Remote Services: Working with ASD
by Zandri Edser
Zandri is an OT Practice Paediatric Occupational Therapist specialising in Sensory Processing Disorder, who has been instrumental in helping The OT Practice develop and refine our service for the remote delivery of therapy. Here she shares an experience, explaining the largely unexpected benefits, of treating a child with ASD remotely.
When remote therapy was introduced one of my concerns was the fact that a great amount of the children on my case load have a diagnosis of Autistic Spectrum Disorder (ASD). ASD is ‘characterized by deficits in social communication and social interaction and the presence of restricted, repetitive behaviours.’ (https://www.asha.org/Practice-Portal/Clinical-Topics/Autism/)
Research and experience tell us that children with this diagnosis struggle with eye contact, reading facial expressions and other social interaction skills. If these things are already difficult for a child in person, surely it would be even more difficult for them when engaging with another person in a distant manner such as being on a screen. Through my experience of delivering therapy remotely over the last few months however, I have been pleasantly surprised. Children are known for being adaptable and resilient and I have seen this to be true to a great extent through this pandemic.
Many of the children I have been seeing for remote therapy sessions have shown growth, but one sticks out in particular. Kyle is a 15-year-old boy with a diagnosis of ASD. As well as this, he was unfortunately the victim of severe bullying at his last school which impacted him greatly on all levels: emotional, mental and physical. When I first started working with Kyle he was completely withdrawn. He would spend most of our session looking down at the table or his feet, use very little communication (be that verbal or non-verbal) and would often refuse to participate in tasks. We made slow progress in both our relationship as well as his skills, however the real turn around came when we started remote therapy.
To say that Kyle has blossomed would be an understatement. As cliched as it may sound, he is a completely different child interacting with me on a screen when compared to how he interacted when we were face to face. Kyle is more engaged and uses a great amount of verbal and non-verbal communication. We laugh together and are able to talk about why he may not want to do a certain task instead of him just refusing. Kyle is now participating in tasks that he previously avoided and is more spontaneous in his interaction and speech. He has become more assertive and autonomous, not always relying on his mother (who joins us for sessions) for answers or explanations. This has allowed him to develop in various skill areas and grow as a person. This response was never one that I had expected. To be completely honest, I had anticipated that remote sessions would fall flat with Kyle but thank goodness we tried as this model of therapy has benefited him so much more than traditional therapy did.
As I saw this change in Kyle, I began thinking about the reasons as to why he is responding better to this model. My intuition and clinical knowledge told me that there must be a great amount to do with the decreased pressure on things like eye contact as well as me not being in his personal space, creating anxiety. Even though our face to face sessions were carried out in his home environment where he was safe and comfortable, I feel he is even more comfortable in this environment with me being ‘at arm’s length’ as it were, allowing him to open up with less apprehension.
Our world has quickly developed into one where the use of technology is the norm. As well as this, we have seen that children often respond very well to screen-based activities. There are a variety of reasons why: fast changing graphics, attention shifts, cause and effect, repetition, immediate feedback etc. This in turn causes technology-based tasks to often engage a child's interest for longer. I also feel that moving the camera also plays a role. At times, the camera needs to be moved down so I can see Kyle writing or doing a certain movement. In this way, he may feel that the attention is not directed so greatly at him, just his hands and his writing for example.
No one model or framework works for every child, however I feel there is definitely a place for considering remote therapy as an option for children going forward, specifically for those on the autistic spectrum. It is a way of developing a therapeutic relationship in a less anxiety provoking way, giving the child time and space to ‘suss the therapist out’ as well as give them time to think about the responses that may be expected from them. In a way, they get to practice certain skills in a more comfortable, less demanding way.
I envisage this to be graded to eventually carrying out the sessions face to face but having built a foundation beforehand. Research indicates that children with an ASD diagnosis are often visually driven and thus using a screen as a tool is more motivating for them on a sensory level. Remote therapy is also a great way to enhance carry over of skills since you are working within the child's home as well as with their parent / caregiver. They are therefore able to observe the sessions and learn skills needed to carry over into their day to day tasks with their child.
The familiarisation of remote therapy has been an unanticipated silver lining to the COVID-19 pandemic. I have seen growth in myself as a therapist as well as my clients and I hope to continue to use this model in the future as an additional tool in my box.
