Autism Spectrum Disorder and Physiotherapy A Motor Connection?

1. Autism Spectrum Disorderand PhysiotherapyA Motor Connection? Robyn Smith Department of Physiotherapy University of Free State 2012

2. 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

4. Causes of autism • Epigenetic – disorder has a strong genetic link. • Abnormalities of chromosome 5have 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”

5. 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

6. NB!! What is autism? A complex neurodevelopmental disorder, that is present from early on in life

7. 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)

9. ASD Rett Syndrome Asperger’s syndrome ASD spectrum Children usually more verbal • Affects mainly girls • Initially develop normally • Reversal of development or stagnation • Loss language and hand skills • Caused by spontaneous mutation of defect in the 2 (MeCP2) gene

10. Physiotherapy in the dark about ASD? Look at the definition of ASD physiotherapy does not seem relevant in treatment thereof 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 IMPAIRED MOTOR DEVELOPMENT?

11. 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...... thetime arrived physiotherapists start solving the puzzle of their role in treatment of ASD

12. Developmental Disorder So is ASD a relevant concern for physiotherapists involved in early intervention services? IS MOTOR SYSTEM INVOLEMENT Significant rise in incidence Prevalence of 1 in 110 children Front line practitioner status Interdisciplinary approach to early intervention services

13. 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

14. Providing perspective on the movement disorder aspect of ASD • 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) Delayed milestone acquisition occurs in approximately 30% Approximately 39% children with ASD have low muscle tone (Ewell, 2011)

15. Why the need to be able to move? “I like to move it, move itI like to move it, move itYah I like to Move it“ King Julien Madagascar the movie DreamWorks ®

16. The need to move it, move it.... • The ability to moveand 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

17. 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

18. 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)

19. 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 (Petruset al. 2008 ; Redlich, 2010)

20. 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)

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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)

27. Looking at ASD from an ICF perspective..... iinInfluence of personal & environmental factors are important in ASD

28. Do all children with ASD require physiotherapy? Definitely NOT

29. So what exactly is the role of Physiotherapy in children with ASD?

30. 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

31. 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

32. Physiotherapy focuses on addressing the underlying problems , not simply symptoms ..... not aiming at developing splinter skills Aim is to help lay the foundationsfor the development of gross motor skills to support participation in the community and with their peers

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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 interpretation of information provided by sensory systems needed for the execution of complex motor tasks is deficient

39. 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 children in organising sensory information Help them find a path through an activity

40. 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)

41. 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; Petruset al.2008)

42. 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; Petruset al., 2008) Sparked interest use of physical activity and exercise as an intervention strategy for stereotypical behaviour in ASD

43. 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.)

44. 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)

45. 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

46. 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)

47. 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)

48. Parting thoughts..... • Physiotherapy intervention is indicated for children with ASD who have definite motor delays/deficitsand 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

49. 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

50. 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