Discussion on “Does Your Baby Have Autism?” by Teitelbaum and Teitelbaum

As a pediatric physical therapist specializing in developmental disabilities, I have worked with a lot of children with autism spectrum disorders (ASD) over the past 10 years. After several months of physical therapy, I frequently saw how related areas of development, such as communication and social skills, would improve after addressing their motor deficits. I saw most of these children from the ages of 3 and up and have relied on parental reports to describe early development. Parents often reported that their children never crawled and never liked to be on their bellies. Both parent report of atypical development during the first year of life and my observations of motor deficits of the older children with ASD made me question whether motor development could be a missing link in early screenings of children later diagnosed with autism. Thus, it was with keen interest that I approached the reading of Osnat and Dr. Philip Teitelbaum’s book, Does Your Baby Have Autism?.

The Teitelbaum’s present their results from two decades of observation and early detection of autism and Asperger’s syndrome in babies. Foregoing the traditional approach of detection based on language deficits and socialization, this husband and wife team utilized movement analysis based on the Eshkol -Wachman notation system to track atypical movement patterns by watching videos parents made of their infants later diagnosed with autism. The results are intriguing.

The book begins by briefly introducing the reader to the Teitelbaum’s research identifying children with Asperger’s and autism by analyzing videotapes of the children as infants. Explanations of the differences observed are broken up by gross motor skill in each chapter.

Chapter 1 presents a brief history of autism, current diagnosis methods, and treatments. A new way to diagnose autism is then presented. They describe “precursors” that can be observed in young infants and state that “the key to this early recognition is…movement.” “This enables the observant parent to detect the potential for autism long before a child is old enough to socially interact or to start speaking.” The author’s state their goal is early identification and this is also a goal that the mainstream medical community agrees will lead to earlier treatment and better outcomes.

Chapter 2 talks about the symmetry of motor development. The Teitelbaums state that infants should present with equal use of both arms and legs and demonstrate the ability to initially bring their body into the midline, and later begin to cross midline.

This chapter is a good explanation to parents of one of the key things that a physical therapist will look at when evaluating a child for a motor disorder. Children with cerebral palsy affecting one side or a child with a brachial plexus injury will show a preference early on in development of one arm over the other. More mild asymmetries may go unnoticed by a child’s pediatrician during routine visits and therefore no further assessment by a specialist would be done.

In this chapter the researchers go on to provide a description and illustration of Moebius Mouth, a triangular appearance of the upper lip. While it is not presented as a diagnostic observation, the Teitelbaum’s claim that if it lasts several months and there are other areas of concern there is potential that autism will develop. If correct, such a link would have a profound effect on the early detection of autism and thus, this aspect of their findings alone may warrant further research by the autism community.

Chapter 3 reviews developmental reflexes, such as the ATNR (fencing position) and grasp reflex, and the predictable timeline that these reflexes appear and then integrate into the more mature movement system. The authors state that when an infant’s reflexes don’t “appear and fade in a predictable manner… this signals a potential neurological disorder, and possibly, the beginning of autism”.

The presence and integration of reflexes is another area that physical therapists assess when evaluating a child. A lack of reflex integration can indicate a lack of postural development and leads to challenges with head/eye control, coordination, and balance. A lack of reflex integration is commonly seen in children with neurological disorders. For example, a child with cerebral palsy may have an integrated grasp reflex that makes the development of voluntary grasp and release difficult to achieve or a child with developmental coordination disorder might involuntarily move his arms when he turns his head to look at the teacher.

Chapter 4 describes typical motor development, including pushing up on the belly, rolling, sitting, crawling and standing. It sets the stage for the next 4 chapters that break down each milestone to describe motor differences the authors have observed in their research of infants later diagnosed with autism or Asperger’s. It also emphasizes the importance of children achieving each gross motor milestone without skipping one, such as crawling.

As stated earlier, the absence of crawling or crawling with atypical patterns, are frequently reported to me by parents of children with ASD. However, this usually does not lead to greater attention to a child’s motor development by medical professionals, unless other red flags are present.

In chapters 5-8, the authors describe the typical and atypical development of righting (the term they use for rolling back to belly), crawling, sitting and walking.

Of note in Chapter 7 is the “Teitelbaum Tilt Test.” In this test the infant is held upright and slowly tilted 45 degrees to the side. The child is expected to respond by keeping her head upright. They state that an absence of this response is an indicator that autism may later develop.

I found it confusing that the authors chose to take a standard head righting reaction test and name it after themselves. This is not a test unique to the Teitelbaums, although it is being applied for a unique purpose.

Head righting reactions are physiologically connected with the vestibular system of the inner ear, so the authors go on to discuss this system here. The authors state that the vestibular system is a sensory system that is frequently abnormal in children with ASD. An example described in this chapter is how children with ASD can often spin and spin and don’t get dizzy. “Swing therapy” is a method the authors recommend to “stimulate your baby’s sense of balance.” The authors recommend having a child sit on the parent’s lap on an adult swing daily and swing up to an hour or until the child indicates he wants to get off.

It is documented in a multitude of places that children with autism present with differences to their vestibular system. Physical and occupational therapists will often utilize a wide variety of swings and other sensory experiences to help facilitate the development of this system. The author’s suggestion of “swing therapy” is a nice one-size-fits-all approach for parents to try, but there are many ways that a medical professional can help parents to individualize this sensory input for each child depending on their needs.

Chapter 9 presents the major obstacles to parents who have concerns about their child’s development based on the observations recommended in this book. The authors describe a variety of programs available for children with autism and gives options for families wanting to put together a treatment team for their child. They also mention the important role of the pediatrician in ruling out other causes of atypical movement in infants.

Finally, the conclusion summarizes the author’s deviation from looking at social and language deficits in the identification of children with autism to looking at motor development during infancy and empowers parents to be observers of their child’s development and to advocate for their children despite any skepticism that may be encountered along the way.

While it is certainly true that many parents of children with autism and other developmental disorders are the first to notice that something is different about their children, placing the onus of initial analysis and interpretation upon parents is misguided. The task of distinguishing between abnormal motor development and typical variations in development should not and cannot fall alone onto parents. It is up to professionals to listen to parents with an open mind and to look at concerns with a careful eye.

Unfortunately, because this method of screening is based upon small research studies currently outside the mainstream of autism research, the Teitelbaums recommendation that parents report unusual movement patterns to pediatricians is somewhat inadequate. It is quite possible that due to unfamiliarity with the patterns described, most pediatricians, with the exception of developmental pediatricians, will be ill equipped to adequately address the parent’s concerns.

In the author’s research, they found abnormal motor patterns in every child they observed that later was diagnosed with autism or Asperger’s. However, out of a population of typically developing children, many of these patterns can also be observed as a normal variation. More research needs to differentiate which deviations are more important than others or perhaps that a certain number of deviations must be present to cause concern. We don’t want to go too far in either direction- misdiagnosing too many children as “at risk for autism” or ignoring the possibility of earlier identification and treatment for children who later are diagnosed with ASD.

Throughout this book the authors describe many of the components of development observed and tested when physical therapists evaluate infants. Physical therapists are trained to observe and analyze typical and atypical motor development and then to help children with developmental delays to attain new gross motor skills and also to improve the quality of movement. It seemed like a big void in this book to offer exercises to treat the described motor deficits without recognizing that this is the expertise of pediatric physical therapists. Although the role of physical therapy has frequently been overlooked in the past in the care of children with ASD, more therapists, families and physicians are seeing the positive impact physical therapy can have for children with ASD. Early detection based on atypical movement would be an ideal role for physical therapists to collaborate in the early screening process.

The Teitelbaum’s research has opened the door to systematically observe infants behavior and intervene as early as possible. My hope is that more research is done to determine reliability and to help with differential diagnosis between autism, other neurological disabilities and normal variation in development.