Kids playing catch, running, jumping, climbing on jungle gyms and flying down slides are all common sites at recess yards across America. Yet for the estimated 1 in 88 children with Autism Spectrum Disorder (ASD), physical impairments often go hand-in-hand with the disorder's social and neurological impairments. Long the realm of occupational and speech therapy, some pediatric physical therapy programs have taken an interest in these patients, recognizing their need for PT interventions starts at a young age.
According to Autism Speaks, children with ASD can have trouble with sitting, walking, running and jumping. These children can face difficulties with posture, coordination and balance. Many children with autism have low tone. Some researchers estimate that 51% of them have hypotonia, affecting how they use their muscles.
"Kids with autism often have weakness in their trunk or core," said Caryn Harris, PT, TERRIOKIDS, Bakersfield, Calif. They can have delays in the onset of postural control muscle. When a non-autistic child throws a ball, for example, certain trunk muscles must activate. That activation is not consistent with a child on the spectrum.
"Balance and coordination is often a problem," noted Courtney Loepker, PT, DPT, formerly of Cincinnati Children's Medical Center. Many children on the spectrum first come to physical therapy at Cincinnati Children's because they walk on their toes and need to be fitted for shoe inserts and other orthotics. Neurotypical children have an expected reaction when they lose their balance; kids with ASD have delays in their reactive control, making common childish play, like hopping on one foot, very troublesome.
Beyond larger postural and core-based issues, fine motor skills are a problem area with these patients too. "It's important we hop on the motor skills end early because poor motor skills are related to poor social skills. If they can move through space with confidence, they can expand their social realm," said Patricia West-Low, PT, DPT, PCS, staff therapist, Children's Specialized Hospital, Mountainside, N.J.
West-Low is onto something. A recent study of toddlers and preschoolers with autism out of Oregon State University showed a connection between fine motor skills and communication and socialization. The children who tested higher on motor skills also tested higher on activities of daily living, like talking, walking and playing.1 A decreased ability to perform activities of daily living impairs a child's function both at home and at school.
Activities of daily living are an occupational therapy stalwart, and when working with kids on the spectrum, interdisciplinary collaboration is crucial. "We're constantly consulting OT," noted Harris. "They give us ideas to help provide sensory input." In a recent case, Harris was trying to reach a hyporesponsive child who couldn't maintain a quadruped position to crawl. An occupational therapist recommended gentle joint compression.
Children with ASD can present with abnormalities of the respiratory, muscular, cardiovascular, and neuromotor systems. Often, it's an occupational or speech therapist who first recognizes deficits and refers them to physical therapy. Even so, West-Low said, "I would encourage physical therapists to learn the red flags." All pediatric PTs, she believes, should know the early warning signs of autism so they can refer babies and toddlers to additional services. The Centers for Disease Control's Learn the Signs Act Early program has resources for healthcare professionals on what to look for.
Therapists share advice and consult on each other's patients. "It's a really strong collaboration. PT, OT and speech are constantly communicating," West-Low observed.
When it comes time for therapy, the PTs at the outpatient facility at Children's Specialized see kids once per week for a one-hour sessions. The length of care varies for each child and their goals. Some of the activities West-Low and her fellow physical therapists work on may include core muscle activation and cardiopulmonary and postural muscle endurance. Kids may play with blowing toys, like whistles and bubbles, because it activates their core and their respiratory system. For a balance challenge, they may kick a ball while standing on one foot.
"A lot of the kids hold their breath when they need stability." West-Low observed. "When they do breathe, it's very shallow." This kicks in their fight-or-flight mental response. Keeping their arousal levels at baseline and their respiratory system in check is another function of physical therapy.
Getting them Moving
Indoor suspension equipment, such as homes, focus on postural control. Older kids use fitness equipment, like treadmills, stationary bikes, and ellipticals. The physical therapists at Cincinnati Children's will place children with autism in swings and have them throw and catch bean bags while suspended. For core strengthening, Loepker has kids do sit-ups and the Superman stretch on therapy balls.
"Physical therapy sets these kids up for less pain and dysfunction as adults," she noted. Addressing their functional deficits helps them to become more engaged with the community and to negotiate different environments.
Physical therapy at TERRIOKIDS begins with a complete gross-motor skills assessment. "PTs can help in being objective in describing what to do and showing the physical progress of intervention," Harris explained. "I think we can really help the field."
Sessions address issues of trunk and postural control. The goal is for kids to do activities safely and with control. The rock wall for climbing and the treadmill, which is on an incline to provide resistance for more proprioceptive input, are other popular pieces of therapy equipment.
"We have to consider the child may have sensory processing difficulties," noted Harris. Indeed, sensory issues are common among children with autism. At Children's Specialized, standing and walking on textured surfaces and pushing, pulling and other resistive activities provide vestibular and proprioceptive input. A trapeze swing works on the core muscles.
The takeaway for physical therapists is not to overwhelm a child with sensory processing issues with too many new sensations. These patients may have gravitational insecurity, where anything unstable is frightening. Starting with small movements is critical. "These are gradually integrated. Introduce them right away, [and] it would throw them over the edge and they'd never want to come and see us," advised West-Low.
Dealing with autism is a 24-7 job that requires more than a weekly physical therapy session. "Listen to the parents. They know their kids better than anyone else," advised Loepker. "Autism affects every aspect of their lives."
"Families come to the clinic for strategies to incorporate at home," observed Harris, and simple home activities are part of the treatment plan. Often, parents want the kids to become more physically active, and with good reason. Children on the spectrum who have low tone are hypoactive and prone to develop obesity.
Physical therapists suggest activities that will help both parents and children in their day-to-day lives, individualized to each family's needs. Raking leaves is an ideal proprioceptive activity. A PT will teach a parent resistive pushing in the form of wrestling to help calm a child. A higher-functioning child can sit on a therapy ball to do their homework. With all home programs, moderation is key. "If you give them ten different things, the likelihood they will do all of them is slim," Loepker explained.
As both parents of children with autism and their physical therapists know, there are unique challenges when working with this population. "We have to take distractibility and lack of eye contact into consideration," said Harris. Self-stimming, repetitive behaviors like rocking or flapping, is another problem, as is elopement, the tendency of children with ASD to wander, and their poor ability to follow directions. At Cincinnati Children's, there are support staff on call to assist if a child acts out.
"You have to think outside the box," Harris noted. "Are you explaining it to them in a way they understand?" She's had success using picture boards to convey instructions to nonverbal kids. Since children with autism communicate in many different ways, the therapist must learn their language and the best way to get through to them. Here, collaboration again comes into effect, as the child's speech therapist would be an ideal person to consult.
"Therapists must be very present and read the child's cues," explained West-Low. Their regulatory states vary so quickly, a PT must be careful not to throw them over the edge, sensory-wise.
Loepker urges her fellow physical therapists to recognize that progress while working with children with autism is often slow and steady. Clinicians need to keep realistic expectations. "As physical therapists we want to see results as fast as possible and know we're making a difference," she said. "Celebrate the baby steps and the small victories."
To other pediatric physical therapists who've yet to focus on kids on the spectrum, West-Low advises them to find a mentor. Reading articles and taking continuing education courses is great, but talking to colleagues who have first-hand experiences with this population is perhaps the best way to learn. Says Harris, "Don't just think in our PT world; it has to be a team approach."
1. Oregon State University. Autistic children with better motor skills more adept at socializing. Available at: http://oregonstate.edu/ua/ncs/archives/2013/sep/autistic-children-better-motor-skills-more-adept-socializing. Accessibility verified September 24, 2013.
Danielle Bullen is on staff at ADVANCE. Contact: firstname.lastname@example.org