|Year : 2020 | Volume
| Issue : 4 | Page : 151-154
Effect of tele-occupational therapy on self-determined routine task performances in a young adult with autism, intellectual disability, and obsessive-compulsive disorder: A case report
Aishwarya Swaminathan1, Anuradha Venkatesh Pai2
1 School of OT, D Y Patil University, Mumbai, Maharashtra, India
2 OT Training School and Centre, Mumbai, Maharashtra, India
|Date of Submission||04-Feb-2021|
|Date of Acceptance||01-Mar-2021|
|Date of Web Publication||22-Apr-2021|
A-401, Suyog Sanmuh CHS, Sector-8, Plot No-41-44, Sanpada, Navi Mumbai - 400 705, Maharashtra
Source of Support: None, Conflict of Interest: None
A 19-year-old male with autism, intellectual disability (ID), and obsessive–compulsive disorder (OCD) presented with difficulty in self-determined routine task performances. Tele assessment was performed pre- and post-tele-occupational therapy (OT) intervention, using Yale Brown Obsessive–Compulsive Scale (Y-BOCS), Self-Determination Observation Checklist (SDOC), American Institutes for Research Self Determination Scale (AIRSDS) parent and educator form, and Routine Task Inventory-Expanded (RTI-E), to assess compulsive behaviors, self-determination from therapist, parent, and educator perspective, and routine task performances, respectively. Postintervention, favorable improvement was observed for the scores of Y-BOCS (25%), SDOC (therapist 29%), AIRSDS (parent 15% and educator 13%), and RTI-E: Activities of daily living (ADL) (20%), instrumental ADL (10%), communication (8.3%), and work behaviors (16.7%). This case report indicates that OT had a positive effect on the self-determined routine task performances in a young adult with autism, ID, and OCD.
Keywords: Activities of Daily Living, Cognitive Behavioral Training, Self-Determination Training, Tele-Rehabilitation, Tele-Occupational Therapy
|How to cite this article:|
Swaminathan A, Pai AV. Effect of tele-occupational therapy on self-determined routine task performances in a young adult with autism, intellectual disability, and obsessive-compulsive disorder: A case report. Indian J Occup Ther 2020;52:151-4
|How to cite this URL:|
Swaminathan A, Pai AV. Effect of tele-occupational therapy on self-determined routine task performances in a young adult with autism, intellectual disability, and obsessive-compulsive disorder: A case report. Indian J Occup Ther [serial online] 2020 [cited 2021 Jun 20];52:151-4. Available from: http://www.ijotonweb.org/text.asp?2020/52/4/151/314219
Routine task performances are occupational performances in areas of activities of daily living (ADL), instrumental activities of daily living (IADL), communication, and work readiness. Self-determined routine task performances require choice making, planning, goal setting, problem–solving, and self-monitoring skills. Self-determined routine task performances are affected in individuals with disabilities as compared to their typical peers. Occupational therapy (OT) can have a positive effect on the self-determined routine task performances, in individuals with varied disabilities, but empirical research in this area is lacking. The rationale of this unique case report is to study and understand the effect of tele OT on self-determined routine task performances in a young adult with autism, intellectual disability (ID), and obsessive–compulsive disorder (OCD). The tele mode of OT was used as it became the need of the hour for timely service provision without making the patient wait during the lockdown period.
| Introduction|| |
A 19-year-old male had a diagnosis of autism and moderate ID since the age of 3 years. He started showing compulsive symptoms checking behaviors at age of 18 years. As mentioned by his parent (mother) and teacher, the checking behavior was in the form of repeated opening and closing of windows/doors interfering with his everyday routine task performances. He would get up right in the middle of the routine tasks to indulge in the compulsive behavior, and trying to make him stop this behavior to get back to the tasks was stressful for him. Moreover, therefore, he got an additional diagnosis of OCD and was started on medication (selective serotonin re-uptake inhibitor: Fluoxetine Prozac) for the same.
| Patient Information|| |
He has been attending a special school since he was 5 years old and was presently attending school through online tele-mode (due to the COVID pandemic) to learn everyday activities, functional academics, and vocational tasks.
The timeline for assessment, intervention, and follow-up is described in [Table 1].
Assessment and Clinical Findings
Tele-assessment was done through parent, teacher interview, and observation of performance through Google meet, using Yale Brown Obsessive–Compulsive Scale (Y-BOCS), Self Determination Observation Checklist (SDOC), American Institute of Research Self Determination Scale (AIRSDS) parent and educator form, Routine Task Inventory-Expanded (RTI-E), to assess compulsive behaviors, self-determination from therapist, parent, and educator perspective, and routine task performances, respectively. All assessment scales have good psychometric properties [Table 2]. The assessment was done pre- and post-tele-OT intervention provided for 8 weeks [Table 3].
The OT intervention was provided through online tele-mode for 30 min per day, 3 days/week, 8 weeks, as a part of patient's online school activity. The Google meet platform was used for the tele-OT. iPads were used as the remote devices by both the patient and the therapist. The comprehensive tele-OT included some components of cognitive behavioral therapy (CBT) and self-determination training (SDT) in the context of routine task performances at home, from where the patient attended the online sessions, with assistance of his parent (mother). Since every week had three sessions, it included one each of routine tasks during each session, from ADL, IADL, and a vocational activity as follows, ADL (grooming, dressing, bathing, walking/exercising, feeding, toileting, taking medications, and using adaptive equipment), IADL (housekeeping, preparing/obtaining food, spending money, doing laundry, traveling, shopping, telephoning, and care for others), and vocational activity of candle making stressing on work readiness (maintaining pace/schedule, following instruction, performing simple/complex tasks, getting along with co-workers, following safety precautions, responding to emergencies, planning work, and supervising others). During these routine task activities, the components of CBT combined with SDT were provided as: exposure/response prevention, antecedent control, and social stories were used to explain rules before activity about not getting up during the activity to open/close the windows/doors. Visual cue cards were used for the following, Red Cross signs on window panes/doors, making activity choice from options, choosing number of steps of activity from options, setting goals, problem–solving, and self-monitoring. Assertiveness training was also given so that the subject could have positive self-talk (“Yes I can”) to overcome the urges to indulge in OCD behaviors and also communicate effectively with therapist, parent, and educator during the sessions to reduce anxiety. Once the activity was completed, the participant received positive reinforcement in the form of visual star card and verbal praise. Parent (mother) and educator were trained to use these components of CBT and SDT with the young adult patient.
Follow-up and Outcomes
Postintervention at week 9, favorable improvement was observed for the scores of Y-BOCS (25%), SDOC (therapist 29%), AIRSDS (parent 15% and educator 13%), and RTI-E as rated by parent and educator in ADL (20% and 22%), IADL (10% and 13.4%), communication (8.3% and 8.3%), and work behaviors (16.7% and 15%).
| Discussion|| |
Decrease in Compulsive Behaviors
To accommodate the cognitive and social deficits in terms of triple diagnosis, some modifications need to be made to the CBT, the first line of treatment for OCD behaviors. In lines with this, the present case study used an OT intervention with only a few components of CBT along with SDT.
As per [Table 3], it was observed that the compulsive behaviors decreased, which could be due to the OT provided, based on components of CBT incorporating SDT such as choice making opportunities and assertiveness training. This is supported by a study by Bavaro, in which the author explains that OT using combination of psychotherapy and providing nonthreatening environment, in which patients feel free to express their choices/needs, helps in reducing the obsessive–compulsive behaviors. The author also mentioned that the OT role is to reduce or compensate for the stress of compulsions, through provision of activities of “just right” volitional and difficulty level using model of human occupation. In the present case report, the CBT and SDT provided in the context of routine task performances, may have compensated for the stress of compulsions, and thus reduced the OCD behaviors.
Improvement in Self-Determined Routine Task Performances
As per [Table 3], it was also noticed that the self-determination skills improved as rated by the therapist, parent as well as the educator. This may have occurred due to the OT based on the SDT that was provided with components for choice making, goal setting, planning, problem solving, and self-monitoring. This is in accordance with a study by Vicente et al., which states that though individuals with disabilities are less self-determined than their peers without disabilities; however, their self-determination skills can be improved with appropriate training, supports, and opportunities. These opportunities for self-determined participation in routine task performances were provided by the OT intervention in the present study.
In this case report, the improved self-determination skills may have led to improved routine task performances [Table 3]. This is supported by the study Kelly and Shrogen, who state that improved self-determination skills can lead to improved task performances and decreased off task behaviors.
Overall, it was observed that OT had a positive effect on the self-determined routine task performances of ADL, IADL, communication, and work behaviors which are important occupational performance areas for the young adult with autism, ID, and OCD. Limitation of this study is that the results cannot be generalized due to the single subject design. Moreover, future research can be conducted on similar lines using designs such as one group pre-post study or two group comparative study.
Since the patient had moderate ID with communication difficulties, he could not express his own perspective, so the parent and the educator perspectives were noted. As per AIR-SDS scores, they mentioned that, though the patient had the capacity for self-determination, they were not providing him with the necessary opportunities, for practicing his self-determination skills earlier to this study. Now, they learned the importance of opportunities for learning self-determination skills, decreasing OCD behaviors, and improving his routine task performances. They mentioned to continue implementing the CBT and SDT training with the patient.
The informed written consent was taken from the parent (mother) of the patient.
Declaration of Patient Consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
We would like to thank the Almighty God and our parents.
We would also like to thank Dr. Sunil Mokashi sir, Dean, School of OT, D Y Patil University, Nerul, Navi Mumbai and Dr.Rashmi Yeradkar, Incharge, OT Training School and Centre, LTMMC, Sion.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Vicente E, Mumbardó-Adam C, Guillén VM, Coma-Roselló T, Bravo-Álvarez MÁ, Sánchez S. Self-determination in people with intellectual disability: The mediating role of opportunities. Int J Environ Res Public Health 2020;17:6201.
Storch EA, Rasmussen SA, Price LH, Larson MJ, Murphy TK, Goodman WK. Development and psychometric evaluation of the Yale-Brown Obsessive-Compulsive Scale-Second Edition. Psychol Assess 2010;22:223-32.
Kose LK, Fox L, Storch EA. Effectiveness of cognitive behavioral therapy for individuals with autism spectrum disorders and comorbid obsessive-compulsive disorder: A review of the research. J Dev Phys Disabil 2018;30:69-87.
Bavaro SM. Case report: Occupational therapy and obsessive compulsive disorder. Am J Occup Ther 1991;45:456-458.
Kelly JR, Shrogen KA. The impact of teaching self-determination skills on the on task and off task behaviors of students with emotional and behavioral disorders. J Emot Behav 2014;22:27-40.
[Table 1], [Table 2], [Table 3]