Excerpt from: From Flapping to Function: A Parent's Guide to Autism and Hand Skills
When I hear the word autism an image of four-year old Gary pops into my mind.
Gary is lining up cars, end to end, while children around him make their cars roll, beep, and drive over paper roads. Gary doesn't seem to notice what they are doing, even as he crawls over another child's leg to reach the bucket of toys.
Gary glances at a toy just long enough to reach for it before looking away. he sits with his knees bent and feet outside his hips, in a position called W-sitting because his legs form a "W" shape. While picking up cars with his left hand Gary shifts his weight to his right side. His wrist is loose and floppy. He grasps the cars with his fingertips, as though they were slimy fish he wanted to keep from touching his palms. When another child jostles the perfectly aligned cars, Gary grunts and without missing a beat, adjusts them. Then he abandons his cars, stands up, and flaps his hands while walking around in circles.
The boy shown in the photographs was an occupational therapy client who shared many similarities with Gary.
You may have imagined a similar child- a child who does not play with toys the way most children do- or whose hands flap more often than play. A multidisciplinary team observing Gary would all contribute important findings. An occupational therapist (OT) would note that his eye-hand coordination seems fairly normal, in that he uses his eyes to guide what his hands do. On the other hand, Gary does not look directly at objects, he avoids using his palms to grasp them, and he seems unaware when his body moves into a space occupied by another child. These are signs of a sensory processing disorder (SPD), or difficulty receiving and responding appropriately to sensory information. A physical therapist (PT) would note hypotonia ("floppy muscles") and poor postural control, because he leans on his hands to hold himself up. A speech-language pathologist (SLP) would note his lack of social awareness- he doesn't even protest when another child bumps his cars. He doesn't use toys functionally or vocalize while playing like the other children who are making their pretend cars drive, crash and say "beep, beep." The way Gary doesn't look at other children and repetitively lines up his cars would draw a child psychologist's attention. Gary's preschool teacher would be concerned that he cannot name the colors of the cars or engage in pretend play, such as forming an imaginary steering wheel with his hands and pretending to drive.
As the team discusses their observations, the picture of Gary that emerges is typical of children on the autism spectrum. The way that Gary grasps manipulates, and uses the cars while ignoring his peers demonstrates difficulties with
- Postural control: his body and hands seem to be floppy and weak.
- Visual skills: he avoids looking directly at the objects in his hands.
- Play skills: he lines up the cars rather than using them in pretend play.
- Communication and social skills: he does not imitate other children or share the play experience with them.
- Sensory processing: he has difficulty interpreting and responding to touch and other stimuli.
Every child is unique and that includes children with developmental differences. However, when writing my book, I took a comprehensive look at how children with autism spectrum disorders (ASD) typically use their hands, what challenges they face, and what strategies can help them reach their potential. I stress "reach their potential," because there is currently no cure for autism or its associated challenges. There are, however, many effective and fun strategies that parents can implement.
How is Autism Spectrum Disorder Defined?
The diagnostic and Statistical Manual (DSM), 5th edition published by the American Psychological Association in 2013, lists the formal diagnostic criteria for ASD:
- social communication impairment, and
- restricted interests/repetitive behaviors (including hyper-or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment)
Note that the DSM-5 describes autism as a "spectrum" with varying degrees of severity, ranging from mild to severe. Autism now includes higher functioning individual's who would previously have been diagnosed with Asperger's syndrome.
Psychologists use the terms hyper- and hypo-reactivity, respectively, to describe atypically intense and diminished responses to sensory stimulation. Therapists and educators frequently use synonyms like over-responsive and under-responsive, and parents may describe their children as seekers or avoiders, or sometimes both at the same time. My book discusses these concepts in further detail.
Gary, my imaginary child with ASD, lines up cars, a task that requires a high degree of visual attention and dexterity. In a 4-year-old child, lining up cars may signal a restricted interest or repetitive behavior, especially if other types of play are absent. On the other hand, many typically developing young children also enjoy lining up cars, so its important to look for a cluster of red flags and not to panic over a single behavior that may be quirky but not atypical.
Although the DSM-5 diagnostic criteria do not cite difficulties with movement, motor signs are common and may show up differently, depending on each child's individual characteristics:
- subtype of autism
- cognitive abilities (thinking skills)
- sensory processing- how the brain organizes and responds to information from the senses in order to learn.
What is Sensory Processing Disorder?
Occupational therapist, Dr. A. Jean Ayres devoted her life to developing sensory integration theory. The disorder is currently called sensory processing disorder (SPD).
Sensory integration is the process involved when a child takes in information from the environment through her sense organs, interprets it in her brain, and then uses it in a functional way to move, play, and work.
There is debate on whether SPD is an independent disorder or represents the observed symptoms of various other, more well-established, disorders. SPD is not recognized by the Diagnostic and Statistical Manual of the American Psychiatric Association, and the American Academy of Pediatrics has recommended that pediatricians not use SPD as a diagnosis. Therapists do not make diagnoses. However, according to the Star Institute, SPD can be identified and categorized by an occupational therapist with advanced training in sensory processing and integration. Of primary importance is linking sensory impairments to challenges in functioning at home or school.
You can observe a child's sensory integration at work as he climbs a play structure, puts on a helmet or mounts a horse. He will use the visual information that he takes in with his eyes to locate the steps, place one foot in the stirrup and swing the other leg over the horse. Tactile information from the skin enables him to grasp the reins or fur effectively. His brain interprets sensations from the eyes, skin, muscles, and inner ears so that he knows where his body is in relation to the saddle.
Other Conditions that Commonly Occur with Autism Spectrum Disorders
Autism spectrum disorders quite often appear together with other neurological conditions such as attention deficit/hyperactivity disorder (ADHD). However, these neurological conditions often occur independently of an ASD diagnosis, meaning many children who have ADHD or other diagnoses do not have the social and communication challenges associated with ASD.
Sensory processing disorder is also commonly associated with ASD. As previously mentioned, SPD is a controversial diagnosis because it is not defined in the DSM-5. Yet, many parents and therapists recognize that some children have unusual reactions to touch, sound, light or movement- such as not reacting to a clap of thunder or running from the room when static comes on the TV. Children who have both ASD and symptoms of SPD often have difficulty attending to and tolerating certain types of sensations.
Other diagnoses that may cluster with ASD are these:
- hypotonia- low muscle tone
- learning disability- a specific condition that interferes with the ability to learn certain skills, independent of intelligence
- obsessive-compulsive disorder (OCD)- a type of anxiety in which the child repeats certain behaviors over and over
Intelligence is independent of autism. Children with ASD may have cognitive abilities that range from severely below average to gifted. Diagnosis and treatment of disorders that commonly co-exist with ASD (such as SPD) may help children better learn and develop functional hand skills.
Scott D. Tomchek and Jane Case-Smith, Occupational Therapy Practice Guidelines for Children and Adolescents with Autism (Bethesda, MD:AOTA Press, 2000).
Jane Case-Smith, Occupational Therapy for Children (St. Louis, MO: Mosby, 2009)
A. Jean Ayres, Sensory Integration and the Child (Los Angeles: Western Psychological Services, 1979).
Heather Miller Kuhanceck and Renee Watling, eds., Autism: A Comprehensive Occupatonal Therapy Approach 3rd ed. (Bethesda, MD: AOTA Press, 2010)