Most people with autism will tell you that they enjoy being around family and friends and engaging in social play and recreation. Yet we still assume that they do not care about joining in with group activities and prefer solitary play!
So what is getting in the way?
Autism’s core characteristics include difficulty with social communication and forms of restrictive stereotypic behaviors. As if this wasn’t enough to create difficulty in developing friendships and participating in active physical play, research also shows that children with autism have significant gross motor delays and motor learning differences that may compound these challenges.3 It’s even suspected that motor challenges contribute to daytime problem behaviors and reduced quality of life.4
This is where therapists come in. When PTs and OTs see a child with autism, we can identify gross and fine motor delays and gait abnormalities along with strength, balance, coordination, and cardiovascular endurance deficits. The bigger problem is for other providers and parents to realize that these impairments are present and possibly contributing to the functional and participation challenges of their child.
Children with autism acquire developmental motor skills such as rolling, sitting, crawling, and walking as expected for their age. However, they struggle to acquire more complex motor skills, like running with agility, jumping, and manipulating gross motor toys.
Since children with autism also have differences in the way they process sensory information, using their skills in open, unpredictable situations in which the environment changes constantly is even more difficult. For example, think of a game of tag where kids are running in all directions, where once they are touched they have to switch from running away to running toward their peers while still keeping track of obstacles or game boundaries.
What activities would be relevant to a young child with autism? Catching a ball and then passing it to a play partner? Running away or trying to catch a friend? Why would they need these skills when what they appear to enjoy most is sitting for hours on end and exploring the moving parts of toys or the sensory aspects of their environment?
We make the mistake of assuming that they are not interested in these higher level skills, but how would you feel if you were expected to sail across a lake on a windsurf board, knowing you couldn’t stand on it for three consecutive seconds and were scared of drowning if you fell off?
Participation Level—Introducing Jackson and Diego
Let me introduce you to Jackson. Jackson doesn’t play with the other children at his daycare. His teacher must hurry to remove the wooden blocks before he scatters them around the floor. He is encouraged to sit with his language learning materials and sorting activities, always under close supervision.
While other kids squat, walk around, bump into each other, and share toys more or less successfully, Jackson sits. When his older sister goes to gymnastics lessons, Jackson stays home with his dad because his noises distract the class.
Now let me introduce you to Diego. At recess, Diego walks the perimeter of the playground fence. He sometimes runs quickly, apparently unaware of the tag game his peers are playing nearby. While the neighborhood kids learn to ride two-wheeled bikes, he watches from the window.
Both of these children love to rough house with their parents and siblings at home, yet they rarely participate in active play outside their home, whether at school or in their community.
So what can a therapist do?
1. Focus on Participation
By facilitating participation instead of focusing on impairment and activity level, you can triple the impact of the work you do in therapy appointments. Engage parents and encourage the children themselves to tell you exactly what they want to do. The Canadian Occupational Performance Measure is an excellent tool to achieve this—plus, it acts as a patient/family-reported outcome measure!
2. Use Your Movement System Expert Skill Set
You have the power to make participation happen. You know better than anybody how to analyze and create step-by-step acquisition phases for the complex motor skill required for the child to participate in desired activities.
Evidence-based strategies exist and are easy to incorporate in your work. They include:
- Picture schedules
- Video modeling
- Peer modeling
- Parent-mediated intervention
- Teaching in the natural environment
- Aerobic exercise
For example, think about how you can enhance your motor teaching strategies to make them accessible to a child like Jackson or Diego, who has difficulty attending to lengthy verbal explanations or your demonstrations. Maybe create a quick video of a peer demonstrating for Jackson the sequence of actions required to build the wall by first gathering a few blocks and then placing one on top of the other. Allow Jackson to watch the video before engaging in the activity (given that video permission is on file for the other student).
Want to help Diego play tag? With the help of a speech therapist, you could create a story written in first person (a script) showing him running to a peer then running away from his friend so that Diego can read about the sequence of actions and see pictures of himself and his peers appearing to play together. In addition to providing knowledge about the game, it may boost his confidence for the next time the opportunity to play is presented.
Another solution is to use the pediatric home exercises available in MedBridge’s home exercise library. Available to watch on tablets or phones through the MedBridge GO app, these short exercises feature simple-to-understand explanations and children performing the exercise.
3. Leverage Interprofessional Collaboration
Ask your speech-language therapist colleague for their expertise in incorporating well-designed visual supports and core vocabulary in your lessons. OTs and PTs can work hand in hand to problem-solve the sensory over-stimulation of a gymnastics class your patient’s mother would like for them to try. Maximize practice opportunities by engaging the child’s behavioral interventionist, parents, and teachers to agree on motor behaviors to practice. Decide together how you will track changes in performance and, ultimately, changes in participation.
Putting It Together
How might this look for Jackson at his daycare? If you were an early intervention therapist collaborating with other therapists and Jackson’s early education teacher, you might decide to teach Jackson a simple sequence, using visual supports, to build a wall with the wooden blocks. You can engage his peers to help out and then work on his balance by taking turns stepping over the wall they just created. The visual schedule includes the step of picking up the blocks and putting them in the bin at the end of the activity. To track the effectiveness of this intervention, the daycare teacher makes sure to provide time every day for playing with the blocks and then keeps a tally count of the times Jackson steps over the built walls without knocking over the construction.
And what about Diego? If you were a therapist working at Diego’s school, you might use cones at recess to make the boundaries of a tag game. Using colorful scarves, you can help Diego run and then pull on his peer’s scarves to “tag” them. By engaging his peers, you can instruct them to walk or run slowly to give Diego a chance. When a peer pulls Diego’s scarf, you can help him freeze. With the guidance of Diego’s SLP, you include core vocabulary of “pull,” “stop,” “wait,” and “go.”
By participating, Diego learns to run with agility while visually tracking and preparing to pull the scarf. Additionally, he gets daily aerobic exercise, which is known to promote attention and decrease maladaptive behaviors later during class.5 Diego’s PE teacher can then introduce the scarves in her own tag games and ask Diego to be the first “tagger.” Diego beams with excitement because he knows he can do this!
Children with autism and their families want to have friends and engage in play and recreation in their community. The combination of a lack of specific motor skills and anxiety can inhibit initiation or present as maladaptive behaviors. By rising to the challenge and stepping out of your comfort zone, you can be an advocate for children with autism and improve participation outcomes.
- Solish, A., Perry, A., & Minnes, P. (2010). Participation of children with and without disabilities in social, recreational and leisure activities. Journal of Applied Research in Intellectual Disabilities, 23(3): 226–236.
- Potvin, M. C., Snider, L., Prelock, P., Kehayia, E. & Wood-Dauphinee, S. (2013). Recreational participation of children with high functioning autism. Journal of Autism and Developmental Disorders, 43(2): 445–57.
- MacDonald, M., Lord, C., & Ulrich, D. A. (2013). The relationship of motor skills and social communicative skills in school-aged children with autism spectrum disorder. Adaptive Physical Activity Quarterly, 30(3): 271–82.
- Hedgecock, J. B., Dannemiller, L. A., Shui, A. M., Rapport, M. J., & Katz, T. (2018). Associations of gross motor delay, behavior, and quality of life in young children with autism spectrum disorder. Physical Therapy, 98(4): 251–259.
- Tomporowski, P. D. (2003). Cognitive and behavioral responses to acute exercise in youths: a review. Pediatric Exercise Science, 15(4): 348–359.