The Cowden Preautism Observation Inventory: With Effective Intervention Activities for Sensory Motor Stimulation and Joint Attention

THE COWDEN PREAUTISM OBSERVATION INVENTORY

ABOUT THE AUTHOR Doctor Jo E. Cowden was Professor of Motor Development and Pediatric Adapted Physical Activity at The University of New Orleans for more than 25 years. She also served as Director of the UNO Pediatric Motor Development Clinic, specializing in assessment and program development for infants and toddlers with delays and disabilities. Many of the infants and young children had a diagnosis of autism. No disability was too severe, and no infant or child was ever turned away from the clinic due to the nature of their disability. Doctor Cowden served as Project Director of three federally funded training grants for infants and young children with delays and disabilities. Her last state grant on Project GUMBO (Games Uniting Mind and Body) for children with physical disabilities is presently continued by the Louisiana State Department of Education. Doctor Cowden served as Director of the Third International Symposium on Adapted Physical Activity hosted by the University of New Orleans, which was the beginning of her tenure at The University of New Orleans. She also served as the Symposium Director of the Fifth North American Federation of Adapted Physical Activity in New Orleans. Experts on mental and physical disabilities, social-communicative, and developmental psychology were brought to New Orleans, providing numerous opportunities for teachers and professionals to attend and develop current knowledge. Doctor Cowden served on the editorial board of the Adapted Physical Activity Quarterly from 1997 to 2005. She is highly published and has presented nationally and internationally on infants with delays in pediatric adapted motor development including autism. Pictured with Doctor Cowden is Addie Kara, an American Eskimo rescue dog and author pup!

THE COWDEN PREAUTISM OBSERVATION INVENTORY With Effective Intervention Activities for Sensory Motor Stimulation and Joint Attention By

JO E. COWDEN, PH.D.

Published and Distributed Throughout the World by CHARLES C THOMAS • PUBLISHER, LTD. 2600 South First Street Springfield, Illinois 62704

This book is protected by copyright. No part of it may be reproduced in any manner without written permission from the publisher. All rights reserved.

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Printed in the United States of America MM-R-3

Library of Congress Cataloging-in-Publication Data Cowden, Jo E. The Cowden preautism observation inventory : with effective intervention activities for sensory motor stimulation and joint attention / by Jo E. Cowden. p. cm. Includes bibliographical references and index. ISBN 978-0-398-08643-5 (pbk.) -- ISBN 978-0-398-08644-2 (ebook) 1. Autism in children—Diagnosis—Propular works. I. Title. RJ506.A9C686 2011 618.92’85882–dc22 2011000257

“Hope” is the thing with feathers . . . That perches in the soul . . . And sings the tune without the words . . . And never stops . . . at all . . . Emily Dickinson

FOREWORD Today, as I read Kanner’s vivid descriptions of the eleven children, written in 1943 [primary source for academic and professional recognition of autism], I see my own daughter on almost every page. Though I thought Isabel was developing normally until the age of two, a look back at our home videos shows how little eye contact she made in infancy and how seldom she tried to communicate with us. Even today, she plays the same way, finding and maintaining sameness wherever she can, whether it be by repeatedly drawing the same picture over and over again, or rewinding a video or DVD to watch the same fragments of a scene multiple times. (Grinker, 2007, pp. 49–50)

his reflection from the anthropologist-author of Unstrange Minds: Remapping the World of AUTISM is illustrative of the many parents who report lack of awareness of risk behaviors or “preautistic symptoms” of their own infants from birth onward. Had they been better observers, these parents surely would have sought early intervention and basked in the hope that the life of their infant, as well as their family, would be changed for the better. Dr. Jo E. Cowden is the author of this hope-inspired book you are choosing to read. To the best of my knowledge, it is the first book to specifically address preautism, a condition of unresponsiveness to and extreme lack of concern for caregivers and environment that is manifested by numerous risk behaviors from birth through age one year. Cowden gave considerable thought to the order of ideas in her title, The Cowden Preautism Observation Inventory: With Effective Intervention Activities for Sensory Motor Stimulation and Joint Attention, deciding that her original observation inventory should come first, with initial focus on enabling parents to interact with and screen young infants, then concentrating on professionals who will most likely help parents with further learning about preautism, the benefits of which they will pass on to their infants. A look at the Table of Contents reveals comprehensive coverage of all aspects of preautism and autism, possible causes, the latest findings on related brain organization and brain plasticity, effective intervention and behav-

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ioral strategies, theoretical principles of intervention, preautism sensory motor curriculum, therapeutic riding, and much more! Almost 300 illustrations clarify text and direct relationships between observation and intervention. Many photographs model ways that parents and professionals work together in maximizing integration of social interactions with sensory-motor stimulations. A major strength of this book is encouragement of positive attitudes, selfconfidence, and realization that power does come with increasing knowledge. Most persons love to look at babies; we are fascinated by the very young of every species; much of what some of us do is mindless gazing, loving, and marveling at the miracle before us. However, few persons who do this (or wish they had time to do this) know what to look for or that the process of observation is important. Parents must be carefully taught what to look for (especially interacting behaviors like making eye contact, responding to human sounds, and reaching arms toward caretaker); to make happy sounds of praise and love throughout observation; and to maintain an atmosphere of hope in discovery of new solutions. A key principle is to not look only for preautism or failure to behave as other babies do. Look because you want to get to know this tiny individual as much as possible and as soon as possible. Look because you know that observation (whatever it shows) will lead to creativity, altered perceptions of interventions as joyful play, courage to try new interventions in varied environments, and confidence in seeking help from specialists who use such therapeutic media as swimming, rhythms, and therapeutic riding. Everyone seems to know about autism (commonly diagnosed around age 2 or 3), but few individuals understand the need for parents, parents-to-be, caretakers, and direct- and related services providers to become everyday (indeed, every minute) caring, fully engaged, expert observers of sensory motor behaviors from birth onward. This goal and subsequent attention to appropriate, individualized interventions can be achieved, however, only when professionals make the information in Cowden’s book widely available through workshops, conferences, webinars, preservice and inservice university courses, practica, clinics, continuing education, and individual tutoring and mentoring. The demand for professionals who can do this is greater than ever before. So also is the need for print and online materials on preautism. This book aims to meet the urgent need of direct care providers and professionals to teach these providers. Preautism is an area (or category) of new knowledge that Dr. Jo E. Cowden has developed for this book, the third in her series of outstanding, crossdisciplinary textbooks (1998, 2007, 2011) on typical and atypical infant and early childhood sensory motor development, assessment, and interven-

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tion (both theory and practice). As author of Adapted Physical Activity, Recreation, and Sport: Crossdisciplinary and Lifespan (2004, now in its sixth edition), I strongly support Cowden’s scholarly development of a well-documented crossdisciplinary body of knowledge that meets societal needs and is attractive to university undergraduate and graduate students specializing in such diverse areas as nursing, occupational and physical therapies, speech and creative arts therapies, kinesiology, special education, early childhood and family studies, and adapted physical activity sciences. Use of Cowden’s book with rich opportunities for extensive home-school practica and mentoring by faculty representing different academic disciplines, will lead to meaningful research and publications that, in turn, will enhance the lives of families with infants with preautism and the continued development of our knowledge base on preautism. My best wishes to those of you who share this book with us. CLAUDINE S HERRILL Professor Emeritus, Texas Woman’s University

PREFACE he incidence of autism is increasing at an alarming rate and now occurs in 1 percent of American children. The rate of autism is 1 in 91 births, and 1 in 58 are boys. Parents and professionals are becoming more aware of autism spectrum disorders (ASD) and want to positively affect the development of infants. This book provides guidance to families for detecting early signs of preautism in their infant or toddler. Mothers of infants born prematurely were given many prescriptions to control preterm labor. Procedures in the Neonatal Intensive Care Unit (NICU) were administered to help the baby survive. Medications administered during the prenatal, perinatal, and neonatal periods may be linked to autism. Preautism is used in the title of this book and name of the observation inventory implying need for careful and thorough assessment of infants from birth through the first year of life. Avoiding the use of “autism” during this time period prevents labeling infants and newborn babies. It allows parents to record, videotape, and justify further testing by using The Cowden Preautism Observation Inventory (CPAOI) to establish a baseline of behaviors and skills. Instead of having a parent on the verge of panic, the concerned parent can eliminate his or her concerns or justify meeting with their pediatrician and other professionals. If further assessment is needed, the parent has documented all behaviors and movements of their baby. Videotapes have been used to record unusual or different actions. The parents are prepared because the CPAOI presents thorough information in a simple format. It allows them to learn what to look for in their baby, especially if other family members have a diagnosis of autism. Preautism is defined as a condition in infants who demonstrate an extreme detachment, unresponsiveness, and lack of concern or interest in other young children or family. Infants are born with the predisposition for this condition. There are signs of immature neurological and brain development. One easily recognizable factor is extreme head growth in circumference during the first year of life. The infant does not exhibit spontaneous and intentional shared enjoyment or affection toward anyone. There is impairment in the use of gestures and

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nonverbal behaviors, joint attention with eye-to-eye contact, facial expressions indicating lack of facial recognition, and no spoken language. Movements, such as attempts to roll or sit, are accomplished in unusual ways with a total lack of symmetry. Sitting posture indicates hypotonic or weak muscle tone, retention of primitive reflexes, and delayed righting and protective reactions. Infants with preautism demonstrate unusual visual scanning patterns, showing no recognition of other persons in their environment. Infants often demonstrate restless and purposeless movements in their cribs. There will be no imitative or pretend play. This author believes that preautism can be assessed during the first year of life. The CPAOI is presented with criteria that are designed for parents who may suspect their baby is developing differently than other infants. The CPAOI is easily administered for families and professionals through critical observation. A cluster of clinical and developmental signs and symptoms can be detected from medical information, complications during pregnancy, cognition/prelanguage, social-communication-play, sensory motor skills, central nervous system maturity, and developmental movements. Parents who have any doubts about their baby’s development should screen now with the CPAOI. If recorded signs begin to develop in clusters of negative items within different areas of the CPAOI, parents should take their copy of the CPAOI to their pediatrician. Concerned parents can record and videotape observations throughout each day. Questions will arise about be haviors observed or medications that were administered and recorded information will be available. There will be no guessing when asked questions by physicians, psychologists, and interventionist. The CPAOI has simple directions for recording observations of behaviors as present, absent, or emerging. Parents need to realize that all typical behaviors do not always appear within the specific months provided on the CPAOI. Infants do mature slightly differently in time and rate of development. If months are not written beside the behavior, they are not considered typical developmental skills or behaviors. Immediate attention should be paid to skills that are not developing as scheduled for infants and behaviors that do not appear to be normal. Look over the CPAOI items immediately and begin to determine whether they are applicable to infants and toddlers with whom you are concerned. If there is any doubt about a baby’s development, act now. Early screening and intervention have demonstrated improved outcomes for young children with autism. An in-depth chapter is included on brain plasticity, the ability of the brain to change and reorganize neural pathways. The brain is not “hard-wired” like a machine. The brain can change structure and function, allowing for the

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process of adaptation. An understanding that knowledge is not fixed can be extremely positive for professionals and families faced with challenges of infants demonstrating signs of preautism. It is important to realize that if the brain begins to lose functionality and skills, it has the ability to find other pathways for learning. Brain plasticity is the foundation for success of early sensory stimulation programs for infants with preautism. Genetic and environmental causes are discussed in detail. Acetaminophen (administered for pain to infants), terbutaline (drug used for preterm labor), glutamatergic dysfunction (excitatory neurotransmitter of the brain), and calcitriol (vitamin D deficiency) are linked to causes of preautism. Vaccines are not linked to autism, and the much debated study (Wakefield et al., 1998) and its retraction from The Lancet are critically reviewed. An entire chapter is devoted to neurological problems, immature brain development, and medical problems associated with preautism. Medical complications are also included in the CPAOI. Sensory motor curriculum and joint activity skills specific to preautism are detailed. Activities presented include: • Tactile stimulation of infants for awareness, recognition, and discrimination. • Vestibular stimulation for developing equilibrium reactions and balance. • Visual motor awareness and joint attention exercises. • Visual motor and joint attention to engage eye contact. • Visual motor recognition and joint attention for facial expression and memory. • Visual motor tracking and control to coordinate eye movements. • Auditory awareness, recognition, and sound discrimination. • Kinesthetic awareness, imitation of movements in play, and social routines. Other specific activities and exercises are included for developing muscle tone, strength, and reflex integration. This book has more than 250 new figures/pictures and activities for infants and toddlers. I strongly believe that therapeutic riding is one of the most beneficial activities for infants indicating signs of preautism. Infants and toddlers who demonstrate signs of preautism on the CPAOI should be enrolled in a certified therapeutic riding program. Horseback riding gently and rhythmically moves their bodies in a manner similar to upright locomotion, developing balance, equilibrium, strength, and motor control. Infants and toddlers in crease patience, confidence, and discipline. Socialization is a valuable asset

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for infants, young children, and the entire family. Riding is more than a physical experience. A special calming effect creates time for interaction and the beginning of unwritten communication. What are the signs for preautism that parents can identify and detail for their pediatrician? Can behaviors demonstrated by older children be eliminated if sensory stimulation activities are provided during early periods of brain growth during the first year of life? Causes and clinical indicators of autism are thoroughly discussed. Using the CPAOI as an observational assessment guide allows parents to begin to verify any concerns about the development of their infant. Effective intervention can alter genetic expression, brain development, and behavioral outcomes. There is no doubt that early intervention improves skills and behaviors when initiated during the infant and toddler developmental period. The CPAOI provides the information to discover and identify weaknesses and strengths of infants and toddlers who may have preautism. Specific principles for intervention will assist with planning and program development. More than 20 comprehensive strategies for effective intervention have been summarized from past experiences, and a section to assist parents with their concerns includes specific guidelines for selection of early intervention programs. J.E.C.

ACKNOWLEDGMENTS

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wish to acknowledge:

Connie L. Phelps, Chair of References Services at Earl K. Long Library at The University of New Orleans, who provided detailed assistance for the references in this book. She has skills to find information when given very limited information for bibliographical research. Considered a skilled detective! Dr. Claudine Sherrill, Professor Emeritus, Texas Woman’s University, Denton, Texas, my mentor across generations, scholar, and a genuine friend. Anita Hartzell Hefler, who administers the program at the Greater New Orleans Therapeutic Riding Center, encouraging fun, independence, selfesteem, and excellence in individuals with delays. The infants, toddlers, and families who participated in motor interventions for 25 years at The University of New Orleans, and who have provided me expertise in the field of autism, motor development, and early intervention. All of the parents and friends who sent pictures of their infants. Margaret Huffman, my sister, who always provides love, faith, and incredible strength. Dr. John Hevron, who has the knowledge and curiosity to seek ultimate answers for autism and medical problems of infants. Jean Burke, whose faith, patience, and love have provided me with encouragement necessary for completion of this book. Her wisdom helped me continue to search for details when I could find no answers. Addie Kara, American Eskimo rescue dog, who never leaves my side. xv

CONTENTS Page Foreword by Claudine Sherrill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Chapter 1. UNDERSTANDING AUTISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Cowden Preautism Observation Inventory (CPAOI) . . . . . . . . . . . 5 Section 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Cognition/Prelanguage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Section 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Social-Communicative-Play . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Section 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Sensory Motor Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Visual System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Section 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Auditory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Section 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Tactile System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Section 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Vestibular-Kinesthetic Systems . . . . . . . . . . . . . . . . . . . . . . . 12 Section 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Central Nervous System Maturity . . . . . . . . . . . . . . . . . . . . 13 Righting Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Section 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Developmental Movements . . . . . . . . . . . . . . . . . . . . . . . . . 14 Section 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Fine Motor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Process and Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Administration Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Recording Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 xvii

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The “Floortime Approach” . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Reversal of Thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Genetic Predisposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Immature Brain Development . . . . . . . . . . . . . . . . . . . . . . . . . 22 Early Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 The Struggle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Formal Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Why Does My Child Have Autism? . . . . . . . . . . . . . . . . . . . . . . 34 Environmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 2. BRAIN PLASTICITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Brain Reorganization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Sensory Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Sensory Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 3. CLINICAL INDICATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Major Brain Structure Immaturity . . . . . . . . . . . . . . . . . . . . . . . . 55 Prematurity and Low Birth Weight . . . . . . . . . . . . . . . . . . . . . . . . 61 Birth Asphyxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Respiratory Distress Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Hyperbilirubinemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Phototherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Dysmorphic Feature—Moebius Mouth . . . . . . . . . . . . . . . . . . . . . 69 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 4. SIGNS AND SYMPTOMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Motor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Muscle Tone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Reflexes and Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Delayed Righting Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Delayed Motor Milestones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Lying Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Rolling Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Sitting Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Four-Point Crawling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Walking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

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Motor Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Stereotypic Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Social-Communicative-Play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Cognition/Prelanguage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 SENSORY SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Sensory Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Visual System—Visual Motor Responses and Tracking . . . . . . 90 Auditory System—Sound Awareness and Localization . . . . . . 92 Tactile System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Vestibular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Kinesthetic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 EFFECTIVE INTERVENTION AND BEHAVIORAL STRATEGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Effective Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Role of the Parent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Behavioral Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Causes of Acting Out Behavior . . . . . . . . . . . . . . . . . . . . . . . 104 Establish Baseline Recording . . . . . . . . . . . . . . . . . . . . . . . . . 106 Environment for Observation . . . . . . . . . . . . . . . . . . . . . . . . 106 Behavioral Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 PRINCIPLES OF INTERVENTION . . . . . . . . . . . . . . . . . . . . . 109 Intervention Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Implementation and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 123 Qualitative Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 PREAUTISM SENSORY MOTOR CURRICULUM . . . . . . . . 128 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Sensory Motor and Joint Activity Skills . . . . . . . . . . . . . . . . . . . 130 Tactile System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Vestibular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Visual System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Visual Motor Awareness and Joint Attention . . . . . . . . . . 136 Visual Motor Attention and Joint Attention . . . . . . . . . . . 136

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The Cowden Preautism Observation Inventory

Visual Motor Recognition-Memory and Joint Attention . . 137 Visual Motor Tracking, Control, and Joint Attention . . . . 137 Auditory Awareness, Recognition, and Discrimination . . 139 Kinesthetic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Kinesthetic Awareness Activities . . . . . . . . . . . . . . . . . . . . . 141 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 9. THERAPEUTIC RIDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Research Measurements after Riding . . . . . . . . . . . . . . . . . . . . . 152 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 10. ACTIVITIES FOR HYPOTONICITY . . . . . . . . . . . . . . . . . . . . 158 Supine Position (on back) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Prone Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Rolling Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Four-Point Creeping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Exercises for Progression to Standing and Mobility . . . . . . . . . 167 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 11. ACTIVITIES FOR REFLEX INTEGRATION AND DECREASING MUSCLE TONE . . . . . . . . . . . . . . . . . . . . . . . . . 172 Assessment for Asymmetrical Tonic Neck Reflex . . . . . . . . . . . 173 Activities for Integration of Asymmetrical Tonic Neck Reflex . 173 Assessment of Tonic Labyrinthine Supine Reflex . . . . . . . . . . . 175 Activities for Tonic Labyrinthine Supine Reflex . . . . . . . . . . . . 175 Assessment of Tonic Labyrinthine Prone Reflex . . . . . . . . . . . . 177 Activities for Integration of Tonic Labyrinthine Prone Reflex . . 177 Symmetrical Tonic Neck Reflex . . . . . . . . . . . . . . . . . . . . . . . . . 180 Appendix—Infant Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Cowden Preaustim Observation Inventory . . . . . . . . . . . . . . . . . . . . . . .CD-ROM

THE COWDEN PREAUTISM OBSERVATION INVENTORY

Chapter 1 UNDERSTANDING AUTISM INTRODUCTION

he Cowden Preautism Observation Inventory (CPAOI) is a criterion-referenced screening instrument used for identifying preautism behaviors in infants and young children. It is not intended to provide a standardized evaluation or diagnosis. The inventory presented as preautism signs and symptoms was selected from a broad range of infant developmental literature and assessment instruments, as well as from experience and collaboration with families, teachers, therapists, and other medical personnel. As director of a university-based clinic for infants and toddlers with disabilities for more than 25 years, a comprehensive foundation of knowledge was utilized to develop the inventory. The purpose of the CPAOI is for immediate screening for medical and intervention services. The first section of the inventory is devoted to family history. Parents complete this section, providing information for siblings who have a diagnosis of autism. Birth order of siblings should be identified. Medical information related to the infant’s birth is extremely important. Brain circumference at birth should be recorded and thereafter in 6-month intervals, until 2 years of age. Prematurity, low birth weight, muscle tone, hyperbilirubinemia, phototherapy, respiratory distress, terbutaline (Brethine), acetaminophen, glutamatergic dysfunction, vitamin D deficiency, and seizures are other pertinent birth history that should be carefully examined. Selected items included are considered the most relevant for identification of social behavior abnormalities and developmental skills. It is

T

3

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The Cowden Preautism Observation Inventory

important to recognize skills that should be acquired, in addition to observation of different or unpredictable behaviors. They are classified as core areas of infant development: • Cognition/Prelanguage (34 behaviors/skills) • Social-Communicative-Play (34 behaviors/skills) • Sensory Motor Skills Visual System (18 behaviors/skills) Auditory System (11 behaviors/skills) Tactile System (8 behavior/skills) Vestibular-Kinesthetic Systems (16 behaviors/skills) • Central Nervous System Maturity (Reflexes, Righting Reactions, 10 skills) • Developmental Movements (15 skills) • Fine Motor Development (20 behavior/skills) Specific attention was given to abnormalities of social orienting of infants throughout all sensory systems. Lack of attraction to people, facial expressions, or emotional responses to others were strongly emphasized in each core area of infant development. The inventory includes early signs of central nervous system immaturity and atypical developmental movements. For the purposes of this book, preautism is defined as the period from birth to 1 year old. An infant is born with signs of preautism, and all research indicates that autism is genetic. There are signs of immature neurological development, and the infant was most likely born premature and with low birth weight. From the very beginning of life, the infant appears distant, unresponsive, and detached and has an inability to relate to others. There is no cooing or babbling. Language will not develop, and the child will remain completely nonverbal. The infant does not respond to gestures or to his own name. There is no eye contact with anyone, and the infant’s eyes appear to focus to the side of his face rather than straight ahead. Interest is shown in inanimate things. There is no focus on new toys, shared enjoyment, fun, or affection to anyone. The infant lacks facial recognition or any facial expressions. Joint attention with family and play does not exist. An infant exhibiting signs of preautism is obsessed with lining up toys or objects, at times from smallest to the largest, or other times

Understanding Autism

5

attention may be given to stacking blocks as high as possible. When the blocks fall, the infant will repeat the procedure over and over again. Any disturbance in selected routines will be upsetting to the infant or toddler. The CPAOI is presented in the first chapter so that concerned parents can easily find the inventory. Parents should carefully read the CPAOI and observe their infant to confirm whether there may be problems related to preautism. A description of the CPAOI follows with simple instructions for recording observations. COWDEN PREAUTISM OBSERVATION INVENTORY (CPAOI) Birth to One-Year-of-Age NAME ________________ DATE OF BIRTH ______ DATE OF EXAM ______ OBSERVER ___________ FAMILY PRESENT _________ OTHER __________ CHRONOLOGICAL AGE _____ DEVELOPMENTAL AGE _____ SEX _____ Medical Information Brain Circumference Birth _____ Six mos _____ One yr _____ Two yrs _____ (Size inches) Premature

Age _____ Adjusted age _____

Birth Weight

Lbs _____ Ozs _____ Apgar score _____

Muscle Tone

Hypotonic _____ Hypertonic _____ Variable _____

Birth Complications Hyperbilirubinemia

Present _____ Describe _____________

Phototherapy (time under lights)

Present _____ Describe _____________

Respiratory Distress (time in seconds)

Present _____ Describe _____________

Seizures

Present _____ Describe _____________

Moebius Mouth (tented upper lip & flat lower lip)

Present _____ Describe _____________

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The Cowden Preautism Observation Inventory

Was terbutaline administered for premature labor? _______________________ Describe complications during delivery. _________________________________ Was oxygen administered during the first week of the infant’s life? _________ Why? _______________ Did the infant display typical behaviors and then atypical behaviors began? ________________ Describe the change in behaviors or movement disturbances. ______________ Did the infant ever appear to ignore, act out or not hear sounds? __________ Were there specific concerns in the infant’s health during the first 3 months? ____________________ Does the infant have siblings with a diagnosis of autism? _______ Age _______ Describe other specific concerns. ________________________________________

Section 1 Cognition/Prelanguage

Present

Absent Emerging

Comfort sounds (0–2)

______

______

______

Infant explores environment visually (0–5)

______

______

______

Calm interest in sights, noise, voices (0–3)

______

______

______

Sucks well from breast or bottle (0–2)

______

______

______

Makes sucking sounds (0–2)

______

______

______

Laughs (1.5–4)

______

______

______

Squeals to express delight, excitement (2.5–5.5)

______

______

______

Seeks social attention with looks, vocalizations and gestures (3–8)

______

______

______

7

Understanding Autism Present

Absent Emerging

Indicates awareness of strange situations (3–6)

______

______

______

Happy smiles (2–5)

______

______

______

Vocalizes randomly-cooing (2–7)

______

______

______

No cooing. Cooing started, stopped (2–7)

______

______

______

No babbling (4–8)

______

______

______

Rocks excessively in crib (1–6)

______

______

______

Searches with eyes for sounds (2–3)

______

______

______

Finds partially hidden object (4–6)

______

______

______

Responds to name (5–8)

______

______

______

Listens to familiar words (5–6) (pet’s name, sibling’s name)

______

______

______

Distinguishes between friendly and angry voices (5–7)

______

______

______

Responds to facial expression & responds to emotional intent of speaker (6–7)

______

______

______

Infant physically explores surroundings (6–11)

______

______

______

Works to obtain out-of-reach object (5–9) (pivot, roll, wiggle, crawl)

______

______

______

Hand gestures conveying intentions (4–10)

______

______

______

Response to simple requests with gestures (7–12)

______

______

______

Waves bye-bye (6–9)

______

______

______

Plays with paper (7–9)

______

______

______

8

The Cowden Preautism Observation Inventory Present

Absent Emerging

Slides toys in play (6–11)

______

______

______

Imitates new gestures (9–11)

______

______

______

Social pointing (Initiate by 10–12)

______

______

______

Social back and forth babbling (9–12)

______

______

______

Eye contact (Must be present with gestures)

______

______

______

Shift of gaze (Follows gestures with eyes)

______

______

______

Joint attention—triadic connection (Child excitement, object/event, person)

______

______

______

Moves arms symmetrically (0–2)

______

______

______

Self-engaged with object (0–3)

______

______

______

Infant turns eyes toward light source (0–5)

______

______

______

Smiles spontaneously (1–4)

______

______

______

Gleam in eyes showing joy (2–5)

______

______

______

Brings hands to midline in supine (1–4)

______

______

______

Activates arms on sight of toy (1–3)

______

______

______

Begins play with rattle (2–5)

______

______

______

Grasps toys actively (2–4)

______

______

______

Shared attention—looking, turning toward sounds (0–3)

______

______

______

Infant responds to a voice outside of field of vision (0–5)

______

______

______

Section 2 Social-Communicative-Play

9

Understanding Autism Present

Absent Emerging

Expressions of intimacy/relatedness (2–5)

______

______

______

Infant reaches out in preparation to be picked up by mother (4–8)

______

______

______

Sustained engagement or expressions of joy (2–5)

______

______

______

Infant explores adult facial features (0–5)

______

______

______

Infant discriminates between familiar people and strangers (6–11)

______

______

______

Plays pat-a-cake & peek-a-boo games (6–12) ______

______

______

Demands shared social interactions (10–18) ______

______

______

Seeks social environment (4–12)

______

______

______

Lack of interactions or responding (4–10)

______

______

______

Infant seems to remain in a shell (4–12)

______

______

______

All play is solitary and repetitive (2–12)

______

______

______

Watches speaker’s eyes-mouth (1–5)

______

______

______

Plays with another infant (3–6)

______

______

______

Self-absorption—withdrawal (2–5)

______

______

______

Enjoys frolic play (4–8)

______

______

______

Enjoys being alone

______

______

______

Plays with a single toy or routine object (6–9)

______

______

______

Lines up toys in a routine (ritualistic) (Lines up crayons instead of coloring)

______

______

______

Stacks blocks incessantly

______

______

______

10

The Cowden Preautism Observation Inventory Present

Absent Emerging

Simple relational play (9–12) (Combines two objects, spoon to cup)

______

______

______

Infant tries to imitate others (10–15) (Uses props to imitate sweeping floor)

______

______

______

Unpredictable, impulsive behavior (4–10)

______

______

______

Repetitive behaviors (10–18)

______

______

______

Looks through parent (1–12)

______

______

______

Alertness (Newborn–2) (Easy to engage, looks at colorful objects)

______

______

______

Lack of sustained attention to sights (0–3)

______

______

______

Awareness (Newborns–2) (Follow moving person with eyes in supine)

______

______

______

Tracks with eyes to midline (2–3)

______

______

______

Tracks past midline, downward (2–3) upward, 180 degrees

______

______

______

Eye contact (Should make brief eye contact during feeding and not look through person) ______

______

______

Visual tracking (Tracks moving ball momentarily)

______

______

______

Reacts to disappearance of slowly moving object (2–3)

______

______

______

Tracks with eyes without head movements (4–6)

______

______

______

Section 3 Sensory Motor Skills Visual System

11

Understanding Autism Present

Absent Emerging

Looks at tiny objects (4–6)

______

______

______

Looks at distance objects (5–6)

______

______

______

Reaches and grasps an object (5–6)

______

______

______

Visual attachment to object

______

______

______

Defensiveness (Oversensitivity to light)

______

______

______

Distractions (Inability to attend to multi-stimuli)

______

______

______

Sensitivity (Avoids glaring lights or eye contact)

______

______

______

Visual fixation (Eyes focus on light or appear to inspect an object) ______

______

______

Section 4 Auditory System Responds to sounds (0–1) (Startles and shows responses to sounds Acuity appears appropriate)

______

______

______

Listens to voice for 30 seconds (1–3)

______

______

______

Looks for sounds (2–4)

______

______

______

Turns to voice (3–5)

______

______

______

Awakens or quiets to mother’s voice (3–6)

______

______

______

Turns eyes and head to sound of hidden voice (3–7)

______

______

______

Responds to name (5–7)

______

______

______

Localizes sound with eyes (3–5) (Responds to sound of voice, looks for sound source, looks to side, below)

______

______

______

12

The Cowden Preautism Observation Inventory Present

Absent Emerging

Sustained attention to sounds (0–3)

______

______

______

Ignores sounds as if not heard (0–12)

______

______

______

Unusual alertness (6–12) (Loud sounds cause yelling or infant appears not to hear sounds, ignores, shuts-down)

______

______

______

Cuddling pleasurable (Newborn–6)

______

______

______

Quiets when picked up (0–1)

______

______

______

Shows pleasure when touched (0–3)

______

______

______

Hands to mouth exploration (3–6)

______

______

______

Obsessed with feeling textures (3–6)

______

______

______

Likes to be held (0–12)

______

______

______

Prefers to be alone

______

______

______

Tactile defensiveness (Newborn–12) (Does not like to be stimulated by touch)

______

______

______

Hypotonic muscle tone (mushy)

______

______

______

Head lag when pulled to sitting (3–5)

______

______

______

Poor visual tracking (2–9) (Does not track past midline & track objects)

______

______

______

Section 5 Tactile System

Section 6 Vestibular-Kinesthetic Systems

13

Understanding Autism Present

Absent Emerging

Rocks in crib

______

______

______

Self-stimulatory behaviors (0–3)

______

______

______

Delayed inhibition of tonic neck reflexes (4–6)

______

______

______

Poor righting reactions (6–8 not present)

______

______

______

Upright sitting (Falls to side and forward often hitting face)

______

______

______

Obsessive rolling and rocking

______

______

______

Demonstrates repetitive twirling/circling movements with string or grass

______

______

______

Extremely messy eating habits

______

______

______

Integration of biting reflex (3–5)

______

______

______

Closes lips on spoon to remove food (6–8)

______

______

______

Finger feeds small pieces of food (9–11)

______

______

______

Bites and chews crackers (9–11)

______

______

______

Over or under reaches for object (4–6)

______

______

______

Reflexes (Birth-disappear by 4–6 mos)

______

______

______

Flexor Withdrawal (1–2) (Pulls leg up when sole of foot scratched)

______

______

______

Extensor Thrust (2–4) (Does not extend legs when pressure applied to soles)

______

______

______

Section 7 Central Nervous System Maturity

14

The Cowden Preautism Observation Inventory Present

Absent Emerging

Asymmetrical Tonic Neck (Turn head to side, arm extends on face side, arm flexes behind head)

______

______

______

Symmetrical Tonic Neck (Raise head in 4-point crawl position. Arms extend forward, legs flex Flex or lower head, arms flex, legs extend)

______

______

______

Tonic Labyrinthine—Prone (Infant demonstrates increased flexion of arms and legs)

______

______

______

Tonic Labyrinthine—Supine (Infant demonstrates increased extensor of extremities)

______

______

______

______

______

______

______

______

______

______

______

______

Tilt Reaction (7–8) (Infant is held vertical. Tilt about 45 degrees from vertical. Head should be held vertical indicating head righting.) ______

______

______

______

______

Righting Reactions Neck Righting (0–2) (Head turned to side when supine, body automatically rolls in same direction) Protective Extension (Appear by 6–8) Arms downward (6–8) (Extends arms symmetrically to front) Arms to side (6–8) (Extends arms symmetrically to side)

Section 8 Developmental Movements Head control (0–2) (Does not lift head in prone position)

______

15

Understanding Autism Present

Absent Emerging

Head lag when pulled to sitting

______

______

______

Rolling (6–8) Corkscrew-segmental motion

______

______

______

______

______

______

Sitting (4–6) Non-supported (Falls over easily, usually forward)

______

______

______

Crawling (6–8) Used arms and legs on tummy

______

______

______

Creeping (9–11) Creeps on hands and knees (Four-point position)

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

At what age did infant learn to walk alone

______

______

______

Arms held in high guard arm position

______

______

______

Tiptoe gait

______

______

______

Uneven arm swing-one arm held in place

______

______

______

Stiff-like, short step gait (Parkinson’s gait)

______

______

______

Arched back when trying to roll

Normal changes from creeping to standing, to walking Standing (11–13) Stands with no attempt to move Stands—begins to cruise Walking (10–14)

16

The Cowden Preautism Observation Inventory

Section 9 Fine Motor

Present

Absent Emerging

Regards colorful object few seconds (0–1) near chest

______

______

______

Looks with eyes at moving person (1–2)

______

______

______

Move arms symmetrically (0–2)

______

______

______

Brings hands to midline in supine (1–3)

______

______

______

Blinks at sudden visual stimulus (2–3)

______

______

______

Activates arms on sight of toy (1–3)

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Inspects own hands (2–3)

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Follows with eyes past midline (2–3)

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Grasps toy actively—voluntarily (2–4)

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Reaches for toy without grasping (2–5)

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Grasp reflex inhibited (3–5)

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Uses palmar grasp (3–5)

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Follows with eyes without moving head (4–6)

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Reaches and grasps toy (4–6)

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Motor Planning (4–6) (over or under reaches for an object)

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Places both hands on bottle (4–6)

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Watches adult scribble (5–6)

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Tries to imitate scribble (10–12)

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Understanding Autism Present

Absent Emerging

Removes round piece from form board (10–11)

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Stacks blocks incessantly (As high as child can reach)

______

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______

Process and Administration To obtain valid information about the development of infants, especially in social and communicative behaviors, several methods should be used. Most often methods will vary from child to child. Most family observations using the CPAOI will include detailed comments. Transactional assessment involves observation and interview techniques to assess the physical environment. Interactions among the child, parent, caregiver, and other professionals must be recorded. Arena assessment is another method that should be considered, especially for infants. One examiner, the facilitator, administers inventory items while other team members observe the infant’s behaviors and skills. Each person records observations that will be shared with the team. One team member is usually responsible for implementation of the actual intervention goals. All observation sessions should be video recorded so video may be examined by session participants. Professionals not present may be able to provide valuable information regarding the infant’s behaviors after viewing the recordings. It is anticipated that much information will be obtained from the recordings that may have been missed during administration sessions. Administration Area The CPAOI should be administered in a comfortable area, utilizing the developmental, individual-difference, relationship-based Floortime model (Greenspan & Wieder, 2006). This approach allows for critical interaction features, warmth, security, relatedness, engagement, emotional signaling, and gesturing. Essential to the development of mind and brain is the development of interactions, sensory motor processing, and motor planning. The observer should select a play-based, interactive space that allows for ability to accurately read, interpret, and

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respond to the sensitivity of the infant’s mood and movements. Developmentally appropriate toys should be incorporated in the playbased area. Levels of family participation are determined by the parents, observer, or administrator of the inventory. The number of sessions may vary, but at least two different sessions should be utilized for inventory observations. It is anticipated that the inventory will allow for an accurate profile to be developed of normal and abnormal social behaviors, prelanguage or communication, and sensory motor skills. Recording Observations Recording methods include recognition of signs, providing age in months, length of time (minutes/seconds), circumference of head size, or other appropriate descriptors. Typical behaviors may not appear or atypical disturbances may become apparent. Signs may be noticed forming clusters of critical information needed to diagnose infants at risk for preautism. No symptom is considered irrelevant. Identifying signs of preautism is the goal so that objectives can be written using specific criteria for functioning outcomes. A mark of (+) should be recorded when the behavior is present and an (O) when the behavior/skill is not seen by the observer. If a preautism sign is thought to be emerging, an (E) should be recorded for emerging development. All measurements such as time, age, or descriptors of how the behavior/skill was attempted should be recorded. Mood or excitability of infants should be noted before, during, and after the administration sessions. Relationship of the infant to the parent or caregiver is also one of the more important behaviors to observe throughout the entire administration of the inventory. A person is designated to record the behaviors while the lead administrator of the CPAOI is giving direct attention to the infant. Team cooperation is very important. If time is taken to look away from the infant, valuable information may be missed during the session. A parent(s) should be present during the observation sessions, but final decisions should be made jointly with other team members. Signs that were found to be atypical or indicate developmental delays should be addressed by developing behavioral objectives. Screening items should be used as criteria for establishing an appropriate, individualized plan, including sensory motor skills. Activities may be di-

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rected by the examiner/observer and implemented by parents or the caregiver. All observations and concerns by family and professionals are extremely important. Videos and family pictures will assist with creating an ever-changing picture of infant development throughout the first year of life. When a behavior is observed, the date, time, place, and observer should be recorded. Several different individuals will be caring for an infant, and everyone’s input is critical. It is emphasized that videos should be recorded in multiple environments. Careful consideration should be given when interpreting screening results and symptom measurements in infants under the age of 12 months. There is always a level of uncertainty by examiners. However, timely intervention is of the utmost importance. Providing any basis of false hopes to families seeking information about their infant can be extremely detrimental. In addition, parents should be helped to find appropriate interventions, support programs, and other treatment options. The American Academy of Pediatrics (Zwaigenbaum et al., 2009) suggested that early intervention for at-risk infants should include initiative activities for exploration, nonverbal intentional, communicative acts, and reciprocal play with social partners. Areas for intervening should be performed in natural learning environments. The “Floortime” Approach Greenspan and Weider (2006) detailed early stages and signs of ASD in infants and young children. The Developmental Individual-Difference, Relationship-Based (DIR) Model/Floortime approach is recommended as a method of intervention for foundations of relating, communicating, and thinking. “Floortime” is the main strategy in the DIR Model. This approach details signs of “shared attention and regulation (begins 0–3 months), engagement and relating (begins 2–5 months), purposeful emotional interactions (begins 10–18 months), and creating ideas (begins 18–30 months)” (p. 30). This model has been proven throughout time to be very successful with infants and young children. Several sessions are required to establish a baseline for intervention, comparing any differences in the clinician’s observed DIR Model/ Floortime approach with family comments. A review of developmental and medical history is required. Sessions are devoted to observing

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The Cowden Preautism Observation Inventory

Figure 1.1. “Floortime” Model is used for assessment of infant as he explores toys.

interactions of parents and/or caregivers with young children. If the infant/child indicates interest, he should be allowed to select preferred toys for play. Sessions should be conducted involving arena assessment, which includes all professional disciplines performing evaluations during the process. A tailored profile can be established for all functioning development areas. This approach allows for determination of processing of facial problems and expressions and not just immediate symptoms. Auditory hearing and comprehension, visual motor responses, and motor planning and sequencing can also be examined (Figure 1.1). This author has observed Dr. Greenspan during a presentation of the DIR Model/Floortime approaches. The DIR Model was used for the basic design of program implementation at The University of New Orleans Motor Development Clinic with infants (6 months to walking) for more than 10 years. There were eight 30 to 45 minute sessions conducted on Saturday mornings. Teaching stations were set up on the floor of two large gymnasiums for involved infants with multidisabili-

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ties, including preautism. Graduate assistants and students, family, and siblings were with the infants during screening and intervention. Home programs were recommended for behaviors, strength, flexibility, and motor skills. Instructional objectives and plans were provided as “homework” for families. Parents or caregivers were questioned about their home participation using recommended activities. The most motivating factor for families and students was successful achievements of many infants taking their very first, upright steps. Modification of behaviors of other infants was the overall objective. Often infants and young children would perform intervention activities better than other children. This motivated parents to practice home activities with their new baby (Cowden, Sayers, & Torrey, 1998; Cowden & Torrey, 2007). REVERSAL OF THINKING

Using the CPAOI, preautism can be assessed during the first year of life. This statement was made in the Preface and is repeated to emphasize the reversal of thinking that must happen. There are clinical indicators that can form a cluster of symptoms, signaling to the family and physicians that the baby is at high risk for developing autism. These symptoms may be derived from a combination of problems experienced by the mother (prenatal), distress for the fetus during pregnancy and labor (perinatal), and during the neonate (newborn) stages of development. These complications have been associated with infants later identified with preautism. The CPAOI includes items that will screen for an infant at risk for preautism. Some indicators should raise immediate red flags for pediatricians, and others will become noticeable to the family of the infant during the first few months of life. Early intervention with diagnosis at 2 years of age is simply not early enough to adequately provide help for the developing brain and neurological system of the infant. We need to change our way of thinking. Examining infants’ early movements can lead us to recognize delays caused by neurological problems of the central nervous system. The time period from birth to 1 year of age is critical for brain development. During this period, infants determined to have signs of preautism should receive sensory motor intervention, providing stimulation that can affect neurological reorganization. The

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The Cowden Preautism Observation Inventory

development of preautism can be slowed and the severity of the syndrome reduced. Genetic Predisposition Autism has a genetic predisposition. All chromosomes involved that predetermine chances for having an infant with preautism have not been identified at the time of publication of this book. However, screenings of families having more than one child with autism strongly suggest that more than 10 genes interact to cause autism (Blaylock & Strunecka, 2009; Meldrum, 2000). It may be interpreted that some infants may be genetically more vulnerable to environmental exposures. However, some families have one child with autism, a second infant, and possibly a third child with autism. It is quite possible for a family to have a second child before the first has even been diagnosed with autism. This fact is staggering. In the past, most children were not identified as having autism until they became eligible for diagnosis and placement in early intervention programs for 2-year-olds. Parents often noticed if their child seemed a little different at birth. The child may have been unresponsive or may have focused intently on an object for extended periods of time. Sometimes a child who seemed to be developing normally occasionally made sudden dramatic changes. A babbling infant became silent, withdrawn, and sometimes self-abusive. Parents are capable and accurate in their concerns. Their information is critical to a diagnosis of preautism. Immature Brain Development Autism is a neurobiological problem with immature brain development. An interaction of neonatal complications and genetics results in a greater incidence of autism. The brain has the ability to change in response to sensory stimulation and the demands of the environment, which is termed brain plasticity. It has the ability to reorganize neural pathways. The brain has the capacity to change structure and function, so if functionality is lost, the process is reversible. Neural pathways may overlap or one pathway may take over another’s function. An infant with autism may have decreased skills; however, these are changes that can be improved. The immature brain can organize itself and

Understanding Autism

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compensate for loss of function and thus adapt. As soon as the child is determined to be at risk for autism, sensory motor intervention can be initiated, which will help with brain reorganization and sensory system development. Evidence over the past 20 years indicates that intensive early intervention by therapists, parents, and teachers in optimal settings has made a dramatic impact on reducing the severity and symptoms of autism. The overall outcome for most young children is exciting and impressive. EARLY EXPECTATIONS

Careful observation of the infant’s early movement patterns provides much information about the functioning level. Muscle tone is the most important factor guiding assessment. Too little or too much tone will influence early movements. Families should watch intently to see when their infant first lifts his head, rolls over, pulls to sitting position, sits with no support, and assumes a four-point position on hands and knees for creeping. In the case of infants at risk for autism, muscle tone may be variable with more hypotonic or flaccid tone. Many developmental stages may be delayed or appear to be abnormal. There are disorders in early movement patterns associated with tone, reflex integration, and equilibrium reactions. These are important signs of sensory motor integration problems of the central nervous system. These problems of movement are also associated with descriptions of various malformations of the developing brain (Chapter 3). Initial pathological processes can be detected at an early stage by the presence of increasing symptoms. Interventions can be tailored during the first few months based on movement disturbances (Ozonoff et al., 2009). These movement disturbances have been described by Teitelbaum and Teitelbaum (2008) as “easy to recognize precursors of autism.” There has been a tendency in most research to overlook these disturbances, paying only specific attention to communication and behavioral-social problems. The Teitelbaums’ premise is simple. If abnormal motor behavior is observable in children at an older age, then crucial signs can be detected in infants at a few months of age. Autism is considered a social, behavioral, and communication disorder. However, a key to early diagnosis of the autistic-child-to-be-kids may be early assess-

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The Cowden Preautism Observation Inventory

Figure 1.2. Symmetry of infant skills is demonstrated while holding ball.

ment of symmetry, reflexes, righting, crawling, and sitting (Teitelbaum & Teitelbaum, 2008) (see Figure 1.2). THE STRUGGLE

Imagine the following—a tiny infant lying on his stomach with his right arm trapped beneath his chest. The arm appears weaker, and all reaching is done with the left arm. He attempts to move forward while reaching for a small toy. However, because he cannot move his thighs forward toward his stomach, he is simply stuck in place.

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Parker was 3 months old in the described position. He looks as if he doesn’t see us at all. It appears that he lives in isolation. Parker exists in a world that his parents notice but do not understand. He started to coo at 3 months; however, that small and important sound soon disappeared, leaving him silent. At 4 to 5 months of age, there was hope that Parker would make babbling vocalizations; however, no sounds appeared. No bah, mah, or gurgles and giggles of loud laughter occurred. Sounds that should have been happening simply did not occur. The pregnancy was the mother’s third; however, this was her first infant to be delivered alive. He was premature, and phototherapy was used for a jaundice condition. There were other neonatal complications associated with autism, including: hyperbilirubinemia, premature birth, low birth weight, asphyxia, and respiratory distress (Cowden & Torrey, 2007; Cowden, Sayers, & Torrey, 1998). From the very beginning, Parker gazed into space as if no one was there. He paid attention to a door knob, yet gave no visual awareness of movement in his environment. He made no eye contact with anyone. Parker’s strengths and weaknesses had to be intently watched to help him learn. The doctors had said that Parker was most likely severely mentally retarded. However, his mother simply could not accept such a quick diagnosis. She spent every waking moment with Parker and observed skills that indicated a high level of intelligence. She was not convinced that her baby had a severe disability. What is this state of interest in nothing? Why such attraction to an object rather than to his mother? After Parker discovered a way to move, he would simply find a spot he liked and move in a circle around it . . . over and over. What is this strange willed movement, lack of social interaction or communication, and distant looks through people into nowhere (Park, 1995; Teitelbaum, Teitelbaum, Nye, Fryman, & Maurer, 1998)? Infants with autism have been referred to as puzzle children. Seeking answers to help them change is similar to the process involved with solving a crossword puzzle. You go with the answers that you have, and each answer provides further clues for the next step. “The answers do not simply come out of just one book . . . or purely from the results of one specific research approach . . . the answers come from many sources” (Gold, 2002). Three considerations were suggested for neurodevelopment treatment. First, if an infant with autism experiences a

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The Cowden Preautism Observation Inventory

problem in one part of the brain, how does this affect other parts of the baby’s neurological system? What may he be experiencing in his world? Second, if we continue to treat these infants and young children as if they experience their world as most people do, then we have placed impossible demands on them. Third, if we still consider dysfunctional actions in the brain as a final prognosis, this is an erroneous concept. Today, we know that plasticity allows for the brain to change and to reorganize neural pathways. It is important for parents and professionals to understand that if the brain begins to lose functionality, the loss is reversible. From the perspective of the child with a delay, these are changes that can be improved. We can learn new skills based on brain reorganization in response to sensory stimulation, substitution, and new experiences. The earlier intervention begins in the home with the family and their recognition of clinical indicators, signs, and symptoms, the sooner the family will have an understanding that something could potentially be wrong with the development and early movements of their infant. Many simple and easy activities/exercises can be done to help with reorganization of the brain and the infant’s sensory systems (Chapter 5). Many other simple activities are provided for weak muscle tone and reflex integration, which is a very strong part of intervention before 6 to 8 months of life (Cowden & Torrey, 2007). Therefore, we must develop new ways of thinking and understanding that early sensory stimulation can affect positive, neurobehavioral changes in the newborn and young infant (see Figure 1.3). PREVALENCE

ASDs must be considered a crisis and an urgent public health concern. New statistics estimate the prevalence of autism to be 1 percent of American children (Kogan et al., 2009). Autism may be considered one of the most devastating disorders of childhood due to its prevalence, morbidity, outcome, impact on the family, and cost to society. The rate of autism is 1 in 91 of American children, and 1 in 58 are boys. This is a rise in rate from the previous 2002 prediction of 1 in 150. Based on the 2009 report, it is estimated that 673,000 children

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Figure 1.3. Newborn experiences sensory stimulation playing with toys.

between the ages of 3 and 17 have a current diagnosis of autism. The rise in incidence and prevalence may be due to increased recognition of environmental contributions, early medical diagnosis, family and educational awareness, and improved assessment and methodology of studies. The odds of boys having autism are four times higher than girls, with white children being more likely to have the condition than black or multiracial children. The average age of diagnosis of autism is decreasing. Understanding prenatal, perinatal, and neonatal development of autism provides knowledge to the underlying causes (Charman & Stone, 2008; Rice, 2002, 2006) (see Figure 1.4).

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Figure 1.4. African American infants are less likely to have autism.

FORMAL CRITERIA

The formal criteria for determining the presence of autism is found in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM–IV; American Psychiatric Association, 2000) and the International Classification of Diseases (ICD–10; World Health Organization, 1999). Based on these instruments, a child must show abnormalities before 3 years of age in social interaction and language as used in social communication or symbolic/imaginative play. This diagnosis must focus on the history of the child’s development and observation of the child’s behavior. Absence of typical behaviors and presentation of atypical behaviors at this early age become problematic. It is extremely important to examine the components of gaze and face processing and determine abnormalities observed in infants at risk for signs of autism (see Figure 1.5).

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Figure 1.5. Delight is displayed by infant to family members.

Most clinicians are not acquainted with signs from birth to 2 years of age nor do typical office visits allow for critical observations and assessment. Perhaps this is why parents are most often the first to recognize that something is different in the development of their child. Unfortunately, a simple blood test cannot be used for the diagnosis of autism as with many other conditions (Chawarska, Klin, & Volkmar, 2008; Chawarska, Volkmar, & Klin, 2010; Volkmar & Wiesner, 2009). Using the present criteria, a diagnosis is unlikely to be made before the child indicates delayed or impaired language at 3 years of age. Acquarone (2007) stressed that with a diagnosis based on DSM–IV, a child having difficulty with communication during the first year of life would potentially miss out on much-needed early intervention services. There are early warning symptoms, and many occur before the infant is 6 months old, especially in the way the infant displays interest and coordinates moving and exploring his environment (see Figure 1.6). Because DSM –IV was not designed for use with children under the age of 2 years old, the American Academy of Pediatrics (Zwaigen baum et al., 2009) reviewed the challenges of determining best prac-

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The Cowden Preautism Observation Inventory

Figure 1.6. Early coordination and exploratory movements are demonstrated.

tices for diagnostic assessment of preautism before 2 years old. An initial framework for early diagnosis of possible autism in infants and toddlers was suggested along with determining the focus of interventions. Early interventions should include natural learning environments and child-initiated activities for sensory motor exploration. Development of nonverbal intentional communicative acts and reciprocal play with social partners should be stressed (see Figure 1.7). The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM–V) scheduled release date has been extended to May 2013, allowing more time for public review. This will coincide with the release of revisions of ICD–10, possibly in 2014. The proposed changes to DSM–V have many professionals concerned with vague diagnostic wording for the new manual and the loss of Asperger’s syndrome. Fears are confirmed that infants and young children will remain undiagnosed. The subjectivity of the criteria should be elaborated in an explanatory text where autism within a hierarchy of severity appears to be missing. It is as if time stands still for the families and professionals needing immediate change to provide appropriate screening, assessment, and

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Figure 1.7. Infant initiates exploratory movements in natural environment.

early intervention services. Perhaps, for now, everyone needs to think “outside the box” to create plans for current screening instruments and effective intervention techniques during the delayed writing of new guidelines affecting children with autism (see Figure 1.8). In some cases, autism can be diagnosed by the time the child reaches 18 months old, although more and more studies are suggesting that autism can be clearly detected from birth to 6 months old (National Institute of Neurological Disorders & Stroke, 2009; National Institute of Mental Health, 2007; Teitelbaum & Teitelbaum, 2008; Volkmar & Wiesner, 2009; Wiseman, 2009). Due to increased media coverage and rapidly expanding research publications, the American Academy of Pediatrics published clinical reports ( Johnson, Myers, and the Council on Children with Disabilities, 2007; Zwaigenbaum et al., 2009) to assist pediatricians with the early identification of autism. The report provides information including history, diagnostic criteria, definitions, and early signs for recognition of infants who may have autism. Because parents have become more aware and are usually the first to notice unusual behaviors in their infant, it is essential that all pediatricians become educated to provide strategies for assessing and manag-

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The Cowden Preautism Observation Inventory

Figure 1.8. Professionals must develop screening instruments and think “outside of the box.”

ing infants with autism. Their knowledge should include educational and community resources. The American Academy of Pediatrics has also developed and distributed several documents to support pediatricians in the identification and care of children with autism. They include: “Autism A.L.A.R.M.” ( Johnson, 2004); “Is Your One-Year-Old Communicating with You?” (American Academy of Pediatrics, 2005); “Management of Children with Autism Spectrum Disorders” (Myers & Johnson, 2007); and “What Are Autism Spectrum Disorders and What Are the Symptoms?” (American Academy of Pediatrics, 2010). When parents become concerned about early unusual developmental movement patterns and social communication problems of their infant, they should be able to obtain documents from their pediatrician to help them become better in formed. The National Institute of Neurological Disorders and Stroke (NINDS) condensed an Autism Fact Sheet (2009). They refer to autism as “classical autism.” The Institute lists three distinctive behaviors.

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Children with autism have difficulties with social interaction, display problems with verbal and nonverbal communication, and exhibit very unusual repetitive behaviors. The NINDS (2009) concluded there is no cure for autism. However, children’s neurobehavioral skills improve with age, and the Institute believes that the hallmark feature of autism is impaired social interaction. The Institute strongly suggests that there is a genetic predisposition to autism. They have found several abnormalities in brain development caused by genes that control brain growth and suggest that infantile autism could result from unusual neurological changes early in fetal development. The Institute negates the theory that parental practices are responsible for autism (NINDS, 2009). The key to detecting infantile autism and Asperger’s syndrome (a milder form of autism) lies in observing and analyzing infants’ positions and the resulting attempts at movement, rather than waiting until the child displays abnormal motor development and social behaviors in school. Based on an understanding of brain plasticity and the development of the nervous system, early diagnosis provides the opportunity for earlier specific suggestions for treatment and developmental activities. Research by the Teitelbaums (2008) indicates that assessment of infants will allow for early intervention, which ultimately leads to a better outcome. Home videos were used to study early infant movements and detect early motor development problems, including asymmetrical patterns in the infants’ movements, lack of the ability to develop a segmental rolling pattern, difficulty in assuming a creeping pattern, followed by what was suggested as the “clumsy child syndrome.” Early movement patterns that provide evidence or indications of preautism from birth to 6 months old will be examined in Chapter 4. These are movement problems that are clearly observable by parents, medical doctors, and early intervention professionals. This author believes the way to prevent so many children and their families from severe destruction of their lives is to provide early assessment at the infant/birth age and to intervene immediately with appropriate social, communication, prelanguage, and sensory motor programs. Parents must be trained to detect early problems and be able to ascertain that there may be a significant problem. Pediatricians, occupational therapists, physical therapists, and early intervention spe-

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cialists must become more aware of the clear indications of infantile autism. WHY DOES MY CHILD HAVE AUTISM?

Genetic and environmental factors are currently considered as the primary cause (Dawson, Sterling & Faja, 2009; Folstein & RosenSheidley, 2001; Herbert, 2010; NINDS, 2009). Neurological immaturity (a failure of the brain to develop appropriately), and prenatal, perinatal, and neonatal complications have recently been identified as frequent in infants later diagnosed with autism. Incidence and interaction between neonatal complications and familial factors resulted in greater incidence of autism, and gene-environment interactions may also contribute to prevalence increases (Cowden & Torrey, 2007; Froeber, 2009; Dawson, 2008; Herbert, 2010; Larsson et al., 2005). Studies are underway to determine chromosome linkage and autism susceptibility. Certain genes in autism include those that play a role in early fetal and brain development. Chances for improved brain and behavioral development will be increased, and the full syndrome of autism may be prevented (Dawson et al., 2009; Zwaigenbaum et al., 2009). Advanced paternal and maternal ages have emerged as significant factors related to the birth of infants who may show signs of preautism. A 10-year increase in paternal age demonstrated a twofold increase in the risk of autism. Mothers over the age of 35 have increased risk for numerous obstetric problems, which may contribute to prevalence of autism. Birth order is also an important factor. It is conclusive that if you wait to have children, you put your first-born at risk for autism (Grohol, 2009; Kolevzon, Gross, & Reichenberg, 2007; Schendel & Bhasin, 2008). Environmental Factors Environmental factors include elements that change the infant’s brain structure, thus triggering autism. Concerns of increased prevalence of ASDs have been related to environmental causes (Blaxill, 2004). The causes may include toxins, infectious agents, and exposure to thalidomide, valproic acid, pesticides, and viruses. Metals such as lead, aluminum, nickel, and cadmium are also linked to autism. House-

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hold cleaning agents, MSG, and petroleum-based chemicals are considered dangerous environmental factors. Most recently, acetaminophen has been linked to the puzzle of autism (Good, 2009; Herbert, 2010; Schultz et al., 2008; Torres, 2003). Glutathione is a critical antioxidant, and high use of Tylenol (acetaminophen) impairs glutathione metabolism (Kongshavn, 2010). Acetaminophen is commonly used to suppress fever in very young children and depletes glutathione. Controversy does exist among researchers and physicians; however, the fact remains clear that the rise in ASD corresponds with the rise in use of acetaminophen after aspirin was thought to be connected to Reyes Syndrome in 1980. Schultz et al. (2008) noted that acetaminophen was widely used to treat adverse effects of the MMR vaccinations, including fever and rash. Parents were often told to administer Tylenol to infants before they received their MMR vaccines. As early as 2001, the American Academy of Pediatrics (AAP) noted the frequent use of acetaminophen in children. Acetaminophen depletes glutathione, a substance produced in the liver for neutralizing toxins to the body of mother and fetus. Although risk of toxic reactions in drugs was very low, incidents of overdose cases had increased. Inappropriate dosages, toxicity of acetaminophen, genetic differences in infants and young children, chronic diseases, and even delayed treatments for acetaminophen poisoning were linked to an increase in overdose cases. Acetaminophen is in many children’s over-the-counter medicines; therefore, parents should read labels carefully. The AAP suggested recommendations due to the given absence of published safety and efficacy data. A closer examination and more indepth laboratory studies need to be performed on the effects of acetaminophen and other fever-reducing drugs such as ibuprofen. No studies have been reported suggesting the ill effects of ibuprofen relating to autism. Terbutaline (Brethine/Bricanyl) is another environmental factor that needs to be further investigated. Terbutaline is a developmental neurotoxin or short-acting agonist beta 2 adrenergic receptor. The Federal Drug Administration (FDA; 1974) approved terbutaline for use as a medication for asthma, chronic bronchitis, and other lung diseases. The current labeling of terbutaline does not carry sufficient warnings for tocolysis in preterm labor. The FDA (1997) followed by issuing let-

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ters to doctors concerning the dangers of using terbutaline for treatment of preterm labor. Terbutaline has been used off label and extensively enough that it is today an accepted member of the armamentarium tools to treat preterm labor. It is used daily at East Jefferson and most hospitals, to treat preterm contractions. This class of drug that is used to treat preterm labor is known as tocolytics. Most experts feel that tocolytics at best stave off labor for up to 72 hours, which gives time to get steroids on board. They all have a downside and should be used with caution. The most recent citation from ACOG was a 2008 practice bulletin that listed terbutaline as a drug used in the treatment of preterm labor and did not condemn its use. Let’s face it, who does autism affect? It is the preterm baby who ends up in the NICU with phototherapy and many other interventions, one of which is terbutaline used in an attempt to prevent the preterm delivery in the first place. Is terbutaline causative or an innocent bystander? I guess I’m a little cynical, but we went through years of anguish and litigation with Thimerasol in vaccines before it was exonerated. Hopefully, this ongoing prospective study (Centers for Disease Control, 2006) will clear the air. In the meanwhile, I don’t know any obstetricians who have completely abandoned terbutaline. ( J. Hevron, personal communication, August 23, 2010)

The Centers for Disease Control and Prevention (CDC) initiated a 5-year study (2006) for investigation of terbutaline, unborn babies, brain development, and autism. It is a multisite study focusing on maternal-fetal issues during pregnancy, and it involves following the development of 2,700 children. The results of this study will be available in 2011. Andrew Zimmerman, MD, serves as consultant for the CDC study from Johns Hopkins and indicates that there is abundant evidence that autism occurs before birth and is due to genetic factors. There are other external factors of the disease, including pregnancy labor drugs such as terbutaline, infections, and other environmental factors (CDC, 2006; Connors, Levitt, Matthews et al., 2008; Conners, Crowell, Eberhart, Copeland et al., 2005; Herbert, 2010). The popular preterm labor drug, terbutaline, may also leave infant brains more susceptible to exposures of environmental contaminants such as pesticides and mold (Kilburn, Thrasher, & Immers, 2009). Witter, Zimmerman, Reichmann, and Conners (2009) recently published new information regarding the use of beta 2 adrenegic agonists,

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specifically terbutaline. Most likely there is a genetic predisposition to the teratogenic effects for ASDs. In early fetal life and newborns, terbutaline crosses the placenta and blood-brain barrier (BBB) stimulating all tissues of the fetus. During these critical periods of prenatal development, terbutaline can cause developmental malformations. The exact dose and duration of drug exposure that induce severe brain and organ development are not established. However, greater or equal to 2 weeks of continuous high-dosage exposure is likely related to the time of maximum brain development during the second and early third trimester. It is during this time period that ASDs are related to this teratogenesis. Treatment duration should be as short as clinically feasible. When any other alternate drug is ineffective, the risk of not treating the mother and fetus are greater than the use of terbutaline. Terbutaline has recently been identified as a source of concern for its relationship to autism. Until long-term prospective studies are completed, it should be used with caution in treating preterm labor ( J. Hevron, personal communication, August 23, 2010). Other studies on the effects of terbutaline on microglial activation areas of the brain presented results of overstimulation with neuroinflammatory pathways causing behavioral abnormalities that are similar to processes underlying autism. Literature supports the need for further research (Kilburn, Thrasher, & Immers, 2009; Rhodes, Seidler, Abdel-Rahman, & Tate, 2004; Zerrate, Pletnikov, & Connors et al., 2007). Glutamate (glutamatergic dysfunction) is an excitatory neurotransmitter of the brain. It is required for fast synaptic transmission and brain plasticity. Metabolism of glutamate is linked to disorders of the central nervous system, including the increase in the numbers of infants and young children with autism. This disorder may have been long overlooked, especially because it plays an important role in brain functions. Observed alterations of glutamatergic neurotransmissions include: loss of eye contact, deficiencies in neurobehavioral and social functions, repetitive dysfunction, seizure activity, learning and memory, motor coordination, and increased abnormalities of chromosomes. Glutamatergic acid in higher concentrations become neurotoxins ( J. Hevron, personal communication, August 19, 2010). Abnormalities can occur in the architecture of the brain affecting cortical, cerebellar loss of Purkinje cells, enlargement of amygdale, and executive pre-

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frontal lobe functions (see Chapter 3 for discussion of the immature brain). Due to fluctuations of glutamate brain levels during prenatal brain development, the timing can affect outcome of neurological syndromes. The immature central nervous system is extremely sensitive to disturbances in the synaptic environment, especially increases in glutamate receptors, which can cause neurodegeneration. Pregnant mothers exposed to substances such as barbiturates, benzodiazepines, anticonvulsants, and anesthetics trigger degeneration in the developing brain and nervous system. Glutamatergic dysfunctions can cause disruptions that lead to free access of the BBB affecting prenatal development (Blaylock & Strunecka, 2009; Blaylock, 2003; Meldrum, 2000; Purcell, Jeon, Zimmerman, & Prusiner, 1981). Research authorities investigated vitamin D deficiency as a cause of autism during gestation and early childhood (Cannell, 2010; Cannell & Hollis, 2008; Currenti, 2010; Herbert, 2010; Herndon, DiGuiseppi, Johnson et al., 2009). Young children do not meet national recommendations for daily intake of vitamin D partially because of medical advice to avoid sun exposure. Calcitriol is an active form of vitamin D, which plays an important role and is responsible for early components of brain growth. Calcitriol serves as a shift or change of direction in brain tissue influencing genes for powerful brain growth. It has been strongly suggested (Cannell, 2010) that vitamin D deficiency has become an added concern, and “either during pregnancy or early childhood may be a trigger for the genetic disease of autism” (p. 1128). Further evidence linking vitamin D and autism highlighted the connection between wealthy and well-educated women and the practice of using sunscreen or avoidance of sun and a decrease in vitamin D. Vitamin D is essential for early brain growth (Bhasin & Schendel, 2007; Eyles, 2010). Further support for in-depth research should be continued on the effects of vitamin D especially during early prenatal development. After intensive epidemiological studies, The Institute of Medicine Safety Review Committee (2004) concluded that there was no evidence of a causal association between the measles-mumps-rubella (MMR) vaccines and mercury-containing vaccines and infants with autism. Since the publication by the previously mentioned safety review committee, studies examining the connection between MMR vaccine and autism have supported this conclusion (American Acad -

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emy of Pediatrics, 2007; Johnson, Meyers, & the Council on Children with Disabilities, 2007; Mayo Clinic staff, 2008; The National Institute of Mental Health, 2004). The American Academy of Pediatrics (2010) has issued new recommended immunization schedules for persons ages 0 to 6 years in the United States. Current information can be found at http://www.aap .org/healthtopics/Immunizations.cfm, AAP Children’s Health Topic Immunization/Vaccines. Concerned parents’ questions have been addressed regarding the importance and ingredients of vaccines and range of recommended ages for certain high-risk groups. Vaccines are safe and prevent millions of children from becoming infected with diseases resulting in lifelong disabilities or death. A detailed chart provides schedules for well-child visits for exams/immunizations beginning at 3 days after discharge from the hospital; 2 weeks, 2-, 4-, 6-, and 9-month visits; and continuous scheduling after reaching 1 year old. It is critical that parents note the importance of continuity of care for optimal health of their child (Mannheim & Zieve, 2009). The much debated study (Wakefield et al., 1998) on the MMR vaccine was retracted by The Lancet (Park, 2010; Pope, 2010). Britain’s General Medical Council (GMC) issued a statement declaring that Dr. Wakefield used unethical methods and found him guilty of “a callous disregard” of the pain for children in the study, dishonesty, and irresponsibility. The GMC has announced sanctions for Wakefield and others involved in the publication of the article. Dr. Richard Horton, editor of The Lancet, said it was obvious that the study involved a biased selection of patients and that several elements of the paper were incorrect. Dr. Wakefield proposed that the MMR vaccine led to gastrointestinal problems. According to Wakefield, the virus that was used in the vaccine grew in the gastrointestinal tract, causing the bowel to become porous, leading to an inflammatory condition. Substances leaked from the bowel, contaminating the blood and causing nervous system damage. Therefore, according to Wakefield (1998), children developed autism. The Centers for Disease Control and Prevention issued a statement that the retraction adds to the most recent and overwhelming body of knowledge that the MMR vaccine is not linked to autism (Park, 2010). After intensive coverage by the media, retraction of the article from the journal may be too late to make any difference in public opinion.

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Wakefield has been barred from practicing medicine in Britain after the country’s top medical group found his research to be unethical (Cheng, 2010). His autism center in Texas has faced similar skepticism from the medical community, especially because he opened the center with no medical license. He resigned from the center in 2010. Most recently, Deer (2011) published the secrets of the MMR scare. The Wakefield study (1998) launched worldwide panic of vulnerable families worried about their children. All children case subjects in the study had research data altered by the authors. Pre-existing developmental concerns were documented about 5 of the 12 subjects in the study. Information was distorted, or changed about other children’s medical problems after medical school “research review.” No case was free from changes, alterations, or misreporting. There were multiple discrepancies and data published that simply were not true. During the first and second trimesters of pregnancy, many abnormalities can develop in the brain stem, cerebellum, medial-temporal lobe, and surrounding areas, including the cerebrum, the area for cognitive executive functions of the brain. The mechanisms underlying autism include the following overlapping factors: • Genetic factors are currently considered as the primary cause of autism. • Prenatal, perinatal, and neonatal complications are identified as occurring frequently in infants with autism. • Neonatal complications (hyperbilirubinemia, premature birth, terbutaline, asphyxia, use of phototherapy, and respiratory distress) are significantly greater in infants with autism than typical newborns. • Glutamatergic acid in high concentrations is a neurotoxin. • Acetaminophen is linked to autism impairing glutathione, a substance produced in the liver for neutralizing toxins to the body of mother and fetus. • Terbutaline (Brethine/Bricanyl) is not approved by the FDA for preterm labor; however, it is highly used in most hospitals. Warnings were issued to doctors concerning the dangers of use for preterm labor. • Vitamin D deficiency is a cause during gestation and early childhood.

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• Interaction between neonatal complications and genetics results in greater incidence of preautism. • Neurological immaturity (a failure of brain development) and diffuse system involvement affects several neurological sites simultaneously. • There is no evidence of causal association between the MMR vaccines and infants’ autism. SUMMARY

The foregoing information indicates that preautism involves changes in brain anatomy and functional neural pathways. Genetics, immature brain development, and environmental factors, including acetaminophen, terbutaline, glutamatergic dysfunction, and vitamin D deficiency, are discussed as causes of preautism. An in-depth discussion of neuroplasticity and neurobiological differences evident in autism are defined and detailed in Chapters 2 and 3. REFERENCES Acquarone, S. (2007). Signs of autism in infants. Recognition and early intervention. London: Karnac. American Academy of Pediatrics. (2005). Is your one-year-old communicating with you? Elk Grove Village, IL: American Academy of Pediatrics. American Academy of Pediatrics. (2007). Vaccine studies: Examination of the evidence. Retrieved from http://www.aap.org/immunization/families/faq/vaccinestudies.pdf American Academy of Pediatrics. (2010). Immunizations/vaccine schedule. Children’s Health Topics. Retrieved from http://www.aap.org/healthtopics/Immunizations.cfm American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Text Revision. Washington, DC: American Psychiatric Association. Bhasin, T., & Schendel, D. (2007). Sociodemographic risk factors for autism in a US metropolitan area. Journal of Autism and Developmental Disorders, 37, 667–677. Blaxill, M. (2004). What’s going on? The question of time trends in autism. Public Health Reports, 119(6), 536–551. Blaylock, R. (2003). The central role of excitotoxicity in autism spectrum disorders, JAMA, 6, 10–22. Blaylock, R. & Strunecka, A. (2009). Immune-Glutamatergic dysfunction as a central mechanism of the autism spectrum disorders. Current Medical Chemistry, 16,

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157–170. Cannell, J. (2008). On the aetiology of autism. ACTA PEDIATRICA, 99, 1128–1130. Cannell, J., & Hollis, B. (2010).Use of vitamin D in clinical practice. Alternative Medicine Review, 13(1), 6–20. Centers for Disease Control. (2006). CDC launches multi-state study on autism. Retrieved from http://www.biospace.com/collaborative/news_story.aspx?News EntityId=32419 Charman, T., & Stone, W. (Ed.). (2008). Social & communication development in autism spectrum disorders: Early identification, diagnosis, & intervention. New York: Guilford Press. Chawarska, K., Klin, A., & Volkmar, F. (2008). Autism spectrum disorders in infants and toddlers: Diagnosis, assessment and treatment. New York: Guilford Press. Chawarska, K., Volkmar, F., & Klin, A. (2010). Limited attentional bias for faces in toddlers with autism spectrum disorders. Archives of General Psychiatry, 67(2), 178–185. Cheng, M. (2010). Britain bans doctor who linked autism to vaccine who linked autism to vaccine. Retrieved from http://richarddawkins.net/articles/473003-britain-bansdoctor-who-linked-autism-to-vaccine Conners, S., Levitt, P., Matthews, S., Slotkin, T., Johnston, M., Kinney, H., Johnson, W., Dailey, R., & Zimmerman, A. (2008). Fetal mechanisms in neurodevelopmental disorders. Pediatric Neurology, 38(3), 163–174. Conners, S., Crowell, D., Eberhart, C., Copeland, J., Newschaffer, C., Spence, S., & Zimmerman, A. (2005). Beta (2)-adrenergic receptor activation and genetic polymorphisms in autism: Data from dizygotic twins. Journal of Child Neurology, 20(11), 876–884. Cowden, J. E., Sayers, L. K., & Torrey, C. C. (1998). Pediatric adapted motor development and exercise: An innovative, multisystem approach for professionals and families. Springfield, IL: Charles C Thomas Publisher, Ltd. Cowden, J. E., & Torrey, C. C. (2007). Motor development and movement activities for preschoolers and infants with delays. A multisensory approach for professionals and families (2nd ed.). Springfield, IL: Charles C Thomas Publisher, Ltd. Currenti, S. (2010). Understanding and determining the etiology of autism. Cellular and Molecular Neurobiology, 30(2), 161–171 Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder. Developmental Psychopathology, 20, 775–803. Dawson, G., Sterling, L., Faja, S. (2009). Autism. Risk factors, risk processes, and outcome. In M. DeHaan & M. Gunnar (Eds.), Handbook of developmental social neuroscience (pp. 435–458). New York: Guilford Press. Deer, B. (2011). How the case against the MMR vaccine was fixed. British Medical Journal, 342, c5374. Eyles, D. (2010). Vitamin D and autism: Does skin color modify risk. ACTA PAEDIATRICA, 99(5), 654–647. Federal Drug Administration. (1974). Terbutaline and autism spectrum disorders. Re trieved from http://autism.lovetoknow.com/Terbutaline_and_Autistic_Spectrum _Disorders

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Federal Drug Administration. (1997). Clinical policy bulletin: Terbutaline pump for preterm labor. Bulletin 468, Aetna. Retrieved from http://www.aetna.com/cpb /medical/data/400_499/0468.html FDA. (1997). Clinical. Folstein, S., & Rosen-Sheidley, B. (2001). Genetics of autism: Complex etiology for a heterogeneous disorder. National Review Genetics, 2, 943–955. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC378556/ Froeber, J. (2009). Extremely premature infants more likely to test positive for autism. Retrieved from http://www.cnn.com/2009/HEALTH/01/30/health.premature .autism/index.html Gold, S. (2002). Autism. Neurological research and neuro-developmental approaches. Eugene, OR: Fern Ridge Press. Good, P. (2009). Did acetaminophen provoke the autism epidemic? Alternative Medicine Review, 14(4), 364–372. Greenspan, S. I., & Weider, S. (2006). Engaging autism. Cambridge: Da Capo Press. Grohol, J. (2009). Older parents, birth order linked to autism. Retrieved from http://psychcentral.com/blog/archives/2009/01/04/older-parents-birth-order-linked-toautism/ Herbert, M. (2010). Contributions of the environment and environmentally vulnerable physiology to autism spectrum disorders. Neurology, 23, 103–110. Herndon, A., DiGuiseppi, C., Johnson, S., Leiferman, J., & Reynols, A. (2009). Does nutritional intake differ between children with autism spectrum disorders and children with typical development? Journal of Autism and Developmental Disorders, 39(2), 212–222. Institute of Medicine. (2004). Immunization safety review: Vaccines and autism. Retrieved from http://www.nap.edu/openbook.php?record_id=10997 Johnson, C. P. (2004). Autism A.L.A.R.M. AAP News, 24(2), 74. Johnson, C. P., Meyers, S., & the Council on Children with Learning Disabilities. (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120(5), 1183–1215. Kilburn, K., Thrasher, J., & Immers, N. (2009). Do terbutaline-and mold-associated impairments of the brain and lung relate to autism? Toxicology and Industrial Health, 25, 703–710. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19793774 Kogan, M., Blumberg, S., Schieve, L., Boyle, C., Perrin, J., Ghandour, R., Singh, G., Strickland, B., Trevathan, E., & van Dyck, P. (2009). Prevalence of parent-reported diagnosis of autism spectrum disorder among children in the US, 2007. Pediatrics, 124, 1395–1403. Kolevzon, A., Gross, R., & Reichenberg, A. (2007). Prenatal and prenatal risk factors for autism. Archives of Pediatric &Adolescent Medicine, 161, 326–333. Kongshavn, P. (2010). The science of glutathione. Retrieved from http://www .scribd.com/doc/6635930/The-Science-of-one-Patricia-Kongshavn Larsson, H., Eaton, W., Madesen, K., Vestergaard, M., Olesen, A., Agerbo, E., Schendel, D., et al. (2005). Risk factors for autism: Perinatal factors, parental psychiatric history, and socioeconomic status. American Journal of Epidemiology, 161(10), 916–925.

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Mannheim, J., & Zieve, D. (2009). Well-child visits. Retrieved from http://www.nlm .nih.gov/medlineplus/ency/article/001928.htm Mayo Clinic Staff. (2008). Autism causes. Retrieved from http://www.mayoclinic .com/health/autism/DS00348/DSECTION=causes Meldrum, B. (2000). Glutamate as a neurotransmitter n the brain: Review of physiology and pathology. Journal of Nutrition, 130, 1007S–1015S. Myers, S., & Johnson, C. (2007). Management of children with autism spectrum disorders. Pediatrics, 120(5), 1162–1182. National Institute of Mental Health. (2004). Immunization safety review: Vaccines and autism. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK25338/ National Institute of Mental Health. (2007). Autism spectrum disorders (Pervasive developmental disorders). Retrieved from http://www.nimh.nih.gov/health/publications/autism/complete-index.shtml National Institute of Neurological Disorders and Stroke. (2009). Autism fact sheet. NINDS, Publication No. 09–1877 Retrieved from http://www.ninds.nih.gov/dis orders/autism/detail_autism.htm Ozonoff, S., Sigman, M., Stone, W., Tager-Flusberg, H., & Yirmiya, N. (2009). Clinical assessment and management of toddlers with suspected autism spectrum disorder: Insights from studies of high-risk infants. Pediatrics, 123, 1383–1391. Park, C. C. (1995). The siege: A family’s journey into the world of an autistic child. Boston: Little, Brown and Company. Park, M. (2010). Medical journal retracts study linking autism to vaccine. CNN.com. Retrieved from http://www.kcautv.com/Global/story.asp?S=11923323 Pope, T. (2010). Retracting a medical journal’s linking autism to vaccine. New York: NYTimes.com Prusiner, S. (1981). Disorders of glutamate metabolism and neurological dysfunction. Annual Review of Medicine, 32, 521–542. Purcell, A., Jeon, O., Zimmerman, A., Blue, M., & Pevsner, J. (2001). Postmortem brain abnormalities of the glutamate neurotransmitter system in autism. Neurology, 57, 1618–1628. Rhodes, M., Seidler, F., Abdel-Rahman, A., & Tate, C. (2004). Terbutaline is a developmental neurotoxicant: Effects on the neuroproteins and morphology. Experimental Therapeutics, 308, 529–537. Rice, C. (2002). Prevalence of autism spectrum disorders—Monitoring network, 14 sites, United States. National Center on Birth Defects and Developmental Disabilities, Atlanta: CDC. Rice, C. (2006). Prevalence of autism spectrum disorders—Autism and developmental disabilities monitoring network, United States. National Center on Birth Defects and Developmental Disabilities, Atlanta: CDC. Schendel, D., & Bhasin, K. (2008). Birth weight and gestational age and characteristics of children with autism, including a comparison with other disabilities. Pediatrics, 121(6), 1155–1164. Schultz, S., Klonoff-Cohen, H., Wingard, D., Akshoomoff, N., Macera, C., & Ming, J. (2008). Acetaminophen (paracetamol) use, measles-mumps-rubella vaccination, and autistic disorder: The results of a parent survey. Autism, 12(3), 293–307.

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Teitelbaum, O., Benton, T. Shah, P., Prince, A., Kelly, J., & Teitelbaum, P. (2004). Eshkol-Wachman movement notation in diagnosis: The early detection of Asperger’s syndrome. Proceedings of the National Academy of Sciences of the USA, 101 (32), 11909–11914. Teitelbaum, O., & Teitelbaum, P. (2008). Does your baby have autism? Garden City Park, NY: Square One Publishers. Teitelbaum, P., Teitelbaum, O., Nye, J., Fryman, J., & Maurer, R. G. (1998). Movement analysis in infancy may be useful for early diagnosis of autism. Proceedings of the National Academy of Sciences, 95, 13982–13987. Torres, A. (2003). Is fever suppression involved in the etiology of autism and neurodevelopmental disorders. BMC Pediatrics, 3, 9. Retrieved from http://www.bio medcentral.com/content/pdf/1471-2431-3-9.pdf Volkmar, F., & Wiesner, L. (2009). A practical guide to autism. What every parent, family member, and teacher needs to know. Hoboken, NJ: John Wiley & Sons, Inc. Wakefield, A. (1998). MMR vaccine and autism. The Lancet, 354(9182), 949–950. Wiseman, N. (2009). The first year: Autism spectrum disorders. An essential guide for the newly diagnosed child. Cambridge: Da Capo Press. Witter, F., Zimmerman, A., Reichmann, J., & Conners, S. (2009). In utero beta 2 adrenergic agonist exposure and and adverse neurophysiologic and behavioral outcomes. American Journal of Obstetrics & Gynecology, 201(6), 553–559. World Health Organization. (1999). International statistical classification of diseases and related health problems in occupational health. (ICD –10). Geneva: Protection of the Human Environment Occupational and Environmental Health Series. Zerrate, M., Pletnikov, M., Connors, S., Vargas, D., Seidler, F., Zimmerman, A., Slotkin, T., & Pardo, C. (2007). Neuroinflammation and behavioral abnormalities after neonatalterbutaline treatment in rats: Implications for autism. Jouranl of Pharmacology Experimental Therapeutics, 322, 16–22. Zwaigenbaum, L., Bryson, S., Lord, C., Rogers, S., Carter, L., Chawarska, K., Dawson, G., Dobkins, K., Fein, D., Iverson, J., Klin, A., Landa, R., Messinger, S., Ozonff, S., Sigman, M., Stone, W., Tager-Flusberg, H., Yirmiya, N. (2009). Clinical assessment and management of toddlers with suspected autism spectrum disorder: Insights from studies of high-risk infants. Pediatrics, 123, 1383–1391.

Chapter 2 BRAIN PLASTICITY DEFINITION

rain plasticity, or neuroplasticity, refers to the ability of the brain to change and reorganize neural pathways. Once it was thought that the brain was “hard-wired” like a machine. It is important to understand that the brain can change its structure and function depending on what it senses and perceives. Based on what we may be thinking or the actions we pursue, the brain rewires or reorganizes neural pathways. It has the capacity for adaptation. It is important to understand that if the brain begins to lose functionality, this loss is reversible. Nerve pathways in the brain may overlap in function and take over for another’s functions. When there is loss of skills, the brain finds another pathway for learning. From the perspective of an infant with preautism, these changes can be improved. Doidge (2007) referred to a catchy phrase (first purportedly spoken by Freud in the 1880s), “Neurons that fire together wire together.” This simple phrase provides a foundation that helps us understand that our brains are constantly changing and evolving. Understanding that knowledge is not fixed can be extremely positive and powerful for professionals and families of young children with disabilities. Plasticity of neural function is the foundation for success of early sensory integration programs for infants with autism.

B

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Figure 2.1. Water skills are enjoyed by infant reflecting balance and neural organization.

BRAIN REORGANIZATION

An infant learns new skills based on brain reorganization in response to sensory stimulation, substitution, and new experiences. Actually, the brain never stops changing and making neural connections. If a neuron (nerve cell) does not have a purpose in the transmission of information, it will not survive. With learning, more synapses or linking of neurons occurs. It is a physical process, and each time a new movement is learned it reflects new “wires” or neural pathways (Figure 2.1). Changes in the brain’s reorganization can result in either improved skills or a weakening of skills. It is the plasticity of the brain that allows it to adapt to its environment. The brain can reorganize under the following conditions: 1) The immature brain organizes itself. 2) With brain injury, the brain compensates for loss of functions. 3) The environment can influence plasticity.

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4) Brain plasticity is not a single change; however, there are agedependent factors. Exercising of the brain, or brain aerobics, is spoken of throughout many readings (Merzenich, 2009). Compared to exercising the body for fitness or a specific athletic event (diving and mental practice), the brain also needs the same developmental strengthening for brain plasticity. SENSORY PROCESSING

The structural basis for sensory processing begins with the functional stage of neural connections, the neural synapse. The synapse between any two neurons is subject to tremendous modification from second to second, day to day, and continuing through time. In comparison with muscle strengthening, the expression use it or lose it is often applied. If a muscle is not used, it will lose tone and weaken. When consistently used for a demanding task, the muscle gains strength. When muscle tone is optimal, the body is more efficient at all tasks (Figure 2.2). The same is also true of the neural synapse. With use, the neural synapse increases the readiness of fundamental nerve connections necessary for the brain to process information. Researchers have used various terms for sensory processing: sensory substitution, polysensory processing, intermodality exchange, and sensory integration. Recently, Bach-y-Rita and Kercel (2003), neuroplasticity pioneers, referred to neurons firing, polysensory processing, and sensory substitution. With advances in technology, they were able to demonstrate how substitution of the senses and use of different sensations from the same area of the brain can help with compensation of brain dysfunction. His research includes auditory-visual substitution or seeing with the ears, tactile-visual substitution or seeing with the skin, and tactile-vestibular substitution or balancing through tongue receptors. The Tactile Communication Neurorehabilitation Laboratory at UW-Madison (TCNL) has continued research for sensory and neurological disorders by applying the principles of neuroplasticity. Yuri Danilov, Neuroscience and Rehabilitation, Kurt Kaczmarek, Tactile Com munication and TCNL Director, and Mitchell Tyler, Sensory Sub -

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Figure 2.2. Infant reaches for object to balance while developing strength.

stitution and Clinical Studies, comprise the senior staff of the TCNL laboratories, combining more than 65 years of experience. They have continued the research of Bach-y-Rita (Danilov, Kaczmarek, & Tyler, 2010). Merzenich (2009) has provided tremendous insight into brain plasticity. His studies with animal and human brains have been related to genetic histories of damaged brains and how to improve the operations. He has developed brain exercises for individuals with anatomical and physiological problems, which help with the reversal of dysfunctions. When he first started his work in neuroscience, most of his colleagues thought that the brain was rigid in its organization. Merzenich has opened many doors in plasticity research, which can be applied to young children with learning difficulties. It is especially important in autism, where normal neural processing for sensory modalities is providing abnormal representation of sensory input. The inherent plasticity of the brain provides the foundation for improvement.

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What does the concept of brain plasticity mean to the parents and interventionists of infants and young children identified with signs of preautism? It means that infants and young children absolutely can be helped, and their brains can be changed when signs of preautism are identified on the CPAOI. The value of the CPAOI must be stressed again. Parents can interact through daily play, learning to identify signs of normal development and those linked to preautism. It must be remembered that brain plasticity is the key to change. If signs are identified on the CPAOI, parents should not feel stressed. They can focus on providing the information to their pediatricians, and other professionals with the knowledge to help their infant. We must change what we are doing, because it simply is not working. New interventions are being used in many specialized areas. Brain exercises may be used to stimulate the central nervous system. Many specific activities and exercises are recommended for sensory stimulation in the chapters to follow. This author is recommending a totally different type of early intervention, therapeutic riding (Chapter 9), for stimulation of pathways of the brain. Positive comments are numerous from parents about the benefits of therapeutic riding. The environment provides a totally new type of atmosphere for the young child and their family. The specially trained horses are calming to children. They are gentle and can be touched—feeling warmth. The gait patterns of the horse rhythmically move the child’s body stimulating all sensory systems. For infants who are learning to walk, the movement gait of the horse is the same as the human gait. Therapeutic riding provides the use of different sensory sensations. As Bach-y-Rita and Kercel (2003) discovered new ways of reorganizing neural pathways, therapeutic riding provides similar stimulations. Therapeutic riding provides sensory input to the immature brain that is different. However, therapeutic riding does not take an understanding of high technology. It is simple, it is available in most all states, and it works! SENSORY INTEGRATION

A. Jean Ayres (1979) defined sensory integration (SI) as, “the interaction and coordination of two or more functions or processes in a manner which enhances the adaptiveness of the brain’s response. Through integration, a ‘whole’ is either revised or produced from fragmented

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parts. Information from the environment is organized and interpreted for the planning and execution of interaction with the environment...” (p. 26). It occurs at all levels of the brain. Sensory integration means bringing something together. It is the organization of sensation. Sensations flow into the brain as streams flow into rivers. Our body is continually receiving sensory input about the environment surrounding us at any given point in time. We receive information from our eyes (visual sense), from our ears (auditory sense), from our muscles (kinesthetic sense), from our skin and deep tissue (tactile sense), and from our inner ear (vestibular sense). These five senses are the most highly used for learning new movements and skills. These sense modalities develop in utero in the following sequence: tactile, vestibular, auditory, vision, and kinesthetic. Cratty (1979) defined the development of skill as “some learning has taken place or an integration of behavior has resulted” (p. 23). Skill deficits of autism are accompanied by reduced neural activity in brain regions associated with specific functions (Figure 2.3). Integrative processes occur in all domains of brain function; however, those concerned with sensory motor integration are of particular significance to infants with learning problems. Intersensory integration follows a developmental sequence. Inhibition of sensory input is as important as sensory stimulation. Movement is one of the most powerful organizers of sensory input (Figure 2.4). The following are relevant components of sensory integration: 1) The brain is the organizer of all sensory information. It filters the information so that it is meaningful. When sensory information becomes disorganized and has not been sorted into an order, there is no clear integration. Sensory information is not clear and cannot be processed to form perceptions or behaviors for learning. 2) Sensory integration provides energy and knowledge needed to provide direction for the brain. Without sensory processing of new information, sensations become meaningless. 3) Sensory information comes into the brain as the heart pumps blood throughout the body. The heart is the controller of the circulatory system and regulates all circulation throughout the body. Sensory integration brings all of the parts of sensory infor-

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Figure 2.3. Infant receives stimulation from tactile, vestibular, auditory, and kinesthetic systems.

mation received by the brain and puts it all together so that it becomes meaningful. 4) Sensory integration is the organizer that allows for development of sequences of movement . . . lying, sitting, crawling, standing, and walking. Sensory integration is genetic, and each child is born with capacities for sensory integration, but it must be developed by interacting from within and with the environment. The process of adaptation is learned. 5) An adaptive response is a purposeful movement that helps the brain to self-organize. Infants make sensory integration happen as they play and organize self-directed movements. SUMMARY

We now have an understanding that an infant’s brain and neurological system have the capacity for change and reorganization. Effective

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Figure 2.4. Cruising skills are demonstrated while infant takes first step.

early intervention addressed by clinicians and specialists through sensory system stimulation offers new hope for families. REFERENCES Ayres, A. J. (1979). Sensory integration and learning disorders. Los Angeles: Western Psychological Services. Bach-y-Rita, P. (2007). Plasticity and the senses. PBS Wired Science. Retrieved from http:neurons.wordpress.com/2008/01/10plasticity-and-the-senses-paul-bach-yrita/ Bach-y-Rita, P., & Kercel, S. (2003). Sensory substitution and the human machine interface. Cognitive Neuroscience, 7(12), 541–546. Cratty, B. (1979). Perceptual and motor development in infants and children. Englewood Cliffs, NJ: Prentice Hall. Danilov, Y., Kaczmarek, K., & Tyler, M. (2010). Tactile communication and neurorehabilitation lab. Retrieved from http://kaz.med.wisc.edu/people_senior.php

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Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontiers of brain science. New York: Penguin Books. Merzenich, M. (2009). Brain plasticity offers hope for everyone. Retrieved from http:// www.sharpbrains.com/blog/2009/03michael-merzenich-

Chapter 3 CLINICAL INDICATORS his chapter includes information directly related to clinical indicators of preautism in the age range of birth to 1 year of age. There is anatomical evidence that neuropathology of infantile autism has its origins in early brain development. In the past, most young children were assessed in early intervention programs and diagnosed with autism at 3 years old. A chapter on Infant Neurology is included in the Appendix if needed for review.

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MAJOR BRAIN STRUCTURE IMMATURITY

Infants and young children with autism have altered brain anatomy, with a failure of brain and neurological system development. The results are simultaneous problems affecting numerous neurological sites. Functional magnetic resonance imaging scans (fMRI), computed tomography (CT), and single photon emission computed tomography (SPECT) have been used by researchers to study the brain. One of the most significant findings has to do with enlarged brain size. Abnormalities in brain enlargement (size and weight) can be determined by measuring head circumference (Courchesne, Carper, & Akshoomoff, 2003; DiCicco-Bloom et al., 2006). Underlying mechanisms for brain development in autism suggests pathologic brain processes such as inflammation early in the developmental course of autism. Rapid head growth becomes noticeable during the first year of life (Figure 3.1). Dawson (2008) described a developmental model of risk and risk processes in children with autism. Identified risk factors were atypical 55

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Figure 3.1. Enlarged head is noticeable in 6-month-old.

patterns of head growth and circumference. Brain size was smaller at birth, changing to significantly larger during the first year. Overall brain size appears to be increased in infants with autism by about 5% to 10% during the first year of life. At toddler age, head circumferences were about normal for the child’s age. Head circumference can be used as an early predictor for the vulnerability of autism (Elder, Dawson, Toth, Fein, & Munson, 2008). The brain stem is an upward extension of the spinal cord. The Reticular Activating System (RAS) originates in this area and is subdivided into the medulla oblongata, pons, and midbrain. The RAS plays a central role in behavioral alertness and is responsible for filtering out repetitive sensory stimuli, preventing sensory overload (Melillo & Leisman, 2004). The brain stem of an infant with preautism is shorter than a normal brain stem. Structures at the junction of the pons and midbrain appear closer to the medulla, almost as if a band

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of tissue were missing. There is research evidence indicating the pathological process started during the prenatal developmental period of the brain (Bauman & Kemper, 2005). In addition, research reports have also suggested functional abnormalities indicating that the midbrain and pons were significantly smaller in children with autism. All ascending and descending nerve pathways pass through the brain stem. Because the brain stem is shorter, it may affect degrees of alertness governing primitive reflex activity and integration of muscle tone. The cerebellum is the second largest portion of the brain. It is located posterior to the medulla and pons. It is believed that the cerebellum receives stimuli from all of the sensory modalities. Its primary function is to regulate muscular coordination for balance and integrate postural and equilibrium reactions. Both ascending and descending spinal tracts pass through the cerebellum controlling fast versus slow movements, jerky versus smooth coordination, and the precise starting and stopping of movements. The cerebellum is sometimes referred to as the “little brain” because it provides for the automatic phase of movements that no longer require conscious thought. Current research suggests that the cerebellum may not just have major control over motor functions but is also involved in numerous contributions to all brain functions, especially behavioral and cognitive operations (Melillo & Leisman, 2004). Due to the nature of cerebellar abnormalities, it is suggested that most problems are prenatal in origin. Abnormal growth and physical connectivity associated with synapses and tracts are apparent throughout cerebellum development (Figure 3.2). There are decreased numbers of Purkinje cells in the cerebellar vermis, which are responsible for inhibitory responses. These cells are responsible for the output of all motor coordination in the cerebellum. The Purkinje cells are also thought to receive sensory information from the vestibular system of the inner ears, which provides information about the body’s movement through space. There are also a decreased number of granular layer cells (cells deep in the innermost layer of the cerebellum). These small neuron cells exceed the number of neurons in the cerebral cortex responsible for higher mental functions and behavioral reactions and they serve to provide excitatory impulses. The density and number of cells misrepresent the importance of the cerebellum in the entire function of the

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Figure 3.2. Trimester growth of spinal cord, brain stem, and cerebellum.

brain. When there is a failure of neurological cellular development, most often neurobehavioral delays and functions should be assessed (Melillo & Leisman, 2004; Skoyles, 2002). Scientific interest in the role of the amygdala has recently increased regarding functional changes appearing abnormal in infants with

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preautism. The amygdala is a collection of nuclei located in the medial-temporal lobe of the brain. It develops during the first 2 months of the embryonic stage; however, separate nuclei do not differentiate until birth. This suggests strong implications for the amygdala to have an important role in changes of the brain or brain plasticity. Sensory information is received by the amygdala, and the cells respond to tactile, visual, auditory, and olfactory sensory modalities.The amygdala sends impulses to the trigeminal nerve and facial nerves, which are involved in facial expressions and muscle movements. It is strongly connected with retention of primitive reflexes (Baron-Cohen et al., 2000; Dziobek, Fleck, Rogers, Wolf, & Convit, 2006; LeDoux, 2008). The amygdala is not the cause of autism, but it appears to have a connection to limited interest patterns and repetitive routines of children with autism. Because autism involves emotions, anxiety, fears, social interactions, and a wide variety of behavioral functions, the amygdala may be linked to changes associated with reversibility in loss of functions and neural plasticity. The amygdala is enlarged in children with autism. Damage to the amygdala impairs judgment of social intelligence or socially appropriate behaviors and emotions. The amygdala’s response to repeated exposure to faces is reduced in individuals with autism (Baron-Cohen et al., 2000; LeDoux, 2008; Lombardo, Chakrabarti, & Baron-Cohen, 2009; Schultz, 2007; Schumann et al., 2004; Volkmar and Wiesner, 2009) (Figure 3.3). The corpus callosum connects the right and left cerebral hemispheres in a typical brain; however, in an infant or a young child with autism, evidence suggests the major fiber pathways between the hemispheres are reduced in size. Studies using positron emission tomography (PET) map out the neural systems affected by autism. Included in studies using PET were brains responsible for emotional and social functions, perceptual systems, and social-cognitive systems (BogerMegiddo et al., 2006; Petropoulos, Friedman, Artru, Dawson, & Dager, 2006). The thalamus and hypothalamus are bridged to the spinal cord and regulate sensory and motor integration. The hypothalamus also regulates body temperature, emotions, hunger, and thirst. Many functions associated with infantile autism are linked to the thalamus and hypothalamus, including poor sensory integration and dysfunctional emotional behaviors. Serotonin, a neurotransmitter involved in brain

Figure 3.3. Midsagittal section of brain stem, reticular activating system, midbrain, cerebellum, amygdala, corpus callosum, thalamus, hypothalamus, cerebrum, and motor cortex.

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chemistry, originates in the midbrain areas. Serotonin is not necessarily a cause of autism, but abnormal levels present as early symptoms (Hollister, 2008). The cerebrum (cerebral cortex) is the most highly developed part of the human brain and is responsible for thinking, perceiving, producing and understanding language, motor functions, and personality. Due to pathological problems associated with fetal brain stem development, functional neural networks to the cerebrum do not mature. The prefrontal cortex of the cerebrum is linked to neurological abilities impaired in autism. It is the part of the brain that plays the dominant role in thinking, goal direction, planning, and verbal working memory. The prefrontal cortex also includes areas involving purposive movements and development of motor skills. Motor incoordination has been associated with this area, causing the inability to screen nonmeaningful stimuli resulting in distractible reactions, perseveration, and repetitive behaviors associated with autism. The prefrontal lobe of the cerebrum has direct connections with the cerebellum and motor areas involving coordination of movements of the eyes and head and association areas for speech. Because there are many dysfunctions in the cerebellum, it is theorized that the cerebral cortex and cerebellum connection also causes impaired higher brain functions associated with autism. With understanding of developmental origins and abnormalities in early brain growth, it is projected that new assessment tools will be designed for diagnosis during the first year of life (Courchesne, Carper, & Akshoomoff, 2003; DiCicco-Bloom et al., 2006; Melillo & Leisman, 2004; Skoyles, 2002). PREMATURITY AND LOW BIRTH WEIGHT

There is growing evidence linking preemies more than 3 months early to risk for autism. One in 10 infants born extremely premature have later tested positive at age 2 for autism. Preemies have not had time for brain development to be completed, and risk factors suggest that early screening for signs of autism are warranted in very low birth weight infants. Fetal distress or fetal hypoxia with an Apgar score of 7 have also been noted as a high predictor of autism. Not all infants who are born premature will have autism, and not all children who have

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Figure 3.4. Infant shows no social interaction with interventionist.

autism have a difficult birth. However, infants born preterm and with low birth weight are at greater risk for autism. Pediatricians must screen for autism if there are any concerns about the infant’s development and especially if the baby is born with extremely low gestational age (Froeber, 2009; Kuban, O’Shea, Allred, Tager-Flusberg, Goldstein, & Leviton, 2009) (Figure 3.4). Infants born premature and with low birth weight (especially girls) are twice as likely to develop autism. Low birth weight girls with mental retardation have a significant fourfold increased risk for autism. Even though autism is genetic and affected by the environment, boys and girls who are born with low birth weight have risk factors for the disorder. A full-term infant is considered to be between 37 and 41 weeks gestation; therefore, a premature infant is less than 37 weeks gestation or

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Figure 3.5. Newborn shows eye expression and facial glow as she holds favorite toy.

below birth weight of 2,500 grams (approx. 5.5 lbs.). Very low birth weight (VLBW) is less than 1,500 grams (3 lb. 5 oz.), and extremely low birth weight is 750 grams (1 lb. 10 oz.). Survival of VLBW infants has increased in recent years due to improvements in neonatal intensive care. However, many infants born with VLBW, prematurity, and other neonatal complications do not survive during the first year. Low birth weight and gestational age are linked to perinatal risk factors for disturbances in social interaction, communication, and behavior. In preterm infants and VLBW infants, there has also been a high rate of diagnosis of autism at 4 years old. These data support comprehensive screening for social and behavioral dysfunctions and benefits of early, intensive intervention (Figure 3.5). Technology and improved medical management have made it possible for infants as young as 23 weeks gestation (micropremature infants) to survive; however, these children will be at high risk for many medical complications. Health factors for premature infants improve as the period of gestation increases. Research associates early neuro-

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Figure 3.6. It is common for an infant weighing 3 lbs. 5 ozs. (VLBW) to survive.

logical abnormalities with later cognitive outcomes. Early intervention programs provide assessment and activities for parents of these infants, which lead to improved outcomes (Figure 3.6). Premature Labor. Contractions of the uterus, and cervical dilation occur prior to 37 weeks of gestation. Premature labor may be caused by stress, nutrition, age, prenatal exposure to drugs (alcohol, cocaine/crack, marijuana, and methamphetamines), cigarette smoking, chronic diseases (hypertension, cardiovascular disease, and diabetes), infectious diseases, and other factors. Placenta Previa. A fertilized egg is introduced in the bottom of the uterus instead of the top of the uterus causing the placenta to implant and cover the opening of the cervix. Maternal bleeding can occur, possibly a large amount in a short period of time, causing trauma to

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the mother and high occurrence for loss of the unborn infant. Abruptio Placenta. This condition involves varying degrees of separation of the placenta from the wall of the uterus, which interferes with crucial functions of the placenta. The placenta’s functions are to provide oxygen and nutrients to the fetus and eliminate waste products. Aminiotic Fluid and Premature Rupture of Membranes. One of the most important roles of the amniotic fluid is to serve as a shock absorber in a temperature-controlled and gravity-free environment for the fetus. If the membrane surrounding the infant breaks prematurely, early delivery puts the infant at high risk for infection. Factors that may cause a premature rupture of membranes and loss of fluids include stress, fetal movements, nutrition, and exposure to teratogens (agents that may cause harm to a developing embryo, causing congenital abnormalities). Entangled Umbilical Cord. The umbilical cord contains all the nutrients and oxygenated blood from the fetus side of the placenta and connects to the fetus. In normal circumstances, the cord is cut upon delivery and is shed by the infant 7 to 10 days after birth. Under some circumstances, the infant becomes wrapped in the cord, causing decreased blood supply to the infant and possible asphyxiation. Monitoring equipment provides information that assists with determining the amount of time the infant may have had limited oxygen supply. A lack of oxygen may cause neurological damage. BIRTH ASPHYXIA

Birth asphyxia is a term used to describe factors related to the inadequate intake of oxygen by the infant during the birth process (before, during, or immediately after birth). Other terms used for birth asphyxia include perinatal asphyxia and fetal distress. Due to decreased oxygen intake, chemical changes in the infant’s body include low oxygen levels in the blood (hypoxemia) and acid accumulation in the blood (acidosis). Symptoms before delivery may include abnormal heart rate/rhythm or an increased acid level in the infant’s blood. After birth, signs include bluish or pale skin color, low heart rate, weak muscle tone and reflexes, weak cry, gasping or struggled breathing, and meconium aspiration (accumulation of feces breathed by fetus). There

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are many causes of birth asphyxia listed as follows: • Low blood pressure of the mother. • Lack of enough oxygen in the mother’s blood due to heart or respiratory problems. • Lowered respiration of the mother during anesthesia. • Lack of relaxation of the uterus during labor to allow for oxygen circulation to the placenta. • Early separation of the placenta from the uterus. • Compression of the umbilical cord decreasing blood flow. • Poor placenta function occurring due to high blood pressure or post-term pregnancies. After birth the infant may have lower oxygen concentration. Causes are severe anemia, low blood pressure or shock, respiratory distress problems, and heart or lung disease. Birth asphyxia is a concern because the fetus may respond to low oxygen with a slowed heart rate, lowered blood pressure, and decreased blood flow out of the heart. This may cause other organs to be affected by lowered oxygen. Damage to brain tissue may result in serious complications that cause seizures and other neurological problems. The American College of Obstetricians and Gynecologists (2008) proposed the following guidelines for diagnosis of damage from low oxygen in a baby: • Severe acid levels (pH less than 7.00) in the arterial blood of the umbilical cord. • Continual Apgar score of 0–3 for longer than 5 minutes. • Evidence of neurological problems (seizures, coma, poor muscle tone) and problems with one or more organ systems. Birth asphyxia is a condition that may not be predictable or preventable. In all cases, prompt treatment is the most important factor (Figure 3.7).

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Figure 3.7. Infant born premature and extremely low birth weight is compared in size to pen. http://blog.beliefnet.com/stevenwaldman/2008/10/number-of-fetusesbabies-aborte.html

RESPIRATORY DISTRESS SYNDROME

Respiratory distress syndrome (RDS) is defined as respiratory difficulty in newborn infants caused by a deficiency of surfactant. Deficiency of surfactant (elastic properties of pulmonary tissue) causes the lungs to collapse during normal breathing (Batshaw, Pelligrino, & Reizen, 2007). Infants with RDS often spend a substantial period of time in a Neonatal Intensive Care Unit (NICU). Several neuropathogenic factors occurred at a higher rate in infants with autism, including RDS, low birth weight, low Apgar score, and elevated serum bilirubin. HYPERBILIRUBINEMIA

Neonatal jaundice occurs in about 60% of all newborns, causing a yellowing of the skin and other tissues, especially the eyes. It is caused by an accumulation of bilirubin in the blood. When the level of bilirubin becomes too high, it can be treated with simple phototherapy.

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Norms exist for bilirubin in term and nearly term babies based on the age in hours after birth. Medical records and parental interviews of children diagnosed with autism indicate a higher incidence of hyperbilirubinemia. It usually occurs in conjunction with other unfavorable events in pregnancy, delivery, and neonatal phase of development (Melillo & Leisman, 2004). Excessive neonatal jaundice may lead to kernicterus, which is a form of brain damage. Signs in the neonate that should be noted include excessive lethargy, too sleepy, difficult to arouse, high pitched cry, decreased muscle tone with episodes of hypertonicity, and arching of the head and neck backward. The tonic neck reflex can also be observed in children older than 1 year. The American Academy of Pediatrics (2009) requested the U.S. Agency for Healthcare Research and Quality (AHRQ) to examine the relationship between severe hyperbilirubinemia and neurodevelopment, the efficacy of phototherapy, the reliability of various strategies for predicting hyperbilirubinemia, and the accuracy of transcutaneous bilirubin measurements. Because neonatal jaundice may present on the second or third day of life, the following become very significant: • Hospital discharge before 48 hours of life, with no early follow-up (especially for infants born at 35 to 37 weeks gestational age). • Failure to check the bilirubin level in an infant noted to be jaundiced in the first 24 hours. • Failure to recognize the presence of risk factors for hyperbilirubinemia. • Underestimating the severity of jaundice by clinical (visual) assessment. • Lack of concern regarding the presence of jaundice. • Delay in measuring serum bilirubin despite marked jaundice. • Failure to respond to parental concern regarding jaundice, poor feeding, or lethargy. All jaundice should be medically evaluated with careful consideration given to the above listed factors. Prevention of hyperbilirubinemia is the only way to minimize the incidence of kernicterus (American Academy of Pediatrics, 2009).

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PHOTOTHERAPY Phototherapy is used for the treatment of jaundice (hyperbilirubinemia) in newborns and is generally considered safe. Some risks in premature infants have been reported. Usually, the babies with jaundice need phototherapy light for several days. Exposure to phototherapy causes relaxation of the peripheral vasculature, which can increase fluid loss and lead to dehydration. This potentiates hyperbilirubinemia. Concern exists about the risk of retinal damage in infants exposed to the extremely bright light of phototherapy. All infants should wear protective eye coverings while being treated. A marked increase has been observed regarding the prevalence of patent ductus arteriosis (PDA) in premature infants who receive phototherapy. SEIZURES

Seizures may occur in infants with autism. They are a result of an electric-chemical imbalance in the regulatory center of the brain. It is presumed that seizures are genetically determined. The risk of seizures increases with conditions such as perinatal trauma, fetal distress, chromosomal abnormalities, congenital and postnatal infections, drugs, and tumors. There is a classification of seizures that are categorized as partial, which begins in one cerebral hemisphere, or generalized, which involves both hemispheres of the brain (Batshaw et al., 2007). DYSMORPHIC FEATURE—MOEBIUS MOUTH

Moebius mouth is a feature that may be present in autism. Moebius mouth is recognized by a different shape of the mouth. The lower lip of the infant will appear very flat with a tented, almost triangular upper lip. It can often be detected at birth or during the first few months of an infant’s life. It is associated with an abnormal function of cranial nerves VI-Abducens (eye movements) and VII- Facial (muscles used in facial expression). Cranial nerves also affect the ability to smile and perform many visual motor tracking tasks. Moebius syndrome does not always mean that an infant has autism, nor does a child with autism always have a Moebius mouth. However, when a Moebius

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mouth is recognized along with a cluster of signs for autism, it is a strong possibility that the infant will eventually develop autism (Teitelbaum et al., 2004). SUMMARY

This chapter has discussed clinical indicators and medical problems associated with diagnosis of preautism. As a group, infants later diagnosed with autism have more complications during gestation and delivery than normal siblings. In addition to delivery problems, the newborn will spend more time in neonatal intensive care units exposed to excruciating medical interventions and overwhelming sensory stimulation.

REFERENCES American Academy of Pediatrics. (2009). Management of hyperbilirubinemia in the newborn infant. Retrieved from http://www.ahrq.gov/clinic/uspstf09/hyperbilirubin emia/hyperbrs.htm American College of Obstetricians and Gynecologists. (2008). Surgery and patient choice. Obstetricians and Gynecology, 111, 243–247. Baron-Cohen, S., Ring, H. A., Wheelwright, S., Bullmore, E. T., Brammer, M. J., Simmons, A., & Williams, S. C. R. (1999). Social intelligence in the normal and autistic brain: An fMRI study. European Journal of Neuroscience, 11, 1891–1898. Batshaw, M., Pelligrino, L., & Reizen, N. (2007). Children with disabilities. Baltimore: Brookes Publisher. Bauman, M., & Kemper, T. (2005). Neuroanatomic observations of the brain in autism: A review and future directions. International Journal of Neuroscience, 23, 183–187. Boger-Megiddo, I., Shaw, D., Friedman, S., Sparks, B., Artru, A., Giedd, J., Dawson, G., & Dager, S. (2006). Corpus callosum morphometrics in young children with autism spectrum disorder. Journal of Autism Development Disorder, 36(6), 733–739. Courchesne, E., Carper, R., & Akshoomoff, N. (2003). Evidence of brain overgrowth in the first year of life in autism. Journal of the American Medical Association, 290, 337–344. Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder. Development and Psychopathology, 20, 775–803. DiCicco-Bloom, E., Lord, C., Zwaigenbaum, L., Courchesne, E., Dager, S., Schmitz, C., Schultz, R., Crawley, J., & Young, L. (2006). The developmental neurobiolo-

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gy of autism spectrum disorder. Journal of Neuroscience, 26, 6897–6906. Dziobek, I., Fleck, S., Rogers, K., Wolf, O., & Convit, A. (2006). The amygdala theory of autism revisited: Linking structure to behavior. Neuropsychologia, 44(10), 1891–1899. Elder, L. M., Dawson, G., Toth, K., Fein, D., & Munson, J. (2008). Head circumference as an early predictor of autism symptoms in younger siblings of children with autism spectrum disorder. Journal of Autism Developmental and Disorders, 38, 1104–1111. Froeber, J. (2009). Extremely premature infants more likely to test positive for autism. Retrieved from http://www.cnn.com/2009/HEALTH/01/30/health.premature .autism/index.html Hollister, E. (2008). The effect of the neurotransmitter serotonin on autism symptoms. Retrieved from http://serendip.brynmawr.edu/exchange/node/1918 Kuban, K., O’Shea, M., Allred, E., Tager-Flusberg, H., Goldstein, D., & Leviton, A. (2009). Positive Screening on the Modified Checklist for Autism in Toddlers (MCHAT) in Extremely Low Gestational Age Newborns. Journal of Pediatrics, 154, 534-540. LeDoux, J. E. (2008). Amygdala. Scholarpedia, 3(4), 2698. Lombardo, M., Chakrabarti, B., & Baron-Cohen, S. (2009). The amygdale in autism: Not adapting to faces? The American Journal of Psychiatry 166, 395–397. Melillo, R., & Leisman, G. (2004). Neurobehavioral disorders of childhood: An evolutionary perspective. New York: Springer Science + Business Media, Inc. Petropoulos, H., Friedman, S., Artru, A., Dawson, G. & Dager, S. (2006). T2 relaxometry reveals evidence for gray matter abnormalities in autism spectrum disorder. Neurology, 67(4), 632–636. Schultz, R. (2007). Developmental deficits in social perception in autism: The role of the amygdala and fusiform face area. International Journal of Developmental Neuroscience, 23(2–3), 125–141. Schumann, C., Hamstra, J., Goodlin-Jones, B. Lotspeich, L., Kwon, H., Buonocore, M., Lammers, C., Reiss, A., & Amaral D. (2004). The amygdale is enlarged in children but not adolescents with autism; the hippocampus is enlarged at all ages. Neurobiology of Disease, 24(28), 6392–6401. Skoyles, J. (2002). Is autism due to cerebral+cerebellum disconnection? Medical Hypotheses, 58(4), 332–336. Teitlebaum, O., Benton, T., Shah, P., Prince, A., Kelly, J., & Teitlebaum, P. (2004). Eshkol-Wachman movement notation in diagnosis: The early detection of Asperger’s syndrome. Proceedings of the National Academy of Sciences of the USA, 101(32), 11909–11914. Volkmar, F., & Wiesner, L. (2009). A practical guide to autism. What every parent, family member, and teacher needs to know. Hoboken, NJ: John Wiley & sons, Inc.

Chapter 4 SIGNS AND SYMPTOMS his chapter presents information for signs and symptoms of behaviors that may eventually be used for diagnosis of infants with preautism. The CPAOI includes signs and symptoms of preautism throughout the sections. Descriptions of early motor (muscle tone, reflexes, and reactions), social/communication, and cognition/prelanguage signs will be discussed. Typical and atypical behaviors and movements are included.

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MOTOR

The newborn should have the ability to move body parts independently of each other while lying on back (supine) or stomach (prone) positions (Figure 4.1). The head should turn to both sides from the midline position, and the infant should be able to lift its head briefly in the prone position. Arms should be waved freely, and legs should be kicked alternately. Infants will regard a face momentarily and may randomly smile. If presented with a colorful object, hands are usually brought to the midline of the body. Infants should enjoy and be attentive to a wide variety of sounds. Most infants will mold and relax their body when cuddled.

Muscle Tone The single most important factor guiding assessment and intervention is an understanding of muscle tone (Cowden & Torrey, 2007). 72

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Figure 4.1. Infant explores his foot with hands and mouth while making eye contact.

Muscle tone may be defined as contractile tension and readiness of muscles to perform movement. It is regulated by the cerebellar region of the brain, which receives sensory impulses from the muscles and sensory motor centers for vision, hearing, touch, and balance. The identification of muscle tension from normal muscle tone is referred to as hypotonia (weak, floppy, or decreased tone) or hypertonia (excessive, spastic, or increased tone). Infants who exhibit hypotonia or weak, floppy muscle tone may be exhibiting muscle tone associated with infantile autism. The traction response is the most often used method of assessing postural tone in a young child and is demonstrated by pulling the child by the arms to sitting and noting the amount of head lag and elbow flexion. A premature newborn of less than 33 weeks gestation will not demonstrate a traction response. The “lying at rest position” of the infant can also be observed for hypotonia. If the child exhibits a “frog-leg” position with the arms lying limp or flaccid by the head, it is a clinical sign of hypotonia. Reflexes and Reactions The first movements of a newborn hold evidence for the very early detection of autism. Reflexes are involuntary movements that affect

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Figure 4.2. Newborn exhibits Asymmetrical Tonic Neck reflex as he focuses on mobile.

muscle tone, especially flexor and extensor tone, and are stimulated by changing the position of the head in relation to the body. Spinal reflexes are present at birth. They coordinate muscles of the extremities in patterns of either flexion or extension. Both legs should easily extend but not in a frog-like position. Each leg should kick reciprocally, and both legs should be used equally. The legs should not be stiff or crossed. Spinal reflexes are needed at birth but should be inhibited by the central nervous system by 3 to 4 months of age. Primitive reflexes, predominately the tonic neck group of reflexes, interfere with the development of the equilibrium reactions for balance and posture. Delayed integration of primitive reflexes is a causal factor of delayed maturation in all infants, including those diagnosed with infantile autism. The development of motor patterns is de pendent on the suppression of the following primitive reflexes into more refined movements, actions and skills (Figure 4.2).

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Table 4.1 INFLUENCE OF THE TONIC NECK REFLEXES Asymmetrical Tonic Neck, 0-4 months old • Turning of the head to the side causes extension of the arm on the face side and flexion (bending) of the arm at the back of the head • Interferes with rolling over and voluntary hand positioning, reaching, midline skills. Tonic Labyrinthine Supine, 0-4 months old • In back lying position, the child demonstrates increased extensor tone of extremities • Interferes with raising of the head, bending of knees and reaching for feet, bringing of hands to midline Tonic Labyrinthine Prone, 0-4 months old • When lying on the stomach, the child demonstrates increased flexion (bending) • Interferes with distal reach and lifting of head • Interferes with extension of arms and legs Symmetrical Tonic Neck, 6-8 months old • Flexion of the head causes flexion of the arms and extension of the legs • Extension or raising of the head causes arm extension & leg flexion (Bunny-hop) • Interferes with creeping

Primitive reflexes are considered normal from birth to 4 months old; however, if they are not integrated by the central nervous system (CNS), the infant will experience much difficulty in acquiring developmental movement patterns. An infant (6 months old) who cannot roll over with a segmental or corkscrew motion is indicating interference of delayed primitive reflex inhibition. The Tonic Neck Reflexes are the most influential reflexes that need to be understood in relation to infantile autism (Table 4.1). Delayed Righting Reactions Righting or equilibrium reactions are automatic movements that replace the primitive reflexes with unique functions necessary for the development of balance. The first attempts at righting occur when the infant raises and turns the head from the floor followed by one leg crossing the body in a corkscrew motion. When the infant completes the turn, one leg will flex and a position is attained for crawling on the tummy with the head upright. As this movement matures, it will become a segmental roll from back to prone. When the asymmetrical

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Figure 4.3. Infant displays protective extension while balancing on toy.

tonic neck reflex is not inhibited by the nervous system, the extended arm will interfere with the righting reaction process. The infant will typically develop protective extension reactions of the arms and legs between 4 and 7 months. Downward protective extension (parachute reaction) will occur before side and front protective extension. At 6 months, a normal infant should keep the head vertical when the body is tilted. A delayed reaction would be for the head to remain in line with the body. Sitting posture should be attained by 6 months, and the infant will demonstrate balance and protective extension of the arms (Figure 4.3). Common findings indicate that righting and protective extension reactions will be delayed in infants who may eventually be diagnosed with preautism. The infant may tend to fall to the side in sitting position with little to no demonstration of protective extension reactions. Infants who are diagnosed with preautism will usually have low muscle tone, while toddlers exhibit clumsiness, an inability to perform more complex movements (apraxia), and toe walking. Movement dis-

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turbances typically occur on one side of the body, indicating a lack of symmetry. Difficulties may also occur with complex motor behaviors, such as moving on belly using both arms and legs and reaching for a toy. DELAYED MOTOR MILESTONES

Infants exhibiting signs of preautism do attain early gross and fine motor developmental milestones; however, they tend to acquire some movements such as rolling, sitting, hands-knees crawling, and standing in different and awkward manners. An infant might acquire standing and then just stand while leaning against an object or wall with no initiated attempt at movement. Such relative akinesia is a sign of an abnormality. Akinesia is important to understand and may be defined as a difficulty initiating and maintaining a movement pattern. The infant may be delayed or slow in motor initiation, have difficulty reaching a target with a single continuous movement, or have an inability to execute simultaneous or sequential actions. Other negative symptoms include disorders of postural fixation and equilibrium, righting, locomotion, and arm movements. Walking may be attained; however, associated unconscious movements may be demonstrated, such as loss of arm swinging during gait or use of only one arm. Involuntary actions should occur on a timeline. If they do not, this is another sign of preautism. Keen and acute observation is needed to detect disturbances by “how achieved” and “differences after achievement” of a motor stage. Although it has been commonly thought that early motor development is typical for infants with preautism, recent findings indicate that there are subtle but definite differences indicated shortly after birth. (Bjorne & Balkenius, 2005; Teitelbaum & Teitelbaum, 2008; Teitelbaum, Teitelbaum, Nye, Fryman, & Maurer, 1998). These deviations are indicated in several of the common developmental motor milestones. Typically, newborns are symmetrical with two complete identical sides of the body. The development of motor patterns is also symmetrical. When deviations occur from symmetrical to asymmetrical positions in movement, this is a red flag very early in the infant’s development. Lying, rolling, tonic neck reflex interference, sitting, crawling, and walking will be examined.

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Lying Position • Deviations are indicated in the newborn’s lying posture, and by 4 months old, asymmetrical (unevenness or irregularity) posture may be indicated when the infant lies on his or her stomach. The baby tries to reach forward in a prone position but demonstrates the inability to move both arms forward together or separately. Tonic neck reflex retention is obvious, causing flexor-dominant tone when in a prone position. This asymmetry persists throughout the first year and may cause an infant to fall to the side when sitting and even during initial walking patterns. Rolling Position • Rolling from back to front is completed differently in infants with preautism. Infants typically roll over using a corkscrew, segmental rolling pattern, starting on their back and rolling to their stomach. Infants with autism may not roll over at all, may start from lying on their side rather than their back, or they arch themselves sideways by raising their head and hips upward, moving the upper leg forward to help topple the body over to land on their stomach. Also, a child may use an atypical pattern of head and neck flexion to assist in rolling beyond the age of 3 months. This pattern occurs because the asymmetrical tonic neck reflex has not been integrated at 4 to 6 months of age. Postural and equilibrium reactions are also developed later than would normally be expected. Sitting Position • Sitting posture may also be delayed or atypical. Typical infants initiate sitting by 5 months old and sit independently at 6 months old (Figure 4.4). Some infants with preautism are unable to maintain sitting at this age, and some turn their head, rock in place, or play with an object to help maintain stability. This appears related to using vestibular stimulation to help maintain balance. Some infants simply fall over due

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Figure 4.4. Excellent sitting posture is demonstrated.

to delayed righting reactions and uneven distribution of weight. They will not display protective extension of their arms. Four-Point Crawling • Crawling differences in infants with preautism may be evidenced by the inability or difficulty to support their arms, and a greater weakness on one side of the body may occur. This is caused by dominance of the symmetrical and asymmetrical tonic neck reflexes. The infant will often fall to the side, often trapping one arm under the chest. Forward movement using the knees to crawl is difficult. At later ages, once the arms are stronger, the development of crawling in the legs is asymmetrical. Thigh and leg may be carried by flexion of the hip (Figure 4.5).

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Figure 4.5. Infant exhibits strong determination to acquire 4-point crawling skills.

Walking • Walking and gait differences are also noted for toddlers with autism. Walking may be delayed, asymmetry may be evidenced, and toddlers may demonstrate more infantile gaits, with the shifting and transfer of weight from one step to the next not occurring smoothly or at the correct time. Arm positions may be infantile or asymmetrical or may demonstrate nonpurposeful movements (e.g., persistent hand flapping). Sometimes the gait may be considered “Parkinsonian” with a flat-footed step rather than a heel strike, and steps are shorter and slower than would normally be expected. Motor Planning Movements are controlled by the cerebellum of the brain (see Chapter 2). It serves as a tracking system between sensory input and resulting motor actions. Abnormalcy may be indicated when infants and

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Figure 4.6. Motor planning is demonstrated as child climbs up steps.

young children either “overshoot” or “undershoot” their arm or leg movements when doing tasks. Infants may reach for a toy in play and knock it over or have difficulty self-feeding, usually creating quite a mess. For example, the toddler may exhibit difficulty stepping “over” or “on” objects. The foot reaches too high or totally misses the object, causing the child to trip and fall. This is often referred to as motor planning or dyspraxis. Difficulty with motor planning is common in infants and young children with autism, although it is infrequently recognized (Dejean, 2006) (Figure 4.6). Stereotypic Behaviors Infants with preautism often exhibit nonpurposeful movement. Stereotypical motor behaviors may include hand flapping, pacing, spinning, moving in circles, twirling a string, tearing paper, or flipping

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light switches. An oral stereotypic behavior would include humming. Infants and toddlers tend to line up toys or blocks instead of playing in typical ways. The line-up usually has a specific order and meaning to the infant. They will become extremely upset if the order or routine is upset or changed. Low-level repetitive behaviors are associated with infants, whereas more complex repetitive behaviors are associated with toddlers and preschoolers. Infants may demonstrate restless, purposeless movements when resting in their cribs, and sometimes selfinjurious behaviors such as biting and head banging will become a problem (Loh et al., 2007). Movement disturbances and motor development have typically been ignored in infants with preautism. Because assessment and intervention for children from birth to 2 years old is necessary to provide the best possible services for infants who may later be diagnosed with autism, meticulous observation of motor behaviors is crucial. SOCIAL-COMMUNICATIVE-PLAY

With the need to assess and intervene much earlier, four criteria from DSM–IV should be used as a guide for observations and evaluations when the child is under 3 years old. Three of the criteria address the critical importance of social skills. The recommended criteria are: • Lack of spontaneous seeking to share enjoyment, interest, or achievements with other people (e.g., by lack of showing, bringing, or pointing out objects of interest). • Lack of social and emotional reciprocity. • Marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction. • Delay in or total lack of the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime). By 7 months old, the typical infant spontaneously and intentionally orients naturally to occurring social stimuli in the environment

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Figure 4.7. Infant seeks social enjoyment from person in the environment.

(Chawarska et al., 2010; Dawson et al., 2009). This appears in anticipation of reward. Infants who are demonstrating signs of preautism do not seek a social environment or enjoyment from another person’s face or voice. They exhibit poor face recognition, unusual visual scanning patterns, and a lack of facial captivation (Figure 4.7). Lack of social play is apparent as the infant engages most often in repetitive, purposeless, and nonfunctional movements. All play is solitary. If there are other infants nearby, the infant pays no attention. The infant is totally self-engaged with an object. Excessive manipulation or visual exploration of toys and objects is extremely noticeable. As infants become a few months older, repeatedly lining up toys or incessant stacking of blocks becomes very apparent (12 months old). The infant most likely shows little or no affection toward family. They will pay little attention to facial expressions of anyone. They seem to enjoy being alone, and little joy or cooperative interchange is displayed. They may spin, mouth, twirl, or bang objects in a ritualistic manner. Due to the ritual behaviors, the infant will not engage in symbolic or pretend play. Infants remain in the sensory motor stage throughout their lifespan, preferring to play with everyday items such as rocks, dirt, sticks, chains, and strings. If they play with a toy, it will

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usually be in an inappropriate manner. Make-believe or social imitative play appropriate for developmental levels are not evidenced. Some infants will have unusually long attention spans, although they are unable to focus on joint activities with another child or adult. Parents of these infant-toddlers may describe them as independent and may be proud of their supposed self-sufficiency. Behavioral symptoms range from mild to severe, and disruptive activity may be evidenced. Infants are resistant to change in routine, schedules, and activities. Change may provoke disruption or aggression. Social development is greatly “out-of-sync” with motor development ( Johnson, 2008). COGNITION/PRELANGUAGE

Infants typically begin making comfort sounds from birth to 2 months old, followed by cooing. Cooing should be followed by an extensive repertoire of babbling sounds. The infant should react to music by cooing or becoming very quiet and still. Infants who are suspected of having autism may not coo or babble, or the sounds may suddenly stop for no apparent reason. Sounds such as mama or dada should be present between 7 and 11 months of age. Social (back and forth) babbling should be present by 9 to 12 months of age, with several consonants recognizable. Combinations of two or more words should be achieved by 2 years old. Infants watch the speaker’s eyes and mouth and look when his or her own name is called. They should respond to their name by 5 to 6 months old. Infants should attentively listen to familiar words, such as a family pet’s name. There will be a response to simple requests with gestures such as “come here” or “where’s your bottle?” Many of the prelanguage milestones will be achieved during the first year of life, with a sudden decline during the second year. Infants will imitate familiar gestures and should wave or respond to bye-bye by 6 to 9 months of age. By 10 to 12 months, infants should initiate social pointing and “follow a point” by parents with a shift of gaze. As a communicative function, infants point to “request” something out of reach. A “requesting” point does not occur until 12 to 14 months of age.

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Figure 4.8. Toddler intentionally seeks joint attention from another child or parent.

An infant who is suspected to be preautistic will not show a “shift of attention” and will not indicate a change in expression with a smile or frown during an event. Some children may engage in primitive pointing with a gesture of the outstretched arm; however, if there is no eye contact, it does not represent true joint attention. Joint attention ( JA) should occur with face-to-face social play at about 3 months old with interest in objects appearing at 6 months of age. JA must involve the child’s excitement between an object/event and another person and is referred to as “triadic.” An infant who has autism will not show a “shift of gaze” and does not look in the direction of the object or person. There will be no “social connection” between the infant and parent or object (Garon, Bryson, & Smith, 2008; Johnson, 2008; Schertz, & Odom, 2004; Zwaigenbaum et al., 2009). It should also be noted that JA establishes the foundation for language development (Figure 4.8). Delays in comprehensive language and gestures are typical in infants with preautism. Some young children will understand little or no language, fail to acquire speech, and may remain nonverbal. Less severely affected children may have a mixed-receptive-expressive disorder. They have better comprehension than expression, and their

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speech is limited, poorly articulated, and agrammatical. Sometimes a young child will have difficulty sustaining a conversation, even though they have large vocabularies. Other children with autism who speak late may progress rapidly from silence or jargon to fluent, clear, well-formed sentences. These young children may have speech that is literal, repetitive, noncommunicative, and often echolalic. Some of these children speak nonstop to no one in particular in a high-pitched, singsong, or poorly modulated voice and perseverate on favorite topics. The “give and take” of conversation is lacking. Young children are also unable to understand the tone of voice, gestures, or body language. Facial expressions for purpose of communication have no meaning.

Figure 4.9. Body language and facial expressions show communication and development of pre-language skills between mother and her baby.

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SUMMARY

This chapter included a detailed discussion of motor, social-communicative-play, and cognition/prelanguage skills for infants at risk for preautism. The importance of the Tonic Reflex Group and maturation of righting reactions was stressed. Signs and symptoms of preautism become very important when they form an intensive cluster of problems detected from birth throughout infancy. The CPAOI in cludes all signs of symptoms of preautism throughout the nine sections of the inventory. REFERENCES Bjorne, P., & Balkenius, C. (2005). The role for context in motor development in autism. Retrieved from http://cogprints.org/4988/1/bjorne.pdf Chawarska, K., Volkmar, F., & Klin, A. (2010). Limited attentional bias for faces in toddlers with autism spectrum disorders. Archives of General Psychiatry, 67(2), 178–185. Cowden, J. E., & Torrey, C. C. (2007). Motor development and movement activities for preschoolers and infants with delays. A multisensory approach for professionals and families (2nd ed.). Springfield, IL: Charles C Thomas Publisher, Ltd. Dawson, G., Sterling, L., & Faja, S. (2009). Autism. Risk factors, risk processes, and outcome. In M. Dehaan, & M. Gunnar (Eds.), Handbook of developmental social neuroscience (pp. 435–458). New York: The Guilford Press. DeJean, V. (2006). Early signs of autism. New York: The Spectrum Center. Retrieved from http://spectrumcenter.net/Tomatis_tomatis.html Garon, N., Bryson, S., & Smith, I. (2008). Executive functions in preschoolers: A review using an integrative framework. Psychological Bulletin, 134(1), 31–60. Johnson, C. P. (2008). Recognition of autism before age 2 years. Pediatrics in Review, 29, 86–96. Loh, A., Soman, T., Brian, J., Bryson, S., Roberts, W., Szatmari, P., Smith, I., & Zwaigenbaum, L. (2007). Stereotyped motor behaviors associated with autism in high-risk infants: A pilot videotape analysis of a sibling sample. Journal of Autism and Developmental Disorders, 37(1), 1573–3432. Schertz, H., & Odom, S. (2004). Joint attention and early intervention with autism: A conceptual framework and promising approaches. Journal of Early Intervention, 27(1), 42–54. Teitlebaum, O., & Teitlebaum, P. (2008). Does your baby have autism? Garden City Park, NY: Square One Publishers. Teitelbaum, P., Teitelbaum, O., Nye, J., Fryman, J., & Maurer, R. G. (1998). Movement analysis in infancy may be useful for early diagnosis of autism. Proceedings of the National Academy of Sciences, 95, 13982–13987.

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Zwaigenbaum, L., Bryson, S., Lord, C., Rogers, S., Carter, L., Chawarska, K., Dawson, G., Dobkins, K., Fein, D., Iverson, J. Klin, A., Landa, R., Messinger, S., Ozonoff, S., Sigman, M., Stone, W., Tager-Flusberg, H., Yirmiya, N. (2009). Clinical assessment and management of toddlers with suspected autism spectrum disorder: Insights from studies of high-risk infants. Pediatrics, 123, 1383–1391.

Chapter 5 SENSORY SYSTEMS SENSORY DYSFUNCTION

nfants learn from their environment through touching, seeing, hearing, and smelling, if their perceptions are accurate. When sensory input is faulty, the environment is very confusing. For infants with preautism, the brain appears unable to balance senses appropriately. For example, infants may be attuned or painfully sensitive to specific sounds, textures, tastes, and smells. They may become extremely irritated by the feel of clothes touching their skin or will cover their ears and scream at specific sounds. Infants with preautism demonstrate some degree of sensory dysfunction (also referred to as sensory integration dysfunction or sensory defensiveness), and some professionals believe it may actually be the root cause of autism. With sensory dysfunction, a child has a contradictory reaction to particular sensory stimuli, sometimes being hypersensitive and other times oblivious to certain sounds, tactile stimuli, or pain. As described by different researchers, sensory dysfunction is a combination of symptoms resulting from aversive responses to nonharmful sensory stimuli, the overactivation of the protective system, and the inability to process or respond appropriately to incoming sensations. Most individuals are aroused by a specific stimuli and then return to a “normal” level of arousal. An individual with sensory dysfunction may not return to the “normal” level of arousal or may take more time to return to this baseline level. Therefore, the stimuli have a cumulative effect on the individual, and the stimuli build to a level of intolerance.

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Figure 5.1. Newborns spend most of their waking hours looking into space.

The cause of sensory dysfunction is unknown, but several reasons being proposed include genetic predisposition, prenatal or perinatal complications, environmental teratogens, and allergies. Infants with sensory system dysfunction have very low frustration levels. Each sensory system is affected in a specific manner. Visual System—Visual Motor Responses and Tracking Newborns should regard colorful objects momentarily. They should follow a moving person with their eyes when lying supine. An infant suspected of autistic behaviors may demonstrate visual fixation on lights and appear to unusually inspect an object. They may tend to gaze into the distance and appear to look at nothing. Interventionists must take extreme care when assessing stares and gazes. Typical infants, at 2 months old, spend 50 percent of waking hours with a vague indirect expression. When a stimulus becomes too bright, typical in fants will blink suddenly (Figure 5.1). Infants’ eyes should track to the midline of the body by 3 months old. Their eyes may appear jerky at the midline, and some blinking may occur when the eyes change directions in their visual field. Infants

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Figure 5.2. Infant visually discovers himself in mirror.

should demonstrate smooth eye movements when following an object upward, downward, and past the midline. Infants’ eyes (at 5 months old) should be able to track an object without head movement in a sitting position. Infants regard tiny objects such as a raisin and will reach and swipe when the object is within 2 feet. By 6 months old, typical infants will begin to look at distant objects a few feet away (Figure 5.2). Infants with preautism exhibit visual defensiveness (oversensitivity to light), visual overload (inability to recognize things they are looking at even though the infant knows the objects), visual distractions (inability to attend to more than one stimuli at a time), and visual sensitivity (glaring lights or eye contact with an adult or other child). Behavior difficulties often occur due to overstimulation of the visual system. The movement specialist must be aware of the visual stimuli within the intervention environment that will affect the child with preautism. Avoiding fluorescent lights, teaching in a visually limited environment, not requiring eye contact, and concern for light glare are a few examples that address the infant’s visual system limitations.

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Figure 5.3. Head turns to look for source of sound.

Auditory System—Sound Awareness and Localization Newborns should indicate reflexive awareness responses such as startles and responses toward sounds. They should appear alert and attend to voices and various sounds in their environment. Eye searching, smiling, or turning toward a sound may be observed. From approximately 6 months of age, infants should turn eyes and look directly at the source of the sound. Although they might not find the sound location, attempts to search for the sound should be apparent. An infant should look at the person when his or her name is called and respond by 5 to 6 months of age. For short periods of time, they attend to a wide range of sounds and voices. When an infant appears to be ignoring sounds and voices, early hearing acuity tests should be administered (Figure 5.3). As a child receives and differentiates auditory sounds, the auditory system is affected by the volume, pitch, and vibration of the sound. Infants with preautism will experience problems with loud sounds such as fire alarms, other children crying or yelling, and background noises. Some infants simply “shut down” and appear not to hear, whereas others cry, scream, and act out to avoid the overload of auditory input. For the movement specialist, knowledge about difficulty

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processing auditory stimuli is critical for planning the intervention environment and providing teaching directions. The environment may appear orderly to most observers; however, for the infant with signs of preautism, it is a minefield of clatter. Quiet areas, free from distraction and outside noise, a calm voice, and simple directions should be utilized. Tactile System The tactile system, the first to develop, is functioning by 17 weeks gestation. It is the most developed sensory system at birth. In the newborn, touch provides the infant with a means of interacting with his environment and the external world. The tactile modality provides the infant with the first avenues for communication or nonverbal language. A premature or high-risk infant’s initial experience with touch is in a hospital’s Neonatal Intensive Care Unit (NICU). Unfortunately, the experience is not a positive one, and the newborn receives excessive exposure to overstimulation by caregivers and many painful procedures. Within the tactile system, hyperresponsiveness is expressed by tactile defensiveness and sensitivity to pain, temperature, or air currents. Tactile defensiveness is an overreaction to touch experiences. It is often noticed in a newborn or infant who does not like to be held by family or caregivers. A reaction to pain or temperature may be extreme (an itch might feel like fire) or may be expressed by reduced sensitivity (a child may show no reaction to a hot stove). To compensate for the discomfort realized by tactile input, a child might exhibit the following: head banging, scratching, biting oneself, or rubbing against large objects. Movement specialists provide tactile-kinesthetic intervention to calm tactile defensiveness that includes body brushing with a soft towel followed by body massage, body stroking, and slow, passive movements of the arms and legs (Figure 5.4). Vestibular System The vestibular system is responsible for the development of equilibrium and balance. It is viewed as having three major functions: (a) awareness of body position and movement in space, (b) postural tone and equilibrium, and (c) stabilization of the eyes in space during head

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Figure 5.4. Enjoying first touch of spring water.

movements and changes in the position of the head in relation to space and the pull of gravity. The vestibular system is intimately connected with the proprioceptive system, the primary method of receiving sensory information. Infants displaying signs of preautism may have underresponsive and underactive vestibular systems. Infants may also exhibit poor posture, balance, and bilateral coordination (Figure 5.5). Hyperactivity and distractibility indicate levels of arousal experienced by infants from incoming sensory stimuli that vacillates between defensive/anxious and dormancy states. To increase stimulation of the vestibular system, infants may exhibit behaviors such as rocking, twirling, and flicking fingers. The movement specialist may assist in remediation of the vestibular system by including activities such as specific rolling, rocking, and swinging activities. Vestibular or rocking boards and large balls may also be used (Figure 5.6). Kinesthetic System The kinesthetic system is often referred to as proprioception and is defined as the awareness of active movement of one’s own body in

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Figure 5.5. Toddler experiences upright posture, bilateral coordination, and balance during play.

space. Kinesthetic perception is often combined with tactile and vestibular input (Figure 5.7). Infants with preautism exhibit problems with muscle tone, bilateral coordination, delayed equilibrium, balance, and motor planning. They benefit from coactive, guided, and repetitive movement patterns, which allow them to develop an “internal awareness or feel” for movements. Infants with preautism may exhibit over- or underreaching when picking up or mouthing objects. They will engage in selfstimulation by stomping, hand flapping, toe walking, jumping, biting, and head banging. The movement specialist can address intervention through therapy ball and rolling activities and mirror exercises.

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Figure 5.6. Infant is stimulated with vestibular ball.

Figure 5.7. Crawling over obstacle course provides kinesthetic stimulation.

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Figure 5.8. Toddler is “on the move” as she develops equilibrium and body awareness.

Figure 5.9. Infant is supported on family dog providing stimulation for development of muscle tone, strength, and balance.

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Figure 5.10. All sensory systems are stimulated as infants enjoy water play.

SUMMARY

This chapter considered the sensory systems, the functions, and their relationship to preautism. Although sensory domains and systems of infants and young children with preautism may be significantly affected, needs of infants with this disorder will vary greatly. Some young children will function much like an infant who is typical, and therefore some of the symptoms discussed in this section will not be evident. Yet it is critical that the movement specialist work with other specialists in designing an intervention program that is appropriate for each infant. The CPAOI should be used to determine needs for the infant in each sensory system. The sensory systems of the infant with preautism will be dramatically affected. The movement specialist plays a critical role when working with an infant with preautism and the family.

Chapter 6 EFFECTIVE INTERVENTION AND BEHAVIORAL STRATEGIES ffective early intervention and behavioral management can alter genetic expression, brain development, and learning outcomes. This is a strong statement but totally accomplishable through structured, individualized early intervention with infants and families. There is no doubt that early, intensive intervention improves outcome, especially when initiated during the infant-toddler period. Significant impact on outcomes is found in IQ, language, and educational placement (Dawson, 2008; Dawson, Sterling, & Faja, 2009; Smith, Groen, & Wynn, 2001). Effective behavioral strategies combined with early intervention programs is the hope for changes of the future. There is growing consensus that many strategies of specific programs for preautism may differ in philosophy; however, components for effective early intervention are similar. It is critical that parents follow up when they feel their infant is different from others, and most likely they will be correct. The CPAOI can be used to determine specific individualized objectives. The goal of intervention should be to intervene when signs and symptoms of preautism are first detected. Professionals involved with at-risk infants should not wait for a diagnosis of autism to be determined. Comprehensive strategies for intensive behavioral and sensory motor interventions for infants under the age of 1 year are listed (Greenspan & Weider, 2006; Volkmar & Wiesner, 2009).

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• Initiation of screening programs as soon as signs of preautism are identified by parents, pediatricians, or early intervention teams. • Specially trained early intervention professionals. • Follow-up interviews with parents using appropriate screening instruments. • Identification of concerns leading to further assessment. • Consistent rewards with big smiles, eye contact, and vocal praise. • Pediatric audiologist assessment of hearing acuity. • Pediatric assessment of visual acuity. • Address all necessary safety factors for each infant. • Screening and diagnosis of infant’s communication, social, play, and motor skills. • Determine specific learning objectives/outcomes for interventions. • Prepare reports of frequency of problem behaviors from parental input and team observations. • Behavioral procedures for reducing problem and inflexible behaviors. • Separate immediate danger or destructive behaviors from socially unacceptable behaviors. • Create a functional behavior plan with help from an expert and team members as needed. • DIR Model/Floortime environment, allowing for communication through back and forth gestures and emotional expressions. • Continued observations of parent-infant interactions in varied social environments. • Activities designed for use by parents, teachers, therapists, and early intervention specialists. • Parents should be encouraged to use five mediational strategies: focusing, exciting, expanding, encouraging, organizing, and plan ning. • Consistent routines in daily schedules. • Programs designed for implementation in many locations: home, classrooms, day care, office settings, and any other appropriate space. • Activities focusing on sensory motor stimulation, social routines for interaction, joint-attention, imitation, toy play, facial ex-

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pressions, and developmentally sequenced skills. • Use actions in child’s repertoire of hand movements or body actions for teaching imitation. • Provide support to parents and inform them of research progress to ease their frustrations about the future of their infant-toddler. • Overall, intervention should be directed to individualized, functional outcomes. Care should be taken when programs claim dramatic responses or even promise a cure for infants at risk for autism. Objectives should be specific to autism and should not recommend therapies or treatments for unrelated conditions (Cowden & Torrey, 2007; Dawson, 2008; Johnson, Meyers, & the Council on Children with Learning Disabilities, 2007; Myers & Johnson, 2007; Rogers & Dawson, 2010; Schertz & Odom, 2004; Zwaigenbaum et al., 2009). ROLE OF THE PARENT

Parents may participate in the screening process by responding to questionnaires, checklists, or interviews with an early interventionist. Parents can review family videotapes, photos, and baby books to help remember when behaviors were first noticed and when infants acquired developmental milestones. After a comprehensive evaluation, parents need to stay focused, ask questions of the transdisciplinary team, and get recommendations on further treatments. Agencies and schools must prepare and implement instructional goals and specific skills through the Individual Family Service Plan (IFSP). Parents are critical in the process of determining treatments based on the infant/young child’s needs. Parents should leave meetings with names of professionals who families can contact as needed. They should write down everything and keep reports, including information from doctors’ visits. Early intervention is available in all states; however, the implementation lead agency may vary widely among states. The IFSP is developed and reviewed every 6 months to address deficits in learning, communication, imitation, attention, motivation, compliance, and social play interventions. Depending on the particular state, most programs

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will occur in either the infant/young child’s home or child-care center, and early interventionists, therapists, and family members work together. Concerns that parents have when planning for their infant may include: • Success of program for other infants and young children with ASD. • Planning and organization of daily activities. • Placement in regular school classes. • Successful performance of young children in regular school placement. • Predictable routines. • Training of staff with infants and young children at risk for autism. • Attention planned for each child in the program. • Progress measures and assessments. • Monitoring of behaviors, observations, recordings, and measurements. • Rewarding process of behaviors that are motivating. • Environmental organization to minimize distractions. • Effect of failure of a treatment program for child and family. • Home programs from interventions and therapists. • Time, commitment, cost, and location of program. It must be remembered by all involved that parent input for infants and toddlers is absolutely critical for appropriate and comprehensive programs. Infants’ levels of skills can be continually updated with the CPAOI. BEHAVIORAL STRATEGIES

Safety An overall goal for behavior management is to establish safety rules for infants and toddlers with preautism to protect them from hurting themselves, other young children, their family, and interventionists. Interventionist must set specific limits to facilitate compliance for dangerous behaviors. A behavioral specialist is needed for destructive, ag-

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Figure 6.1. House rules should be clear and consistent to prevent infants from getting into potentially dangerous areas.

gressive, and self-abusive behaviors. Specialists, interventionists, and parents must determine the least restrictive environment and developmentally appropriate practices to control these behaviors for infants and toddlers (Greenspan & Weider, 2006). Infants and toddlers with preautism are taught acceptable behaviors and a process for following simple rules. Boundaries are shown to infants and toddlers, and established family house rules are explained as the infant matures (Figure 6.1). Consequences of a gentle nature should be enforced for infants and toddlers who do not accept the boundaries. Avoid taking away play time with friends because socialization with others is important (Figure 6.2). Parents and professionals set consequences for disobeying specific rules. For example, dad told his toddler to stay on the sidewalk. Dad looks and his son is walking in the street. Dad reinforces the established rule by telling his son to never walk into the street and to stay on the sidewalk. Dad must enforce the consequence to stay in the

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Figure 6.2. Infant/toddler is reminded of boundaries and rules of safety.

yard, and the sidewalk is the boundary. The infant cannot walk on the street. Changing vocal tone can catch his son’s attention. Adding a gesture to help his son remember may be needed. Dad can raise his hand and say “STOP” with a firm but calm vocal tone when his son starts toward the street. Consequences need to be increased if his son does not obey the established boundary. His son has difficulty with interaction and joint attention. Dad only needs to enforce the consequence for a few minutes because he wants to increase socialization but maintain the overall goal of safety. If his son reacts by becoming angry and has a temper tantrum, additional consequences are added and explained to his son. Dad must help his son learn to follow rules. Principles for a positive support system should be used. Causes of Acting Out Behavior Intervention teams and parents must observe infants with preautism to determine causes for acting out behaviors. Prevention of conflicts is extremely important. When faced with new frustrations, plan more

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Figure 6.3. When shopping, infants and toddlers should understand that they do not pull cans from shelves.

one-on-one time. Parental input of the behaviors of infants and toddlers in the home is essential to determine problems. Continual observation using the CPAOI will help interventionists determine the cause of anger and acting out behaviors and monitor the infant’s progress. No single symptom should be used for diagnosis of cause for infant problems. Parents need to step back and get the “big picture” of be havior problems. Misdiagnosis leads to additional complications. Don’t pay a lot of attention to an infant when he is misbehaving unless the behaviors are destructive to property, disturbing to others (acting out in restaurant), harmful, or dangerous (Figure 6.3). Praise good behaviors to replace bad behaviors. Always use positive reinforcement. Determine causes of problem behavior and by noting

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specifically what happens before the acting out behavior. Behaviors that change in a certain place or at a specific time are clues to understanding the overall problem. Look for warning signs or subtle behaviors that give clues to acting out behaviors. Changing the content of curriculum activities to be more specific to the interests of infants and toddlers may be necessary. The program of activities may be too difficult and will prevent a back-and-forth flow of interactions among infants, interventionists, and families. Always keep in mind the reinforcement of good behaviors. Consider timeout as an appropriate sanction, but do not leave the infant in isolation very long and always remain in the room. If too much time is used for these restrictions, it may become a developmentally negative experience. Medical and neurological examinations may be necessary to identify contributing factors and rule out other syndromes. Medications may be needed to improve overall functioning of the child with preautism. Establish Baseline Recording Describe the unwanted behaviors and gather direct observation information. This will allow parents and interventionists to tailor activities to the infant’s individual profile. The infant’s emotional response to challenges should be recorded. When a rule is set, make sure the infant understands the consequences. Rules should be clear and specific. Efforts to set limits for facilitation of compliance should always be appropriate for infant and toddler functioning levels. Observe and watch for overall improvements in all core areas of development included in the CPAOI. Environment for Observation When performing observations or functional assessments, make sure the environment is comfortable. If there is too much noise in the room or too many strangers, most likely the lower range of skills will only be determined. Create a calming and containing situation based on the individual infant’s needs. Use information from the parents’ home situations and allow parents to stay in the area and assist as needed. New instruments must be designed for preautism, and a positive environment is critical. The environment should allow for a soft but energized voice tone. Encourage play and follow the infant’s lead. Be

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relaxed and playful. Your reactions need to be modified for the infant in terms of language, auditory processing skills, sensory reactivity, and motor planning. Do not promote a one-size-fits-all program for the environment, observation, and assessment. Behavioral Plan Create a behavioral plan. It can be implemented with other specific learning objectives. Limits are determined to facilitate compliance. The plan includes an intensive, structured daily program of activities. Combine elements from different programs until a program fits the infant or toddler. Progress should be recorded daily. Programs must be designed to prepare infants with preautism for preschool. The program should be continued and modified as needed until it reduces the frequency of undesirable behaviors. Comparisons of recorded behaviors at home should be compared to those prepared by different professionals in varied environments. SUMMARY

This chapter presented ideas for effective intervention. Parents often express their feelings that their infant reacts differently than other young children. The CPAOI can be used to record information about their young child’s progress in environments other than in the home. It provides information to help parents understand what their child should or should not be doing. This chapter presented ideas for establishing safety rules as a part of behavioral strategies. Information is presented to help parents know what to look for in a school program that creates a positive learning environment through effective intervention. REFERENCES Cowden, J. E., & Torrey, C. C. (2007). Motor development and movement activities for preschoolers and infants with delays. A multisensory approach for professionals and families (2nd ed.). Springfield, IL: Charles C Thomas Publisher, Ltd. Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder. Developmental Psychopathology, 20, 775–803.

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Dawson, G., Sterling, L., & Faja, S. (2009). Autism. Risk factors, risk processes, and outcome. In M. DeHaan & M. Gunnar (Eds.), Handbook of developmental social neuroscience (pp. 435–458). New York: Guilford Press. Greenspan, S. I., & Weider, S. (2006). Engaging autism. Cambridge: Da Capo Press. Johnson, C. P., Meyers, S., & the Council on Children with Learning Disabilities (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120(5), 1183–1215. Myers, S., & Johnson, C. (2007). Management of children with autism spectrum disorders. Pediatrics, 120(5), 1162–1182. Rogers, S. J., & Dawson, G. (2010). Early start Denver model for young children with autism. New York: Guilford Press. Schertz, H., & Odom, S. (2004). Joint attention and early intervention with autism: A conceptual framework and promising approaches. Journal of Early Intervention, 27(1), 42–54. Smith, T., Groen, A., & Wynn, J. (2001). Randomized trial of early intervention for children with pervasive developmental disorder. American Journal of Mental Retardation, 106(3), 208. Volkmar, F., & Wiesner, L. (2009). A practical guide to autism. What every parent, family member, and teacher needs to know. Hoboken, NJ: John Wiley. Zwaigenbaum, L., Bryson, S., Lord, C., Rogers, S., Carter, L., Chawarska, K., Dawson, G., Dobkins, K., Fein, D., Iverson, J., Klin, A., Landa, R., Messinger, S., Ozonoff, S., Sigman, M., Stone, W., Tager-Flusberg, H., & Yirmiya, N. (2009). Clinical assessment and management of toddlers with suspected autism spectrum disorder: Insights from studies of high-risk infants. Pediatrics, 123, 1383–1391.

Chapter 7 PRINCIPLES OF INTERVENTION he sensory and motor systems of all infants, even infants with autism are intricately related and dependent upon each other. The baby learns through sensory stimulation gained mainly through the process of active and dynamic movement. The infant develops the ability to lift his head and trunk, maintain a stable sitting and standing posture against gravity, and move without losing postural stability and balance (Figure 7.1).

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Figure 7.1. Newborn lifts head against gravity.

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Figure 7.2. The nervous system learns by doing.

During this process, motor control is initiated through the lower centers of the nervous system experiencing an inhibitory process, whereas higher levels of cortical control are modifying motor responses into new and more mature patterns of movement. Basically, the nervous system “learns by doing.” The sensory input information (e.g., tactile, kinesthetic, visual, vestibular, and auditory) is received and transmitted by the nervous system, integrated at appropriate levels, and transmitted into motor actions, patterns, and movements. It is necessary for movement sequences to be analyzed to determine exactly what may be causing motor delays. When an infant is delayed in obtaining a sitting posture, what factors of muscle tone, strength, balance, and motor control are involved? The cause should influence the teaching strategies used with intervention. Intervention programs developed for infants and young children should be based on theoretical

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principles that provide a directional structure. All infants and young children with weak muscle tone or too much muscle tone must have a sequence for structures of intervention programs (Figure 7.2). INTERVENTION PRINCIPLES

Early intervention is the key to assisting infants and preschoolers with delays or disabilities. Families as well as specialists in various developmental areas are critical in this intervention process. As noted by theorists and interventionists (Gershkoff-Stowe & Thelen, 2004), children frequently perform more poorly before they do better. Therefore, during intervention, the movement specialist and families should expect regression before progression in developing movement behaviors. However, this is not truly regression, but the child’s attempt to self-regulate his behavior and coordinate the components of the task and the environment. During skill development/intervention sessions, the following theoretical principles are recommended. They can be followed in homebased, center-based, and individualized motor sessions. The principles expound on the five theoretical assumptions: 1. Increase or decrease of muscle tone to facilitate effective movement. The interventionist may need to facilitate movements to increase muscle tone and strength. With the diagnosis of autism, it may be necessary to perform activities to strengthen muscle tone. The muscle tone of the newborn infant is predominantly flexor tone, and development of extension gradually occurs in 2 to 3 months. Newborns and infants may need support provided until muscle tone and strength develop in the neck muscles (Figure 7.3) 2. Inhibition of primitive reflexes. Infants with preautism may have the presence of primitive reflexes, and due to improper handling and positioning, the infant may appear to extend or arch backward away from the mother. Infants with autism do not seek cuddling of parents, but a strong part of the problem may be lack of inhibition of primitive reflexes. Assessments should be performed by therapists. These reflexes, which are normal in the first 4 to 6 months, should gradually disappear. When an infant’s development

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Figure 7.3. Mother provides head support for newborn.

has been delayed, it may be necessary to perform exercises that inhibit primitive patterns. Retention of primitive reflexes interferes with more mature forms of mobility (Figure 7.4). 3. Reciprocal innervations. Reciprocal innervations may be defined as the interaction of muscles contracting while the opposite muscles stretch or relax, allowing for freedom of movement of bones and joints. If an infant has retention of primitive reflexes, this component for facilitation of movement is compromised and the infant lacks a smooth flow of efficient muscular actions. As the infant begins to explore his environment, freedom of movement should be noticed by interventionist. An infant suspected of preautism may not demonstrate curiosity of learning through movements (Figure 7.5). 4. Facilitation of movements. Repetitive sensory motor movements may be necessary to facilitate actions of immature nervous system pathways. Infants with signs of preautism need central nervous system stimulation. Caution should be

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Figure 7.4. Tonic neck reflexes are evaluated.

Figure 7.5. Infant demonstrates freedom of movement to explore new environment.

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Figure 7.6. Interventionist demonstrates movement facilitation to father of infant.

taken with infants suspected of preautism. Excitatory responses may be too strong and interfere with this intervention principle. Intersensory integration is usually promoted by providing an environment that allows the infant to move freely. Hands-on or coactive guided activities may be needed. With different levels of autism, different responses may be observed by the interventionist (Figure 7.6). 5. Stimulation of automatic equilibrium reactions. Equilibrium reactions are specific exercises that increase muscle tone, strength, and balance. The vestibular, tactile, kinesthetic, and visual modalities should be stimulated through activities requiring bouncing, rolling, or tilting. Creeping up and down hill on incline mats also stimulates the sensory systems. Vestibular boards are often used, which allows the interventionist to rock the infant back and forth (Figure 7.7). 6. Tactile stimulation for warm-up, relaxation, flexibility, and range of motion. Warm-up is also necessary for infants and young children to perform effective patterns of movement by raising the temperature and increas-

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Figure 7.7. Trunk and neck strength are developed while rocking vestibular board.

ing circulation of the muscles and joints. Parents can move their infant’s extremities through passive range of motion. Deep pressure massage promotes elasticity of soft tissue, which enables the infant to perform some movements that might otherwise be impossible or extremely difficult to perform. Videotape and recorded observations of infants with preautism to examine the infant’s response to movements is essential (Figure 7.8). 7. Positioning for increasing muscle tone, strength, and balance of specific muscles. Strength is defined as the force exerted by muscles in a single contraction. The ability of muscles to sustain repeated contractions is termed muscular endurance. When muscle tone or muscular firmness is de veloped, strength is usually maintained or increased. Through se quences of exercises in various positions, muscle tone and strength will also develop, leading to improved balance and mobility. Most infants with signs of preautism will tend to have hypotonic muscular tone.

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Figure 7.8. Gentle range of motion of extremities by parent.

Play equipment can be used for developing muscle tone for increased strength and balance (Figure 7.9). 8. Coordination of stability and mobility. A blending of stability (holding strategies) and mobility (active movement) is necessary for upright locomotion. It is necessary to have a balanced distribution of tone or tension for static or mobile movements. Four-point crawling is the beginning of movement requiring stability and mobility. Basically, walking is a developed skill of losing one’s balance and regaining it while maintaining an upright position. Clumsy or unbalanced movements can be attributed to unequal muscle tone and lack of coordination during periods of stability and mobility (Figure 7.10).

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Figure 7.9. Father provides support while child is learning to walk.

Figure 7.10. Infant is demonstrating initial balance needed for four-point movement.

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9. Resistance training. With an increase in resistance to movements, muscle tone and strength increase. Infants with signs of preautism usually have weak muscle tone, a condition involving damage to the central nervous system. Sensory input or stimulation results in increased motor output or movement. Therefore, through the use of light ankle weights (e.g., quarter-pound or half-pound), resistance is increased and muscle tissue is developed. When muscle tissue replaces fatty tissue, muscle tone and strength can be increased. Specific combinations of exercises should be performed to strengthen the total body from head to toe. Infants with preautism may respond differently with this principle for increasing strength. Careful observation and videotaped sessions will provide the interventionist with feedback. Light weights or resistance training should be used very carefully with all infants. Identification of flexor versus extensor tone dominance or abductor versus adductor tone dominance should be clearly established prior to using resistance training as a part of an early intervention program. A balance of weak versus strong muscle groups must be obtained to establish a smooth, efficient pattern of movement. For example, an infant who presents fisted or flexed fingers should never be asked to squeeze a soft rubber ball to increase flexor tone strength because the flexor pattern is dominant and therefore is interfering with the quality of fine motor manipulation. The flexor muscle group should be relaxed/stretched by pressing the palm of the hand and extended fingers flat against 4” size balls (Figure 7.11). 10. Exercise sequences, repetitions, and sets. Exercises should be performed to develop flexion, extension, adduction, abduction, and rotational movements of various muscle groups. Repetitions are the number of times a muscle is required to contract during a specific exercise. Sets are the number of times an exercise should be repeated. Through muscle repetitions and increased sets, central nervous system excitation increases the transmission of nerve impulses necessary for the development of muscular strength and motor skill. Infants with autism may tend to want to choose their own repetitive behaviors. If possible, use their actions to acquire your goal as the parent or interventionist.

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Figure 7.11. Light quarter-pound ankle weights are used to increase leg strength.

11. Frequency, duration, and rest. Frequency is how often an exercise is performed, duration is how long an exercise is performed, and rest is required of muscle groups to prevent fatigue. Exerted effort is a positive term used to assist interventionists and parents with an understanding of these concepts. The movement specialist should assist caregivers with determining the infant’s and young child’s exercise sequences, repetitions, sets, frequency, duration, and rest when designing and monitoring individualized and home-based pediatric strength interventions. Infants with a diagnosis of preautism will benefit from a structured program (Figure 7.12). 12. Overload, progression, and maintenance. It is necessary to have a progressive increase in resistance, exercise time, or repetitions for the development of muscle tone and increased strength. Careful monitoring of an infant’s progress by the movement specialist and family is necessary to make positive changes in the inter-

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Figure 7.12. Head, neck, and trunk control are worked on using exercise principles.

vention program. Precautions should always be taken to ensure the safety of the infant and young child. Stimulation of the nervous system is needed for infants suspected of preautism. Using a progressive program of fine motor exercises will help increase hand function and joint attention (Figure 7.13). 13. Dynamic action and adaptation. Theoretically, dynamic action implies a systematic relationship of internal biological changes with external environmental interactions (Thelen & Smith, 1994). The learning and exercise environment is an integral part of the exercise program. Movement provides the oppor-

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Figure 7.13. Structured program for fine motor development and joint attention.

tunity for learning experiences and can be considered the “language of intervention.” Adaptation provides the process that allows for the exchange of internal and external information, therefore establishing the infant’s relationship with his or her surroundings is necessary. Without opportunities for movement, the infant does not have a means to adapt to his or her environment. Dynamic system principles should be used in exercise programs with infants with signs of preautism (Figure 7.14). 14. Psychophysiological Response to Stress (PRS). The challenge of attaining sequential movement skills by infants with preautism may cause adverse or negative elements of psychophysiological responses to stress. Emotional reactions can interfere with neurological, cardiovascular, respiratory, and physiological processing. Infants with delays or disabilities may compensate in different ways to accomplish specific tasks. If hypotonia is present, the infant with

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Figure 7.14. Much internal learning is needed for fine motor activity requiring motor planning.

autism may exhibit atypical ways of moving to obtain a toy. Care should be taken to avoid allowing the infant to lock the knees, ankles, or hips to facilitate moving. An example for a child with hypertonicity may be regressing to primitive reflex control when challenged with the achievement of higher developmental skills. Tactile stimulation and relaxation techniques should also be considered if the infant becomes overstimulated. In addition, PRS may be measured by changes in the child’s cardiovascular and respiratory systems and through judgmentbased and observational assessment.

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IMPLEMENTATION AND EVALUATION

The theoretical premises of intervention are best applied to homebased individualized or center-based pediatric strength and activity interventions, which involve the infant or young child, caregivers, and movement specialist in the design and implementation of the program. The caregiver’s involvement in assessment and intervention is a reliable source of information. Because the intervention is usually implemented in the natural context of the infant’s home environment, this design facilitates interaction between caregivers and infant, utilizes the surroundings most comfortable for the infant, allows the intervention to be implemented at times when the infant is most alert, and increases caregiver knowledge and skills in the facilitation of motor development. A movement specialist working primarily in a center-based program can apply this approach to individual and group interventions implemented at the center as well as provide parent training for home-based implementation of the intervention. A developmental assessment or the CPAOI should be administered prior to designing the intervention program. The assessment should also utilize standardized and curriculum-based instruments along with judgment-based assessment and responses from an interview with the infant’s caregivers. The individually designed program should be based on the theoretical premises of intervention. A balance of the infant’s current abilities and progressive challenges should encourage each child’s advancement to subsequent levels of motor development. The movement specialist should provide the caregivers with detailed and written home programs. It is very important for the movement specialist to discuss with the family the appropriate guidelines for administering the home-based intervention and to continuously monitor the implementation of these guidelines. At a minimum, the guidelines should include the following: (a) An explanation of the exercise prescription, including a demonstration by the movement specialist, the interventionist practicing the exercises with the infant, and an explanation of the frequency, set, and repetitions.

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(b) Importance of the infant’s maintaining proper body alignment during the exercises. (c) Properly adapting the necessary home or commercial equipment. (d) Allowing the infant/young child to put forth exerted effort during the movements. (e) Providing an atmosphere of fun and play during the implementation of the exercises. (f) Following the child’s lead without continuously targeting of weak muscle groups. In essence, the design and implementation of the program is very similar to the currently popular “personal trainer” employed to evaluate someone’s physical fitness status and individualize a fitness routine to help the person achieve desirable fitness goals. QUALITATIVE EFFECTIVENESS

Many times interventionists must provide documentation as to the effectiveness of their programs. Two methods for quantifying a child’s development during intervention have been utilized: interventiondevelopmental quotient and posttest developmental age compared to predicted developmental age (Fewell & G1ick, l996; Fewell & Oelwein, 1991; Oelwein, Fewell, & Pruess, 1985; Snyder-McLean, l987). Snyder-Mclean (1987) proposed the intervention developmental quotient be calculated to determine the child’s rate of progress during the intervention. A child’s pretest developmental quotient can be calculated using a standardized evaluation during the initial assessment process. The pretest developmental quotient is calculated by dividing the child’s developmental age (as determined by the standardized evaluation) by his chronological age. This pretest developmental quotient reflects the child’s entire lifetime of learning from birth through the time of pretest. At the end of the intervention period for which progress or development must be shown, the same standardized eval-

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uation is given as a posttest. To calculate the child’s intervention developmental quotient, subtract the child’s pretest developmental age from the posttest developmental age and divide the difference by the length of intervention. The intervention developmental quotient can then be contrasted with the pretest developmental quotient. Snyder-McLean (1987) suggested the following advantages to the intervention developmental quotient formula: (a) by acknowledging each child’s pretest developmental quotient, it allows for observable changes that may be attributable to maturation; (b) it “factors out the minimizing effects of increasing CA [chronological age] on the size of DQ [developmental quotient] gains associated with intervention” (p. 262); and (c) “this approach is simple and allows evaluation data to be presented to broad audiences in a meaningful way” (p. 262). The intervention developmental quotient formula was used to determine the effects of a strength intervention program designed for infants with Down syndrome (Cowden & Torrey, 2007). Pre- and posttesting involved normative, curriculum-based, and judgment-based measures and video analysis of gait patterns. Eight-week interventions were completed in home-based programming to facilitate muscle tone, strength, and balance development. Intervention included exercise programs using a combination of neurodevelopmental patterning, intersensory modality stimulation, a task analysis approach to equilibrium, gait analysis, and a sequential, interactive progression of exercises in accord with the intervention principles. The caregivers were trained in exercise implementation, positioning and handling, relaxation and stimulation, and the proper use of home-made and commercial equipment. The results of the data offered support for the application of the intervention principles for muscle tone, strength, and balance development of infants with delays or disabilities. Fewell and Glick (l996) employed the second suggested approach to determine the intervention effects of an early intervention program and to determine whether there were differences in the effects of the intervention outcomes for young children who were less impaired than those who were more impaired. They compared posttest developmental ages to predicted developmental ages. “The predicted developmental ages (in months) at posttest were computed by multiplying the pretest DQ [developmental quotient] (proportion) by the amount of time in intervention (in months) and then adding the result to the

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child’s pretest developmental age” (p. 237). They summarized their calculations as follows: Step 1: Pretest Developmental Age in Months/Pretest CA (chronological age) in Months = Pretest DQ (developmental quotient) Step 2: Pretest DQ x Months in Intervention = Predicted Months Gain Step 3: Predicted Months Gain + Pretest Developmental Age (months) = Predicted Developmental Age (in months) at Posttest Statistical analysis was used to determine significant differences between predicted developmental ages and actual developmental ages of the subjects. In their discussion of results, Fewell and Glick (l996) acknowledged the limitation of their formula for predicted gain “being based upon the assumption that without intervention, children will develop linearly and at a constant rate” (p. 241). However, they point out that the formula does account for individual trajectories. In light of their study and the difficulties in finding models that appropriately analyze gain, these researchers suggested, “Perhaps it is time for practitioners, program evaluators, and policy makers to seriously revisit the criteria and measurement for program effectiveness” (p. 239). SUMMARY

This chapter provided principles of intervention from which professionals and families can individualize developmental activity and play programs. In addition, research data were summarized detailing the specific and individual changes of infants with hypotonia. Suggestions were made for justifying qualitative research programs. REFERENCES Cowden, J. E., & Torrey, C. C. (2007). Motor development and movement activities for preschoolers and infants with delays. Springfield, IL: Charles C Thomas. Fewell, R. R., & Glick, M. P. (1996). Program evaluation findings of an intensive

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early intervention program. American Journal on Mental Retardation, 101(3), 233– 243. Fewell, R. R., & Oelwein, P. L. (1991). Effective early intervention: Results from the model preschool program for children with Down syndrome and other developmental delays. Topics in Early Childhood Special Education, 11(1), 56–68. Gershkoff-Stowe, L., & Thelen, E. (2004). U-shaped changes in behavior: A dynamic systems perspective. Journal of Cognition and Development, 5(1), 11–36. Oelwein, P. L., Fewell, R. R., & Pruess, J. (1985). Efficiency of intervention at out reach sites of the program for children with Down syndrome and other develop mental delays. Topics in Early Childhood Special Education, 5, 78–87. Snyder-McLean, L. (1987). Reporting norm-referenced program evaluation data: Some considerations. Journal of the Division of Early Childhood, 11, 254–264. Thelen, E., & Smith, L. B. (1994). A dynamic systems approach to the development of cognition and action. Cambridge, MA: The MIT Press.

Chapter 8 PREAUTISM SENSORY MOTOR CURRICULUM INTRODUCTION

he basis for sensory motor curriculum activities is brain plasticity. It refers to the ability of the brain to change and reorganize neurological pathways. The brain is not “hard-wired” as an electrical device. Depending on what the brain is sensing and perceiving, it can change structure and function. Neural plasticity is the foundation for success of early sensory motor stimulation programs. An in-depth discussion of brain plasticity is included in Chapter 2. Preautism screening is based on neurological processing, which involves sensory stimulation or sensory input to the infant’s central nervous system. An infant with signs of preautism may demonstrate problems associated with sensory dysfunctions. Infants learn through their environments from tactile, vestibular, auditory, vision, and kinesthetic stimuli. Other sensory systems do provide feedback to infants, but activities will only be included for the above mentioned systems. Screening items for Cognition/Prelanguage and Social-Communication-Play will overlap with sensory system stimulation because sensory input is the way infants learn. A discussion of sensory dysfunction was included in Chapter 5 (Figure 8.1). The tactile system, the first to develop, is functioning by 17 weeks gestation. It is the most developed system at birth, providing the newborn with a means of interacting and making initial contact with the external world. The tactile modality has sensory receptors for light skin touch, deep pressure massage, and sensory receptors for pain and

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Figure 8.1. Play overlapping with sensory stimulation.

temperature. Because there are so many sensory receptors and it is the first system to be fully developed in newborns, it is critical to intervene very soon after birth. A premature or high-risk infant’s initial exposure to the new world is often one involving encounters with pain and discomfort in a Neonatal Intensive Care Unit (NICU). Most often the infant’s feet have been used for injections. As soon as possible, positive tactile sensations should be primary and continued with other interventions. Prevention of later problems of tactile defensiveness may be prevented. Sensory input or stimulation may be processed differently by infants. Many infants will be hypersensitive to selected stimuli for specific sensory systems. Other sensory systems may process new information without difficulty. Extreme care must be taken in screening for problems so that activities are directly related to infant sensory weaknesses and strengths. Visual recognition memory must be strongly emphasized through sensory motor stimulation activities. The ability to recall information visually presented is termed visual recognition memory. Visual motor

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Figure 8.2. Visual motor memory skills are predictive for cognitive and language skills.

memory for processing information during the first year of life is predictive of later language and cognitive abilities (Figure 8.2). This sensory motor curriculum includes activities combined with joint attention for awareness, alertness, recognition, memory, and discrimination within sensory systems. Activities are presented in order of development in utero: tactile, vestibular, auditory, vision, and kinesthetic. SENSORY MOTOR AND JOINT ACTIVITY SKILLS

Tactile System Tactile Stimulation of Infants for Awareness, Recognition, and Discrimination Goal: The goals of the tactile system are multiple: to initiate positive tactile stimulation and awareness of the special sensory receptors; to

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Figure 8.3. Infant enjoys tactile stimulation of soft blankets while posing for picture.

decrease sensitivity in free nerve endings located in the skin, joints, tendons, and ligaments corresponding to pain and temperature; and to create continued positive neurological feedback for tactile integration and to decrease negative sensations associated with tactile defensiveness. • Touch and stroke infant’s arms and legs to promote calming sensations. • Gently stroke surface of back of head, neck, and shoulders to provide relaxation. • Touch fingers, hands, nose, ears, toes, feet, calling out names of body parts. • Use different textured fabrics (e.g., blanket, terry cloth, velvet, cotton) to stroke infant’s feet, legs, hands, and arms (Figure 8.3). • Use different levels of tactile pressure (e.g., light, soft, firm, stroking, tickling, gentle massage). • Slowly move infant’s hands and arms back and forth on soft sheet. • Slowly lift infant’s hands and arms up and down from crib or bed. • Support infant upright while touching and softly rubbing fingers, arms, toes, and feet. Watch expressions in a mirror.

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• Rock back and forth while supporting in arms. • Touch skin surfaces with moist, warm cloth. • Provide fuzzy animal toys and play with infant while continually speaking in soft tones. • Assist infant with rolling by turning head and then body in segmental roll. Perform rolling movements on carpet, thin mats, thick 6⬙ mats, very soft, plushy surfaces, and bed mattress. • Assist infant to roll down an incline mat with smooth surface. • After infant attempts to acquire a sitting position, use different surfaces to sit on for tactile input. Use soft foam, air mattress, different textured carpet, tile, gym mats, tilt boards, grass, sand, and shallow 2⬙ water in tub/pool. • Use different surfaces for 4-point crawling, increasing thickness of surfaces so tactile and vestibular sensations are created. • Continue using soft, large towels to rub and massage skin surfaces, especially bottom of feet. • Touch infant from the side, over shoulder, on top of head, under chin, and on feet. • Put small, quarter-pound ankle weights on infant to give light and heavy sensations. Quarter-pound to half-pound weights will also increase leg strength for hypotonia and balance. • Support on small tricycle, securing feet to pedals while pulling trike forward and backward. Vestibular System Vestibular Activities for Developing Equilibrium Reactions and Balance Goal: To engage with infant to develop under responsive vestibular systems, integrate primitive reflexes, and develop postural equilibrium reactions, balance, and bilateral coordination. Automatic responses to maintaining equilibrium and balance of the infant/toddler are termed postural reactions. They should be developed in young children by the age of 2 to 10 months and continue developing throughout the lifespan. Three categories compose reactions: (a) righting head, neck, body; (b) parachute; and (c) equilibrium. Stimulation of the vestibular sensory modality develops balance and movement control. Assessment

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procedures should include: (a) assessment of reactions to see whether the child has the necessary protective skills to prevent injury (e.g., attempts to catch self when losing balance or falling), and (b) assessment of functional movement skills to determine motor delays that exist due to poor balance skills. Activities will be presented in the following sequences: (a) righting reactions, (b) parachute and protective extension, and (c) equilibrium and balance. Righting Reaction Activities • Rolling exercises, from side to side, prone to supine, complete segmental roll. • While providing some support in sitting position, move and tilt infant from side to side and front to back; allow the infant to adjust and maintain sitting position. • Using tilt or vestibular board, provide rocking stimulation in prone, supine, sitting, and 4-point positions (Figure 8.4). • Using physioball/vestibular ball with infant supported in prone position, rock ball side to side, forward and backward, repeat in sitting position. • Place infant in prone position on scooter board and assist him or her with pushing forward, backward, side to side, or slow spinning movements. Parachute Reaction-Protective Extension Activities • Assist infant while performing swinging and swaying movements while supporting infant in prone and sitting positions. • Using physioball/vestibular ball, place infant in prone position and rock forward and backward causing infant to reach out in protective extension. • Using vestibular board, repeat above listed activities. • Perform scooter board activities listed above. Equilibrium & Balance Activities (Total body responses) • Rolling activities: - down & up inclines - through obstacle courses - at targets (e.g., bowling pins) - tuck rolling side to side

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Figure 8.4. Vestibular board is used to develop righting reactions and balance.

• Vestibular board—rock in prone, supine, sitting, and 4-point positions. • Physioball/vestibular ball—prone, supine, and sitting. • Scooter board exercises—prone, supine, sitting, obstacle course. • 4-point position balance exercises, reaching for hanging mobile. • Animal movements (e.g., bear crawl, measuring worm, seal crawl). • Walking patterns: - homolateral pattern - cross-lateral pattern: right arm and left leg forward, left arm and right leg forward - following footprint patterns on floor - backward walking - on heavily matted surface - up and down inclines - stepping through ladder rungs

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Visual System Visual Motor Awareness and Joint Attention Goal: To establish visual awareness of another person or object and break pattern of self-engagement with an object. When infant is selfengaged with an object, follow the infant’s interest. As long as he shows no interest in anything but the object, start with the following activities. When he engages visually with you, change to next level of visual motor attention. • Engage alertness by following infant’s gaze at object and look at object with infant. • Engage with object of interest by looking at object and then at infant by overemphasizing expressions of smiling, laughing at infant, laughing at object, making cheerful gestures. Speak softly and vary tone of voice. • Move object from gaze/stare of infant. Wait to see response. Play with object, toss in air, and toss to parent/other participant, always watching response of infant. • Intervene by rolling a ball back and forth across path of vision of infant. Repeat numerous times watching eyes of infant. • Roll or rock your body between gaze of infant, always changing facial expressions, smiling, laughing vocalizing his name. • Shine a flashlight on object and back and forth from infant’s eyes to object. • Zig-zag pattern of flashlight back and forth from infant’s eyes to object, always vocalizing his name, laughing, smiling, giggling, and watch responses. • Crawl between object and infant looking into eyes of infant. • Sit behind object at level of object, changing facial expressions and looking into eyes of infant. • Play music behind the object, in front of object, and between infant and object. Until the infant attends briefly to another person with eye contact, repeat this routine. He may change objects of interest for self-engagement. Follow infant’s interest.

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Visual Motor Attention and Joint Attention Goal: To establish eye contact for brief periods, slowly increasing time in seconds. Engage with infant to establish eye contact for a period of 5 seconds, slowly increasing time. Use toys of interest to establish eye contact, changes in facial expression, and imitate adult vocalizations. • Participate in a social routine with a stuffed animal toy. Move and talk to pet toy, watching for turn of head to establish visual attention and eye contact. • Crawl, jump, hop, skip around infant while establishing visual attention and noting changes in length in time. • Introduce two toys and encourage infant’s attention and eye contact. • Add several toys to a play routine, encouraging infant to reach and touch toys. Always use varied happy faces with smiles, laughing, giggling, and watch infant for facial expressions. • Introduce bright colored toys, watching for responses. • Combine toys with musical sounds. • Stand and move across room to establish a change of visual attention. • Infant’s attention should be extended to 5–15 second periods of response. • Call pet toy by name encouraging infant to watch and show visual intent to play. Use appropriate animal imitation of sounds for encouragement. • Change toy from dog, cat, horse, and cow using different textures of animal coat. Encourage infant to touch or pet the animal. • Increase varied facial expressions while talking to infant with great enthusiasm during toy play, watching for extended visual attention of 30 seconds or more. Until infant has established several minutes of attention to session activities, repeat routines in each motor session. Add changes or creativity to session activity, but maintain goal of visual attention. As infant shows extended attention span, move to next level of visual system.

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Visual Motor Recognition-Memory and Joint Attention Goal: To establish visual recognition of people, objects, and environmental changes demonstrating eye contact and alertness. Infants should demonstrate recognition memory of a family member, caretaker, or teacher. • Engage infant in a familiar social routine with eye contact. • Look at infant as you approach, presenting usual smile, eye contact, and vocalizations while watching his expression. • Engage a toy/object of interest. Place a cloth over toy and wait for infant to gesture toward or recover object. • Have parent enter room while you are engaging infant in social routine and watch facial expressions. • Put toy/object in box as infant watches and wait for infant to try to retrieve toy. • Put toy behind you and wait for infant to reach or gesture for toy. • Put infant’s favorite toy into box and retrieve a different toy. Watch facial expressions and wait for response. • Present two toys with two cover cloths. Put favorite toy under one while infant watches, and place second toy under another cloth. Ask infant where his toy is hiding. • Replace toys with ball. Roll ball behind box and encourage infant to move box or reach for ball. • Put stuffed dog into pet’s house turned to the side of infant while watching eye contact and facial expressions. Ask infant where “call pet by name” has gone. Encourage infant to find pet. Use creativity, enthusiasm, and varied facial expressions. Reward infant’s success as he demonstrates visual motor memory tasks. Repeat joint activities in several motor sessions. Infant of 3 to 5 months of age should have demonstrated eye tracking movements during routines. Move to next level of visual motor tracking skills. Visual Motor Tracking, Control, and Joint Attention Goal: To establish ability to coordinate eye movements to fixate, track moving objects and body movements in the play and social routine area. Visual acuity should be assessed by pediatric specialist.

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Figure 8.5. Visual attention is established during play routine.

• Infant shows awareness of movements in surroundings. • Infant responds to changes in facial expressions of caregiver’s face. • Infant visually tracks person or objects moving in room. • Infant respond to changes in light and tracks movement of flashlight. • Eyes track across midline from side to side, up and down, circular motion. • Infant visually attends to objects for 5 to 10 seconds (Figure 8.5). • Infant tracks light of flashlight from side to side and up and down. • Infant visually tracks a suspended ball. • In supine, infant raises head to look at wall target placed 12⬙ from floor. • In supine, infant looks from wall to ceiling targets. • In supine, infant arches head/neck backward and looks from wall target to ceiling. • Have infant look at suspended ball at eye level in sitting position. • Track ball across midline of body from side to side, up and down. • Encourage infant to reach out and try to touch swinging ball with hand and fingers (Figure 8.6).

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Figure 8.6. Infant reaches for swinging toy and joint attention is established.

• Mirror play with facial expressions, touching of mirror, and arm/ hand gestures. • Infant tracks rolled ball back and forth and from side to side across midline of body. • Balloon activities- swipe/slap at with hands. Auditory Awareness, Recognition, and Discrimination Goal: To establish auditory awareness, recognition and discrimination of a variety of sounds. Make loud and soft noises and watch attention span of infant. Make different high and low pitch sounds, laughing with infant. Notice if infant seeks social attention with vocalizations and gestures. Infant should distinguish between friendly and angry voices. Hearing should be checked by pediatric specialists (Figure 8.7).

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Figure 8.7. Soft toys were given to infant for joint attention and alertness.

• Engage infant by making normal voice sounds and watch alertness. • Clap hands and make happy, giggling, and laughing sounds. • Introduce toys that make a variety of soft noises. • Shake baby rattlers to side and front of infant’s head. • Vocalize babbling and imitate playful sounds. Watch alertness of infant. • Listen for infant to begin to make vocalizations such as cooing. • Encourage infant to turn head in direction of playful sounds. • Notice when infant quiets to familiar voices. • Encourage infant to look for source of sounds. • Be aware if infant appears to ignore sounds, as if not heard (Figure 8.8). • Intervene with a variety of loud and soft sounds. • Infant should begin to respond to name. • Record length of time that infant listens intently to sounds. • Use different high- and low-pitch sounds with musical instruments. • Move infant’s arms and legs to the beat of music or songs. • Responds to facial expressions and emotional intent of speaker by making various sounds.

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Figure 8.8. Auditory acuity and awareness must be immediately established.

• • • • • • • • • • • •

Vocalize sounds, babbles, and imitation of sounds with infant. Laughs, smiles happily, and reacts to stimulation. Searches for sounds. Introduce animal sounds. Watch for imitation from infant. Imitates syllables/sounds. Responds to requests with sounds and gestures. Responds to name. Moves body to rhythm of music. Follows simple commands. Makes sounds to music. Matches sounds with example or picture of animal. Responds to simple directions (Figure 8.9). Kinesthetic System

Kinesthetic Awareness Activities Goal: To engage with infant through activities for development of an internal awareness and feel for movements, imitation of facial expressions, body movements in play, social routines and gestures.

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Figure 8.9. Responding to directions for safety ride in automobile.

• Touch body parts (nose, ears, mouth, eyes) while looking in mirror. • Move body parts separately, vocalizing names, while looking in mirror. • Use mirrors in play-based environment with repetition of routine movements. • Encourage prone prop position, working on body image with mirror play. • Imitate other person/child’s movements while playing with infant. • On back, move infant’s arms and legs in, out, up, and down, performing angels in snow. • Perform different movement patterns (e.g., crawl, creep, roll under, over, and through an obstacle course). • Push and pull infant through prepared obstacle course while lying prone on padded scooter board or in walker (Figure 8.10). • Support in sitting position on scooter board and move infant through prepared obstacle course.

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Figure 8.10. Infant explores toys and surroundings in mobile chair.

• Swing, sway, stretch, twist, and bend infant’s body during play. • Using carpet squares, arm pull, leg push, knee pull, perform bilateral arm/leg movements. • Sit infant in hula hoop and identify circular space. • Sit in hula hoop space and direct imitation of movements with arms. • Direct infant to crawl and step through hula hoop. • Have infant explore surroundings with new toys (Figure 8.11). • Involve fine motor development with popular items (Figure 8.12). • Body awareness involves exploration of different objects. • Infants play with other children in their space. • Sitting and standing postures on different surfaces (Figure 8.13).

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Figure 8.11. Looking at choices and touching many toys in his environment.

Figure 8.12. Exploring a popular cell phone toy.

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Figure 8.13. Exploring time with a new friend in outdoor environment.

SUMMARY

This chapter included extensive activities for infants indicating signs of preautism in the sensory motor systems. More specifically, a series of exercises were included for play and joint interaction while developing strength and motor skills in the following areas: • • • • • • • • • •

Tactile stimulation for awareness, recognition, and discrimination. Vestibular activities for righting reactions. Parachute reactions and protective extension. Equilibrium and balance for total body response. Visual motor awareness and joint attention. Visual motor attention and joint attention. Visual motor recognition-memory. Visual motor tracking, control, and joint attention. Auditory awareness, recognition, and discrimination. Kinesthetic awareness activities.

More than 250 new activities and pictorial figures were included throughout the book for clarity of introducing activities to infants indi-

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cating signs of preautism. The activities can be expanded by the use of different toys, environments, and interaction by families with facial gestures to establish sensory motor skills and early joint attention.

Chapter 9 THERAPEUTIC RIDING well-planned therapeutic riding program is extremely beneficial for relaxing muscle tone and developing strength. Communication, joint attention, and social skills of infants with signs of preautism are also benefits of the program. Specially trained horses have a visibly calming effect on infants and young children who tend to have attention problems and may be hyperactive (Figure 9.1).

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Figure 9.1. Horses wait for their special riders to arrive.

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Figure 9.2. Infant greets his horse with a kiss to its soft nose.

I strongly believe that therapeutic riding is one of the most beneficial activities for infants indicating early signs of preautism. The infants and toddlers respond to the horses as if they were extra-large teddy bears made for hugging (Figure 9.2). For more than 25 years, graduate assistants, students, teachers, and families attended the Greater New Orleans Therapeutic Riding Center (GNOTRC) on Saturday mornings. It was scheduled as part of The University of New Orleans Pediatric Adapted Motor Development Clinic. Each student had an assigned child for required practica experiences. Infants and toddlers begin the program when they can maintain some supported sitting balance. The trained walkers responsible for the child provide support as needed. One walker is responsible for leading the horse throughout the riding course. Families can observe older children with all types of disabilities riding and enjoying their special time with the horses. During a therapeutic riding session, five to six children are each on their own horse. Each child is assisted up a ramp

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Figure 9.3. More severe child is supported with bolster across saddle while riding.

to mount the horse. Once on the horse, the trained volunteer walkers move into position on each side of the horse and assist with stabilization of the child, while the other volunteer leads the horse into the riding arena. Bolsters are used to support children with severe disabilities who are unable to hold themselves up (Figure 9.3). The infant or toddler is told to sit up straight, maintain posture, look between the horse’s ears, and loosely hold the reins, keeping their feet in the stirrups while the horse is walking. Family members, including older siblings, are taught management skills for the horses and may be trained as volunteers if they wish to become involved. Participants are challenged to maintain balance while horses move forward about the arena, stop and turn, reverse the direction in which they are moving, and step over low obstacles. When the arena director instructs the horses to move to the middle of the arena, children are requested to touch parts of the horse (i.e., tail, ears, and mane), turn to the back of the saddle, and touch parts of their body. All of these

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Figure 9.4. Infant is told to turn on horse and reach to touch the tail of his horse.

skills require maintenance of balance and equilibrium, and they provide practice with body part identification, laterality, and directionality. Young infants are guided through the movements with coactive participation of the walkers (Figure 9.4). The children can stroke, pet, hug, kiss, and enjoy the rhythmical movements of the horse as the large, gentle animal moves around the arena. The horse takes over responsibility in his own way for such a small companion, as if he understands how special the little rider has become. The horse needs its new friend, as the child will learn to love his or her own personal horse. The outside environment has no distractible noises. In the distance, doves can be heard cooing. Sounds are coming from hoofs of the horses in the sand, and gentle sounds come from the horses as they enjoy their time giving all of their comfort to the child. Buster, the property watch dog, lies peacefully beside the arena as the horses walk through their drills (Figure 9.5). The riding is much more than a physical experience. A special bonding takes place that simply cannot be put into words. The horse looks to the new friend for love and attention. The horses are tuned to every emotion and feeling of the rider. They sense if their little one is happy, excited, nervous, or relaxed. The horse has an amazing desire to

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Figure 9.5. Buster, property watch dog, lies outside of arena waiting for horses to arrive for riding sessions.

please the companion. The infant and young child with autism seem to feel the love and trust the horse is giving, which creates time for interaction and the beginning of unwritten communication. Temper tantrums are rarely seen when children are on their horses. Socialization is a valuable asset of therapeutic riding, not only for the children but for the entire family. Smiles and laughter are very apparent among parents as they visit and watch the children enjoying a structured series of riding routines. “Not only do they sit taller and smile more, they extend their dreams beyond the confines of their disability, into new, unexplored worlds. For individuals with impaired mobility, horseback riding gently and rhythmically moves their bodies in a manner similar to the human walking gait. Unique relationships formed with the horse can lead to increased confidence, patience and self-esteem” (A. Hefler, GNOTRC, New Orleans, personal communication, March 31, 2010) (Figure 9.6).

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Figure 9.6. Another rider moves along on her horse, free from limitations of disability.

RESEARCH MEASUREMENTS AFTER RIDING

Children with various disabilities were followed through therapeutic riding activities to record changes in their motor capabilities. JT, a child with cerebral palsy, was studied extensively at The University of New Orleans Pediatric Adapted Motor Development Clinic and at the Greater New Orleans Therapeutic Riding Center. The technique of kinetic analysis of movement was used to evaluate changes in JT after therapeutic riding. JT was premarked with tape on specific joints allowing for observation and photographic analysis of her posture, balance, muscle control, and strength. Prior to riding, the stride of JT’s steps were measured by the use of vertical and horizontal grids. After a 30-minute riding lesson, her gait width of stepping stride for both left and right legs was measured by use of the grids. JT had increased in flexibility, range of motion, and length of stride in her stepping patterns (Figure 9.7).

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Figure 9.7. Walking stride changes (width and length) are pre and post measured on 2” marked grids for kinetic analysis of changes after riding sessions.

Several children with autism and Down syndrome were observed over numerous occasions, and their attention spans extended past 20 minutes while following directions when riding. Children with learning disorders increased concentration, patience, and discipline. The unique relationship formed between the rider and the horse is unexplainable; however, confidence and self-esteem are greatly increased. Other activities that may be beneficial for the same children simply cannot be compared to therapeutic riding sessions. A motor development course was set up outdoors for practice of developmental tasks after the riding session. The toddler was asked to step and then jump on colored forms (Figure 9.8).

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Figure 9.8. Toddler steps and jumps on colored forms after riding session.

Motor development activities were practiced, and the toddler followed directions from his teacher. The jumping tasks on forms were used to direct him back toward stairs (Figure 9.9). Typically, this young toddler was afraid of heights and had not mastered the challenge of climbing up or down on 4⬙ steps in the developmental clinic. After practicing his stepping and jumping skills, he was asked to climb the stairs. A friend held his favorite cat at the top of the stairs as an incentive for him to crawl or step up the stairs. He took on the challenge of climbing the stairs and accomplished the task. His father had never seen him master this task before. The young child’s attention span had now exceeded 40 minutes (Figure 9.10). SUMMARY

Many children have attended the GNOTRC for years. The infants, children, and families are welcome in the barn area to see where the horses live, and they often bring carrots and sugar treats for their horses. There are no limitations on what can be achieved through therapeutic riding.

Therapeutic Riding

Figure 9.9. Colored forms are used to continue activity toward the stairs.

Figure 9.10. Toddler holds rail to climb upstairs to his favorite cat.

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Figure 9.11. Infant is prepared for his special ride. What will he imagine as he rides on Cherokee? (Photograph provided by Anita Hartzell Hefler.)

For infants with preautism, it may be the most rewarding program that a family could seek for their child. It will allow the young infant a chance to avoid barriers faced in daily tasks while developing social and communication skills. The riding therapy stimulates the central nervous system of the infant that was damaged before birth in ways not achievable in many other manners. The benefits of therapeutic horse riding cannot be put into words. Carol Grigg, an artist in Portland, Oregon painted a picture that portrays the strength and power of children participating in therapeutic riding programs. It was called “She Walks With Horses.” She Walks With Horses Since the moment she could sit on a horse, she rode out beyond the ridge. There, out of sight of the camp, she imagined herself the only person on the plain. Heeding the voice of the wind, she was irrestibly drawn to explore, to push back boundaries of her world (Figure 9.11).

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For all we know, children who participate in therapeutic riding programs feel this same power and strength. They may be able to push back boundaries that our world often places on them in life. One mother commented that she becomes teary eyed just re-living the moment when her autistic son spoke for the first time when he petted his new horse.

Chapter 10 ACTIVITIES FOR HYPOTONICITY nfants demonstrating signs of preautism may have weak muscle tone or hypotonicity. During assessment, the specialist must first determine whether the child is exhibiting too little muscle tone (hypotonicity) or too much muscular tension (hypertonicity). Often it is thought that if a young child has hypotonicity, he or she probably will not exhibit delayed primitive reflexes. Although motor tone may be weak, as in the case of infants with autism, an infant trying to accomplish new skills will also demonstrate delay in primitive reflex integration. The CPAOI will allow the interventionist to also see movements with too much tone and fluctuating muscle tone. Incorporating exercises in the natural environment of the home- or center-based facility and improvising as necessary for optimal space is essential for structure and progression of a movement program. It is important to eliminate distractions. Practical, hands-on activities for professionals and families are detailed for weak muscle tone and reflex integration. These activities will develop muscle tone, strength, and improved levels of mobility. After determining the deficit areas affecting movement, engaging in daily activities will facilitate more mature and functional forms of movement. The activities are based on intervention principles to help facilitate exercise and play programs. The parent/teacher should provide guided and patterned assistance as needed to move the infant through the exercises. By allowing the child to support weight through movements, the interventionist can “feel” the muscles contract. Following the infant’s lead in play is extremely important. Toys, bubbles, and music should be incorporated as part of the activity program. One must keep in mind the infant’s potential for

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Figure 10.1. Pillows are often provided for head support until head and neck develop strength.

achievement within the realm of muscular weakness and signs of preautism (Figure 10.1). Hypotonia is exhibited when the infant is placed in the supine (back) position and lacks spontaneous, symmetrical movements. The legs are fully abducted and rotated outward with the side of the thigh lying flat against the surface (e.g., mat, table, floor), and the arms lie to the side either extended or flexed. When placed in a sitting position, the head may fall backward or forward with limp and drooping shoulders. SUPINE POSITION (ON BACK)

• Lift head, touch chin to chest, and have infant look at knees and then toes. • Turn head slowly from left to right, touching chin to shoulders. If hands and arms move, press down on palms of hands to maintain position and eliminate tonic neck reflex (Figure 10.2). • Place incline wedge under infant and pull slowly to sitting position. If the head tends to fall or lag behind the body, increase the height of incline. Home-made equipment may be used.

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Figure 10.2. Turn head from side to side, observing arm and leg flexion and extension movements.

• Provide co-active assistance moving legs in reciprocal pedal motion, helping infant flex and extend legs. As strength develops, allow infant to perform kicking motion with little assistance. Add light quarter-pound ankle weights as infant’s legs become stronger (Figure 10.3). • Raise arm/hand to touch lifted bent knee on same side of body. Repeat on other side and by reaching across to opposite knee. • Lift both arms and pass a toy back and forth from one hand to the other hand. • Flex arms to chest with hands to midline and stimulate infant by turning head from one side to the other side. • Move arms above head, flat on mat. Move legs apart at the same time side to side. • Pull legs into tuck position and have infant roll from side to side, like an egg. • Hold legs in tuck tight position allowing infant to wrap arms around his legs (Figure 10.4).

Activities for Hypotonicity

Figure 10.3. Mother is moving infant’s legs in a pedal motion.

Figure 10.4. Flex infant’s knees to chest and allow infant to hold knees in tuck position.

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Figure 10.5. Place toy in front of infant and encourage infant to reach for toy.

• Assume tuck position with legs, tuck chin to chest, and rock slowly back and forth. • Using a low pull-up bar, have infant lay under 12¢¢ bar, knees bent. Placing the palms up on the bar works on front of arm (biceps muscle) and palms down works on back of arm (triceps muscle). Perform five repetitions and one set of pull-ups. • Log roll to side from supine position and back to other side. • Have infant hold onto a rope while pulling him or her about 6⬙ up and down from floor. PRONE POSITION

(On stomach, legs extended, arms forward in prone prop position.) Support under chest with small (i.e., 4-6¢¢) wedge or bolster. • In prone prop position, have infant reach forward with one arm and pick up toy. Alternate arms (Figure 10.5).

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Figure 10.6. Infant is encouraged to reach for toy.

• Have infant extend arms and reach forward. Encourage him/her to pull body forward like an inchworm. • Roll body into tight ball, supported on knees. • Provide guided assistance by flexing knees and elbows of infant. Support under trunk to allow for holding in 4-point position momentarily. • Pull forward and “slither” along on mat or floor like a snake. • Move object/toy forward and encourage the child to extend the arms slightly and reach for toy (Figure 10.6). • Push up with arms arching back, twist, and rotate from side to side. • Push up with one arm to rotate trunk slightly to the side. Alternate arms. • Lift arms over head, one at a time, in a swimming motion moving forward. • Pattern child to push up on elbows and “walk up” to arms with feet. • Using incline mat, have infant crawl down the mat. • Design an obstacle course for infant to move in prone up hill and down to reward (Figure 10.7).

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Figure 10.7. Design an obstacle course challenging the infant to creep to toy and mother.

• Lay infant on a scooter board. Encourage child to extend the arm using distal reach. Pull to move forward across room area. • Have infant push backward on scooter board. • Let infant play and go any direction pulling and pushing scooter board. • Pull infant around with rope while holding on to scooter board. ROLLING POSITION

Movements will be from supine to prone, prone to supine, and rolling over using different equipment. All muscle groups are utilized through rolling movements, increasing trunk strength and control, and providing vestibular stimulation. • Stretch arms over head and hold toy. Roll from supine to side position and side to supine. • With arms stretched over head holding a towel, roll to the left, back, side, and back to prone.

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Figure 10.8. Interventionist uses coactive movement to assist infant to gain strength by rolling up incline mat.

• Roll completely over as in a log roll. • Using large incline mat, assist infant to roll straight down the incline mat. • Roll up the incline mat with assistance (Figure 10.8). • Roll across mat focusing on visual target. • Place lightweight objects to knock over and have infant roll into the objects. • Roll up in soft blanket or sheet and then assist infant to unroll. • Log roll through a space of many blown bubbles floating in the air. FOUR-POINT CREEPING

Infants with weak muscle tone and signs of preautism may have trouble assuming a 4-point position due to weak muscle tone. Coactive assistance may need to be provided to help infant initiate a typical creeping position. Use visual targets to try and get infant to hold head up and look at target or interventionist. Joint attention can be worked on while developing strength.

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Figure 10.9 Interventionist patterns infant in 4-point movement.

• Provide support to help infant maintain weight on elbows and knees. • Encourage or lift infant’s head up and down while maintain 4point position (Figure 10.9). • Gently rock infant forward and backward while supporting in position. • Pattern the infant to move forward in creeping position moving arm and knee on same side of body (homolateral crawl). • Creep forward using the arm and leg of the opposite side of the body (cross-lateral). • Provide visual targets/toys raised slightly above the infant’s head and ask him or her to creep forward looking at the target. • Creep down on an incline mat. • With assistance have infant creep up on incline mat (Figure 10.10). • Design play areas that encourage infant to creep over and under objects.

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Figure 10.10. Mother encourages infant to creep up the mat to open arms.

• Assuming a 4-point position, infant raises or extends one leg back and up. Repeat with other leg. Support for balance as needed. • In creeping position, add quarter-pound weights to legs and have infant extend leg back and up. Repeat with other leg. EXERCISES FOR PROGRESSION TO STANDING AND MOBILITY

Most of the exercises will be completed with an interventionist or parent working with a single child. The exercises can be made more fun or play-like by the adult singing simple children’s songs or by the addition of small equipment (balloons, bubbles, bean bags, favorite toys). The adult can hold the object or place it on the floor while encouraging the child to focus on it. Once a child has reached the capability of creeping or walking, then partner and small-group instruction is more feasible. The following activities are provided as a foundation and can be further expanded in accord with the motivation and creativity of the adult. In reality, however, the types of activities are also limited by the space, equipment, and personnel available. All exercises move from sitting, kneeling, to standing and stepping patterns with mobility. Activities increase muscle tone, strength, bal-

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Figure 10.11. Infant moves foot under body as he tries to reach toy.

ance, and motor control. Provide assistance as needed, allowing the infant to gain strength. • Encourage infants to creep to toys that allow support for kneeling and standing (Figure 10.11). • Move from 4-point creeping position to kneeling. Interventionist provides support at hips and under arms to help maintain balance. • Tilt child from side to side to stimulate equilibrium reactions. • Support infant with low parallel bars. Walk forward, sideward, and backwards. Patterning or facilitation for position of feet may be needed. • Lift knees up and down and touch bar with light weights. • Place low stairs inside parallel bars and encourage infant to climb up stairs (Figure 10.12). • Special play equipment can be used to provide standing support. • Design obstacle courses to encourage stepping over objects, crawling under objects, climbing over parallel bars or other higher equipment, tires tubes, a tunnel, two chairs with a rope across

Activities for Hypotonicity

Figure 10.12. Parallel bars and light ankle weights are used for support and development of strength.

Figure 10.13. Mini-tramp is used for support, strength, and development of equilibrium reactions.

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them to go under, very low objects to go over (poly spots, rope, cloth), geometric forms to crawl through. The course can be followed with weights on the child’s ankles (Figure 10.13). • Walk toward a partner (child or mother) and touch that person, march to music, sing silly songs, or chant a rhyme. Have the child develop a rhythm as he walks, or have the child move to get a special toy.

Figure 10.14. Infant uses side of crib for support to develop standing balance.

Activities for Hypotonicity

Figure 10.15. First step is attempted while balancing and holding toy.

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Figure 10.16. Infant demonstrates homolateral stepping pattern.

If older siblings are available and have increased language or cognitive levels, game-like situations can be developed. Peer buddies or peer tutors can be very effective in assisting young children and increase the enjoyment of the activity. Depending on the number of adults or peers who are available to assist the teacher, increased pieces of adaptive equipment may be needed to position the infants and young children. The type of positioning equipment utilized depends on the individual needs of each child.

Chapter 11 ACTIVITIES FOR REFLEX INTEGRATION AND DECREASING MUSCLE TONE uscle tone provides the foundation for movement and allows an individual to be “ready” to perform simple motor actions. It is regulated by the cerebellar region of the brain and cannot be voluntarily controlled by the individual. Infants with preautism have extreme damage to the brain, especially the cerebellum. Usually these infants have decreased muscle tone; however, tonic neck reflexes appear to be retained past the first year of life. Increased or exaggerated muscle tone (hypertonicity) is detrimental to voluntary movement and may be an indicator of primitive reflexes. Primitive reflexes are integrated as the infant’s central nervous system matures during the first year of life. Their existence hinders the development of independent movement. When primitive reflexes are present, the infant is unable to progress to more advanced movement patterns and skills. The CPAOI should be used to screen infants for retained primitive tonic neck reflexes. The purpose of the following activities is to decrease delayed neurological actions (i.e., primitive reflexes) that cause increased muscle tone or hypertonicity and interfere with obtaining functional movement skills (e.g., rolling, creeping). The following assessment procedures should be considered: (a) assess for presence of reflexes that would indicate delayed motor development; (b) assess functional movement skills to determine motor delays or patterns that exist due to presence of abnormal reflex patterns; and (c) demonstrate correct positioning and handling to prevent inappropriate sensory excitation that would cause strengthening of primitive re flex patterns.

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Figure 11.1. Infant shows asymmetrical tonic neck reflex when turning head to look across yard.

ASSESSMENT OF ASYMMETRICAL TONIC NECK REFLEX (0–6 MONTHS)

Turning of the head to the side causes extension of the arm on the face side and flexion of the arm at the back of the head. Infants can be assessed in the supine position by changing the position of the head. Standing posture may be acquired, but young children may still display the asymmetrical tonic neck reflex. Table 4.1 described the influence of tonic neck reflexes (see Figure 11.1). ACTIVITIES FOR INTEGRATION OF ASYMMETRICAL TONIC NECK REFLEX

• Use mirrors to assess muscle tone of infant and establish eye contact.

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Figure 11.2. Mirrors are used to assess muscle tone and establish joint attention with infant.

• Turn head from side to side. Watch for changes in muscle tone in extremities. • Turn head from side to side and maintain position of palms of hands on floor or mat. • Raise hand to touch lifted bent knee on same side of body, then reach across the midline and touch other knee. Repeat exercise using other hand (Figure 11.2). • Move arms and legs to flexed, tucked position and rock from side to side and then back and forth. • Assist infant with performing log rolls on the floor and on incline mats.

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Figure 11.3. Child is wearing light ankle weights in tucked position and being assisted to rock from side to side.

• Extend the arms above the child’s head and place a toy in hands. Assist with rolling back and forth without infant dropping toy. • Roll up and down incline mats with assistance and try to keep movements stable. • Rotate infant’s head from side to side and touch ears to floor. Do not allow palms of hands to leave the floor or mat. • Support infant in 4-point hands and knees position while rocking from side to side. ASSESSMENT OF TONIC LABYRINTHINE SUPINE REFLEX (0 TO 4–6 MONTHS)

In supine or back lying position, the infant demonstrates increased extensor tone of the extremities. The infant will demonstrate difficulty raising the head, bending knees into tucked position, and bringing hands to the midline of body. ACTIVITIES FOR TONIC LABYRINTHINE SUPINE REFLEX

• Hold infant in a flexed position and rock from side to side (Figure 11.3).

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Figure 11.4. Bouncing on mini-tramp while holding toddler in tucked/flexed position.

• Flex arms across the chest and bring knees to tight tuck position. • Use selected toys (incline mats) which assist infant to perform pediatric sit-ups. • Lie on side and bend the head while flexing knees and toes. • Use equipment for vestibular stimulation such as rocking board or vestibular ball (Figure 11.4).

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Figure 11.5. Scooter board activities allow for practice prone extension.

ASSESSMENT OF TONIC LABYRINTHINE PRONE REFLEX (0 TO 4–6 MONTHS)

When lying on the stomach, the child will demonstrate increased flexion or bending. The reflex interferes with distal reach and lifting of the head. Extension of arms and legs will be difficult for the young child to achieve. Activities and exercises should stress extension of all extremities. ACTIVITIES FOR INTEGRATION OF TONIC LABYRINTHINE PRONE REFLEX

• Lift head and neck and focus on toy or target. • Raise arms and abduct to each side. • Provide support under infant’s chest with bolster. Have child reach across midline to grasp toy (right then left hand). • Lift and rotate head to one side and look at toy by extended arm (shoulder level). • Lift arms and legs upward in extended position while arching back (Figure 11.5).

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Figure 11.6. Rolling child back and forth on vestibular ball in extended position.

• Lay child on back across large vestibular ball in extended position. • Crawl forward with over arm swimming motion. • Position on vestibular/rocking board in prone position, rocking forward and backward. • Rock side to side on vestibular ball (Figure 11.6). • Place infant in 4-pt. creeping position on rocking board and encourage child to maintain eye focus on toy or wall target. • Hold object above head and perform a log roll (Figure 11.7). • Push backward and forward on scooter board, spin around, change directions. • Use bubble ball bath for relaxing infants with increased muscle tone. • Use bubble ball bath for group play activities. • Bubble ball bath may be used to increase strength with infants with hypotonicity (Figure 11.8).

Activities for Reflex Integration and Decreasing Muscle Tone

Figure 11.7. Young child holds towel above head while assisted to perform log roll.

Figure 11.8. Bubble ball bath allows for freedom of movement and play.

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Figure 11.9. Small pool allows for infant to relax while head is raised and legs float freely.

SYMMETRICAL TONIC NECK REFLEX (0 TO 6–8 MONTHS)

Flexion of head causes flexion of the arms and extension of the legs; raising of the head causes arm extension and leg flexion (i.e., bunny hop). This reflex is usually predominant in infants and young children who have retained reflexes and hypertonicity due to damage to areas of brain that causes cerebral palsy. Infants with preautism would not demonstrate this reflex unless there were multiple disabilities. Aquatic activities would benefit infants with autism and those with cerebral palsy (Figure 11.9).

Appendix INFANT NEUROLOGY

T

he nervous system is very complex, and neurological immaturity and neurobiological abnormalities are a partial cause of ASD. The CNS must be understood to some extent for all individuals to grasp an understanding of what “went wrong with the infant’s neurological wiring” during early development.

CNS: Brain and Spinal Cord The nervous system is composed of the CNS (brain and spinal cord) and the peripheral nervous system (31 pairs of spinal nerves, 12 pairs of cranial nerves), and the autonomic nervous system. The CNS receives and responds to all stimuli and governs and coordinates all activities of the body. From the least to the most complex, the major centers of the CNS are the spinal cord, medulla oblongata, pons, brainstem, midbrain, reticular activating system, cerebellum, thalamus, hypothalamus, basal ganglia, and the cerebrum or cerebral cortex. For the purposes of providing the most detailed information necessary to fully understand preautism functioning, the typical CNS is discussed. Damage to the nervous system may be caused by genetic factors, malnutrition and poor prenatal health care of the mother, increased levels of alcohol and drug levels of the mother, insufficient oxygen during the birth pro cess (asphyxia), and trauma during the delivery process that causes intraventricular hemorrhage. There also can be neonatal complications including hyperbilirubinemia, premature birth, photo therapy for jaundice, and respiratory distress of the newborn. Primary signs of congenital nervous system involvement include infantile autism, mental retardation, cerebral palsy, abnormal muscle tone (e.g., hypertonicity or hypotonicity), delayed sensorimotor responses, and paralysis of one or more extremities. Nervous tissue has the fastest growth rate of all systems of the body. Therefore, the nervous system of the newborn should be functioning adequately at birth. The new181

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born responds to light intensity, moves and turns head to seek sufficient oxygen, shows protective reactions to pain, responds to early reflex stimuli, and searches for the mother’s nipple to receive nourishment. The corpus callosum connects the right and left cerebral hemispheres. The brain stem is an upward extension of the spinal cord subdivided into the medulla oblongata, pons, and midbrain. Ascending and descending nerve pathways pass through the brain stem affecting the degree of individual alertness. The brain stem governs primitive reflex activity (tonic neck reflexes) and integrates muscle tone. The control centers for the sensory modalities are located in the brain stem with the exception of vision and smell. The reticular activating system (RAS) is formulated in this area and is comprised of the medulla, pons, and midbrain. The RAS serves to screen incoming sensory stimulation inhibiting some sensory input and processing other information. Alertness, attention, arousal, reciprocal innervation, and wakefulness are selective functions of the RAS. The medulla oblongata is basically an upper extension of the spinal cord as it enters the brain. It is about the size of a pencil, and ascending and descending sensory and motor tracts pass through the medulla; thus, it serves as a relay station for all information. The pons is located above the medulla and serves as “a bridge of fibers” connecting the medulla to the cerebellum. The functions of the pons are important to head, neck, and eye control of equilibrium and the regulation of coordination associated with attaining upright posture. The midbrain is the portion of the brain between the pons and the cerebral hemispheres composed of the superior and inferior colliculi. The primary function of the midbrain is to serve as a transmitting station for stimulation of the righting and postural reactions. The cerebellum is the second largest portion of the brain. It is believed that the cerebellum receives stimuli from all of the sensory modalities. Its primary function is to regulate muscular coordination for balance and integrate postural and equilibrium reactions. The cerebellum is sometimes referred to as the “little brain” because it provides for the automatic phase of movements that no longer require conscious thought. The thalamus and hypothalamus serve as relay stations for all sensory impulses going to the cerebrum with the exception of the sense of smell. More specifically, the thalamus organizes and integrates sensory impulses and responds to the emotions of fear, rage, and pleasant or unpleasant sensations. The hypothalamus has a variety of functions, including: (a) regulation of emotions and integration of autonomic nervous system responses, (b) temperature and control, (c) water balance, (d) food intake and gastric secretions, (e) heart rate, and (f) expression of emotions.

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The cerebrum or cerebral cortex is the largest portion of the human brain and is divided into two halves (hemispheres). It is the main center for voluntary movement, learning, perception, memory, and communication. The cerebrum can be divided into three areas: (a) afferent (sensory) areas, (b) integrative (association) areas, and (c) efferent (motor) areas. The pyramidal and extrapyramidal systems are the major pathways for movement control. Although the pyramidal and extrapyramidal systems do not work independently of each other, the pyramidal tract stimulates or initiates muscular activity and is more responsible for precise movements necessary for fine and skillful coordination. The extrapyramidal system is more related to movements of automatic control and postural reactions. SUMMARY This appendix provided additional information about the anatomy of the central nervous system (brain, spinal cord). In Chapter 3, clinical indicators of autism were discussed with reference to the brain and cerebral dysfunction related to preautism to assist the reader with basic understanding of infant neurology.

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AUTHOR INDEX A Acquarone, S., 29, 41, 185 American Academy of Pediatrics, 19, 29, 31–32, 35, 39, 41, 68, 70, 185 American College of Obstetricians and Gynecologists, 66, 70, 185, 194 Ayres, A., 48–49, 53, 185 B Bach-y-rita, P., 48–49, 53, 185 Baron-Cohen, S., 59, 70–71, 185–186, 190, 194 Batshaw, M., 67, 69–70, 186 Bauman, M., 57, 70, 186, 189, 195 Belmonte, M., 186 Benton, T., 44, 71, 192 Bhasin, T. K., 34, 38, 41, 44, 186, 192 Bjorne, P., 77, 87, 186 Blaylock, R., 22, 38, 41, 186 Boger-Megiddo, I., 59, 70, 186 C Cannell, J., 38, 41–42, 186 Centers for Disease Control, 36, 39, 42, 186 Chakrabarti, B., 59, 71, 190 Charman, T., 27, 42, 194 Chawarska, K., 29, 42, 45, 83, 87–88, 108, 186, 193, 195 Cheng, M., 40, 42, 186 Courchesne, E., 55, 61, 70, 187, 194 Cowden, J., 3, 5, 21, 25–26, 34, 42, 72, 87, 101, 107, 125–126, 172, 187 Cratty, B., 51, 53, 187

Currenti, S., 38, 42, 187 D Dager, S. 59, 70–71, 186–187, 191, 194, 196 Danilov, Y., 42, 49, 53, 187 Dawson, G., 34, 42, 45, 55–56, 59, 70–71, 83, 87–88, 99, 101, 107–108, 186, 187, 188, 191, 193–194, 196 Deer, B., 40, 42 DiCicco-Bloom, E., 55, 61, 70, 187, 194 Doidge, N., 46, 54, 187 Dziobek, I., 59, 71, 187 E Elder, L., 59, 71, 187 Eyles, D., 38, 42, 188, 195 F Faja, S., 34, 42, 87, 99, 108, 187 Federal Drug Administration, 35, 42, 188 Fein, D., 45, 56, 71, 87, 88, 108, 188, 193, 195 Fewell, R., 124–127 Folstein, S., 34, 43, 188 Froeber, J., 34, 43, 62, 71, 188 Fryman, J., 25, 45, 77, 88, 192 G Garon, N., 85, 87, 188 Gershkoff-Stowe, L., 111, 127, Good, P., 35, 43, 105–106, 188 Greenspan, S. I., 17, 19, 20, 43, 99, 103, 108, 188, 192

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Groen, A., 99, 108, 192 Grohol, J., 34, 43, 188, 195 Gross, R., 34, 43, 77, 190, 195 H Hevron, J., 36, 37 Hollister, E., 61, 71, 189 I Institute of Medicine Safety Review Committee, 38, 43, 189 J Johnson, C. P., 43, 87, 189 K Kelly, J., 44, 71, 192 Kercel, S., 48, 53, 185 Kilburn, K., 36–37, 43, 189 Kolevzon, A., 34, 43, 190, 195 Kongshavn, P., 35, 43 Kuban, K., 62, 71, 190 L Larsson, H., 34, 43, 190 LeDoux, J., 59, 71, 190 Loh, A., 82, 87, 190 Lombardo, M., 59, 71, 190 M Mauer, R. G., 192 Mayo Clinic, 39, 44 Meldrum, B., 22, 38, 44, 190 Melillo, R., 56–58, 61, 68, 71, 190 Merzenich, M., 48, 49, 54, 190, 196 Meyers, S., 39, 43, 44, 101, 108, 189 N National Institute of Mental Health, 31, 39, 44, 191 National Institute of Neurological Disorders & Stroke, 31, 32, 44, 191

Nye, J., 25, 45, 77, 88, 192 O Oelwein, T., 124, 127 Osaku, N., 69,191 P Petropoulos, H., 59, 71, 191, 196 Pletnikov, M., 37, 45, 193 Prince, A., 44, 71, 192 Prusiner, S., 38, 44, 191 R Rhodes, M., 37, 44, 191 Rice, C., 27, 44, 191 Rodier, P., 191 S Schendel, D., 34, 38, 41, 43–44, 186, 190, 192 Schertz, H., 85, 87, 101, 108, 192 Schultz, R., 72, 192 Schultz, S., 192 Schumann, C., 59, 71, 192 Seidler, F., 37, 44, 45, 191, 193 Skoyles, J., 61, 71, 192 Smith, I., 87, 188,190 Smith, L., 127 Smith, T., 108, 187, 192 Snyder-McLean, L., 124–125, 127 Springer, S., 71, 190, 192 T Teitelbaum, O., 23–25, 31, 44–45, 77, 88, 192 Teitelbaum, P., 23–25, 31, 44–45, 70, 77, 88, 192 Thelen, E., 111, 120, 127 Thrasher, J., 36–37, 43, 189, 193 Torres, A., 35, 45, 193 Torrey, C., 21, 25–26, 34, 42, 72, 87, 172, 187 Toth, K., 56, 71, 87, 98, 188 Trikalinos, T., 68, 193

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Author Index V Volkmar, F., 29, 31, 42, 45, 59, 71, 87, 99, 108, 186, 193, 195

Wikipedia, 68, 193 Wiseman, N., 31, 45, 193 Witter, F., 36, 45, 193 Z

W Wakefield, A., 39, 40, 45 Wiesner, L., 29, 31, 45, 59, 71, 88, 99, 108, 193

Zerrate, M., 37, 45, 193 Zwaigenbaum, L., 19, 29, 31, 34, 45, 70, 87–88, 101, 108, 187, 190, 193, 194

SUBJECT INDEX A C Abnormal growth, 57 Abnormal motor behavior, 23 Abruptio Placenta, 65 Acetaminophen, 3, 35, 40–44, 188, 192 Age of diagnosis, 27 Aluminum, 34 Amniotic fluid, 65 Amygdala, 58–60, 71, 186–187, 190, 192 Apraxia, 76 Arena assessment, 17, 20 Asymmetrical Tonic Neck Reflex, 74, 78–79, 173 Atypical behaviors, 6, 28, 72 Auditory acuity, 141 Auditory awareness, 139, 145 Auditory system, 4, 11, 92 Auditory-visual substitution, 48 Automatic equilibrium reactions, 114

Calcitriol, 38 Central Nervous System, 4, 13, 21, 23, 37–38, 74–75, 112, 118, 128, 156, 172, 183 Cerebellar, 37, 57, 73, 172, 190, 195 Cerebellar abnormalities, 57 Cerebellar region, 73, 172 Cerebellar vermis, 57, 61 Cerebral cortex, 57, 61, 181, 183 Clumsy child syndrome, 33 Cognition/Prelanguage, 4, 6, 72, 84, 87, 128 Cognitive operations, 57 Computed tomography, 55 Cooing, 4, 7, 84, 140, 150 Corpus callosum, 59, 60, 70, 182, 186 Cowden Preautism Observation Inventory, 3, 5–17, 50 D

B Babbling, 4, 7–8, 22, 25, 84, 140 Baby’s neurological system, 26 Behavioral plan, 107 Benzodiazepines, 38 Beta2 adrenergic receptor, 35 Birth asphyxia, 65, 66 Blood brain barrier (BBB), 37 Brain anatomy, 41, 55 Brain circumference, 3, 5 Brain plasticity, 22, 33, 37, 42, 46–51, 53–54, 59–107, 128, 187, 190 Brain reorganization, 23, 26, 47 Brain size, 55–56 Brethine, 3, 35, 40

Delayed motor milestones, 77 Developmental movements, 4, 14 Developmental skills, 3, 122 DIR Model, 19, 20 DSM-IV, 28–29, 82 DSM-V, 30 Dynamic action, 120 E Early intervention, 19, 21–23, 29, 30–31, 33, 41, 53, 55, 64, 87, 99–102, 108, 111, 118, 125, 127, 192–193 Effective intervention, 31, 99–100, 107

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Embryonic stage, 59 Enlarged brain, 55 Entangled umbilical cord, 65 Equilibrium reactions, 23, 57, 74–75, 78, 114, 132, 168–169, 182 Extensor tone, 74, 75, 118, 175 Eye contact, 4, 8, 10–11, 25, 37, 73, 85, 91, 100, 135–137, 173 Eye control, 182 Eye gaze, 82 Eye tracking, 137 F Face processing, 28, 72 Facial expressions, 4, 59, 83, 135–141 Facial nerve, 59 Facial recognition/expression, 4, 7, 69, 82, 136 Fetal distress, 61, 65, 69 Fetal life, 37 Final prognosis, 26 Fine motor development, 4, 77, 121, 143 Flexor tone, 111, 118 Floortime approach, 19–20 Floortime Model, 17, 20 Frog leg position, 73 Functional magnetic resonance, 55

Hypertonia, 73 Hypothalamus, 59, 60, 181, 182 Hypotonia, 73, 121, 126, 132, 159 I ICD-10, 28, 30, 45, 193 Immature brain development, 22, 41 Immunizations, 39, 41 Incidence, 22, 27, 34, 41, 68 Infectious agents, 34 Inhibition of sensory input, 51 Intersensory integration, 51, 114 Intervention developmental quotient, 124–125 Intervention principles, 111, 125, 158 J Joint attention, 4, 8, 85, 87, 100, 104, 108, 120–121, 130, 135–137, 139–140, 145, 146–147, 165, 174, 192 K Kinesthetic awareness activities, 141, 145 Kinesthetic system, 94, 141 L

G Genetic predisposition, 22, 33, 37, 90 Gestures, 4, 6, 7, 8, 82, 84–86, 100, 135, 139, 141, 146 Glutamate, 37–38, 43, 44, 190–191 Glutamateragic dysfunction, 3, 41, 186 Glutathione, 35, 40, 43 Glutathione metabolism, 35, 37, 44, 191 Granular cells of cerebellum, 57 H Head circumference, 18, 55–56, 71, 87, 188 Head growth, 55–56 Home activities, 21 Homework, 21 Household cleaning agents, 34 Hyperbilirubinemia, 3, 25, 40, 67–70, 181, 185

Lack of social play, 83 Low birth weight, 3, 4, 25, 61–63, 67 Lying, 24, 52, 72–73, 75, 77–78, 90, 142, 159, 175, 177 M Memory, 37, 61, 129–130, 137, 145, 183, 191–192, 196 Metabolism, 35, 37, 44, 191 Metals, 34 Midline, 8, 10, 12, 16, 72, 75, 90–91, 138–139, 160, 174–175, 177 MMR vaccines, 35, 38, 44 Moebius mouth, 5, 69, 70 Mold and relax, 72 Monitoring behaviors, 102 Motor planning, 16–17, 20, 80–81, 95, 107, 122

205

Subject Index Movement disturbances, 6, 23, 82 Movement patterns, 23, 75, 95, 142, 172 MSG, 35 Muscle tone, 3, 5, 12, 23, 26, 48, 57, 66, 68, 72–74, 76, 95, 110–111, 114–116, 118–119, 125, 147, 158, 165, 167, 172–174, 175, 181–182 Muscular coordination, 57, 182 N Name, 4, 7, 11, 84, 92, 135–137, 140–141, 196 Neonatal complications, 22, 25, 34, 40–41, 3, 181 Nervous system, 4, 13, 21, 23, 33, 37–39, 74–76, 110, 112, 118, 120, 128, 156, 172, 181–183, 196 Neural connections, 47–48 Neural pathways, 22, 26, 41, 46, 47 Neural synapse, 48 Neurobehavioral, 26, 33, 37, 58, 71, 190 Neurobiological, 22, 41, 181 Neurological reorganization, 21 Neuron, 47, 57 Neuropathology, 55, 195 Neurotoxin, 35 Neurotransmitter, 37, 44, 59, 71, 189–191 Newborn, 10, 12, 21, 26–27, 63, 67, 70, 72–74, 93, 109, 111–112, 128, 181,185, 191 Nickel, 34 No eye contact, 4, 25, 85 Nonverbal, 4, 19, 30, 33, 82, 85, 93 Nonverbal communication, 33

Physical therapist, 33 Placenta Previa, 65 Play-based assessment, 142 Polysensory process, 48 Postural reactions, 132, 182, 183 Preautism definition, 3–5 early movement, 33 environment, xii fetal complications, 21 first year of life, 21 genetic predisposition, 22 immature brain development, 22 maternal age, 33 paternal age, 33 Preautism Observation Screening Inventory, 4–17 recording, 18 screening, 3 signs, 18 Precursors of autism, 23 Predictable routines, 102 Prefrontal lobe, 61 Premature rupture of membrane, 65 Prematurity, 3, 61, 63 Prenatal, 21, 27, 34, 37–38, 40, 43, 57, 64, 90, 181, 190, 195 Preterm labor, 35–37, 40 Prevalence, 26–27, 34, 43–44, 69, 190–191, 194, 196 Primitive reflexes, 59, 74–75, 111–112, 132, 158, 172 Primitive reflex inhibition, 75 Protective extension, 14, 76, 79, 133, 145 Purkinje cells, 37, 57 Puzzle children, 25

O Q Occupational therapist, 33 Oxygen, 6, 65, 66, 181, 182 P Pathological processes, 23 Pediatricians, 21, 31–33, 62, 100 Perinatal, 21, 27, 34, 40, 43, 63, 65, 69, 90, 190, 195 Petroleum based products, 35 Phototherapy, 3, 5, 25, 36, 40, 67–69, 191

Qualitative effectiveness 124 R Rate of autism, 26 Reciprocal play, 19, 30 Recognition, 4, 18, 26–27, 31, 41, 83, 129–130, 137, 139, 145, 189, 191–192, 196 Reflexes, 4, 13, 24, 59, 66, 72–74, 75, 79, 111–113, 158, 172–173, 180

206

The Cowden Preautism Observation Inventory

Reflex integration, 23, 26, 158, 172–173, 175, 177, 179 Reorganization, 21, 23, 26, 47, 52 Repetition, 37 Repetitive behaviors, 10, 33, 61, 82, 118 Repetitive dysfunction, 26 Repetitive routines, 59 Research measurements after riding, 152 Respiratory distress, 3, 5, 25, 40, 66–67, 121–122, 181, Righting reactions, 4, 13–14, 75, 79, 86, 133–134, 145 Role of parent, 101 Rolling, 13, 15, 33, 75, 77–78, 94–95, 132–133, 135, 164–165, 172, 175, 178 S Safety, 35, 38, 43, 100, 102, 104, 107, 126, 142, 189, 190 Sense modalities, 51 Sensory exploration, 30 Sensory integration, 46, 48, 50–53, 59, 89, 185, 188 Sensory motor integration, 23, 51 Sensory motor processing, 17 Sensory motor stimulation, 100, 128–129 Sensory substitution, 48, 53, 185 Seizures, 3, 5, 66, 69 Single photon emission, 55 Sitting, 12–13, 15, 23–24, 52, 73, 76–79, 91, 109–110, 132–134, 138, 142–143, 159, 167 Skill, 18, 51, 111, 116–117 Social behaviors, 3, 18, 33 Social-Communicative-Play, 4, 8, 82, 87 Social interaction, 25, 28, 33, 62–63, 82 Standardized evaluation, 3, 124 Standing, 15, 52, 77, 109, 143, 167–168, 173 Success of program, 102

Symmetry, 24, 77 T Tactile system, 4, 12, 93, 128, 130 Tactile-vestibular substitution, 48 Tactile-visual substitution, 48 Teratogenic, 37 Terbutaline, 3, 6, 35–37, 40–44, 185, 188–189, 191, 193 Thalamus, 59, 60, 181, 182 Thalidomide, 34 The Lancet retraction, 39 Therapeutic riding, 147 Tocolysis, 35 Toe walking, 76, 95 Tomography, 55 Tonic neck reflexes, 13, 75, 79, 113, 172–173, 182 Toxins, 34 Traction response, 73 Transactional assessment, 17 Trigeminal nerve, 59 Typical behaviors, 6, 18, 28 V Very low birth weight, 61, 63 Vestibular stimulation, 78, 164, 176 Vestibular system, 57, 93–94, 132 Visual motor awareness, 135, 145 Visual motor recognition memory, 137 Visual system, 4, 10, 90–91, 135, 136 Vitamin D deficiency, 3, 38, 40–41 W Walking, 15, 20, 52, 76–78, 80, 95, 103, 116, 134, 149, 151, 153, 167