According to the CDC, Autism Spectrum Disorder (ASD) affects one in 54 children in the United States. ASD is categorized as a developmental disorder, and affected individuals have difficulty with social interaction, demonstrate restricted interests, have increased sensitivity to sensory input, and engage in repetitive behaviors. Symptoms typically present early in life, but ASD can be diagnosed at any age.
The “autism team” has many members, which may include physicians, psychologists, occupational therapists, physical therapists, speech and language pathologists (SLP), teachers, and behavioral aides. As a physical therapist, I have noticed that I receive many questions as to how my services will assist children with ASD; they are often observed by their families and caregivers to be independently mobile. So, why would they need physical therapy?
It is true that most children with ASD do not present with the profound motor deficits we would “expect” from a child participating in pediatric physical therapy. However, children with ASD are very frequently “low tone,” meaning they have less muscle mass than typically developing children of the same age. If muscle development is limited, so are the neural connections to the musculoskeletal system, causing decreased strength and incoordination. One study showed that in children between 12 and 33 months of age, who were eventually diagnosed with ASD, average gross motor development was 6.4 months behind typically developing children of the same age.1 Gross motor development occurs in a specific order – the adage “you must crawl before you can walk” applies. The foundation of movement is formed during the infant and toddler years. If there are holes in the foundation, then further development is limited.
The gap in gross motor development widens with age, as typically developing peers continue to build on this foundation, honing their skills and adding new ones, while children with ASD create compensations for their own unstable foundations. Further, many gross motor skills are developed through play and imitation of peers, which the social difficulties of ASD may preclude a child from doing.
Children with ASD often have dyspraxia, a condition that causes difficulty with initiating movement and motor sequencing during tasks. One example of this is mistiming when to kick a rolled ball; there is a disconnect between identifying the correct movement and then initiating when it needs to take place. This leads to difficulty with multi-step tasks as well, such as when participating in sports or physical education class.
Dyspraxia can also lead to impaired spatial reasoning, as the child has poor awareness of where his body is relative to the rest of his environment. Children with this condition often bump into objects or other people because they cannot adapt to the changes in their environment. There is also difficulty discerning left from right, which can limit the ability to perform activities that require reciprocal (opposite arm and leg) motion, such as running, skipping, or throwing. Sensory and balance deficits can also contribute to problems with activities that require the feet to leave the ground, such as jumping, sprinting, hopping, walking on uneven terrain, or negotiating unexpected obstacles without loss of balance.
As a physical therapist, my role is to assess a child’s current gross motor abilities, then address any delays that are present. There are many strategies that I employ when treating individuals with ASD. One of the most valuable ways I have found to get a child to engage in therapy is by giving him some control over the session. Because children with ASD have narrow interests, they will disengage from therapy if they are not enticed by the activity. This means giving the child a degree of autonomy in session and allowing him to choose a preferred toy or game. I will then use this toy or game to help to develop a gross motor skill. This skill could be anything from using stairs safely to kicking a ball to a goal, depending on the child’s current level of motor development. If the child is developmentally able to understand the principle of “taking turns,” I may allow him to choose one “game,” and then I choose the next. This method can be applied to developing balance, coordination, core strength, or functional mobility.
If the child has difficulty initiating a motor task, as is the case in a dyspraxic individual, I rely heavily on external cues. I may use visual targets on the ground for foot placement during a stepping game. I also employ visual cues for children who have difficulty with left/right differentiation and reciprocal movements. Instead of left or right, I may use colors to identify left and right. I can have the child place his left foot on a green target on the floor, and his right foot on a red target. We then establish that one foot is the “green foot,” and one foot is the “red foot.” Then we work on kicking or stepping based on color, not laterality. To refine motor sequencing ability, I break multi-step tasks down into a series of smaller objectives, eventually stringing them together. I often employ obstacle courses in these cases, providing step-by-step instructions then phasing out input until I am able to instruct the child to “start here … and end there.”
When a child with autism acquires gross motor skills, he is actually given additional tools to cope with sensory sensitivity, dual tasking difficulties, and even social interaction. Developing gross motor skills requires internal feedback to monitor performance, based on what is happening in the external environment. The child becomes more aware of what is happening in his body as he executes certain tasks. He is able to focus on what he feels internally, not just how overwhelmed he is by external input. When a physical therapist feels it is appropriate, she can then utilize this new awareness and connect it to calming strategies. The child can eventually learn to use these with less and less cuing. As motor sequencing abilities and spatial awareness improve, he can also become more proficient at dual tasking, such as walking in a crowded hall at school and avoiding oncoming students or unforeseen obstacles. Finally, with improved motor skills, a child is more likely to engage in playground games or physical activity, even in a parallel manner, which can allow for improved social interaction and further gross motor development through imitation.
As a child with autism spectrum disorder develops his gross motor skills through participation in physical therapy, it allows him to safely navigate his environment and participate in play with his peers. The lesser known benefit of physical therapy is that it will lead to further integration of the skills the child is acquiring during sessions with other providers. Many children with autism have difficulty integrating input and generating appropriate output; if we can arm them with improved internal awareness through motor development, they can more successfully interact with the world around them.
If you have any questions regarding physical therapy intervention for individuals with Autism Spectrum Disorder, please reach out to Dr. Claire Kopko by phone at 614-245-5359, by email at firstname.lastname@example.org, or visit her website: http://www.clairekopkodpt.com.
- MacDonald M, Lord C, Ulrich DA. Motor skills and calibrated autism severity in young children with autism spectrum disorder. Adapt Phys Activ Q. 2014;31:95-105