S PECI A L I N T ER E ST SE C TI ON QUART ERLY
Sensory Integration
Published by The American Occupational Therapy Association, Inc. Sponsored in part by WPS September 2015, Volume 38, Number 3
Dyspraxia in Autism Spectrum Disorders: Evidence and Implications
Given the poverty of research on dyspraxia in ASDs prior to the 1980s, it is reasonable to assume that Ayres’ understanding of the sensory and praxis issues evolved from her own research and practice (Ayres, 1972; Ayres & Henderson, 1974), rather than from contemporary views of autism. Ayres not only theorized about the role of sensation and praxis in ASDs, she further posited that the application of a specific intervention using natural activities, in the context of play, could facilitate the remediation of these areas, thereby changing nervous system functions. Imbued by a profound understanding of the difficulties experienced by the children she treated, she wrote, “How does it feel to be a dyspraxic child?” (Ayres & Cermak, 2011). In this work, she strived to understand the world of a child with dyspraxia from within, and suggested that we carefully monitor our interventions in order to foster growth, while avoiding resistance and negativism. Always presuming the innate drive toward competence, she instructed therapists to “back off” at times in order for the child’s motivation to self-actualize and for problem solving to flourish. Ayres designed several pediatric measures of praxis, meant to be used in concert with the other sensory tests of the Sensory Integration and Praxis Tests (Ayres, 1989). These included the Imitation of Postures Test (later renamed the Postural Praxis), Oral Praxis, Sequencing Praxis, Constructional Praxis, and Praxis on Verbal Command. Patterns of dyspraxia emerged from a variety of factor analyses that included visual praxis, somatopraxis, and praxis based on verbal command (Ayres, 1989). Additionally, she considered ideation as an essential element of praxis that is often limited in ASDs. The multifaceted view of praxis that emerged from her study of adult literature and from her work in pediatrics provides a broad perspective of praxis that highlights the essential role of sensation in praxis, particularly, of the somatosensory system (Ayres & Cermak, 2011).
Judith Abelenda, MS, OTR; Zoe Mailloux, OTD, OTR/L, FAOTA; and Susanne Smith Roley, OTD, OTR/L, FAOTA Dyspraxia is “a developmental condition in which the ability to plan unfamiliar motor tasks is impaired” (Bundy, Lane, & Murray, 2002, p. 477–478). The purpose of this article is to review current views of dyspraxia and its relationship to occupational therapy services for clients with an autism spectrum disorder (ASD). An emerging body of evidence demonstrates the impact of dyspraxia on participation in individuals with an ASD (Dziuk et al., 2007; Roley et al., 2015). First, this article reviews seminal work on praxis and ASDs, followed by consideration of recent findings on the evidence for a neural basis of dyspraxia in ASDs. Next, we will highlight the risks and implications for occupational performance. Finally, we will discuss how this body of evidence informs occupational therapy practice, especially in applying Ayres Sensory Integration® (ASI) for people with an ASD.
Historical View: Dyspraxia and Autism Ayres (1972) was among the first to describe sensory differences in individuals with ASDs. In her theory of sensory integration (ASI), she hypothesized that difficulties in registering, modulating, and integrating sensations were likely to interfere with the ability to create internal maps of the body for relating to the environment. Her theory also posited that these sensory differences further interfered with the ability to figure out how to use the body in meaningful interactions with people, space, and objects, and to explore new and novel ways of interaction. Thus, she highlighted the connection between sensory integration and praxis and linked difficulties in these areas with the participation challenges commonly observed among individuals with an ASD (Ayres & Cermak, 2011). Ayres (2005) hypothesized that deficits in the central nervous system, specifically the limbic system, interfered with motivational functioning in people with an ASD, which she termed a problem of “I want to do it” (p. 132). Her innovative view led to a deeper understanding of the neural basis for behaviors such as the lack of initiative, now commonly recognized as part of an ASD. Dr. Bauman, a pediatric neurologist and leading researcher in the field of ASDs, stated in reference to the chapter on autism in the anniversary edition of Sensory Integration and the Child (Ayres, 2005):
Current Views: Dyspraxia and Autism Sensory concerns and dyspraxia are ubiquitous in autism. Through retrospective analysis, Roley et al. (2015) found that, in addition to atypical sensory reactivity, children with an ASD display common patterns of somatodyspraxia with vestibular processing deficits, along with strengths in the visual perceptual and visual praxis areas. This classic pattern of somatodyspraxia significantly correlated with the Social Participation scores on the Sensory Processing Measure (Parham, Ecker, Kuhaneck, Henry, & Glennon, 2007), even more than the sensory reactivity scores. Jones and Prior (1985) found a correlation between imitation difficulties and neurological soft signs in a small sample of children with ASDs and posited central nervous system involvement in the disorder. Dawson and Adams (1984) contributed to the understanding of imitation in autism, primarily with a cognitive and behavioral focus. Imitation deficits in ASDs reflect dyspraxia and are often measured by observation of gestures (McDuffie et al., 2007; Rogers, Bennetto, McEvoy, & Pennington, 1996; Smith
It is clear from reading Dr. Ayres’ description of the autistic child and her interpretation of the potential underlying neurobiology associated with some of the clinical characteristics that she was ahead of her time. This chapter was written in 1979, 5 years before the publication of the first report of definable neuro-anatomic abnormalities in the autistic brain (Bauman, 2005, p. 180).
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& Bryson, 2007). Dziuk et al. (2007) indicated that dyspraxia was consistently reported in autism without a clear understanding of the relationship between issues in motor skills and sensory perception. Their study showed deficits in command gestures, imitation, and tool use among those with an ASD. Dowell, Mahone, and Mostofsky (2009) described developmental dyspraxia as “a developmental impairment in the performance of learned skilled movements that does not stem from a basic motor or perceptual deficit” (p. 564). They stated that praxis performance requires basic motor skill, knowledge or representation of the movement, and subsequent transcoding of the representations into movement plans. They found that dyspraxia among those with an ASD is associated with difficulties forming spatial representations of movement, recognizing and understanding the movements of others, as well as with transcoding one’s own representations into motor plans and executing them. They inferred that these difficulties are related to abnormal connectivity between parietal, premotor, and motor cortices. They found a strong correlation between praxis deficits and the core social and communication deficits of those with an ASD. These results suggest a need for further studies on the efficacy of occupational and physical therapy aimed at improving motor functioning, and thereby improving core deficits. Mostofsky and Ewen (2011) explored whether a core feature of those with an ASD, a pervasive impairment in the ability to engage in reciprocal interactions with peers, could be related to the same underlying neural basis as dyspraxia. They found that decreased long-range neural connectivity (between inferior parietal and pre-motor cortices) is conducive to decreased formation of action models, which in turn results in deficits in skilled social gestures. They highlighted that discrete action plans and the sensory feedback, stored as internal action models, form a fundamental mechanism for developing cognition. Moreover, citing Klin, Jones, Schultz, and Volkmar (2003) they sustained that the same faulty action models, when used in feed-forward fashion, are responsible for the theory of mind deficits seen in those with an ASD, or the difficulty reading others’ intentions. The difficulty of performing skilled social gestures, coupled with difficulty reading others, greatly impairs reciprocal interactions. Thus, underconnectivity would be responsible both for decreased abilities to engage in social skills and to interpret others’ actions. Mostofsky and Ewen (2011) related imitation difficulties seen in children with an ASD with their praxis difficulties, since both rely on the same sensory motor circuits necessary for action model formation. They also explained why children with an ASD typically have good development of the early motor milestones that rely on reflexes but show delays with the acquisition of skilled gestures such as pumping a swing, getting dressed, and riding a bike, and with social gestures such as waving goodbye. This study lends support to the statement that autism “reflects a developmental dyspraxia of social/communicative skills” (Mostofsky & Ewen, 2011, p. 439). Currently, it is broadly accepted that an ASD is characterized by neurologically based sensory and motor differences (MacNeil & Mostofsky, 2012; Siaperas et al., 2012). Some authors (De Jaegher, 2013; Donnellan, Hill, & Leary, 2013; Kapp, 2013) have cautioned that, in spite of the knowledge that communication, participation,
Sensory Integration
and relationships require organisms to organize sensory information into synchronized movement plans, most of the available interventions for autism continue to rely on behavioral or cognitive strategies. These strategies are appropriate to teach how to solve explicit social dilemmas in a laboratory setting, but they may not necessarily be enough to enable the use of these skills spontaneously in naturalistic settings where demands are implicit. This questions their generalizability (Klin et al., 2003). This has significant implications for occupational therapy practice, as occupational therapists work with other professionals in understanding and modifying interventions to address sensory and motor issues limiting the ability to generalize skills. Roley et al. (2015) emphasized that it is important to include assessment of somatosensory, vestibular, and praxis functions for individuals with an ASD in the evaluation process; otherwise, these important developmental areas may be missed and remain untreated. If the sensory and motor difficulties experienced by persons with an ASD are overlooked, the sensory-related behaviors may be misunderstood and seen as willful, meaningless, or due to lack of interest in relating (Ayres, 2005; Donnellan et al., 2013). Understanding the sensory nature of behavior allows therapists and caregivers to adjust the sensory environment, consider the sensory challenges within activities, and provide sensory enriched activities in the daily routine. Highlighting that interaction and communication deficits are a reflection of a different neurobiology impacting sensory and movement challenges, Kapp (2013) calls for the need to empathize with those hidden challenges, just as Ayres (1972) did decades earlier. Occupational therapists in their role of advocates in the home and school settings can share information about monitoring and adjusting sensory challenges and opportunities that improve engagement and participation. Donnellan et al. (2013) maintained that understanding motor and sensory differences in ASDs is necessary for individually developed support systems, which will require knowledge of the person’s unique differences and strengths, an investment of time spent with the person, and a presumption of competence. These researchers called for collaboration rather than control, and they reminded the reader that the essential factor of any successful intervention is the quality of the therapeutic relationship. We attach meaning to experiences and make sense of the world within the context of our own actions and our interactions with others (De Jaegher, 2013). However, inefficient sensory and motor functions that are common in ASDs can impact this ability (Klin et al., 2003). Following this premise, De Jaegher (2013), Klin et al. (2003), and others suggest that children with an ASD may be best able to develop social skills in settings rich in sensory motor experiences where the experiences can be perceived with greater salience. Interventions that target the difficulties with social, affect, cognitive, and sensorimotor capacities in real time require therapists who are ready to actively and effectively engage children in coordinated interactions that address individual neurological differences (De Jaegher, 2013). Occupational therapists using ASI to address social participation challenges for a child whose familycentered goal is to increase play with peers, needs to consider the underlying dyspraxia in an environment affording opportunities for self-directed participation in meaningful activities rich in novel
Special Interest Section Quarterly
ISSN: 1095-7250 Chairperson: Annie Baltazar Mori • Editor: Beth Pfeiffer • Managing Editor: Stephanie Shaffer Published quarterly by The American Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, MD 20814-3449;
[email protected] (email). Periodicals postage paid at Bethesda, MD. POSTMASTER: Send address changes to Sensory Integration Special Interest Section Quarterly, AOTA, 4720 Montgomery Lane, Suite #200, Bethesda, MD 20814-3449. Copyright © 2015 by The American Occupational Therapy Association, Inc. Annual membership dues are $225 for OTs, $131 for OTAs, and $75 for students. All SIS Quarterly newsletters are available to members at www.aota.org. The opinions and positions stated by the contributors are those of the authors and not necessarily those of the editor or AOTA. Sponsorship is accepted on the basis of conformity with AOTA standards. Acceptance of sponsorship does not imply endorsement, official attitude, or position of the editor or AOTA.
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sensory experiences within the context of a collaborative therapeutic relationship (Parham et al., 2011). Recent research including a feasibility study (Schaaf, Benavides, Kelly, & Mailloux-Maggio, 2012), two pilot studies (Iwanaga et al., 2014; Pfeiffer, Koenig, Kinnealey, Sheppard, & Henderson, 2011), one randomized controlled trial (Schaaf et al., 2013), and detailed information on ASI application in a case report (Schaaf, Hunt, & Benavides, 2012) seem to confirm that praxis deficits in ASDs and their correlated social and communication impairments can be successfully ameliorated through participation in self-directed, sensory rich activities that promote adaptive responses.
Jones, V., & Prior, M. (1985). Motor imitation abilities and neurological signs in autistic children. Journal of Autism and Developmental Disorders, 15, 37–46. Kapp, S. K. (2013). Empathizing with sensory and movement differences: Moving toward sensitive understanding of autism. Frontiers in Integrative Neuroscience, 7, 38. Klin, A., Jones, W., Schultz, R., & Volkmar, F. (2003). The enactive mind, or from actions to cognition: Lessons from autism. Philosophical Transactions of the Royal Society of London. Series B: Biological Sciences, 358(1430), 345–360. MacNeil, L. K., & Mostofsky, S. H. (2012). Specificity of dyspraxia in children with autism. Neuropsychology, 26, 165–171. McDuffie, A., Turner, L., Stone, W., Yoder, P., Wolery, M., & Ulman, T. (2007). Developmental correlates of different types of motor imitation in young children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 37, 401–412. Mostofsky, S. H., & Ewen, J. B. (2011). Altered connectivity and action model formation in autism is autism. The Neuroscientist, 17, 437–448. Parham, L., Ecker, C., Kuhaneck, H. M., Henry, D., & Glennon, T. (2007). Sensory processing measure. Los Angeles: Western Psychological Services. Parham, L. D., Roley, S. S., May-Benson, T. A., Koomar, J., Brett-Green, B., Burke, J. P., . . . Schaaf, R. C. (2011). Development of a fidelity measure for research on the effectiveness of the Ayres Sensory Integration® intervention. American Journal of Occupational Therapy, 65, 133–142. http://dx.doi. org/10.5014/ajot.2011.000745 Pfeiffer, B. A., Koenig, K., Kinnealey, M., Sheppard, M., & Henderson, L. (2011). Effectiveness of sensory integration interventions in children with a utism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65, 76–85. http://dx.doi.org/10.5014/ajot.2011.09205 Rogers, S. J., Bennetto, L., McEvoy, R., & Pennington, B. F. (1996). Imitation and pantomime in high-functioning adolescents with autism spectrum disorders. Child Development, 67, 2060–2073. Roley, S. S., Mailloux, Z., Parham, L. D., Schaaf, R. C., Lane, C. J., & Cermak, S. (2015). Sensory integration and praxis patterns in children with autism. A merican Journal of Occupational Therapy, 69(1), 6901220010p6901220011– 6901220010p6901220018. http://dx.doi.org/10.5014/ajot.2015.012476 Schaaf, R., Benavides, T., Kelly, D., & Mailloux-Maggio, Z. (2012). Occupational therapy and sensory integration for children with autism: A feasibility, safety, acceptability and fidelity study. Autism, 16, 321–327. Schaaf, R., Hunt, J., & Benavides, T. (2012). Occupational therapy using sensory integration to improve participation of a child with autism: A case report. American Journal of Occupational Therapy, 66, 547–555. http://dx.doi. org/10.5014/ajot.2012.004473 Schaaf, R., Benevides, T., Mailloux, Z., Faller, P., Hunt, J., van Hooydonk, E., . . . Kelly, D. (2013). An intervention for sensory difficulties in children with autism: A randomized trial. Journal of Autism and Developmental Disorders, 44, 1493–1506. Siaperas, P., Ring, H. A., McAllister, C. J., Henderson, S., Barnett, A., Watson, P., & Holland, A. J. (2012). Atypical movement performance and sensory integration in Asperger’s syndrome. Journal of Autism and Developmental Disorders, 42, 718–725. Smith, I. M., & Bryson, S. E. (2007). Gesture imitation in autism: II. Symbolic gestures and pantomimed object use. Cognitive Neuropsychology, 24, 679–700.
Conclusion This article briefly reviewed the current literature on dyspraxia in ASDs and some of the literature that explores how sensory and motor differences in ASDs impact one’s ability to make sense of the world. ASI addresses the sensory and praxis deficits of ASDs in a manner that is mindful of the person’s experience and acknowledges the impact of sensory integration and praxis on participation. It is important to embed the understanding of sensory perceptual deficits contributing to praxis and dyspraxia in ASDs as a routine part of occupational therapy assessment and intervention. Occupational therapists working with people with ASDs are encouraged to include observations and measures of proprioceptive, tactile, and vestibular functions that support praxis, as well as observations and measures of praxis including those that assess ideation, imitation, construction, and sequencing. In this way, occupational therapy practitioners working with individuals with an ASD better understand the contributions to planning, organization, and social skills, and can design interventions that effectively address the barriers to performance. Further research is needed to understand the way in which sensory integration and praxis affects participation in individuals with and without an ASD. ●
References Ayres, A. J. (1972). Sensory integration and learning disorders. Los Angeles: Western Psychological Services. Ayres, A. J. (1989). Sensory Integration and Praxis Tests (SIPT). Los Angeles: Western Psychological Services. Ayres, A. J. (2005). Sensory integration and the child: Understanding hidden sensory challenges (25th aniversary edition). Los Angeles: Western Psychological Services. Ayres, A. J., & Cermak, S. (2011). Ayres dyspraxia monograph (25th anniversary edition). Torrance, CA: Pediatric Therapy Network. Ayres, A. J., & Henderson, A. (1974). The development of sensory integrative theory and practice: A collection of the works of A. Jean Ayres. Dubuque, IA: Kendall/ Hunt. Bauman, M. (2005). Appendix A: Chapter commentaries. The child with autism. In A. J. Ayres (Ed.), Sensory integration and the child (p. 180). Los Angeles: Western Psychological Services. Bundy, A. C., Lane, S. J., & Murray, E. A. (2002). Sensory integration: Theory and practice (2nd ed.). F. A. Davis: Philadelphia. Dawson, G., & Adams, A. (1984). Imitation and social responsiveness in autistic children. Journal of Abnormal Child Psychology, 12, 209–226. De Jaegher, H. (2013). Embodiment and sense-making in autism. Frontiers in Integrative Neuroscience, 7, 15. Donnellan, A. M., Hill, D. A., & Leary, M. R. (2013). Rethinking autism: Implications of sensory and movement differences for understanding and support. Frontiers in Integrative Neuroscience, 6, 124. Dowell, L. R., Mahone, E. M., & Mostofsky, S. H. (2009). Associations of postural knowledge and basic motor skill with dyspraxia in autism: Implication for abnormalities in distributed connectivity and motor learning. Neuropsychology, 23, 563–570. Dziuk, M. A., Larson, J. C. G., Apostu, A., Mahone, E. M., Denckla, M. B., & Mostofsky, S. H. (2007). Dyspraxia in autism: Association with motor, social, and communicative deficits. Developmental Medicine and Child Neurology, 49, 734–739. Iwanaga, R., Honda, S., Nakane, H., Tanaka, K., Toeda, H., & Tanaka, G. (2014). Pilot study: Efficacy of sensory integration therapy for Japanese children with high functioning autism spectrum disorder. Occupational Therapy International, 21, 4–11.
Judith Abelenda, MS, OTR, is the owner of Uutchi Desarrollo Infantil in Vitoria-Gasteiz, Spain;
[email protected]. Zoe Mailloux, OTR/L, OTD, FAOTA, is the Adjunct Associate Professor for the Department of Occupational Therapy at Jefferson School of Health Professions, Thomas Jefferson University, Philadelphia, PA 19107. Susanne Smith Roley, OTD, OTR/L, FAOTA, is the owner of Susanne M. Smith, Inc. in Irvine, CA. Abelenda, J., Mailloux, Z., & Smith Roley, S. (2015, September). Dyspraxia in autism spectrum disorders: Evidence and implications. Sensory Integration Special Interest Section Quarterly, 38(3), 1–4.
Evidence for Using Yoga Interested in learning how sensory-enhanced yoga can affect the symptoms of combat stress in deployed military personnel? Based on a peer-reviewed article, the Critically Appraised Paper (CAP) at http:// goo.gl/5YxlqX provides an at-a-glance summary of how using a hatha yoga program that incorporates sensory strategies such as proprioceptive input, slow rhythmical movements, and deep touch pressure was shown to reduce anxiety and improve occupational performance in veterans experiencing combat stress. For other CAPs and information on opportunities to submit or serve as a reviewer for a CAP, visit http://www.aota.org/Practice/Researchers/Evidence-Exchange.aspx
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A team of researchers is looking for parents and caregivers of children between the ages of 3 and 5 diagnosed with an Autism Spectrum Disorder (ASD) who would be willing to test out an online assessment tool. The purpose of the tool is to help parents evaluate the impact of the sensory environment on participation in common daily activities of their child with an ASD. Participation involves about 30 minutes to complete an online assessment and provide feedback on the experience. All parent participants will be entered into a raffle for an iPad mini as a thank you. If you know any families that are interested in participating, they can complete the online assessment and feedback form at:
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Use clinical reasoning, analyze items, and choose tips
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Generate customized Intervention Reports Record data using the Quick Tips Record Form Email
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