Autism Spectrum Disorder

and Physiotherapy

A Motor Connection?

Robyn Smith
Department of Physiotherapy
University of Free State
2012
 How common is Autism?
• Autism is on the increase
• Incidence 1/110 children Statistics are of concern

• Boys: 1/70

Autism is not going away and is going to have a huge

impact on society in future years
 Causes of autism
• Epigenetic – disorder has a strong genetic link.
• Abnormalities of chromosome 5 have now been linked to
an increased risk for autism
Strong familial genetic disposition with one autistic child
has a 1/20 chance of having another, one twin is autistic
90% chance other is

• Has been linked to the mercury preservative in the

measles-mumps & rubella vaccination may be
contributing factor. No evidence to support this theory.

• ???? environmental factors e.g. endocrine disrupting

chemicals found in plastic items “Extreme Male Theory”
 Autism Awareness
• Little known about autism to date!!!

• Challenges faced by parent and health care professionals:

• Lack of awareness (World Autism day 2 April)

• Lack of treatment facilities
• Lack of trained professional persons to help autistic
children,

burden often falls solely on parents

 NB!! What is autism?

A complex neurodevelopmental disorder,

that is present from early on in life
 Defining Autism Spectrum Disorder (ASD)
• ASD encompasses a variety of developmental disorders

• NB !!! 3 key features in common:

Impaired socialisation
Impaired communication
Repetitive patterns of behavior

• ASD is “spectrum disorders”

affects each child differently
severity of the symptoms can range from mild to severe
children with ASD’s development is often uneven with areas of strengths and
weakness

(Centre for Disease Control and Prevention, 2011; Petrus, Adamson, Block, Einarson, Sharifield &
Harris, 2008)
 ASD
Rett Syndrome Asperger’s syndrome
• Affects mainly girls • ASD spectrum
• Initially develop normally • Children usually more
• Reversal of development or verbal
stagnation
• Loss language and hand
skills
• Caused by spontaneous
mutation of defect in the 2
(MeCP2) gene
Physiotherapy in the dark about ASD?
Look at the definition of ASD
physiotherapy does not seem relevant
in treatment thereof
IMPAIRED MOTOR
DEVELOPMENT?
Physiotherapy seems to overlook ASD

 ASD is not discussed as an entity in

physiotherapy textbooks

 ASD to date is rarely addressed in the

physiotherapy training curriculums in South
Africa
 THE reality is ..... we are seeing more and
more children being referred to our early
intervention services with ASD

The question is ..... do we know enough about

ASD to know what to assess, or how to
intervene in these children

The facts are...... the time arrived

physiotherapists start solving the puzzle of
their role in treatment of ASD
 So is ASD a relevant concern for
physiotherapists involved in early
intervention services?

Developmental
Disorder
IS MOTOR SYSTEM INVOLEMENT

Significant rise in incidence

Prevalence of 1 in 110 children
Front line practitioner status
Interdisciplinary approach to early intervention services
 What do we know about the type of
developmental challenges children with ASD
face?

• Impaired communication
• Impaired socialilisation
• Behavioural problems

DELAYED
AQUISITION OF
MOTOR SKILLS
 Providing perspective on the movement
disorder aspect of ASD

Delayed milestone acquisition

occurs in approximately 30%

Approximately 39% children with

ASD have low muscle tone
(Ewell, 2011)

• The motor symptoms and neurological underpinning

thereof are still poorly understood (Wilson, 2011)

• Few studies have been done to date about the motor

development in children with Autism ( Baranek, 2002)
Why the need to be able
to move?

“I like to move it, move it

I like to move it, move it
Yah I like to Move it“

King Julien
Madagascar the movie
DreamWorks ®
 The need to move it, move it....
• The ability to move and interact with our
environment is critical to our ability to develop
skills - be it social, emotional, cognitive, or physical

• During the foundation years motor skills provide an

important vehicle for learning these skills
 The need to move it, move it....
• As a child grows the complexity of movement
sequences becomes more sophisticated.

In children with ASD early motor deficits fly

under the radar , but become more obvious as
the demands on the motor system become
higher

 Coordinating components complex tasks

 Copying motor activities
 Playing imaginative games e.g. hide and seek,
musical chairs
 The need to move it, move it....
• Lack of motor skills and abilities impact on the child’s ability to
participate in the family and community activities including

 self-care tasks
 play
 education/schooling

(Redlich, J. 2010; Baranek, 2002; Autism & Oughtisms, 2011)

 Understanding why physiotherapy is often
overlooked as a treatment option for children with ASD

In the light of the significance of the child other

difficulties relating communication, behaviour and
sensory modulation, the child’s motor difficulties are
completely overshadowed

........ often unintentionally overlooked

(Petrus et al. 2008 ; Redlich, 2010)

 Movement as a tool:
learning through our strengths

• Even in the face of motor difficulties ,in most

of children with ASD the ability to move is a
definite strength

• Through physiotherapy movement can be

used as a vehicle for learning, be a way
to have fun and engage these children
(Redlich, 2010)
 Physiotherapy and ASD: the motor
connection
• Many children with ASD need help with motor
skills and would benefit significantly from
receiving physiotherapy.

• Appropriate assessment to
identify such deficits as part
of the interdisciplinary approach
to ASD is paramount
How can I identify if a child is at risk for or
possibly has ASD during my
developmental assessment ?
• Front line practitioners

• Autism screening tools/questionnaires

–The Modified Checklist for Autism in Toddlers M-
CHAT (Robins, Fein, & Barton, 1999) or the CHAT-23
questionnaire

• Physiotherapists familiar with key clinical features of

autism and refer to paediatrician
 M-CHAT (Robins, Fein & Barton, 1999)
• Standardised questionnaire
• Considered valid and reliable as a screener
• 87% accurate in identifying a child with Autism
• Can be used in toddlers between ages of 16 -30 months
• 23 questions with yes/no answers
• Can be used as part of your developmental assessment
• Fail if a child has more than 3 items or 2 critical items as
“No” answers
 Critical questions in the M-CHAT
(Robins, Fein & Barton, 1999)
• Does your child take an interest in other children?
• Does your child look you in the eye?
• Does your child point to ask for something?
• Does your child smile in response to your face or your smile?
• Does your child respond to his/her name when called?
• Have you ever wondered if your child is deaf?
• Does your child sometimes stare at nothing or wander with
no purpose?
• Does your child walk?
• Does your child make unusual finger movements near his/her
face?
• Can your child play properly with toys without mouthing
 Developmental Assessment .... neuromotor
focus
• Objective measures to evaluate developmental status :
• Bayley Scales of Infant Development III
• Movement ABC
• Bruininks-Oseretsky test of motor proficiency
(Wilson, 2011)

• Neuromusculoskeletal assessment to included:

• Muscle tone
• Muscle strength
• Joint mobility
• Soft tissue mobility
• Neural mobility
 Child with ASD may benefit from
Physiotherapy if the following indicators
are found ion assessment
• Delay in attaining motor milestones
• Underlying low muscle tone
• Poor balance, coordination and posture
• Problems with motor planning impairment
• Underlying muscle weakness
• Increased neuromusculoskeletal stiffness
• Pain

(Wilson, 2011; National Autism Association, 2011; Ratliffe,1998)

 Looking at ASD from an
ICF perspective.....

Activity/skill limitation Participation limitation

Does not attain milestones

Clumsy gait or toe walking
within predicted age norm

Repetitive winging or rocking Decreased participation in self

movements care activities

Difficulty with playground activities climbing, swinging, Decreased participation in play

hanging, hopping, skipping, walking on a beam and recreational activities

Difficulty with drinking from a cup, dressing oneself,

brushing teeth
iinInfluence of personal &
Keeping bumping into items environmental factors are
and falls a lot important in ASD
Do all children with ASD require
physiotherapy?

Definitely
NOT
 So what exactly is the role of
Physiotherapy in children with ASD?
 Sensory integration difficulties
• Children with ASD may have profound sensory
processing problems

• Hyper-sensitive or under-sensitive resulting in

distorted processing of information from the
environment
Sensory processing
problems negatively
impact on the child’s
ability to develop motor
skills and reach
milestones
Considerations during physiotherapy....

Often the sensory difficulties need

to be addressed first before the
motor difficulties can be addressed

Therapy environment needs to be

“spectrum friendly” OT
 Physiotherapy focuses on
addressing the underlying
problems , not simply
symptoms ..... not aiming at
developing splinter skills

Aim is to help lay the foundations for the

development of gross motor skills
to support participation in the community
and with their peers
 1. Addressing low postural tone
• Physiotherapy and sensorimotor handling techniques
(NDT) can help stabilise postural tone.

• Value of NDT as treatment option

in children with ASD is poorly
researched to date and is still much debated
2. Underlying muscle weakness
affecting postural control and stability
• Weakness can be addressed by means of
functional strengthening, weight training and
other age appropriate activities addressing
core muscle groups
 3. Tight soft tissue structures and joint
stiffness
• Physiotherapy soft tissue techniques and stretching can assist
in lengthening tight soft tissue structures

• Joint mobilisation techniques e.g. OMT can be used to

mobilise stiff joints
 4. Develop the ability to do typical child
activities
• Encourage and facilitate typical activities or skills relevant
to the child’s age e.g. walking, running, jumping, skipping

• Typical age appropriate games e.g. hop-skotch, running

race and clambering

• Roughhousing on mat e.g. pillow fight, playful wrestling

on mat

• Ball activities e.g. soccer, tennis

 5. Improve balance and coordination
• Physiotherapists can assist the child in
improving their static and dynamic balance
by strengthening core stabilisers and
addressing low postural tone.

• Specific goal directed activities will also

help the child to improve their
proprioception and balance

• Activities e.g. walking on a line or beam,

standing on one leg, jumping, skipping,
balance board activities
 6. Develop motor planning skills
• Child with ASD often battles to time, sequence and
execute complex movements or motor tasks.

• Researchers still unsure of the nature of the motor

planning problems

? the plan itself defective or

? the plan itself defective or
interpretation of information
interpretation of information
provided by sensory systems
provided by sensory systems
needed for the execution of
needed for the execution of
complex motor tasks is
complex motor tasks is
deficient
deficient
 6. Develop motor planning skills
• Physiotherapy help the child in
developing motor planning skills

• The use of obstacle courses are

wonderful teaching tools to help a
child with ASD to follow multiple
step directions and develop
planning skills

• Activities like these also help Help them find a path

children in organising sensory through an activity
information
7. Motivate and encourage an active lifestyle

Compared to their peers children with ASD tend to

be less active and are more inclined to being
overweight

• Children with ASD prefer sedentary pursuits e.g. computer games, TV

• Only 20% of children with ASD exercise regularly according to parent

reports (Wilson, 2011)
 7. Motivate and encourage an active lifestyle

• Benefits of formal and informal exercise or

sport in children with ASD include:

– improved cardiovascular fitness and endurance,

– weight control,
– improved attentiveness,
– improved self-esteem and increased peer
interaction,
– reduced self stimulating behaviours,
– help deal with the frustration and sensory
difficulties.
(Baranek, 2008; Wilson, 2011 ; Hawthorne, 2011;
Petrus et al.2008)
Value of aerobic exercise in Autistic children

• It is suggested that aerobic exercise physiologically modulates

stereotypical behaviour through the release of specific
neurotransmitters in the brain (Baranek, 2008; Petrus et al., 2008)

Sparked interest use of physical activity and

exercise as an intervention strategy for
stereotypical behaviour in ASD
Use of physical activity to improve behaviour
in children with autism
• Exercise should be incorporated in the child and family’s
routine

• Children may initially have difficulty in coping with and exercise

programme -one needs to identify and modify personal and
environmental barriers to participation.

• Suggested activities include running, trampolining, martial arts,

cycling, swimming (hydrotherapy) , ball activities, therapeutic
horse riding. (Wilson, 2011; O’ Connor, French, & Henderson, 2000.)
Use of physical activity to improve behaviour
in children with autism
• Research on the value of exercise in improving behaviour in
children with ASD is limited to date (Wilson, 2011; O’ Connor, French, &
Henderson, 2000)
 Considerations during physiotherapy....

• Therapy sessions must be structured

• Need to teach child a route through activities,

break down a task or activities into manageable components

• Make use of goals directed activities

• Make use of aspects that motivate the child or are of interest.

One can make use of their obsessions for positive gains here.

• Keep instructions simple, talk clearly. Child must focus on you

when giving instructions, look you in the eye
 Considerations during physiotherapy....

• Be patient and give child a chance to respond

• Be aware of how the child behaves when faced with

change, and develop ways of handling this
behaviour

• Encourage verbal and other appropriate responses

from the child

• Try and involve the child in social interactions

(Ratliffe,1998; Redlich, 2010; Ewell, 2011 )

 The role of physiotherapy in the
management of ASD is currently
poorly researched and described
????????????

Opinions regarding the role of

physiotherapy in the management of
children with ASD remain
contradictory (Baranek, 2008)
 Parting thoughts.....
• Physiotherapy intervention is indicated for children with ASD
who have definite motor delays/deficits and low muscle tone.

• Not every child with ASD requires physiotherapy .... But

screening is essential in order to identify problems

• Physical activity and play should be encouraged for all young

children with ASD and their families

• More research is needed regarding the value of physiotherapy

intervention in this specific population
Some educational aspects to use...
• Try and teach child to concentrate -go back to basics .
• Break tasks down into its simplest components to limit
anxiety and stress
• Tell them when an activity starts and when it is over
• Social stories often help
• Visual timetable –breakdown of activities and must run
in order
• Objects of reference
• First and then boards
• Zoning of areas
• Communication books, boards and devices
 Occupational therapy
• Address sensory integration problems
• Cognitive stimulation very important
• Perceptual activities

SENSORY ISSUES !!!!

• Deep pressure and brushing with a soft brush often work well to calm
children down
• “Bear Hug”
• Unrolling ear
• Blowing things e.g. Whistle, bubbles etc
 Medication
• Various medications can be used in the treatment of
Autism

• Mood stabilising medications e.g. Tegretol, Lithium

• Antipsychotic medications e.g. Risperdal
• Antidepressant and anti-anxiety medications e.g.
Prozac
• Stimulant medications for ADHD e.g. Ritalin
• Non Stimulant medications for ADHD e.g. Strattera
THANK
YOU
 References
• Adams, JB; Edelson, SM; Grandin, T & Rimland, B. 2004. Advice for parents of
young autistic children. Working paper.

• forgotten physical impact of autism. Available online at;

http://autismandoughtisms.wordpress.com

• Baranek, GT. 2008. Efficacy of sensory and motor interventions for children with
autism. Journal of Autism and Developmental disorders. Vol. 32 (5)October 2003
pp 397-422

• Centre for Disease Control and Prevention. USA . 2011. Autism Spectrum Disorder
(ASD) Available online at: http://www.cdc.gov/ncbddd/autism/index.html

• Downing, PG. 2010. Physical therapy can benefit some children with autism. 18
July 2010, Brownsville Herald
 References
• Ewell, V. 2011. Physical therapy for Autistic Children. Healthmango.
available online at:
http://www.healthmango.com/autism/physical-therapy-for-autistic-ch
ildren/

• Hawthorne, D. 2011. Autism and exercise. Autism today. Available

online at http://www.autismtoday.com/articles/autism_excercise.htm

• Ming, X; Brimacombe, M & Wagner, GC. 2006. Prevalence of motor

impairment in autism. Brain and Development, Vol.29, Issue 9,
October 2007 pp 565-570

• O’ Connor, J; French, J & Henderson, H. 2000. Use of physical activity

to improve behaviour in autism. Palaestra. Summer 200o Vol. 16 nr. 3
 References
• Petrus, C; Adamson,R; Block, L; Einarson, SJ; Sharifnejad, M &
Harris,SR. 2008. Effects of exercise intervention on stereotypic
behaviours in children with Autism Spectrum Disorder. Physiother
Can 2008:60; 134-145

• Ratliffe, KT (ed) . 1998. Sensory processing and cognitive disorders in

childhood in clinical Paediatric Physical Therapy. A guide for the
Physical Therapy Team pp324-327

• Redlich, J. 2010. Autism Spectrum Disorders and Physical therapy:

The motor connection. Austism spectrum, winter 2005

• Redlich, J. 2010. Movement as a tool. How can we learn through our

strengths. Our journey thru Autism
 References
• Wilson, CA. 2011. The role of physical therapy for individuals
with autism Spectrum Disorders

• Smith, R. 2011. Children with Developmental Coordination

Disorder. Physiotherapy Department, UFS, lecture notes
(unpublished)

• Images courtesy of Google images, 2011

• Madagascar characters images (DreamWorks) courtesy of Google

images, 2011