Assessing Individuals with High-Functioning Autism

There are more than 1,700 international students enrolled at the University of Pittsburgh. They come from developing nations and member countries of the G8, representing every continent and region of the world. Some come from wealthy families who recognize that an American university education is essential to advance in a global economy. Others have been singled out by their governments to come to the U.S. and learn science, medicine, engineering, and other disciplines so they can return home and aid their countries and fellow citizens.

Such was the case with Dr. Sana Abu-Dahab, currently chair and assistant professor of occupational therapy (OT) on the Faculty of Rehabilitation Sciences at the University of Jordan in Amman. After receiving her undergraduate degree from Jordan, she was tapped to travel abroad to study pediatric occupational therapy. It became her charge to study the latest methods for OTs working with children with autism. Globally, one in 166 children is born with autism, and in Jordan, diagnosis of autism is on the rise. In the U.S., it is estimated that one in 150 children is born with autism.

Autism is a developmental disorder characterized by qualitative impairments in socialization and communication, and by repetitive and restricted patterns of behavior. It is the result of disturbances in the development of brain connections. Rare cases have been associated with abnormalities in genes that code for the formation or maintenance of contacts between brain cells. Some cases are the result of other neurologic, metabolic, genetic, or infectious diseases. The cause of most cases though is not yet known.

So began Abu-Dahab’s venture into SHRS and the Department of Occupational Therapy, where she first earned a master’s degree. “When it came time for Sana to begin her PhD dissertation, we asked Dr. Nancy Minshew if she would serve on the committee,” says Dr. Margo Holm, professor and director, Post-Professional Education in OT. Minshew, an international authority on autism research and treatment, is director of the NIH-funded Autism Center of Excellence at the University of Pittsburgh–Carnegie Mellon University.
“Sana came forward with four different proposals for her dissertation, which were all excellent. But given the timeframe, we believed they were unworkable,” says Minshew.

Holm and Abu-Dahab suggested a secondary data analysis, using Minshew’s  existing research databases. Holm points out that every person in the database has undergone an Autism Diagnostic Interview and an Autism Diagnostic Observation Schedule. “Both of these tools are used to ensure that there’s standardization across research sites, and that there’s reliability and validity in the diagnosis,” says Minshew. In addition, each individual has an IQ score greater than 80, classifying them as high-functioning.

Using the databases, Abu-Dahab set out to explore motor, sensory-perceptual, and executive functioning skills in individuals with high-functioning autism (IHFA). “Executive functions allow us to anticipate outcomes and adapt to changing situations. The ability to form concepts and think abstractly are often considered components of executive function,” according to Minshew.

Abu-Dahab conducted three studies: in the first, she examined simple motor skills, such as grip strength and the Finger Tapping Test, and complex motor skills, as measured by the Grooved Pegboard test. The data included IHFA and IQmatched typically developing individuals (TDI), ranging in age from 5 to 21 years old. Simple sensory-perceptual skills and complex sensory-perceptual skills were also examined within the same two groups.

Says Abu-Dahab, “The IHFA were found to be significantly impaired, when compared to TDI, on all motor measures across the age continuum with one exception: the speed of tapping revealed no differences between the two groups at a young age (8 – 9 years old),” but for older IHFA (14 – 15 years old) the impairments were significant.
“In children from 5 to 8 years old, the study found that grip strength was significantly weaker than their typically developing peers, which has not been reported in the literature anywhere,” Holm points out.

Minshew states that the grip strength differences that were demonstrated provide additional evidence that the basal ganglia might be involved in or responsible for some of the motor symptoms of autism. “Sana’s research documented the motor problems, sensory problems, and of course, the widely known executive functioning problems. The presence of motor and sensory abnormalities means that what’s different about the brain of a person with autism has to be much broader than just the social, language, and communication systems. We now have to address motor and sensory skills.”

In her second investigation, Abu-Dahab developed a statistical model that explained relationships among factors that predicted or were associated with good and poor complex fine-motor skills or skilled motor movements (psychomotor speed, hand-eye coordination, and manipulative dexterity), as measured by the Grooved Pegboard test. There were several factors that played an important role in complex fine motor skills in the IHFA model, such as educational level, memory, attention, and visual-spatial skills. “But in the TDI model, age, fine motor skills of the non-dominant hand, memory, and problem-solving skills were the influencing factors,” says Abu-Dahab. This means that IHFA may need to rely on structured experiences, such as school, to acquire the complex fine motor skills that are simply or automatically acquired with age in a typically developing individual,” she continues.

Her third investigation also developed a statistical model to delineate relationships among factors predicting good and poor executive functioning skills, as measured by the Wisconsin Card Sorting Test. Says Abu-Dahab, “In general, we found similar factors predicted performance: complex language/concept formation and memory were important factors in both of the models, one for IHFA and one for TDI. However, the order of importance of each factor for contributing to good executive functioning skills was not the same for IHFA and TDI.“

“These findings are of significant clinical importance for guiding assessment and intervention planning for IHFA,” Abu-Dahab continues. “While memory skills appear to enhance the capacity of executive function skills, their influence for IHFA seems to be secondary to complex language/concept formation skills that are usually challenging for high-functioning individuals with autism.”

“We used to believe that rote learning was appropriate for complex motor skill development for IHFA” interjects Holm. “Letters like b, d, p, q are similar, so we would have the children practice copying them over and over again.”

Given Abu-Dahab’s findings, therapists need to focus on attention and problem-solving in addition to practicing complex motor skills. “For example, therapists need to have the child focus on the b and the p in isolation, and point out that both are made of circles and lines, but ask ‘how does the b differ from the p?’” she continues.

“I think that Sana’s work suggests there are many reasons IHFA have difficulty with complex motor skills, and the models she developed provide guidance for therapists – which skills to focus on first, and how to build on those skills. It encourages therapists to think outside the box and determine why they can’t write letters, and offer a functional analysis of behavior,” Holm maintains.

Minshew offers,” I think it’s very important that the occupational therapist, who can be the entry point into the health care system, isn’t just confined to evaluating and working with the motor system or the sensory system, but sees that in relation to all the other impairments. They need to have a holistic view of the child, to tackle more than one challenge at a time.”

In summary, Abu-Dahab’s findings support the importance of motor and sensory skills in the assessment and intervention of individuals with autism of all ages. Her results provide guidance about how to intervene in a tiered approach to build skills in the motor and sensory areas in connection with building skills in language and problem solving. “Sana’s research and return to Jordan exemplify how the training of one person in an area of need – in this case autism assessment and intervention – can introduce improvements to the entire health system of a country,” Holm asserts.