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Abstract
Introduction: Occupational therapy is one of the health care professions that provides assessments and interventions for children
and adolescents with autism spectrum disorder. However, to date, there is no information available regarding occupational therapy
practices in Malaysia for this population. The purpose of this study is to describe the occupational therapy services for children and
adolescents with autism spectrum disorder in Malaysia, including the perceived training needs of practitioners.
Method: We surveyed the registered members of the Malaysian Occupational Therapy Association using a mailed questionnaire.
Results: A response rate of 15.5% was obtained. The majority of the responses were from those working in hospital settings who
had less than 5 years experience working as occupational therapists with children and adolescents with autism spectrum
disorder. The theories, assessments, interventions, and training that related to respondents practices mainly revolved around
sensory-based approaches. Encouragingly, more than 70% of the respondents claimed that they performed assessments of daily
living activities in their service. Client-centred practice was a further feature of occupational therapist respondents involved in this
study.
Conclusion: Future study is needed, especially to engage more respondents and thereby produce more generalizable results and
an in-depth exploration of the continuing education needs of occupational therapists in Malaysia.
Keywords
Theory, interventions, professional development
Received: 18 July 2013; accepted: 2 September 2014
Introduction
The recently published Diagnostic and Statistical Manual
of Mental Disorders 5th Edition (DSM-V) (American
Psychiatric Association (APA), 2013) specied two
major characteristics of impairment in autism spectrum
disorder (ASD).
1. Decits in social interaction and social communication.
2. Restricted, repetitive patterns of behaviour, interests, or
activities.
The DSM-V recognizes that the four previously separate disorders under the Diagnostic and Statistical Manual
of Mental Disorders-IV Text Revision (DSM-IV-TR)
classication (APA, 2000) that is: (a) autistic disorder;
(b) Aspergers disorder; (c) childhood disintegrative disorder; and (d) pervasive developmental disorders not
otherwise specied are actually a single condition with
dierent levels of symptom severity in the two core decits
mentioned earlier. In this study, the ASD criteria, as stated
under the DSM-IV-TR (APA, 2000), were used because
the DSM-V (APA, 2013) was only published after the
research data had been collected. Internationally, it has
Corresponding author:
Masne Kadar, Lecturer, Universiti Kebangsaan Malaysia (UKM), Department
of Occupational Therapy, School of Rehabilitation Sciences, Faculty of
Health Sciences, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300,
Malaysia.
Email: masne_kadar@yahoo.co.uk
34
Literature review
Occupational therapy is one of the most common services
received by children with ASD and their families
(McLennan et al., 2008). In the United Kingdom (UK),
the prevalence of ASD was reported at 1% of the total
population of school-aged children between 5 and 9 years
of age (Baron-Cohen et al., 2009). In the United States
(US), the overall estimated prevalence of ASD was
reported at one in 50 children a signicant increase
from that previously reported (Blumberg et al., 2013).
Occupational therapy within the US, for example, provides various interventions, including early intervention
programmes, social skills training, and educational intervention programmes (Case-Smith and Arbesman, 2008).
Although much is now known about the characteristics
of children who have ASD, the underlying occupational
performance issues and eective interventions for children
with ASD remain poorly understood (Wallen and Imms,
2006). Furthermore, explicit information regarding the
interventions and services received by children with ASD
and their families is limited (McLennan et al., 2008). It was
reported that children with ASD experienced diculties in
personal care activities (Allik et al., 2006; Cermak et al.,
2010; Flynn and Healy, 2012; Twachtman-Reilly et al.,
2008), poor engagement in school or classroom activities
and with peers (Falkmer et al., 2012), and motor diculties that can cause occupational performance problems for
those children (Green et al., 2009; Liu, 2013; Rinehart and
McGinley, 2010; Shetreat-Klein et al., 2012).
To date, there have been three studies reporting on
occupational therapy services provided specically for
children and adults with ASD: Watling et al. (1999a) performed a study in the US; Ashburner et al. (2010, unpublished report) in Queensland, Australia; and Kadar et al.
(2012) in Victoria, Australia. Despite a gap of a decade,
there are strong similarities in the ndings of these studies.
They relate to the emphasis given by the occupational
therapy participants in managing issues and providing
interventions related to sensory processing diculties
exhibited by people with ASD, as well as the need for
knowledge related to sensory-based approaches in the
areas of assessment, intervention, and training in their service for this population. Despite the therapists emphasis
on working with sensory processing diculties in these
reports of their practice, there is currently little evidence
of the eectiveness of the sensory-based interventions or
approaches for children and adolescents with ASD (Hyatt
et al., 2009).
It is also important for occupational therapists to consider the use of other related approaches and/or useful
strategies in their interventions for children and adolescents with ASD (Arbesman and Lieberman, 2010).
Increasingly, studies that investigate the improvement of
occupational performance of children and adolescents
with ASD are being performed (Rodger and
Kadar et al.
35
Method
Design
A self-administered questionnaire was mailed to occupational therapists in Malaysia. The questionnaire used in
this study was adapted from a questionnaire entitled
Current Practice of Occupational Therapy for Children
with Autism: A National Survey of Practitioners, developed
by Watling et al. (1999b) for their survey of occupational
therapists in the US. This questionnaire was selected as the
basis for the questionnaire used in this study. Considerable
modication was required as the original questionnaire
was: (a) designed for therapists based in the US; and
(b) designed and carried out prior to 1999 (Renee
Watling, 2009, personal communication). Permission to
do so was granted by the rst author. The questionnaire
was modied to include more current information relating
to occupational therapy and ASD by reviewing relevant
occupational therapy textbooks and literature (CaseSmith, 2005; Case-Smith and Arbesman, 2008; Kramer
and Hinojosa, 2010; Miller-Kuhaneck, 2004; Mulligan,
2003; Watling et al., 1999a) and was also based on a questionnaire entitled The Paediatric Occupational Therapy
Practitioner Survey (Brown and Rodger, 2001, unpublished tool) (permission to modify the questionnaire was
granted by the author). The modied questionnaire
includes more current assessment tools and interventions
provided to children with ASD compared with the original
questionnaires. To ensure its face and content validity, the
questionnaire was sent to 12 experts in the occupational
therapy and/or ASD eld internationally (including
experts from the US, Australia, Malaysia, and Taiwan).
The purpose of sending the initial questionnaire to the
experts was to ensure that the questionnaire design works
in practice, to identify and amend problematic questions,
rene the questionnaire, and identify problems
relating to the content, wording, layout, length, and
instructions included in the questionnaire. The questionnaire was further tested by six Malaysian occupational
therapists who had experience of working with children
with ASD, in order to ensure that the English language
used in the survey was applicable to Malaysian occupational therapists. None of the six therapists tested suggested that the questionnaire should either be in Malay
language or be in two languages (that is, English and
Malay) because English is used in most of the teaching
delivery and training activities of the occupational therapists in Malaysia. The feedback received was used to
Research ethics
Ethics approval was gained from the Monash University
Human Research Ethical Committee (MUHREC) project
number CF09/3131 2009001710. In order to conduct
research in Malaysia, another ethical approval was also
requested from The Research Promotion and CoOrdination Committee, Economic Planning Unit (EPU),
Prime Ministers Department, Malaysia reference
number UPE: 40/200/19/2505.
Respondents
The respondents in this survey were Malaysian qualied
non-international occupational therapists who were members of the Malaysian Occupational Therapy Association
(MOTA). To be included in the study, respondents must
work or have worked with children and adolescents with
ASD in occupational therapy services, either in Peninsular
or East Malaysia. MOTA were consulted for their help in
identifying potential respondents for the survey.
The rst author was given access to the MOTA
member information database in order to source addresses
to which the survey could be mailed. However, out of 459
ordinary members listed (December 2009), only 362 members had their full names and addresses recorded in the
database. The remaining 97 members had incomplete
names or addresses. It was not known whether the complete details of members were current. There was also no
indication on the database of the members service areas
or specialties (such as whether they are working in the
paediatrics area or in any other specialized areas) to
enable the researchers to select and mail the surveys only
to those in the target group for the purpose of this study;
36
hence, the survey was mailed to the 362 Malaysian occupational therapists whose full names and addresses were in
the MOTA database.
Table 1. Participants experiences working as occupational therapists, working with children with ASD, and their academic
qualification.
Participants working experiences
Procedures
Ethical approval was granted by the Monash University
Human Research Ethical Committee (MUHREC) and
The Research Promotion and Co-Ordination Committee,
Economic Planning Unit (EPU), Prime Ministers
Department, Malaysia. The self-administered survey was
mailed to members on the MOTA database, together with
an introductory letter, explanatory statement, and
stamped, self-addressed envelope. In order to encourage
the response rate, reminders were sent out at two and four
weeks after the survey was sent (Salant and Dilman, 1994).
Return of the anonymous surveys by the respondents was
considered as their consent to take part in the study. To
ensure the privacy and condentiality of the respondents,
no identifying information was kept or recorded by the
researchers. No incentive was provided for participating
in the survey.
Frequency Percentage
Data analysis
Numerical data were entered into the SPSS 18.0 and analysed to generate descriptive statistics such as frequencies
and percentages. The answers given to open-ended questions were categorized following the content analysis process described by Liamputtong (2009: 281). Firstly, all
responses to open-ended questions were read entirely to
gain an understanding of their meaning. Codes were then
assigned to all answers for each question by the rst
author. These codes were then grouped together into categories and the replies for each code and category were then
counted (Liamputtong, 2009). However, to prevent bias,
an audit trail was performed by the third author to ensure
the coding and categorizing was accurate. Where discrepancies arose, the responses to the open-ended questions
were referred to in order to ascertain the correct coding
and categorizing.
Results
Response rates
A total of 78 respondents returned their survey during the
3-month data collection period. However, 26 were
excluded, because they indicated that they had never
worked with children with ASD. These 26 negative
responses were excluded from the survey sample total of
362, making the valid response rate 15.5% for a total of
52 respondents. According to Weisberg et al. (1996), the
response rate for postal surveys tends to fall between 10%
and 50%. The response rate for this study is at the lower
end of this range. Due to the limitations of the MOTA
database, we cannot be sure if this is a valid response rate
representative of Malaysian occupational therapists who
have worked with children and adolescents with ASD.
Interventions
The six interventions/programmes indicated as being
often and always used were: (1) play therapy (86.6%);
Kadar et al.
37
reported that they always worked with parents/caregivers, 51% reported they sometimes worked with teachers/education sta, and 38% reported they worked with
speech therapists/speech pathologists. Furthermore, the
majority of the respondents felt moderately condent
when working with children and adolescents with ASD
(59.6%), 38.3% felt high or very high condence, and
2.1% felt low condence.
Professional development
Training/certification/continuing education courses either
attended or listed as desirable to attend. The three most
frequently attended courses for professional development
related to the provision of services for children and adolescents with ASD were:
1. sensory-based interventions/trainings (n 12);
2. knowledge/understanding about ASD (n 9); and
3. behavioural skills training (n 4).
Discussion
Descriptions of the occupational therapy
practices in Malaysia with children and
adolescents with ASD
The fact that the majority of the respondents in this study
worked in hospital-based settings is consistent with the
statement made by Muthuraman Sellathurai Pathar, the
President of the Malaysian Occupational Therapy
Association (2011, personal communication). The data
gathered in this study were largely from respondents
who have worked as occupational therapists and with children and adolescents with ASD for less than 5 years.
Most respondents were from Peninsular Malaysia; thus,
generalization of the results obtained in this study to the
practices of all Malaysian occupational therapists working
with children and adolescents with ASD is limited.
38
Low
preferences
(%)
Moderate
preferences
(%)
High
preferences
(%)
Preferred the
most (%)
51
51
51
0.0%
0.0%
2.0%
3.9%
3.9%
0.0%
21.6%
31.4%
21.6%
31.4%
49.0%
49.0%
43.1%
15.7%
27.5%
51
2.0%
3.9%
29.4%
31.4%
33.3%
49
50
50
47
10.2%
6.0%
10.0%
14.9%
30.6%
6.0%
20.0%
14.9%
44.9%
30.0%
38.0%
27.7%
8.2%
50.0%
28.0%
23.4%
6.1%
8.0%
4.0%
19.1%
n number of participants providing rating. In a five-point Likert scale: 1 (not preferred), 2 (low preference), 3 (moderate), 4 (high preference),
and 5 (preferred the most).
Further study is needed in order to get a more representative description of the occupational therapy practices
in Malaysia with children and adolescents with ASD.
Similar to the ndings from Ashburner et al. (2010,
unpublished report), Kadar et al. (2012), and Watling
et al. (1999a), respondents from Malaysia also reported
the use of theories, assessments, and interventions associated with sensory-based approaches for children and
adolescents with ASD. These are evident in the high
reported use of the sensory integration FOR (Kimball,
1999) to guide their practice and also in the choice of sensory integration training (Kimball, 1999) and sensorimotor stimulation (Huebner and Lane, 2001) in their
interventions. However, this is quite concerning as, while
none of the respondents in this study reported that they
have received specialized training or are certied in sensory integration, some of them are using sensory integration intervention approaches in their services for children
and adolescents with ASD. Unlike users of sensory-based
stimulation, therapists who want to provide sensory integration therapy should undergo extensive training and be
certied in that therapy.
It is interesting to note that, besides assessments and
interventions based on sensory integration and sensorybased stimulations, the majority of respondents also
indicated performing activities of daily living skills assessments, developmental screenings and evaluations, and
gross or ne motor skills assessments. This is an encouraging result to see, especially the fact that 76.9% of the
respondents stated that they performed activities of daily
living skills assessments in their practices with children and
adolescents with ASD. According to Green et al. (2009),
motor impairments are found to be common in children
with ASD, which might explain why the majority of the
respondents reported performing gross or ne motor skill
assessments in their services for children with ASD.
Occupational therapists perspectives on occupationbased practice can be varied (Estes and Pierce, 2012;
Mullersdorf and Ivarsson, 2011); however, interventions
based on daily occupation in order to achieve independence, such as self-care activities, should be the main focus
Kadar et al.
39
Key findings
. Occupational therapy practices in Malaysia for children
and adolescents with ASD highly utilized sensory integration therapy and sensory-based approaches in their theories, assessments, and interventions.
. An encouraging percentage of participants performed the
interventions of daily living skills in their service for children with ASD.
Acknowledgements
We would like to extend our gratitude to the occupational therapists
in Malaysia who were willing to spend their valuable time in completing the questionnaire. We would also like to thank the Malaysia
Occupational Therapy Association (MOTA) for its help in assisting with the addresses for mailing the survey to its members.
Furthermore, we would like to acknowledge Dr Jill Ashburner for
freely sharing her information on a survey of current practices, training, and professional development needs of occupational therapists who
provide services to people with autism spectrum disorder (Ashburner
et al., 2010, unpublished report) and for her generous help.
Funding
This research received no specic grant support from any funding
agency in the public, commercial, or not-for-prot sectors.
Conclusion
This is the rst published study reporting on the occupational therapy practices in Malaysia with children and
adolescents with ASD. Regardless of dierences in cultural, educational, and health care systems, results from
this study illustrate similarities in occupational therapy
References
Allik H, Larsson J-O and Smedje H (2006) Sleep patterns of
school-age children with Asperger syndrome or highfunctioning autism. Journal of Autism and Developmental
Disorders 36(5): 585595.
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Kadar et al.
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