Scoring a young person with ASD and intellectual impairment
Question:
The client completed 3 consecutive running stitches but didn’t identify that the stitches were not tight on either the front or back.
Response:
They don’t have to get the tension correct to score the running stitch. This equates to a score of 3.4.
Question:
When I asked him if it was like mine he said ‘yes’; I further prompted him and instead of pulling it tight he went to undo all the stitches. I prompted him to tighten them without undoing, which he did.
Response:
You do not prompt people to correct a stitch. The manual states: (I am quoting the new manual here) If the person makes errors such as a stitch over the edge of the tool, skipping a hole, going in the wrong direction using wrong lace going in and out of the same hole or completing the stitches in a different section of the tool, note behaviour and allow person time to recognise and correct errors. DO NOT PROMPT the person to recognise or correct an error.
Question:
On the whipstitch he did one correct but then changed to the running stitch. He wasn’t able to correct himself, I gave him another demonstration and he attempted it but got tangled up at the back and wasn’t able to undo it himself.
Response:
If the person can do one stitch going over the edge of the leather from front to back for back to front and cannot find errors, this equates to a score of 3.4 At 3.4 the person will often revert to doing running stitches. We are not scoring errors here of twists and crosses at the back.
Question:
Should I have finished the assessment here or moved on to the cordovan?
Response:
You should technically keep going as long as the client will tolerate. Respect a decline to continue and score at that point. Use your clinical judgement to offer to cease the assessment. I usually find that I stop at the whip stitch if the person has difficulty with the running stitch and cannot do the whip stitch. Did you do the cross-in-back and twist errors? I suspect he would not have corrected these but this is often a good place to stop. It would be reasonable to observe that he did not recognise the tangled mess at the back as an error and that he wasn’t recognising and correcting twist errors as he went. However, when you insert the errors according to the protocol, it gives you more observations to report on and to confirm your clinical judgement.
Question:
I introduced the cordovan; he was able to do the first step but then not complete the second and then passed it back to me after a few attempts. I was going between 3.4 and 3.6. Is this correct?
Response:
To score 3.6 the person needs to do at least 2 whipstitches in consecutive holes going from front to back. They should recognise errors on the front of the leather. They will not look for mistakes on the back. They should stop before filling up all the holes or using all the lace.
Question:
My hesitation came from the descriptors around function not necessarily matching his overall performance. I have all of the books, but struggling to get started. Can you guide me here please on how to accurately score him?
Response:
The screen is considered to be highly accurate within one Level.Mode. You need to consider scores one n=mode above and below the screen score. If the person’s occupational function reflects abilities predicted at a mode above or below, that is their VALIDATED ALLEN COGNITIVE LEVEL.MODE
ASD and a score of 5.8 or under
Question:
I received a query from a mental health OT about a client with ASD that she assessed:
Description of client’s performance:
The person was able to complete 3 single cordovan stitches without a demonstration or trial and error. He was observed to do the stitch in an awkward way but none the less brought the needle to the front of the leather, pushed needle through the next hole from front to back, left the lace a little tight ( no loop) then awkwardly, from a strange angle, brought lace to the front and went through the “loop” keeping the lace to the left - but was holding the leather up and looking from behind . I don’t know how he did (as very hard to keep it to the left at that angle) but repeated it 3 times the same way and didn’t need to pull it tight due to no loop; repeated 3 stitches the same way quickly using the same method – they were a little loose but not too bad. I then showed him a demo (to see if he could follow instructions and do all the steps) - he repeated all steps correct including loop and did it the same way I demonstrated (e.g. angle – he held it at the front) except missed the tightening sequence. He said he forgot what came next – prompted to tighten and got it right three times. In the whip stitch he was not able to untwist in situ – he said he could not figure it out – I prompted him to loosen it a little and then did it. I feel he takes the meaning of instruction “You need to leave the lace in,” too literally i.e., can loosen it. In the Running, his stitches were loose.
Would the person be rated at 5.8 or lower?
Response:
Assessing neurodivergent people is always interesting. We could really use some studies to help us interpret what we are seeing. Neurodivergent people approach tasks in a different way to neurotypicals. They often have focal deficits in their executive functions, auditory processing difficulties, low muscle tone, among other things. With neurotypicals, I always suggest assessing global cognition first before looking for focal deficits, but for neurodivergent people, you have to observe for both during the ACLS. According to the ACLS manual, you can score this person 5.8, however, I doubt that this accurately reflects his functional cognitive abilities. If his occupational performance does not reflect abilities predicted at Level.Mode5.8, then your approach of providing a demonstration is good.
Neurodivergent people often approach tasks in an intuitive way (or it looks intuitive to a neurotypical). For example, think of the student with exceptional mathematical ability who can consistently get the correct answer to a complex maths problem and can’t explain how they got the answer but has no friends and spends their lunch breaks in the library playing chess with the librarian.
I would normally provide a hint to the person about leaving the loop and not pulling the lace tight. I would offer this hint immediately after he did the first cordovan stitch. The question is, if the person then does 3 correct stitches without further hints or demonstrations, do you score 5.8 or 5.6, or give another hint? My view is that the screen is considered highly accurate within one Level.Mode and so I would use collateral, clinical observation, and/or an ADM to provide a validated score.
‘In the whip stitch he was not able to untwist in situ – he said he could not figure it out - I prompted him to loosen it a little and then did it.’ You should not give a hint here. You can only provide one hint when the person fails to make 3 correct stitches without a hint or demonstration. According to the manual, you would score him 4.2 as he could not untwist without a hint or demonstration. I feel he takes the meaning of instruction ‘You need to leave the lace in,’ too literally i.e. can loosen it.
Concreteness in thinking is common in ASD, especially in people with mild cognitive impairments. You get this concreteness in other people with cognitive deficits as well, but it seems to be more marked in the neurodivergent.
‘In the Running his stitches were loose.’ - This is not reflected in the official scoring.