RECOVERY TECHNIQUES FOR MOTOR DYSFUNCTIONS IN AUTISTIC CHILD, SEVERE FORM, IN ORDER TO PREPARE THE ACQUIREMENT OF WRITTEN LANGUAGE
In the article, I presented techniques for motor recovery of autistic child through graphics. I chose learning / correction techniques of fine movement coordination difficulties. They allowed the acquirement of graphic gesture, required for writing. From the casuistry assisted in the years 2010-2015, I selected a group of 10 children who corresponded to the diagnosis of autistic disorder, according to ICD-10.
What is called Autistic Disorder in CM-10 is a complex and serious disorder with onset in early childhood, which, among its many physical symptoms, is also accompanied by motor dysfunctions, and impairment of family balance, for whom the situation is a drama. Since 2013, DSM V included what is called autistic disorder in the broader framework of autistic spectrum disorders. Moreover, the new name not only replaces what was previously called (DSM III, DSM III-R, DSM IV-IM, DSM IV-TRIM) “Pervasive developmental disorders”, but it radically restructures its content. Boundaries between what, under the name of “Autistic disorder”, “Rett disorder”, “Disintegrative disorder of childhood”, “Asperger disorder” and “Pervasive developmental disorder without further specifications” constituted distinct diagnoses are erased and merged being considered a relatively uniform clinical reality. It is true that a set of specifications which allow the identification of clinical forms of incorporation thus eliminated for those familiar with it, without being recognized the status of diagnostic entity, operate within it.
Among the specifications, a three-step quantitative criterion occupies an important place. This refers to the amount of the need for support, a need required by the level of dysfunctions present within the sphere of constituent components of the diagnostic criteria A and B. It is the sphere of social communication and repetitive behavior. The introduction in the diagnosis of a quantitative criterion, an aspect which was absent in CIM-10, is actually very useful from the perspective of a therapeutic process, since, on the one hand, it and its effectiveness vary depending on the severity of the disorders, and on the other hand, it allows a better evaluation and comparison of results. These are the reasons that made us adopt it in this study, too. In the present study, we addressed the severe form of the cases in the international classification belonging to autistic disorders, namely in which, within the DSM V, the components of diagnostic criteria A and B are targeted.
The recovery of autistic disorders imposes several conditions, namely:
1. early and simultaneously approach of all the problems;
2. family involvement and its transformation into a co-therapist;
3. involvement of professionals who are qualified in different fields;
4. individual and group intervention;
5. combination of medication adequate to each case designed to promote emotional and social discontact, stereotypes, state of agitation, fear and other related disorders;
6. psychologist – doctor – psychotherapist collaboration. In this framework, the recovery of movement disorders is an objective of prime importance as it is well known that normal development in babies involves a positive interaction between the mental and motor development.
MATERIAL AND METHOD
From the casuistry assisted in the years 2010-2015, I selected a group of 10 children who corresponded to the diagnosis of autistic disorder, according to ICD- 10. Only the cases in which diagnostic criteria A and B of the diagnosis scale of Autistic Spectrum Disorder in DSM V imposed according to the severity scale, a huge support were kept.
DSM V Severity scale Table 1
A1 – qualitative alteration of social interaction;
A2 – qualitative alteration of communication;
A3 – the narrow, limited, repetitive and stereotyped feature of behaviors, interests and activities.
Criterion B: appearance before the age of three
B1 – motor acts, use of objects or stereotyped or repetitive language;
B2 – insisting on inflexible/rigid adherence to routine or ritualized patterns of verbal or non-verbal behavior;
B3 – fixed and very limited interests, abnormal in intensity or focus;
B4 – hyper or hypo-responsiveness to environmental input/ sensory afferents.
There are cases which, years ago, were considered without real chance of recovery.
Exclusion criteria: signs of neurological damage, epilepsy, birth defects, mild and medium forms or which have no nuclear family or family who cannot cooperate.
Additional criteria for inclusion: both parents’ presence throughout the therapeutic recovery process. Batch structure: 8 boys and 2 girls, aged 3 years when taken in the study. The selected children did not have systematic acquisitions in order to participate in standardized testing such as Oszeretski test, Liebmann test, side examination. In this context, by complying with the conditions of the six points above and engaging means and techniques presented over the years, I will detail the therapeutic intervention necessary for the acquirement of motor skills. Thus, we started the intervention with the acquirement of digital clamp. For the three fingers of both hands – thumb, index and middle – to form the clamp to hold the string, I used a game that mimics the snowdrop: all fingers are gathered, being inclined downward, reaching all fingertips.
Then, the same movement is executed when they are elevated. Repeat five times with breaks of relaxation. In the beginning when the child is shown by a speech therapist, it is recommended that the parent participating in therapy helps him, intervening when and where appropriate. Another game is the one with laundry hooks, made of wood or plastic. It is important to diversify material (wood, plastic) because an autistic child has a certain kinesthetic sensibility and any shift of different objects used during the games will be accepted with difficulty. The child is shown how to hold the hook with two fingers (index finger and thumb). At first it can be held with three fingers. It is exemplified on a rope, how to open and grasp the laundry hook, then he is helped with the adult’s hand over his hand. The hooks can be grasped to the walls of boxes of various shapes, round or square, and exercises can be combined using different categories: by color, by shape (smaller, bigger).
Another game difficult at first, is to put beans in a bottle. It is important to follow hand-eye coordination (both hands being in action, the one keeping the bottle and the one keeping the grain of beans). It is recommended that adult who participates is warned that the grain of beans must be caught correctly, not let the child take more grains simultaneously! It is repeated five times, and a pause with breathing exercises is taken. Other games with seeds can also be used. Show the child how to pour the contents of a vessel into another vessel (rice, oats, beans), how it can be taken with spoons of different sizes (at first, the adult’s hand must be over the child’s hand when using the spoon!), with the fist or two fingers. It is repeated five times, then he returns to muscle relaxation, executing raindrops game.
The game with beans can be diversified: the child is proposed to remove a grain of beans from the semolina bowl with the fingers. He will need to put his hands in the semolina to find the grain of beans. The separation of the grain of beans from the semolina can be done using strainer. Then another exercise: the child must take corn, wheat grains from a flat plate with his fingers. On a shiny platter, semolina or flour is sprinkled thinly and evenly. Swipe your finger over this layer. The bright line of the platter shall be followed! He may repeat by himself after several attempts. Then he moves to the sandbox, which more difficult to handle: lines are drawn, then it is caught between the fingers and dropped, creating threads of sand. This exercise was used for the learning of all graphic elements, letters and numbers, the sandbox being liked by children, but it needs attention because the desire to overturn the box or to put the fist and then to throw sand around the room appears!
Puzzles – those with geometric figures, which have small buttons on them, allowing easier handling.
– Tack pad is very important because in addition to developing dexterity, it is also worked on spatial orientation (tacks are placed in different corners of the board up/down in the upper left/right corner). These controls help further explanations, when graphic activity in the notebook is started and the child can be helped with the adult’s verbal explanations without indications through gestures.
– Counting beads on an abacus. The beads may be of plastic or wood. Abacus may be smaller, in the beginning, then larger in size. Beads can be counted by leaps and not counting in order!
– Looking into books – this is an exercise that must be followed carefully, because it is a motor stereotype for many autistic children. It can be beneficial if it is correctly explained to the child how to look into the pages of books, and then small explanations about what is on each page are also given, making him look into it in a slow pace and with some interest.
– We can also imitate raindrops, playing the piano or the flute (wooden flute, not the one made of plastic which we use for different kind of exercises) with the fingers.
For the segmental control at the age of 4-5 years we can imitate simple gestures of hands:
1. The child’s open hands are presented to him, palms turned toward him (40 cm between hands and 20 cm away from his chest); then fists are closed; left hand open, right hand closed; previous position reversed; left hand vertical, right hand horizontal, left hand touching in right angle; reversed position.
2. Bridge (movements are also accompanied by the lyrics of the song “Stone Bridge”).
3. Bud flower (tighten fists – they are opened simultaneously with the command bud-flower!)
After these learning/correction exercises, we have found that we can correct the difficulties of coordinating fine movements (uncertainties in hand coordination, keeping the pencil in the right position, modeling with wax, and also the duration necessary to complete a motor task, observing the pace imposed by the teacher!)
Studying curricula simultaneously with the initial observation of children, both in the family environment and in the educational one, we identified written language requirements in the field of motor skills, ever since the lower kindergarten group. I shall illustrate the activity category and teaching material for each group.
Within the mathematical activity in lower kindergarten group children are asked:
– to classify objects by the criterion of shape and size;
– to build structures according to a given model.
Type of activity: exercises with individual material.
Items: separating toys from other objects; grouping cars by size (here, an additional explanation: he shall not put them in line – as a stereotype. The speech therapist shall encounter opposition at this type of exercise!); building according to a model, a train of cubes (1 – red, 1 – blue).
– to place objects in the indicated positions
– to put a toy in the required position: up-down. In the practical activities and home activities, the child is asked to eat alone (therefore, to be able to use a spoon, a fork, and the exercises that we have shown above are useful); to crumple and tear the paper; to put in plane or space the elements of a building.
In plastic education classes, the objectives are as follows:
– to draw lines on limited surfaces boldly;
– to discriminate colors according to criteria related to aspects found in the immediate environment.
It shall be followed if the child: – holds easily enough the pencil in his hand; – colors balloons by exceeding the contour line or not. In these exercises, autistic children start the graphical act by the uncertainty of pressing. The pencil requires certain steps until the child reaches graphical autonomy: adult hand over the child’s hand, careful observation of the execution of clamp with the correct position of the three fingers, gradual withdrawal of covering the child’s hand until the adult’s hand becomes like a shadow. There is only one objective for physical education: to execute, upon command, movements of different parts of the body. Examples: he goes in the indicated direction; he puts forth his hands; he claps his hands (this exercise overlaps with a stereotype often met in autistic children); he raises hands. In middle kindergarten group, within the activity of educating the language, there is a measurable behavior: to sort and match different contours. As an evaluation item: put at least 6 chips over the right shadow in the game “Find the right shade.” The first measurable objective of written language appears – draw simple graphic signs:
Measurable behaviors appear in the mathematical activities:
– to assess the quantity globally;
– to grasp spatial relationships taking himself as a benchmark;
– to execute series of objects, making simple structures;
– to establish the appurtenance of an object to a class;
– to count the objects of a group without relating the number to quantity.
– he perceives the group with more (less) objects;
– he places the rabbit in front of him (behind, near the leg);
– he arranges the beads alternatively (a small one / a big one);
– he sorts the group of cars; – he recognizes the group of 3 objects;
– he forms the group with 1 object; – he differentiates objects by shape.
“Put only the round objects in the basket. Which objects remained?”
– he differentiates objects by color;
– „Name the colors of the objects. Group objects by color!”;
– He carries out the correspondence in order to determine the group with more, less or equal objects.
– „Form pairs between the objects of the two groups”.
Example – Form pairs between the groups:
– he recognizes and uses geometrical shapes: circle, square and triangle.
– „Color the circles in red and the squares in blue”. Which shapes remained uncolored?
I have presented examples of kindergarten activities, which require motor skills development, to emphasize the importance of knowing these measurable objectives, without which we cannot talk of recovery in autistic child when he is integrated in a full-time kindergarten. The intervention and the treatment must be individualized depending on the associated symptoms which may occur. Each child has difficulty in accepting the novelty, shows specific deficiencies, which oblige us to proceed to the diversification of skills.
Techniques also help me in cognitive development, but they are not a general objective, but an operational one. Different games are resumed at different intervals, when either the fatigue of small hand muscles or a correct execution of the clamp during graphical act is noted. We evaluate skills in a way, but recovery, as mentioned above, is individualized, depending on the inner dynamics of each child. Family involvement as co-therapist in educational activities is the key to optimal functioning of psychopedagogical intervention!