is evidence to support a genetic cause of ASD, according to

Abrahams and Geshwind, “…the most common genetic forms account for not more than 1–2%

of cases” (2008). Therefore, genetics could significantly contribute to some cases of ASD, but it

is suspected that it is in combination with a variety of other causes.

Environmental. Several researchers have examined various environmental combinations

to determine the cause of ASD. Parental age at the time of birth is a risk factor that increases as

each of the parent’s age advances. Conditions at the time of birth may also contribute to increased

risk factors such as low birth weight and age of gestation (Kolevzon, Gross & Reichenberg, 2007).

On that account, environmental factors at the time of gestation and birth may be causes of ASD.
AUTISM SPECTRUM DISORDER

Neurological abnormalities. Various researchers have been focused on finding a neurologic

link to the cause of ASD. A study published in 2012 aimed to study the anatomical structures in the

brains of female children. This study concluded that in the left superior frontal gyrus, the female

children with ASD had more gray matter than the control group of female children. The study also

revealed that the females with ASD had a more complex circuit of increased cortical volume

(Calderoni, et al., 2012). Piven, Saliba, Bailey and Arndt concluded that in individuals with ASD the

cerebellar volume is enlarged compared to individuals without ASD, possibly contributing to the

cause of the disorder (1997). The number of Purkinje cells found in the brains of those with ASD has

been discovered to be significantly low, contributing to possible causes of ASD (Rivito et al., 1986).

Finally, decreased activation of the frontal lobe has been found in individuals with ASD as well

(United Kingdom Medical Research Council, 2001). In summary, increased gray matter, cortical and

cerebellar volume, as well as decreased Purkinje cells and activation of the frontal lobe can all

attribute to the cause of ASD.

Chapter 2
METHODOLOGY

History

Mikey is an eight-year old male who was diagnosed with ASD with a severity requiring

substantial support at age four by his pediatrician. Mikey is in third grade and has seen an

occupational therapist through his public school system for the past two years. Mikey has difficulty

maintaining social interactions and engaging in age appropriate play with his peers and sibling.

Reason for referral

Mikey’s parents have expressed that he is having difficulty with his morning routine,

causing behavioral issues. When Mikey has these issues his entire day is thrown off, resulting in

trouble concentrating on schoolwork and increasing difficulties interacting with his peers

throughout the day. Mikey’s parents would like a home evaluation and recommendations from an

occupational therapist in order to allow him to better function, especially during the mornings.

Mikey’s family would be willing to purchase accommodations to better help Mikey function, and

would commit to occupational therapy treatment outside of the school.

Evaluation Procedure

Three home visits were conducted to observe the child on the weekend mornings as well

as in the morning and at night on a school day. The Sensory Profile (Dunn, 1999) and the Revised

Knox Play Scale (Knox, 1974) were conducted.

References

Abrahams B. S., & Geschwind D.H. (2008). Advances in autism genetics: on the threshold of a

new neurobiology. Nature Reviews Genetics, 9(5), 341-355. Retrieved from

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&v=2.1&u=lom_wmichu&it=r&p=AONE&sw=w&asid=c3ba2d4ad4cf402a5a2102b94f

739230

Ajzenman, H. F., Standeven, J. W., & Shurtleff, T. L. (2013). Effect of hippotherapy on motor

control, adaptive behaviors, and participation in children with autism spectrum disorder:

a pilot study. American Journal of Occupational Therapy, 67, 653-663. :

10.5014/ajot.2013.008383

American Psychiatric Association. (2013). Neurodevelopmental Disorders. In Diagnostic and

statistical manual of mental disorders (5th ed.). :

10.1176/appi.books.9780890425596.dsm01

Bolton, P., Macdonald, H, Pickles, A., Rios, P., Goode, S., Crowson, M., Bailey, A., & Rutter,

M. (1994). A case-control family history study of autism. Journal of Child Psychology

and Psychiatry, 35(5), 877-900. : 10.1111/j.1469-7610.1994.tb02300.x

Brown, C. E. (2014). Ecological models in occupational therapy. In B. A. B. Schell, G. Gillen, &

M. E. Scaffa (Eds.). Willard and Spackman’s occupational therapy (12 ed., pp. 495-499).

Philidelphia, PA: Lippincott Williams & Wilkins.

Calderoni, S., Retico, A. Biagi, L., Tancredi, R., Muratori, F., & Tosetti, M. (2012). Female

children with autism spectrum disorder: An insight from mass-univariate and pattern

classification analyses, NeuroImage, 59(2), 1013-1022.

Chapter 3
RESULTS
Evaluation Results

Caregiver interview and observation. Mikey’s parents revealed that Mikey will

sometimes scream when he is awakened by noises in the house such as the blender, his alarm

clock, or his sister crying. They have found that Mikey has a difficult time waking, getting ready

for school, interacting with peers, and completing coursework during these days. They have also

stated that Mikey has trouble sleeping through the night and he frequently appears fatigued but is

unable to nap during the day. Mikey was observed to crave proprioceptive input, as evidenced by

flopping on the floor, and demonstrating poor motor coordination. Mikey was unable to engage in

interactive play with his three year old sister, and when asked to share toys with her, he ignored

the request. When observed during play, Mikey was preoccupied with a single spinning toy,

engrossed in ritualistic, repetitive play with the object. Mikey was observed turning the lights on

and off repetitively in his room for several minutes before transitioning into a different room.

Sensory Profile. On the Sensory Profile (Dunn, 1999) Mikey scored as a

“Probable/Definite Difference” in sensory registration, sensory seeking, and sensory avoiding

sections.

Revised Knox Play Scale. Mikey was found to be at the developmental level of a 12 month

old for the cooperation subsection, which assessed his ability to socialize positively with

individuals during play, in the Revised Knox Play Scale (Knox, 1974). He scored within the 24-

month age level for imitation, which is mimicking aspects of a situation, and humor subsections,

which assesses the child’s ability to tell jokes and understand humorous events. In the sections of
AUTISM SPECTRUM DISORDER

Interest (attention to the occupation) and Dramatization, which is Mikey’s ability to fantasize and

imagine himself in another role, Mikey’s score was consistent with that of a 30 month old.

Manipulation of Objects, specifically fine motor skills, was scored at the development of a 36

month old, while Gross Motor (play involving the whole body) and Type of Participation (social

engagement during play) were at the level of a 48 month old. Finally, Purpose, which is the goal

directedness of Mikey’s play, was scored at a level of a 60 month old.

Treatment Plan

After evaluating Mikey, it was determined that he has delays in play skills related to

attention, registration, and sensory processing.

It is recommended for Mikey to receive intensive treatment from an occupational

therapist outside the school to work on management of symptoms in order to enhance his

participation in occupations. If possible, it is recommended that Mikey see this occupational

therapist at home, in order to provide treatment in the least restrictive environment. The

following are examples of what an occupational therapist will focus on during treatment with

Mikey, and some outside referrals that the occupational therapist may recommend.

Long-term goals. After speaking with Mikey’s school occupational therapist and his

parents, the occupational therapist came up with the following two long-term goals for Mikey.

Mikey will demonstrate improved sensory modulation as evidenced by waking and

following morning routine without crying and throwing self on floor with assistance from

parents for one verbal and/or visual cue for each step of the routine by week four.

Mikey will participate in goal directed, cooperative play with parents for at least one hour

a day with three verbal and/or visual cues from parents in order to stay on task by week

four.
AUTISM SPECTRUM DISORDER

Treatment session. After Mikey’s home evaluation visits were complete, he began

seeing the occupational therapist five times a week for 45-minute sessions. The following

theoretical frameworks were used to develop a treatment plan specially designed for Mikey. A

description of each framework used is followed by an example of treatment.

Model of practice used- PEOP. According to, Christansen & Baum (as cited in Brown,

2014) the PEOP model is a model that focuses on four main elements. The first element is the

person, which includes values, interests, skills and life experiences, as well as cognitive,

physiological, spiritual, neurobehavioral and psychological aspects of an individual. The next

element is the environment. This includes the physical and cultural environments, as well as social

support and systems. Occupation in this model encompasses actions, which are observable

behaviors, and tasks, which are actions with a common purpose. Occupational performance is a

convergence of the above three elements, and changes as these elements change. The PEOP is a

holistic model, which is used frequently by occupational therapist.

Sensory Integration theory. Sensory Integration Theory was used to remediate some the

sensory processing challenges Mikey was experiencing. In Sensory Integration theory, children

are exposed to sensory stimuli at a level of a just right challenge in order to facilitate increasing

competent processing of this information. In theory, when a child is processing sensory input

more effectively, they are able to produce adaptive behavior that is appropriate for the situation.

Several occupational therapists have used Sensory Integration Theory to develop and

operationalize treatment strategies that can be used with children with ASD. The following is a

description of each approach with an example of how it could be used to address Mikey’s

challenges.
AUTISM SPECTRUM DISORDER

Ayres Sensory Integration (ASI). According to, Ayres (as cited in Parham & Mailloux, 2010)

Sensory Integration is the “organization of sensation for use.” ASI intervention is designed to

concentrate on engagement in occupation in order to encourage the involvement of the client in

everyday situations of their life.

There are six principles used to guide ASI. The first guiding principle is the fact that adaptive

responses are elicited from systematically used sensory input. The second principle is that adaptive

responses cannot be made without registration of meaningful sensory input. Thirdly, the

development of sensory integration is contributed to by an adaptive response. Fourth, a child’s

general behavioral organization is enhanced by an improved organization of adaptive responses.

Fifth, more advanced and complex patterns of behavior involve associations of more primitive

behaviors. The last principle is that the more a child’s activities are directed by their intrinsic drive,

the greater the prospective for the activities to advance neural organization. ASI is a strategy many

pediatric occupational therapy clinicians use to treat individuals with sensory processing disorders.

For instance, during an individualized treatment session in the occupational therapy sensory gym,

the occupational therapist organizes the room so Mikey has multiple choices planned out by the

therapist to play with during the session. The occupational therapist only leaves toys down that will

be able to be graded to facilitate adaptive responses to sensory stimuli in the environment such as

sound and proprioceptive input. For Mikey, the therapist might hang a platform swing and place a

ball on the swing with a basketball hoop nearby. The therapist might encourage Mikey to sit on the

swing while throwing the ball at the hoop. During this activity, he would be practicing his

equilibrium response by slowing and grading the amount of force needed to throw the ball as well

as adjusting for changes in depth perception as the swing moves.

Hippotherapy. Hippotherapy (HPT) involves the use of equine movement in order to

provide therapy. When used for twelve weeks, once a week for 45 minutes, HPT has been found

to improve adaptive behaviors, postural control, and participation in occupation for individuals

with ASD (Ajzenman, Standeven, & Shurtleff, 2013).

Group-Based Social Skill Training Programs. Group based social skill training

programs are therapist lead groups where other children with the same diagnosis, or similar

diagnoses are lead through a training program to improve social skills. These groups can happen

in the school or clinic. Strong evidence supports the use of these programs for intervention.

Studies have shown an increase in social skills, autistic behaviors, and increased positive

interactions have resulted from the use of these groups (Tanner, Hand, O’Toole, & Lane, 2015).
AUTISM SPECTRUM DISORDER

Chapter 4
DISCUSSION, SUMMARY, AND CONCLUSION
DISCUSSION:
The occupational therapy recommendations were made on the basis of the chosen frames

of references, and model of practice, as well as on evidence. The occupational therapist did the

above research in order to guide her care and plan with Mikey. While sensory treatment is critical

for one with ASD, it is not the only thing occupational therapists bring to the table when treating

individuals for ASD. Much evidence exists for the use of sensory treatment approaches, but it is

vital that occupational therapists begin to research and document the use of other techniques in

treatment that are within our scope in order to preserve the holistic nature of occupational therapy,

and to treat our clients with the best care.

SUMMARY:

The case study talks about Mickey’s health problem, what are the causes and the proper

treatment for his disorder. There are many factors that affect ASD for instance the environment,

genetics, and neurological abnormalities.

CONCLUSION:

In conclusion, ASD is a very broad condition that can impact many factors of a child’s life.

It is important that occupational therapists consider the client holistically, and base their treatment

off of evidence-backed interventions. There are a wide variety of treatment approaches that can

be considered, and while sensory-based interventions are important, clinicians must supplement

these approaches with other methods that are not sensory based
AUTISM SPECTRUM DISORDER

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Lower Purkinje cell counts in the cerebella of four autistic subjects: Initial findings of the

UCLA-NSAC autopsy research report. American Journal of Psychiatry, 143(7), 862-866.

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improve social participation, play, leisure, and restricted and repetitive behaviors in

people with autism spectrum disorder: A systematic review. American Journal of

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