Exercise Therapy Implications for Autism

Autism is a complicated disorder which only recently has been classified as a neurological, development disease that affects approximately 400,000 individuals in the United States today (11). Despite the progress that has been made in diagnosis and treatment, there are still several facets of the disease that remain a mystery to scientists and researchers, in particular the cause and treatment. Before one can explore these new research topics, it is first important to understand what is known about the disease, specifically classification and diagnosis, including signs and symptoms. Webster's dictionary defines autism as "a mental disorder originating in infancy that is characterized by self-absorption, inability to interact socially, repetitive behavior, and language dysfunction (as echolalia)." This definition, while explaining signs and symptoms, well has a slightly outdated idea of classification.

Today the disorder is considered to be a neurophysiologic dysfunction with strong genetic implications, not simply a mental disease. Autism is further referred to as a spectrum disorder, because the symptoms described above can affect individuals over a broad range from verbal to nonverbal, intense hyperactivity to extreme withdrawal, as well as varying levels of learning disability. The disease further can be classified into two subtypes: High functioning autism and Asperger syndrome (12). Individuals with high functioning autism (affecting about 20% of the population with autism) demonstrate a history of language delay, while children with Asperger syndrome do not show the same language delay yet show further undeveloped social interactions (12). Again, due to the broad spectrum of classification a child's symptoms may not place them clearly into one of the subsets, thus a rating scale, The Childhood Autism Rating Scale (CARS) (a rating system used to generalize and categorize the symptoms of the child with autism), has been utilized to determine the severity of their disorder (3).

Autism, moreover, is diagnosed via stereotypical signs and symptoms generally before the age of three (11). There are four categories of repetitive behaviors that have been developed to aid in diagnosis. The categories include stereotyped motor mannerisms, (included rocking and self injury), preoccupation with inanimate objects, unusual patterns of interest with a narrowing intensity, and finally an extreme need for repetition and sameness (10). A child with autism may exhibit some or all of these symptoms in any variety from low to high behavioral patterns. Patients with a more severe disorder tend to be nonverbal with exaggerated repetitive behaviors which can lead to a difficulty in coping with social and emotional situations, making independence in later stages of life challenging without proper therapy.

In order to understand and treat the child's autism it is important to first understand the motivations behind the repetitive patterns and behaviors. There have been several developments in recent years which have clarified the motivations of the patient with autism. Once considered a purely emotional disorder, autism was believed to be caused by "cold" parenting which let to the behavior problems in the child (12). It was further believed that early vaccinations received in the first 18 months of development were causing autism, when in actuality one of the only known causes of autism is intrauterine exposure to rubella, which those vaccinations prevented (12). These theories however, have been disproved by new technology such as MRI scans, which have shown abnormalities in the brain development of the child with autism, particularly in regards to the enlargement of the brain volume (12). There have further been links to abnormal serotonin and dopamine levels, neurotransmitters in the body which have a stimulatory, euphoric effect as well as cerebellum activity which may account for the disordered movements in children with autism (10).

Further studies suggest that the risk of autism spectrum disorder may increase in the children of mothers who suffer from diabetes mellitus or epilepsy (6). More genetic implications explaining the disorder reside in the higher percentage of males afflicted with autism then females. This information suggests that autism may be a sex linked disorder with the mutation lying somewhere on the X chromosome (males would have a higher probability because they only have one X chromosome, either have the disorder or do not, while females have the chance of being a carrier with no visible symptoms) (13). Studies isolating a region on the distal X chromosome suggest that this could be the locus for the mutation, or the "fragile region" (13). These single studies do not, however, provide enough evidence to clearly pinpoint the genetic cause of the disorder, yet further testing could prove to be significant.

While studies provide information into the neurological nature of the disease, autism is still an idiopathic disorder. Thus, it is important to concentrate on therapy and treatment to improve the quality of life of individuals with autism, while a finite biochemical cure is unknown. Several forms of therapy are used today to combat the various repercussions of the disease such as verbal, social, behavioral, and physical delays (11). Classic examples of therapy include speech therapy as well as music therapy, which concentrate primarily on verbal and communicative skills. In a study by Kaplan and Steele on music therapy programs, 40 individuals with autism received musical therapy in hopes to improve in the aforementioned areas (4). The therapy included group sessions with interactive instrument play and singing, as well as individual sessions focusing more on musical instruction (4). The results illustrated that in both group and individual sessions, students with autism showed improvement in verbal and communicative skills along with some cognitive and social improvements; however, the students with individual based lessons showed even higher levels of improvement (4). It is clear from this study that music therapy has a significant impact on the child with autism. In both, speech and music therapy communication skills are improved in verbal children, while some nonverbal children can begin to form words and even sentences which has meant vast improvements for both the children and families.

The physical aspects of the disorder, moreover, have also become a topic of interest for the medical community and therapists alike. Several studies have been conducted based on the correlation between autism and gastrointestinal problems. A large percentage of children with autism have displayed symptoms such as acid reflux, diarrhea, and constipation; thus, varying dietary changes have been administered on a research level to attempt to alleviate some of these symptoms (3). GI tests have included the administration of a peptide secretin which helps to alleviate high acidity levels in the duodenum, common to the patient with autism (3). This showed significant improvement in a small study including improvements in behavior and social skills; however, with a larger scale trial there was not enough evidence to support a correlation between the secretin intake and improved behavior (3). Further, diets low in gluten and casein, as well as ketogenic diets, were tested in response to abnormally high peptide levels in the urine of the patients with autism (3). Some of these diets, consequently, showed an improvement in patients with less severe autism on the Childhood Autism Rating Scale (3). A study was also conducted using a combination of Vitamin B6 and magnesium to attempt to reduce repetitive and undesirable behaviors in the child with autism based on the success rate in the administration of Vitamin B6 in patients with schizophrenia (8). The study with autism however, resulted in no clear conclusion, while large dosed treatments seemed to have some positive effects (8).Thus, altering the diet to the specific needs of the patient with autism has proven to be the most helpful in alleviating the physical discomfort of the child.

The effects of autism additionally encompass musculoskeletal and neuromuscular behavior. A neurological characteristic of autism, for example, that affects the musculature of the patient is hypersensitivity. Hypersensitivity, or over-stimulation of one or all the senses, can lead to repetitive behavior such as walking on ones toes, which in turns leads to the overdevelopment of the gastroc and soleus muscles such that one physically can not put their heels down (14). A behavioral problem thus becomes a physical manifestation which requires treatment like physical therapy. Hippotherapy is a type of physical therapy in which the patient receives therapeutic treatment through the motion of the horses (7). Hippotherapy allows for the patient to work their postural muscles for support, while their hips move with the horse's hips, thus conditioning the patient to experience the same motion as walking (7). This not only improves the neuromuscular function, but aids in many of the emotional dysfunctions in the child with autism as well. The connection made with the animal may result in a gradual decrease in hypersensitivity, while providing an emotional connection which can improve social interaction.

Two patients, for example, have experienced some of these effects through their involvement in hippotherapy. One nonverbal child has learned basic communicate, and having once experienced behavioral withdrawal now interacts with the therapist, horse, and volunteers. He still, however, displays an attachment to inanimate mechanical objects, in particular the fan, but that behavior is also lessoning. The other patient's behavior, though less severe, has improved significantly while at the same time experiencing the physical gain as he learns to walk with his heels down. Exercise also has proven to be an effective tool in reducing stereotypical musculoskeletal behaviors. It has been proven that at least 15 minutes of moderate to vigorous exercise yield improvements in cognitive, physiological, and behavioral aspects of the disorder (5). Physical therapy and exercise, therefore, can attend to not only the physical needs of the child, but the social and emotional needs as well.

Beyond the classic examples of therapy, there have been several new methods developed, including the use of positive touch and deep pressure. Temple Grandin, an assistant professor of Animal Science at Colorado State University, a graduate from the PhD program in Animal Science, and a woman with autism has provided an undeniable link to the study and understanding of autism (9). Dr. Grandin not only has provided insight into the disease by explaining subcategories of the disorder, separating abnormalities into neurophysiological, neuroanatomical, etc., but she developed a squeeze machine based on sensations that gave her comfort (9). Hypersensitivity in the child with autism has served as an explanation for many of the behavioral problems associated with the disorder. Both the withdrawn nature and the hyperactivity of patients with autism can be a product of the intense "wave" of sensation the children experience at normal levels tactile, visual, and even auditory stimulation (1). Thus, Dr. Grandin's machine allowed for the comfort of deep pressure applied laterally to the body in a gradual, self-administering fashion which has proven to have significant impact on behavior (2). Clinic studies utilizing the hug machine as a therapeutic method have shown a decrease in tension, aggression, and anxiety in children with autism (2). Similarly, positive touch in the form of massage administered by the parent has proven to decrease aversion to touch and formulaic behaviors while increasing the bond between parent and child (1). Massage is useful, moreover, because of the routine, melodic motion which fits into the sameness that the child with autism needs. It is clear, therefore, that Dr. Grandin's hug machine and positive touch therapy have provided new and invaluable methods to the treatment of hypersensitivity, as well as most behavioral and social problems in the child with autism.

In the past 50 years the knowledge concerning autism spectrum disorder has increased ten fold, providing insight into the classification, diagnosis, and treatment of the disorder. Great strides, further, have been made to increase the quality of life for the individual with autism, from alleviating physical discomfort to providing classical and alternative therapy. Speech and music therapy has made strides in improving communication and social skills, while physical activity and hippotherapy have minimized repetitive behaviors. Dr. Temple Grandin has also provided the insight necessary to connect with the child with autism while explaining the methods of deep pressure and therapeutic touch. Even more alternative therapies are developed every day. For example, Israel Paskowitz, a father of a child with autism in California discovered that his son was only calm in the water, so he began taking him surfing with him (15). This activity then developed into Surfer's Healing, a nonprofit camp run today as a form of therapy for children with autism to help cope with hypersensitivity and behavioral problems (15). Thus, it is clear, that while autism spectrum disorder is in the forefront of medical research, it is the efforts of the therapists and the support of the families that has the most significant impact on the improvement in social, behavioral, and physiological dysfunction.

REFERENCES

• Cullen, L.A., Barlow, J.H., and Cushway, D., Positive touch, the implications for parents and their children with autism: an exploratory study, Complement Ther Clin Pract. (2005), 11(3): 182-9.
• Edelson S.M., Edelson M.G., Kerr D.C., and Grandin T., Behavioral and physiological effects of deep pressure on children with autism: a pilot study evaluating the efficacy of Grandin's Hug Machine, Am J Occup Ther., (1999), 53(2): 145-52.
• Erickson C.A., Stringler K.A., Corkins M.R., Posey D.J., Fitgerald J.F., and McDougle C.J., Gastrointestinal Factors in Autistic Disorder: A Critical Review, J Autism Dev Disord., (2005): 1-15.
• Kaplan R.S., and Steele A.L., An analysis of music therapy program goals and outcomes for clients with diagnoses on the autism spectrum, J Music Ther., (2005), 42(1): 2-19.
• Kern L., Koegel R.L., and Dunlap G., The influence of vigorous versus mild exercise on autistic stereotypical behaviors, J Autism Dev Disord., (1984), 14(1): 57-67.
• Leonard H., De Klerk N., Bourke J., and Bower C., Maternal health in pregnancy and intellectual disability in the offspring: a population based study, Ann Epidemiol, (2005).
• Meregillano G., Hippotherapy, Phys Med Rahbil Clin N Am, (2004), 15(4): 843-54
• Nye C., Brice A., and Nye C., Combined vitamin B6-magnesium treatment in autism spectrum disorder, Cochrane Database Syst Rev., (2005), 1(4).
• Ratey J.J., Grandin T., and Miller A., Defense behavior and coping in an autistic savant: the story of Temple Grandin, PhD., Psychiatry, (1992), 55(4): 382-91.
• South M., Ozonoff S., and McMahon W.M., Repetitive behavior profiles in Asperger syndrome and high functioning autism, J Autism Dev Disorder., (2005), 35(2): 145-58.
• Stopka C., and Todorovich J.R., Applied Special Physical Education and Exercise Therapy, (2005), Pearson Custom Publishing, Boston, MA: 118-123.
• Toal F., Murphy D.G., and Murphy K.C, Autism-spectrum disorders: lessons from neuroimaging, Br J Psychiatry, (2005), 187: 395-397
• Vincent J.B., Melmer G., Bolton P.F., Hodgkinson S., Holmes D., Curtis D., and Gurling H.M., Genetic linkage analysis of the X chromosome in autism, with emphasis on the fragile X region, Psychiatr Genet., (2005), 15(2): 83-90.
• www.instatnanatomy.net/anatomy.html (1999-2003).
• www.surfershealing.org (2005). (Good video on this website!)

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