Transcript Autistic Spectrum Disorder Does Physiotherapy have a role

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
• 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
Asperger’s syndrome
• ASD spectrum
• Children usually more
verbal
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?
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)
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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)
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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:
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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
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Delay in attaining motor milestones
Underlying low muscle tone
Poor balance, coordination and posture
Problems with motor planning
Underlying muscle weakness
Increased neuromusculoskeletal stiffness
Pain
impairment
(Wilson, 2011; National Autism Association, 2011; Ratliffe,1998)
Looking at ASD from an
ICF perspective.....
Activity/skill limitation
Participation limitation
Clumsy gait or toe walking
Does not attain milestones
within predicted age norm
Repetitive winging or rocking
movements
Decreased participation in self
care activities
Difficulty with playground activities climbing, swinging,
hanging, hopping, skipping, walking on a beam
Decreased participation in play
and recreational activities
Difficulty with drinking from a cup, dressing oneself,
brushing teeth
Keeping bumping into items
and falls a lot
iinInfluence of personal &
environmental factors are
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
interpretation of information
provided by sensory systems
needed for the execution of
complex motor tasks is
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
children in organising sensory
information
Help them find a path
through an activity
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/physicaltherapy-for-autistic-children/
• 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