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- Dr.Joni Redlich PT,DPT
Originally published in Autism Spectrum, Winter 2005
Movement is an integral part of our social, emotional, and physical lives. A 4-month old excitedly kicks her arms and legs in response to the funny face dad makes, so he does it again. An 8-month old will crawl to retrieve her favorite rattle, shake it to hear the sound it makes, and then look at mom to share the experience with her. An 18 month-old takes moms hand, walks her to the kitchen, and says “juice” while pointing to the refrigerator. As a child grows, the length and complexity of movement sequences become more sophisticated.
Children with autism spectrum disorder (ASD) often cannot coordinate the myriad of movements needed to complete these interactions. Although children with ASD are often not diagnosed until they are far out of infancy, studies of home videos of children later diagnosed with ASD showed motor differences that had been undetected as infants (Teitlebaum 1998, Teitlebaum 2004).
Motor differences are often due to motor planning challenges, sensory processing differences, atypical reflex development and underlying decreased tone. Motor planning challenges make it difficult for a child to time, sequence, and execute a movement, such as reaching for an object, crawling towards mom, or activating a toy. Sensory processing differences often cause children with ASD to take in misinformation from the environment. The child may be over or under sensitive to smell, sight, sound, touch, or movement. Low tone, or decreased stiffness of the muscles, requires the child to use more energy to move, can delay motor development, and further alters the sensory feedback a child receives during movement. The child with ASD will learn to roll, crawl, and walk, but the quality of their movements may be poor. As the child gets older, they may struggle to function at more sophisticated levels when they have not mastered these core skills. As a result of differences during development, children with ASD often have deficits in equilibrium and righting reactions (moving the body to maintain an upright position), protective reactions (putting a hand out to catch yourself when falling), and movement strategies (persistent w-sitting). These differences may present as clumsiness, lack of coordination, lack of attention, hyperactivity, gross motor skill delay, flat feet, toe-walking, postural instability, poor posture, decreased respiratory control, oral motor difficulty, and flexibility restrictions (Ghaziuddin & Butler, Gillberg, Kohen-Raz et al., Hallet et al., Vilensky et al.).
During a Physical Therapy Evaluation a child’s neuromuscular, musculoskeletal, and cardiopulmonary systems are assessed. The therapist will look closely at a child’s ability to take in sensory input and control motor output. They will assess the facilitating and limiting factors for different gross motor skills, such as walking, jumping, running, stair climbing, and kicking a ball. Through play, the therapist can observe how a child uses his balance reactions, protective reactions, and motor planning skills, and the strategies that the child implements to move in and out of different positions. The therapist also observes the child’s posture in a variety of positions, and how the child’s posture affects their breath control, oral motor control, and vocalizations. The therapist will analyze which muscle groups are being overused and which muscle groups are being underused. Joint range of motion, especially for overused muscle groups, such as the calf muscles for children who persistently walk on their toes, is measured. Joint laxity is also assessed, especially for overstretched joints, such as for flat feet or for a child who often locks their knees and elbows.
During a Physical Therapy Treatment a child may work to:
- Improve postural control to increase stability during fine motor, gross motor, and self-care activities.
- Improve static balance to improve motor control and attention and decrease impulsivity.
- Learn to perform the ideation, sequencing, timing and execution components of motor planning.
- Maximize sensory processing and organization skills to put into controlled motor skills.
- Lay down the foundations of gross motor skills to support participation in community and peer activities.
In addition, Physical Therapists will work with children and their parents to help the child to develop an active lifestyle. Exercise is important both for health and for self-image, such as keeping up with peers in gym class or in sports activities. In addition, aerobic exercise can decrease behavior problems and an active lifestyle will naturally give a child more sensory input.
To conclude, children of all ages learn through movement and need to master core motor skills in order to maximize their overall potential. Beginning as infants we develop stability so that we can learn to use our hands and feet independently from the rest of the body. We also learn how to manipulate the environment and how to move our bodies within it. We use movement to bond and communicate with others and to explore our world. Limitations in motor skills can lead to difficulty with all areas of development. Physical Therapy can be a beneficial part of a team approach to help children with ASD to be as successful and independent as possible in school, home and in the community.
References:
Intellect Disabil Res 42 (Pt1): 43-8. Gillberg, C. (1998). “Hyperactivity, inattention and motor control problems: prevalence, comorbidity and background factors.” Folia Phoniatr Logop 50(3): 107-17.
Hallet, M., M.K. Lebiedowski, et al. (1993). “Locomotion of autistic adults.” Arch Neurol 50(2): 1304-8.
Kohen-Raz, R., F. R. Volkmar, et al. (1992). “Postural control in children with autism.” J Autism Dev Disord 22(3): 419-32.
Teitelbaum, O., Benton, T., Shah P.K., Prine, A., Kelly, J.L., Teitelbaum, P. (2004). “Eshkol-Wachman movement notation in diagnosis: The early detection of Asperger’s syndrome.” PNAS; 101(32): 11909-11914.
Teitelbaum, P., Teitlebaum, O., Nye J., Fryman, J., & Maurer, R.G. (1998). “Movement analysis in infancy may be useful for early diagnosis of autism.” PNAS; 95: 13982-13987.
Vilensky, J.A., A.R. Damasio, et al. (1981). “Gait disturbances in patients with autistic behavior: a preliminary study.” Arch Neurol 38(10): 646-9.
Great information! It seems that so much of the time children with ASD qualify for OT, but many times not PT. Such has been the case with my son who could absolutely benefit from PT.
Thanks for the comment! Unfortunately it seems that is often the case. While OT has an important part to play on the treatment team for kids with ASD, PT is an often overlooked piece of the puzzle.
Agreed – very nice synopsis, Joni. I’ve said the same, but here and there and all over my blog. Trying for parents to get the idea that it is the ‘heavy work’ (always prescribed with the other sensory techniques) that is making the difference in their children.
Thanks Barbara!
i want to add that physical therapy can improve balance and coordination !
Great stuff! I work with several kids on the ADS spectrum during the winter months at a ski resort here in the Hudson Valley, NY. The physical and emotional skills these students have gained through the challenges on the ski slope is totally amazing. An uplifting experience for ALL. Gordie Pine, Adaptive ski instructor, Hunter Mtn.
Thank you do much for sharing that. If you would be interested in posting a short article about your experiences I would love to post it. Spread the word about such a great program!
Many parents expect others to provide what they themselves need to be providing – interaction with the child. The most important thing for a young autistic child is to have interactive play with the parents on a consistent daily basis. One or two sessions a week in the home setting will be of little benefit without the parent’s continual physical activities/play with the child.
Many parents need guidance in how to play with their child who is on the spectrum. As therapists our goals aren’t to “fix” things in an hour or two a week during our sessions, but to set the groundwork for the parent to follow through. Gross motor play is a fantastic tool to improve engagement and interaction between parents and children with autism. Coaching them to take advantage of this is where the therapist’s role comes into play.
Thank you so much for sharing this article and all of its very important information. As you point out, movement is such an integral part of learning – from day one. And, although we strive to remind parents to include movement in their child’s early years, the special movement needs of children on the spectrum – before they are diagnosed – are not recognized and the children struggle with learning many gross and fine motor skills. As you indicated in one of your replies, Physical Therapists have much to offer and are often not called in to address these needs, in conjunction with Occupational Therapy. Thank you for giving us something to share with parents and other therapists to move us out of that box and into a more collaborative team.