Because children generally do not understand the long-term benefits of rehab, they may be less willing to participate in activities than their adult counterparts, thus challenging PTs to find creative ways to engage them in therapy. Add in a condition that damages patients' communication and social skills, however, and simply getting patients involved can be even more difficult than the therapy itself. According to Karen Parr, PT, an independent clinician who's worked with special education teachers in the Orange, CA, area, this is usually the case when therapists treat children with autism.

"Most of these kids have very limited communication skills, and some of them are completely nonverbal and won't respond to directions or even questions," she explained. "And it's very frustrating for parents and also for therapists who don't have a lot of experience with this population."

Fortunately, therapists like Parr can overcome these challenges by making therapy more fun, and by incorporating activities that will motivate their young patients nonverbally. By educating parents or caregivers about activities they can do outside of the clinic to further their patients' progress, PTs can help kids with autism reach higher levels of function.

Effects of Autism
While autism can have a damaging effect on patients' social development, communication and behavior—not to mention motor control and other physical skills—the casual observer usually won't recognize the condition. "People watching these kids run and play may assume there's no problem, because autism is not [visually] obvious," Parr explained. "The [physical] abnormalities these children have—a lack of coordination and body awareness, and gait deviations—are subtle, and many parents won't notice a problem until a therapist points it out."

Among children with autism, these physical issues are typically minor when compared to the much more damaging cognitive effects. Although it's frequently misdiagnosed and considered a "disease," autism is actually a severe form of a group of disorders termed pervasive developmental disorders (PDDs). PDDs do not necessarily cause any physical deficits, but instead are characterized by impairments in social relatedness and communication skills, and by the presence of unusual activities and interests.¹ Attention deficit/hyperactivity disorder (AD/HD) and seizures are also associated with autism.

Because physical issues are secondary to the cognitive issues associated with autism, a pediatrician has typically already diagnosed patients with the disorder before PTs are involved. Parr noted, however, that many patients with autism—particularly very young children—are initially misdiagnosed with other conditions. "A lot of children are diagnosed with 'developmental delays,' but that doesn't tell the therapist much," she explained. "So I'll usually look at the child's gait, motor skills and muscle tone during the evaluation, but I also ask the parents about behavioral issues as part of the patient's history." Communication and social problems, abnormal repetitive movements and resistance to touch, Parr said, are common among this population.

Current research also suggests that autistic children have subtle abnormalities in body movements that can be diagnosed by as early as three months of age. By examining videotapes of babies who were later found to have autism, Dr. Philip Teitelbaum, a psychologist at the University of Florida, Gainesville, found that the infants showed a specific cluster of movement abnormalities when rolling over, sitting up, crawling and walking.² For example, babies with autism tended to crawl on their knees and forearms, rather than the hands, and had difficulty sitting up and rolling over. Although further studies are necessary to confirm these findings, therapists who treat developmentally delayed children may want to ask parents if their children exhibited these symptoms as infants. If so, autism could be the cause.

PTs' Roles in Treatment
While most kids with autism display some physical symptoms, Parr said that PTs' roles with this population are usually limited to tone reduction and work on gross motor skills. "Autism is really a behavioral disorder, and the symptoms are often managed by a physician through medication, or [non-medically] by special education teachers and parents," the PT explained. "When PTs and OTs are involved, it's usually on a short-term basis, to correct poor posture and body mechanics, address any muscle tone issues, and educate [caregivers] on activities they can do at home to help their children."

When hypertonicity is the problem, Parr said, she'll usually use massage to break up tone, or warm water aquatic therapy. Diminished muscle tone usually requires some strengthening, either through functional activities such as work on transfers and balance, or for older children, exercises on standard gym equipment. "Regardless of what you're doing, it's very important to keep [pediatric] therapy fun, especially with autistic children," she added. "Most kids with autism have a lot of trouble following directions, and some are completely unresponsive, so unless you make therapy a game the patient may be reluctant to take part." For example, Parr said, therapists may have their patients reach for building blocks and post pictures on a bulletin board for work on gross motor coordination.

The PT added that music can also be used for these benefits. Because children with autism tend to respond best to highly organized activities, the structure and repetition in music can help therapists structure activities and motivate their young patients. "When working on problems with gait, for example, I've had patients march to the beat of a song while I correct irregularities in their stride and work on posture," Parr said. "And while I haven't done this personally, I know therapists who'll sing directions to activities to their patients, and some who've even recorded these songs onto tapes that parents can take with them and use for home activities." Although any therapist can incorporate music into treatment to make activities more fun, Parr recommended consulting a certified music therapist for ideas.

Caregiver Involvement
Although therapists can play a valuable role in these areas, most treatment for kids with autism will take place in schools, the patient's home and other non-clinic settings. As a life-long condition with no true "cure," many insurers will only reimburse therapists for the bare basics of rehab. The key to successful rehab, then, is for the PT to educate parents and caregivers on the child's condition, and educate them on activities they can take with them to further their child's progress.

"Unless the PT works in a school setting, or the child has another condition that requires therapy along with autism, PTs probably won't see the patient for many sessions," she concluded. "So from the first day of rehab you need to get the caregiver involved in therapy. PTs can show these patients activities that will help correct problems with posture, gait and tone, but it's up to [caregivers] to continue this process after discharge."

References

1. Barshaw, M. (1997). Children with Disabilities, 4th ed. Baltimore: Paul H. Brookes Publishing Co.

2. Blakeslee, S. Movement may offer early clue to autism. New York Times, Jan 26, 1999.

Mike Le Postollec is on staff at ADVANCE and can be reached at mlepostollec@merion.com.