There are two schools that are “offshoots” of Kris’ Camp. After a few years doing Kris’ Camp, parents wanted to have the philosophy based in a school setting, so they started the schools. I wrote this paper describing the evidence base for how we approach autism.
Although evidence-based medicine (and therapy) is a term thrown around a lot, exactly what that means can differ. For example, one person might weigh a randomized controlled study, where things can be controlled better in a lab setting, while others may need to rely more on observation and experience. In fact, the American Physical Therapy association defines evidence base as:
Evidence-based practice includes the integration of best available evidence, clinical expertise, and patient values and circumstances related to patient and client management, practice management, and health policy decision-making.
This paper details the evidence base behind approaching autism as a cognitive motor sensory processing difference.
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Introduction
Rehabilitation scientists speak about the key ingredients of therapy. That is what are the components of a program, more importantly, what are the successful ingredients of a program? Most, if not all, educational and therapeutic programs are based on typical neurologic development. (Prizant, Wetherby, Rubin, & Laurent, 2003)(Gutstein, Burgess, & Montfort, 2007; Vismara & Rogers, 2008; Greenspan & Wieder, 1999). Yet, through imaging, experimental and clinical research, we now know differential brain connectivity is at play in autism spectrum disorder (ASD). Shouldn’t we base our evidence based practice on differential barin connectiivty? This paper addresses evidence base sensory motor supports, based on strong brain connections.
If an educational strategy is evidence-based, data-based, or research-based, educators compile, analyze, and use objective evidence to inform the design an academic program or guide the modification of instructional techniques. This may include research studies, consults with parents and other educators as well as a teacher’s observation and experience. (Biesta, 2010)
Similarly, in the fields of occupational, physical and speech therapies, there are three components of evidenced based practice that includes research studies, client consideration and clinical expertise. (Schreiber & Stern, 2005)
This paper outlines the scientific research – imaging and experimental studies, that are behind approaching autism as a cognitive motor sensory processing difference/disorder. Beyond the scientific papers, we have used this approach for 20+ years at a therapy intensive program for children with autism and their families, and thus have had decades of therapy and family experience that also evidences successful outcomes. This educational and therapeutic model approaches autism as a cognitive motor and sensory processing disorder, based on different brain connectivity. (MacNeil & Mostofsky, 2012) (Mostofsky, Powell, Simmonds, & Goldberg…, 2009; Mostofsky & Ewen, 2011; DiCicco-Bloom et al., 2006)The overarching umbrella is that competence is assumed. That is, our clients and students are much smarter and more capable than they are able to demonstrate, and that with proper sensory supports they are able to better achieve their potential.(Jimenez & Mims, 2015; Berger, 2013a)
Autism as a Cognitive motor Sensory Processing difference
Developmental dyspraxia has been associated with increased autism severity and decreased IQ as measures on a standardized test. In other words, the worse praxis ability, the more affected a person is by autism and the worse they do on a standardized IQ test. (MacNeil & Mostofsky, 2012; Mostofsky, Dubey, & Jerath…, 2006; Dewey, Cantell, & Crawford, 2007) Importantly, developmental dyspraxia in the most recent studies evaluating praxis and autism is tested using the definition and assessment for adults with apraxia. We’ll get to this in a minute, but the definitions of developmental dyspraxia vary depending on the health field a person is in. In the adult apraxia literature developmental dyspraxia is defined as a disorder of purposeful movement. In other words, difficulty with movements that meaning is attached to.(Rothi & Heilman, 2014)
The reason why this is important is because developmental dyspraxia as defined by occupational or physical therapists has historically been defined as a disorder of motor planning, or a disorder of learning a sequence of a movement. (Franchuk, 2003)The primary therapy assessment for praxis, the Sensory integration and Praxis test, assesses praxis by asking the test taker to perform a series of meaningless gestures such as touch your nose then touch your ear. Or, to do a series of movements with your hands such as: open palm, closed palm, open palm, palm closed. On the other hand the most recent studies looking at developmental dyspraxia and autism examine whether the person can wave goodbye or demonstrate how to use a hammer by gesturing. (Smith & Bryson, 2007; Mostofsky et al., 2006; Dewey et al., 2007)Developmental dyspraxia as defined this way, as producing or pantomiming a meaningful movement, has found that persons with autism have more difficulty with praxis than children with developmental coordination disorder, similar language impairment and typical children age matched for a verbal ability.(Dewey et al., 2007; MacNeil & Mostofsky, 2012)
Also, by testing praxis using meaningful gestures, researchers were able to demonstrate that persons with autism had difficulty producing gestures such as pretending to hammer a nail with a hammer or pretending to cut a piece of paper with scissors. But on the other hand, when the actual object was present, persons with autism were able to better produce the gesture or movement.(Dewey et al., 2007) In adult apraxia tests, researchers evaluate whether or not there is understanding based on if the person can perform a gesture without the object present in contrast to when the object is present. The idea being that if a person can’t perform the gesture by imagining the movement in their minds eye, but they can perform the task with the actual object, then they understand what is being asked but they can’t perform the movement without the additional cue of the object. In order to be able to access the movement without the additional cue, a person needs a well-connected frontal lobe. The frontal lobe is the front part of the brain and is the most affected in persons with autism, in terms of different, less-efficient brain connectivity.(Carper & Courchesne, 2000)
The important takeaway here is that the person with autism can’t access the movement solely from thinking it in their mind’s eye. Instead they need an external cue. If we extend this to the cognitive motor system in general, we can begin to see how it may be difficult for someone to initiate, inhibit or sustain a movement. An example I frequently use to illustrate how the cognitive motor system works is to imagine yourself sitting in a three hour lecture. After an hour goes by you have the urge to go to the bathroom, so you look at the clock and see that there’s 30 minutes left until the next break and evaluate whether you need to go right now or if you can sit and wait until the break. If you decide you can wait, you wait. If you decide you need to go right away, you might lean over to the person next to you and tell them I’ll be right back I have to go to the bathroom. In order to do this, you need to have a good cognitive motor system. Because persons with autism don’t have an efficient cognitive motor system, they may have difficulty with initiating, inhibiting or sustaining going to the bathroom. In other words, they may get “stuck” in the chair and not make it to the bathroom. Or, they may just get up and walk out of the room. If they can’t speak words out of their mouths, they can’t tell the person next to them what they are doing. Oftentimes this then is interpreted by behavioral analysts that they are ‘escaping’, when in fact they have to go to the bathroom but can’t tell you. (Cooper, Heron, & Heward, 2020)
So why would it be that persons with autism have difficulties with the cognitive motor system? Why would it be if they have difficulty with initiating inhibiting and sustaining?
There have been numerous imaging studies detailing differential brain connectivity in persons with autism.(Carper & Courchesne, 2000; Mostofsky & Ewen, 2011) In order to be able to decide whether or not you need to go to the bathroom right away or you can wait, you need an efficiently connected frontal lobe in order to connect the intention with the movement. You have to think the thought in your head, make the decision and then execute the movement, based on whether or not you need to go right now or you can wait. You can also think of this as “top-down processing” where you think the thought in your head, and the act on the movements needed to complete the thought. The frontal lobe is the area of the brain that processes this.(Funes, Lupiáñez, & Humphreys, 2010) Again, the frontal lobe of the brain is the most affected in persons with autism.(Courchesne & Pierce, 2005; Villalobos, Mizuno, Dahl, & Kemmotsu…, 2005)
So what supports do we use to support improved cognitive motor control in persons with autism? Some primary examples: 1) Use of the object pathway of the visual system. 2) Use of external cues. 3) Use of short connections that process ‘in real time proprioception’. 4) Multimodal cues. And, 5) Rhythm cues.
The object visual pathway
There are two main parts of the visual system: the visual motor pathway and the object pathway.(Braddick & Atkinson, 2011) The ‘object’ pathway of the visual system processes objects, pictures, but also the whole words and their meanings. One common method of communication support that is used with persons with autism is the picture exchange communication system (PECS).(Bondy & Frost, 2011) For those unfamiliar with PECS, PECS uses laminated cardboard pieces with pictures on them. PECS is used mostly to request items such as I want a drink. The limitation of using PECS is that 1) it limits the individual to just the choices on the board and often times just to requests and 2) often times the kids get stuck on one particular request such as “I want a coke.”(Arthur-Kelly, Sigafoos, Green, Mathisen, & Arthur-Kelly, 2009) But if the object pathway is also the pathway the processes whole words and their meanings, why not support your student using the written word? For example, we use white boards with a regular curriculum that assumes confidence that our students can and will learn.(Berger, 2013c)
The short proprioceptive connections
Imaging studies in persons with autism evidence that short connections that join adjacent areas of the brain, or the radiate white matter, are well or over-connected in persons with autism. (Herbert et al., 2004; Izawa et al., 2012; Haswell, Izawa, Dowell, Mostofsky, & Shadmehr, 2009)Some of these connections that have been well studied are short connections that connect the back part of the brain, or the primary sensory cortex, to the primary motor cortex. All of the information that is transmitted through these fibers is what I call “in real time proprioception”. So, whenever you flap your hands or jump, pace or move your body, these connections are stimulated. From autobiographical accounts we see that people with autism don’t feel their bodies unless they are moving in some way.
The Reason I Jump author, Naoki Higashida, says:
“When I’m jumping, I can feel my body parts really well, too—my bounding legs and my clapping hands—and that makes me feel so, so good.”
In a Time magazine article, June 13, 2006, Chammi Rajapatirana says:
“I can’t feel my hand unless I feel your hand on my hand. I can’t feel my legs unless I am stomping my feet..”
We also have noted clinically improved regulation with weighted blankets or resistive vests. In our approach, we access the short proprioceptive connections with deep pressure squeezes, heavy weights, touch cues as well as sensory supports such as ace wraps or resistive vests.(Guinchat et al., 2020; Berger, 2013b)
Additional research that indicates this short proprioceptive pathway is strong in persons with autism includes 1) persons with autism are over reliant on the proprioceptive system for motor learning, 2) increased connectivity in the short proprioceptive connections is associated with decreased motor ability and praxis ability and 3) The more over connected these pathways are, the more severe autism score a person has received. In other words, the more someone is affected by autism, the more there is different brain connectivity.(Lidstone, Rochowiak, Mostofsky, & Nebel, 2021; Larson, Bastian, Donchin, & Shadmehr…, 2008)
To illustrate further what relying on the proprioceptive system for motor learning means, I use the example of hitting a tennis ball with a racket. If I were to ask you to pantomime hitting a tennis ball with a racket you might pretend to throw the ball up in the air and serve it, or you might perform a back serve or a front serve. In order to do this you have to have been able to pull that picture up in your mind’s eye of what the movement would look like to hit a tennis ball with the racket. On the other hand if you were actually playing tennis it quickly lose the game if you relied solely on your proprioceptive system. Instead as the ball comes to you you adjust your body in order to be able to hit it. This motor pathway is the visual motor pathway, and this pathway is not well-connected in persons with autism.(Lidstone & Mostofsky, 2021) Though it may seem counterintuitive that persons with autism have difficulty with pantomiming gestures but also rely on the proprioceptive system for motor learning, it helps to think that someone with autism can learn a motor skill or gesture through repetition, as is done in applied behavior analysis (ABA), but once they have learned that skill they will likely have difficulty using it spontaneously.(Cooper, Heron, & Heward, 2020) Also, once they have learned it, they will likely have difficulty breaking out of the motor pattern that they learned it in. In other words if they learned hitting a tennis ball with a racquet using an overhand serve, they would have difficulty moving out of this pattern, say to an underhand serve.(Dewey et al., 2007) Autistic persons I’ve worked with who were learning to play tennis, for example, can learn to hit the ball if they are standing in one position and the ball falls in the area where that movement would easily meet the ball (the ‘strike’ zone). But, they have a lot of difficulty adjusting their body if the ball were to fall out of that zone.
This over reliance on the proprioceptive system for motor learning paired with the inability to break out of that motor pattern once it is established, is most probably why when students learn a motor task through ABA and repetition, there is a lot of difficulty generalizing this to a different context.(Cooper, Heron, & Heward, 2020)
Fronto striatal loops
In order to understand better the reliance on over-learned pattern movements, it’s important to touch on brain connections called frontostriatal loops. There are connections in the frontal lobe down into a deeper part of the brain called the striatum, and all over-learned behavior, or habit, is represented here.(Middleton & Strick, 2000) We all have these loops, but if your brain is not efficiently connected in the frontal lobe, you may have more difficulty breaking in and out of these patterns. This is why when teaching someone with autism a task it is OK to teach them in a repetitive manner with something like tying your shoes or eating with a spoon, but to teach someone how to use the spoken word in a repetitive manor leads to being able to say the word but an inability to generalize in conversation.
Multimodal cues
Typical children preferentially pay attention to biological movement of a random stick figure movement. A study done by researchers at Yale University looked at whether or not children with autism did the same thing.(Klin, Lin, Gorrindo, Ramsay, & Jones, 2009) What they found was that children with autism did not pay attention preferentially to biological movement, but instead they preferentially attended to movements that had both an auditory and visual component, such as playing patty cake. There is also evidence that the main sensory nucleus of the brain, the thalamus, is over connected to the cerebral cortex or thinking part of the brain.(Mizuno, Villalobos, Davies, & Dahl…, 2006; Casanova, Buxhoeveden, Switala, & Roy, 2002; Kallai, Makany, Csatho, & Karadi…, 2007) Because of this, this approach utilizes multimodal cues that combine auditory and visual at the same time. Moreover, we have found using multimodal cues leads to a greater focus and improved processing for the given task.
External cues or bottom-up processing
There is a scientific term called thigmotaxis.(Kallai, Makany, Csatho, & Karadi…, 2007) Persons with autism are thigmotaxic. What this means is that one is over-reliant on external cues. To illustrate this you can think about how children with autism can be prompt dependent for tasks learned in a repetitive manner such as is used in ABA. They learn how to speak “Hi.”, but can’t seem to access this without someone telling them to say hello. Other ways in which thigmotaxis can be seen is when a child may be stuck on the light switch so if they see the light switch, an external cue, they have difficulty inhibiting going over and turning it on and off.
There are many examples of how this plays out for individuals with autism, but because persons with autism rely on external cues to navigate their environment, we can use this to support them. One way is to write “I can” statements on a whiteboard. An example: “I can quiet my voice.” You can think of this external cue as supporting the thinking process and processing of information so that a person can regulate better. Because someone with autism may have difficulty with regulating their voice, controlling it from a top-down brain process within the frontal lobe, they can instead look at the statement and then control better. They are then using bottom-up processes.
Rhythm
Music therapists have investigated the use of rhythm and how it impacts the motor system. Many of the first studies looked at how using an external rhythm helped folks with Parkinson’s disease or stroke improve their walking. More recent research has focused on autism, and how rhythm can support better control over their cognitive motor system. To illustrate how rhythm can support the motor system, think if you’re at a country rock concert with the beat of good song, often people find themselves swaying or tapping their toe to the rhythm of the beat. Without getting into the neuroanatomy, you can think of it as an external scaffold so that one doesn’t need higher level motor areas in the frontal lobe. External rhythm allows you to bypass the higher motor areas in order to move. At Kris’ Camp, we use rhythm to support our students to initiate, inhibit and sustain their movements.
Summarizing…
At Kris’ Camp we use sensory supports to facilitate improved cognitive motor control for the individuals we serve. We have found that when we use these supports and assume the individuals we work with are smarter than they can demonstrate, but are hindered by an inefficient cognitive motor system, our students are better able to regulate and demonstrate their competence. Further, this approach is supported by experimental and imaging studies as well as clinical and student/family experience and as such, is evidence-based.
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