Occupational Therapy for Children with Autism

For many young people with autism, their sensory perception does not provide them with accurate information about the world.

Children and adults with autism exhibit challenges processing and integrating sensory information. Powerfully explained in the works of noted academic Temple Grandin, herself a person with autism, the scientific community now understands that children and adults with autism can have a widely different experience of the world.

For many young people with autism, their sensory perception does not provide them with accurate information about the world. Instead, sounds are too loud or too soft. Tactile information is too intense or hardly there at all. This leaves the child only able to process one sense at a time, or occasionally, none.

Recommended course: Evidenced-Based Pediatric Yoga Tools for Children with Developmental Disorders, Autism Spectrum Disorder, and Sensory Modulation Dysfunction

Chronic and perpetual dysregulation

Studies have shown that children with autism are in a chronic and perpetual state of physiological dysregulation. Explored in the work of American psychologist and neuroscientist Dr. Stephen Porges, a body experiencing physiological dysregulation will trigger a state of neuroception. Their nervous system interprets these signals as ‘danger.’ This puts the individual in a continual state of fight, flight, or freeze. These autonomic states correspond to dedicated neural paths that inhibit the cortical circuits necessary for communication.

According to Dr. Porges’ Polyvagal Theory, accessing prosocial behaviors requires the brain to be in a state known as “social engagement.”

Social engagement is dependent on the myelinated vagus, which originates in the nucleus ambiguus in the brain stem. The myelinated vagus fosters calm behavioral states by inhibiting the influence of the sympathetic nervous system on the heart. In this “quiet alert” state, the individual is calm and interested in their environment, neither overwhelmed nor underwhelmed.

This is the physiological state in which cortical control of facial expression, vocalization and listening is accessible. It provides the circuits for social engagement.

Functional connectivity

Functional connectivity is critical to binding sensory perceptions and, indeed, to overall cortical functioning. Studies show impaired functional connectivity in individuals with autism. Poor functional connectivity may be directly related to asynchronous transmembrane currents, which could be the result of the chronic state of physiological dysregulation many children with autism experience.

The synchronous timing of the crests and troughs of transmembrane currents allow information in neuronal assemblies (groups of tens of thousands of individual neurons) to pass their information efficiently. If the transmembrane currents become asynchronous, then information is not passed properly, which leads to poor sensory integration.

Recommended course: Pediatric Occupational Therapy Module 3: Autism, Social Participation, Depression & Handwriting

Synchronous currents and self-stimulating behaviors

Synchronous timing of the currents requires a state of physiological homeostasis. Unfortunately, children and adults with autism are not in a state of physiological homeostasis. Rather, they demonstrate a perpetual state of physiological dysregulation.

Consider the self-stimulating behaviors of children with autism: hand flapping, finger flicking, staring at rotating fans, etc. They are all rhythmic in nature. These rhythmic, self-stimulating behaviors may be a nonconscious autonomic compensation for a lack of synchronous transmembrane currents.

By engaging in the behaviors, these children’s nervous systems may be doing their best to process sensory input while creating a modicum of rhythmic current flow. If that is so, trying to extinguish these behaviors seems counterproductive.

Attunement and attachment

In attachment literature, there is a vital concept called attunement. For a child to form an attachment or relationship with their caregiver, the caregiver must first attune to the child. Attunement aligns child and caregiver, communicating emotion through expressions, gestures, vocalizations, and eye contact.

Attachment researchers Beebe and Lachmann suggest the key mechanism behind attunement is the perception and production of similarity. When the movements of the caregiver have enough similarity to the movements of the infant, the proprioceptive input generated in the infant will correspond to what the infant sees in their caregiver’s movement. This creates correspondence in their mirror neuron system and their own proprioceptive feedback.

Researchers also contend that when the movements of the caregiver have enough similarity (or matched specificities), this reorganizes inner as well as relational processes. Thus, physiological arousal, behavior, and subjective state are all organized concurrently; they are all aspects of the same phenomenon.

Mirror neurons

Mirror neurons were discovered in the 1990s by Italian brain researchers examining the brains of monkeys. These brain cells, located in the motor areas of the cortex, fired not only when the monkey grasped an object, but also when the monkey observed another monkey or a human grasp an object.

Since those initial studies, scientists have discovered neurons with mirroring properties for emotions, touch, and hearing. The combination of all three mirroring types of brain cells is called the mirror mechanism.

Some researchers go as far to postulate that the mirror mechanism establishes a direct link between the person who is acting and the one observing. It is the “neural glue” that allows people to form relationships.

Unfortunately, in many cases, it is that very mirror mechanism that is impaired in children with autism.

Somatic attunement

Somatic attunement describes the way in which a therapist can use his or her body to attune to the child with autism. By imitating the child with autism, including their self-stimulating behaviors, the therapist attunes their body to the child's. Once the therapist attunes their body to the child’s, it makes it a lot easier for the child to attach to the therapist.

As the therapist mirrors the hand-flapping, rocking, or finger-flicking, they may help activate a poorly or nonfunctional mirror neuron system and amplify the synchrony of the transmembrane currents.

Attunement will take time. A child who does not make any eye contact may, after many sessions, begin to make fleeting eye contact. Ideally, those moments of connection will increase in frequency, then in duration. Continued use of this intervention will help move the child out of their self-stimulatory behaviors and into more intentional movements. Instead of merely flapping, they may begin to move their hands over their head, or in a different, similar motion. This is a sign that the child is now more aware of their environment.

Vocalizations and entrainment

If the self-stimulatory behaviors do not easily lend themselves to imitation—for example, if the child incessantly jumps into the ball pit, or swings on the swing, or runs in circles—therapists can also use their voice to entrain to the child’s movements.

Entrainment occurs when independent rhythmical systems begin to “couple” and beat together, e.g. when we walk, our arms and legs synchronize to the common beat of our gait. If a child is running, the therapist can vocalize in the same rhythm as their foot falls across the floor. Or maybe if they swing on a swing, the therapist might hum a simple melody in the rhythm of their swinging. If they jump on a trampoline, they can clap or vocalize to the rhythm of their jumping.

In this way, the therapist uses the principles of entrainment to somatically attune his or her body to the child’s body in a cross-modal correspondence to their motor behavior.

From a sensory and regulatory perspective, if the therapist is imitating or entraining to a child, they neither give the child too much, nor too little stimulation. Thus, little by little, the child’s nervous system grows calmer. Over time, this moves the child out of the chronic fight/flight/freeze response and closer to social engagement.

Find more on this topic, along with hundreds of hours of in-depth courses for occupational therapists, in HomeCEU’s online learning library.

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This article was written by Michelle Colletti, PhD, OTR/L .