Case Report: ASI intervention on a child with autism in Saudi Arabia

Objectives

Before assessing the efficacy of OT-ASI in SA, it is necessary to examine such an intervention’s feasibility when applied to individuals and to address implementation obstacles (Portney & Watkins, 2000). While previous studies based on children with impaired SI suggest that OT-ASI can improve SI and occupational performance, such studies did not focus on Arab countries (Schaaf & Nightlinger, 2007). Moreover, many such studies failed to use replicable protocols (Schaaf et al., 2018). The current study hypothesized that participation challenges of children with ASD were linked to SI impairments. Therefore, this study had the following objectives: (1) identify barriers associated with providing OT-ASI to a child with ASD in SA and (2) establish the efficacy of this intervention in the SA context. In line with these objectives, this research set out to answer the following question: to what extent is OT-ASI appropriate and effective in the Saudi context?

Case study participant

The inclusion criteria were: a) diagnosis of ASD by a multidisciplinary team using standardized tools, such as the The Autism Diagnostic Observation Schedule (ADOS) (Lord et al., 2000); b) living in Riyadh; c) parents providing voluntary consent; d) attending a mainstream preschool; e) experiencing challenges with activities of daily living (ADLs); f) aged 4-12 years. Individuals with other medical conditions were excluded. Recruitment was through parent invitation at Riyadh’s Centre in October 2018 at Autism Research (CFAR). The study was presented to CFAR at King Faisal Hospital and ethical approval granted for it to proceed.

One Saudi girl, referred to as L, aged 4 years and 7 months, met the criteria. L was diagnosed with ASD at 2 years and 3 months. She attended school full-time, where she participated in small groups of students with special educational needs. Her teachers had not undertaken ASD-specific training, and she was not receiving ASD-specific interventions. However, she had participated in a 2-month home-based speech intervention, completing 3-6 sessions weekly. While this appeared to improve her communication skills, L’s interactions with her peers and teachers were limited, and she exhibited frequent tantrums during transitions or changes to routine. Despite her poor communication skills, her cognitive development was typical. There was no relevant family medical or social history.

Step I

The study was guided by data-driven decision making (DDDM), a systematic process that aids OTs in clinical reasoning while addressing client needs (Schaaf & Mailloux, 2015). The study involved eight steps.

The first step involved a semi-structured interview with L’s mother, using occupational profiles, to identify how L interacts with her environment (AOTA, 2017) and her participation strengths and challenges (Schaaf & Mailloux, 2015). These profiles were translated into Arabic so the mother could understand them. L was reported to not initiate actions independently and often seem clumsy. She was described as a fussy child. She was unable to put on socks and shoes. She struggled to play with her peers and bumped into others, impacting social relationships. She also had difficulty writing. L’s teacher reported that L had a limited attention span and struggled to accept rules and use crayons.

Step II

In step II assessments were completed to identify factors affecting participation. To assess impairment related to SI and praxis, we used the Sensory Integration and Praxis Tests (SIPTs) and the Arabic Sensory Processing Measure-Preschool (SPM-P; Centre for Autism Research). The SIPTs comprise 17 individual sub-tests for children aged 4-8 years, measuring neurological ability to integrate the sensory inputs required for coordination, motor planning, visual-spatial actions, and perception (Schaaf & Lane, 2015). The SIPTs discriminate between normal and dysfunctional children in the United States at a statistically significant level (Schaaf & Mailloux, 2015). Of the 17 test items, 13 show reliability scores of.70 or more, which indicates heigh reliability. Moreover, the test has high inter-rater reliability due to the detailed scoring and because therapists using the SIPTs undertake training (Schaaf & Mailloux, 2015). Each SIPT results in a standard score that reflects the child’s performance compared to age-matched norms; the average score for a group of a given age is 0 (Schaaf & Mailloux, 2015). Scores below -1 standard deviation are considered evidence of dysfunction.

The Arabic SPM-P consists of home and classroom forms, which are suitable for children aged 2-5 years (Alkhalifah et al., 2020). The home form has 75 items and the classroom form has 62. The home form has excellent internal consistency when used with ASD (α = .93) and typically developing (α = .95) children (Alkhalifah et al., 2020). The Arabic classroom form has not yet been assessed, though the English version has excellent internal consistency when used with clinical (α = .93) and typical (α = .94) samples (Jorquera-Cabrera et al., 2017). Both forms use Likert scales to measure sensory behaviour frequency in sensory processing, praxis ability, and social participation (Alkhalifah et al., 2020; Jorquera-Cabrera et al., 2017). Both were used in this study because assessing children with ASD in different environments gives a comprehensive understanding of SI function (Jorquera-Cabrera et al., 2017).

L attempted 13 of the 17 SIPTs, completing 12 (see Figure 1). Scores indicated difficulty with tactile and kinesthetic processing, especially manual form perception, finger identification, and graphesthesia. L struggled in motor planning as measured by postural praxis, oral praxis, sequencing praxis, design copy, and bilateral motor coordination. Similarly, she scored low for space visualization. L was unable to participate in the localization of tactile stimuli, kinesthesis, and constructional praxis tests, and unable to fully participate in motor accuracy and postrotary nystagmus tests.

Figure 1. L’s Sensory Integration and Praxis Tests scores.

The findings from the Arabic SPM-P home and classroom forms are illustrated in Table 1. The environmental difference score demonstrated consistency across environments. Both measures indicated that L struggled with body awareness, balance and motion, social participation, hearing, and touch. The SPM-P revealed problems in planning and idea items and suggested her tactile, body awareness, and auditory systems were hyper-responsive.

Additionally, we used the Peabody Developmental Motor Scale-2 (PDMS-2), a task-observation test designed to evaluate fine and gross motor skills in children aged 0–5 years (Folio & Fewell, 2000). We selected the PDMS-2 because L’s challenges were associated with impaired fine and gross motor skills, which are common in ASD (Provost et al., 2007). Using a motor skills measure that assesses visual-motor integrations was important as visuomotor connections seem to be aberrant in ASD (Sharer et al., 2015).

L performed very poorly on tests of both fine and gross motor skills on the PDMS-2, and her total motor quotient score was very poor (Table 3). Additionally, on clinical observation, L was unable to maintain a flexion position for more than 10 seconds, while prone extension was achieved for 3 seconds. She showed difficulty with sequential finger touching and ramped arm movements. She also avoided touch in the absence of vision.

Step III: Hypothesis Generation

In step III, hypotheses were generated to link the assessment findings to L’s performance on ADLs (Schaaf & Mailloux, 2015). Overall, the findings suggested L’s participation challenges were due to impairments related to SI and praxis. Specifically, it was hypothesized that L had somatodyspraxia (Schaaf & Mailloux, 2015).

Step IV: The Goal Development and Scaling

In step IV, goals were established using the Goal Attainment Scale (GAS; King’s College London) (Ruble et al., 2012). The GAS is both systematic and sensitive to changes in functioning associated with ASI. It entails describing the individual’s present level of functioning for a given goal and then scaling it for the anticipated level of function over the intervention period. GAS helps assess outcomes that are challenging to measure with traditional instruments (Mailloux et al., 2007), and is a valid and reliable tool (Steenbeek et al., 2007) for individuals with ASD (Ruble et al., 2012). In a recent systematic review of ASI, Schaaf et al. (2018) concluded that “GAS is a strong, sensitive, and meaningful outcome” (p. 7). GAS uses a five-point scale, with values ranging from -2 to 2, scaled with equally spaced probability intervals (Kiresuk et al., 2014). A score of 0 reflects the anticipated level of function, while -1 and -2 suggest a level of attainment less/much less than anticipated, respectively, while +1 and +2 suggest better/much better than anticipated, respectively. Scores for each goal are used to calculate T-scores, representing the extent to which functioning improved to the degree anticipated.

The first author worked with L’s mother to identify specific and measurable goals reflecting L’s functional challenges (Schaaf & Mailloux, 2015). L’s mother knew about her difficulties in school and could contribute to setting both school- and home-based goals. As recommended by Ruble et al. (2012), goals were quality checked by the second author.

L’s goals were:

These goals were based on the premise that improving sensory processing would increase participation in everyday activities (Schaaf & Mailloux, 2015).

Step V

In step V, the authors determined the proximal and distal outcomes to use to track progress.

Distal Outcome Measure: Changes in L’s goals were measured by GAS, enabling the evaluation of progress toward specific, measurable, and time-dependent goals

Proximal Outcome Measures: The Arabic SPM-P and the PDMS were used as secondary outcome measures. The former was used to measure sensory reactivity, praxis, and social participation, the latter to measure fine and gross motor skills.

Step VI

In step VI, the intervention was planned. We agreed that L would participate in 1-hour ASI sessions twice weekly for 10 weeks, meeting her mother in person and her teacher over the phone every week for 30 minutes. Each session would provide sensory-rich experiences to elicit changes in the aberrant SI hypothesized to underlie L’s participation challenges. For therapy room sessions, interventions would consist of a beginning, middle, and end (Schaaf & Davies, 2010). Schaaf and Davies (2010) emphasized that ASI entails attention to meaningful activity, requiring adaptive responses and active participation from the child. Accordingly, L’s sessions were designed to provide a challenge level that was “just right” for her sensory systems (Schaaf & Lane, 2015).

Step VII

In step VII, the intervention was conducted. The first author, a licensed OT with certification in ASI and six years of experience working with children with ASD, delivered the intervention activities tailored to L’s needs. L had numerous opportunities to play with tactile-rich apparatus, to improve her proprioceptive and tactile perception, and praxis. Moreover, through pulling, pushing, and hanging activities, she was encouraged to stretch and engage her muscles. She participated in various active sensory–motor activities. She used a scooter board to experience proprioceptive and vestibular sensations and increase body awareness. She also engaged in jumping into a ball pit, climbing, rolling, and crawling. There were opportunities to change the apparatus and the rhythm, duration, frequency, and/or intensity of sensory experiences, based on L’s responses. In line with ASI principles, the first author and child cultivated an active, trusting relationship, with the former monitoring activity demands to ensure a just-right level of challenge (Schaaf & Mailloux, 2015).

The use of the ASI Fidelity Measure also ensured the intervention was in line with ASI principles (Parham et al., 2011). This measure defines the structure of the intervention and process elements (Parham et al., 2011, 2011; Schaaf & Mailloux, 2015). A score of 80 is a tentative cut-off point for adherence to ASI (Parham et al., 2011). The measure has high interrater reliability for both total fidelity scores (.98) and individual items (.94–.99). The validity of the measure is strong as raters can distinguish ASI sessions from other interventions with 92% accuracy (Parham et al., 2011).

All 20 sessions were videotaped, and the second author, trained in the application of the measure and with 30 years of experience working with children with ASD, assessed four randomly selected tapes. Additionally, the second author provided weekly consultations to the first author and was available throughout to discuss intervention challenges. Only one session produced an unacceptable fidelity score, after which the authors collaborated to ensure acceptable fidelity in all other sessions. The mean fidelity score across the four sessions assessed was 85 (SD = 9).

Step VIII

In step VIII, outcomes were measured and progress monitored, which included the mother’s ratings for each goal and consultation with L’s teacher to calculate a T-score using Kiresuk et al.’s (2014) formula. Outcomes for the dressing goal (rating = 1) exceeded expectations. Outcomes for the other goals (ratings = 0) were consistent with expectations. L’s post-intervention T-score was 62, suggesting she performed better than expected.

When interviewed six weeks post-intervention, L’s mother described her as happier, more sociable, better able to play safely, and less impulsive. She said:

When interviewed six weeks post-intervention, L’s teacher said that her “attention in the classroom was so much better and she is starting to participate in making choices during activities.” Both reported that L’s fine motor and social skills had improved and she showed fewer difficulties when playing.

The secondary outcomes showed that L improved in various domains. The results for the Arabic SPM-P home and classroom show L improved in sensory reactivity, praxis, and social participation in both home and classroom settings (Table 1). Similarly, the PDMS-2 data indicated L’s overall motor skills improved (Table 2). In a conversation six months post-intervention, L’s mother reported that, despite receiving no additional sessions, L’s behaviour at home and school continued to improve.

Preliminary evidence for the efficacy of ASI in SA

Post-intervention, L performed better on sensory and motor tasks and, in the context of ADLs, she demonstrated improvements in fine, gross, and overall motor skills. Previously, her performance was characterized as “very poor”, subsequently it was “average” or “below average”. These findings are in line with the review of Schaaf et al. (2018).

Jasmin et al. (2009) found that sensorimotor deficits in those with ASD underlie their day-to-day functioning. Congruent with this, L’s improvements in sensory processing and motor skills were reflected in enhanced performance in ADLs. For all tasks identified by GAS, she exhibited increased ability. She improved, as much as anticipated, her capacities to draw, play appropriately, and dress herself, positive changes that were reflected in the comments of L’s mother and teacher.

Limitations

As the study focused on OT–ASI with one child, the results are limited with respect to generalizability. While case histories only provide level V evidence, they are useful for exploring transitions to different cultures (Schaaf & Nightlinger, 2007). Another limitation is that the evaluation was completed by the therapist delivering the treatment (not independent assessors).

Key points for occupational therapy