BRIEF REPORT Proprioceptive Processing Difficulties Among Children With Autism Spectrum Disorders and Developmental Disabilities Erna Imperatore Blanche, Gustavo Reinoso, Megan C. Chang, Stefanie Bodison KEY WORDS autistic disorder developmental disabilities feedback, sensory proprioception somatosensory disorders OBJECTIVE. Sensory processing difficulties among children with autism spectrum disorders (ASD) have been extensively documented. However, less is known about this population’s ability to process proprioceptive information. METHOD.
We used the Comprehensive Observations of Proprioception (COP; Blanche, Bodison, Chang, & Reinoso, in press) to describe the proprioceptive difficulties experienced by children with ASD. A sample of 32 children with ASD, 26 children with developmental disabilities excluding ASD, and 28 typically developing control children were studied using the COP. RESULTS. Children with ASD present with proprioceptive processing difficulties that are different from those of children with developmental disabilities and their typically developing counterparts. Specific data, potential clinical applications, and directions for future research are described. CONCLUSION.
Results suggest that the COP has useful clinical research applications. Further assessment of psychometric properties, clinical utility, and meaningful differences among diverse clinical populations are needed. Blanche, E. I., Reinoso, G., Chang, M. C., & Bodison, S.(2012). Brief Report—Proprioceptive processing difficulties among children with autism spectrum disorders and developmental disabilities. American Journal of Occupational Therapy, 66, 621–624.
http://dx.doi.org/10.5014/ajot.2012.004234 Erna Imperatore Blanche, PhD, OTR/L, FAOTA, is Associate Professor of Clinical Practice, Division of Occupational Science and Occupational Therapy, 1540 Alcazar, CHP-133, University of Southern California, Los Angeles, CA 90089; firstname.lastname@example.org Gustavo Reinoso, PhD, OTR/L, is Director, Advance Therapy Systems, Dundalk, County Louth, Ireland. Megan C. Chang, PhD, OTR/L, is Assistant Professor, Department of Occupational Therapy, San Jose´ State University, San Jose´, CA. Stefanie Bodison, OTD, OTR/L, is Postdoctoral Fellow, Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles.
Sensory processing difficulties among children with autism spectrum disorders (ASD) have been extensively documented (Baranek, David, Poe, Stone, & Watson, 2006; Baranek, Foster, & Berkson, 1997; Ben-Sasson et al., 2009; Jones, Quigney, & Huws, 2003; Leekam, Nieto, Libby, Wing, & Gould, 2007). Less frequently described are the proprioceptive difficulties of this population. Although reports have been emerging (Glazebrook, Gonzalez, Hansen, & Elliott, 2009; Haswell, Izawa, Dowell, Mostofsky, & Shadmehr, 2009; Mukhopadhyay, 2003; Weimer, Schatz, Lincoln, Ballantyne, & Trauner, 2001), the evidence is mixed. Proprioception, defined as the sum of neuronal inputs from the joint capsules, ligaments, muscles, tendons, and skin, is a multifaceted system that affects motor control and is hypothesized to have an impact on behavior regulation (Ayres, 1972, 1989; Blanche & Schaaf, 2001; Dunn, 1999, 2001; Mukhopadhyay, 2003) and motor control (Ayres, 1972, 1989; Lephart & Fu, 2000).
Although some proprioceptive difficulties are identifiable in clinical practice through observation, clinicians lack a systematic, comprehensive tool that measures more than one aspect of proprioception in children with ASD. Most of the difficulties in proprioceptive processing are reported in parent questionnaires (Dunn, 1999; Parham & Ecker, 2007) and standardized tests such as the Kinesthesia and Standing/ Walking Balance subtests of the Sensory Integration and Praxis Tests (Ayres, 1989). In this study, we compared the performance of children with ASD with that of children with developmental disabilities (DD) and with matched control children on the Comprehensive Observations of Proprioception (COP; Blanche, Bodison, Chang, & Reinoso, in press), a scale that measures proprioceptive processing by direct observation.
The COP comprises 18 items focusing on motor and behavior regulation aspects of proprioceptive processing among children. The COP has demonstrated psychometric properties including adequate validity and reliability for clinical use and research, which are described elsewhere (Blanche et al., in press). In this study, we used only 16 items; 2 items were eliminated from the analysis because of incomplete scores in the data set. The COP items used were as follows: decreased muscle tone; joint hypermobility; poor joint alignment and cocontraction; inefficient ankle strategies; inadequate weight-bearing and weightshifting patterns; decreased postural control; decreased feedback-related motor planning abilities; decreased feedforward– related motor planning abilities; inefficient grading of force; tiptoeing; pushing others or objects; enjoyment when being pulled; tendency to lean on others; overactive; overpassive; and crashing, falling, running.
The COP guides clinicians’ observations and helps them identify adequate performance (i.e., muscle tone, joint alignment) and deviation from typical parameters (i.e., decreased muscle tone, decreased joint alignment) using specifically and operationally defined criteria. The measure requires the clinician to observe the child during the usual developmental assessment (i.e., gross motor testing, clinical observations, free play) to rate the aforementioned items. If additional activities are required to collect the necessary information, they are completed subsequently. Our purpose in this study was to evaluate comprehensively proprioceptive processing difficulties among children with ASD using an observation-based, psychometrically sound assessment (COP) and to elucidate the unique nature of these difficulties. Method We used a retrospective group-comparison design.
The participants included 32 children diagnosed with ASD and without any additional motor difficulties (mean age 5 6.3, standard deviation [SD] 5 1.3, range 5 3–10 yr); 26 participants with DD excluding ASD (mean age 5 6.8, SD 5 1.9, range 5 3–10 yr) who were referred to an occupational therapy clinic, with DD diagnosed by the referring professional (children with cerebral palsy or ASD were not included in the sample with DD); and 28 age-matched control participants without known proprioceptive difficulties or DD (mean age 5 6.7, SD 5 1.8, range 5 4–10 yr).
The participants with ASD were diagnosed clinically by a pediatric neurologist or clinical psychologist using Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000) criteria and parent and teacher reports. De-identified data were collected from a chart review at two occupational therapy clinics by means of the COP, following a protocol with institutional review board approval described in detail in the original study (Blanche et al., in press). The de-identified data of the typically developing matched control children were collected in a natural setting. Results We used analysis of variance for the threegroup comparison and applied a post hoc analysis with Tukey–Kramer method for pairwise comparison (Kramer, 1956). Tukey–Kramer is used because it is a conservative method recommended for use in situations of unequal sample size (Dunnett, 1980).
Significance level was set at p < .05. The results shown in Table 1 indicate that the three groups were significantly different on allCOPindividualitems, on the total scorefor the COP scale, and on the four factors. Post hoc analysis with Tukey–Kramer’s adjustment indicate that the ASD and DD groups were not significantly different except on four items: feedback-related motor planning; tiptoeing; pushing others or objects; and crashing, falling, and running. The ASD and DD groups were also not significantly different on Factor 1 (decreased tone and joint alignment) and Factor 3 (decreased postural control and grading of force). Discussion This study’s results suggest that children with ASD present with distinct patterns of proprioceptive processing difficulties on four items measured by the COP, when compared with typically developing children and children with DD.
These difficulties include difficulty with feedback-related motor planning skills; tiptoeing; pushing others or objects; and crashing, falling, and running. Our findings suggest that proprioceptive difficulties among children with ASD may contribute to decreased motor planning and postural control and to disruptive behaviors that negatively affect their participation in daily tasks. Our findings add to the varied literature on proprioceptive processing in ASD. Fuentes, Mostofsky, and Bastian (2011) and Weimer et al. (2001) did not find proprioceptive differences in their cohorts of participants with ASD. However, their studies focused on isolated aspects of proprioception, such as the perception of joint position or balance and visuomotor functions. Conversely, Grob, Kuster, Higgins, Lloyd, and Yata (2002) did find proprioceptive processing difficulties.
Additional studies may also seek to determine whether patterns of scores on the COP are different when other variables such as IQ or chronological age are controlled. The COP is a useful clinical tool for measuring the proprioceptive difficulties presented by children with ASD and may aid clinicians in planning further assessment and observations as well as incorporating intervention strategies in different settings. Implications for Occupational Therapy Practice The results of this study have the following implications for occupational therapy practice: • The COP is a useful clinical tool for identifying proprioceptive difficulties in children with ASD. • The COP can help clinicians plan intervention strategies for children with ASD. s Acknowledgment We thank the staff at Therapy West, Inc., Los Angeles. References American Psychiatric Association. (2000).
Diagnostic and statistical manual of mental disorders (4th ed., text rev.).Washington, DC: Author. Ayres, A. J. (1972). Sensory integration and learning disorders. Los Angeles: Western Psychological Services. Ayres, A. J. (1989). Sensory Integration and Praxis Tests. Los Angeles: Western Psychological Services. Baranek, G. T., David, F. J., Poe, M. D., Stone, W. L., & Watson, L. R. (2006). Sensory Experiences Questionnaire: Discriminating sensory features in young children with autism, developmental delays, and typical development. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 47, 591–601. http://dx.doi.org/ 10.1111/j.1469-7610.2005.01546.x Baranek, G. T., Foster, L. G., & Berkson, G. (1997). Tactile defensiveness and stereotyped behaviors. American Journal of Occupational Therapy, 51, 91–95. http:// dx.doi.org/10.5014/ajot.51.2.91 Ben-Sasson, A., Hen, L., Fluss, R., Cermak, S. A., Engel-Yeger, B., & Gal, E. (2009).
A meta-analysis of sensory modulation symptoms in individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 39, 1–11. http://dx. doi.org/10.1007/s10803-008-0593-3 Blanche, E. I., Bodison, S., Chang, M., & Reinoso, G. (in press). Development of the Comprehensive Observations of Proprioception: Validity, reliability and factor analysis. American Journal of Occupational Therapy. Blanche, E. I., & Schaaf, R. C. (2001). Proprioception: A cornerstone of sensory integration intervention. In S. S. Roley, E. I. Table 1. Analysis of Variance for the Three-Group Comparison and Post Hoc Analysis With Tukey–Kramer’s Adjustment for Pairwise Comparisons Mean (SD) Post Hoc Comparison With Tukey–Kramer’s Adjustment Measure ASD (n 5 32) DD (n 5 26) TYP (n 5 28) ANOVA ASD–DD ASD–TYP DD–TYP Decreased muscle tone 2.5 (0.8) 2.1 (1.0) 1.2 (0.4) * * * Joint hypermobility 2.2 (0.9) 2.4 (1.2) 1.0 (0.2) * * * Poor joint alignment and cocontraction 2.8 (1.0) 2.5 (1.0) 1.0 (0.2) * * * Inefficient ankle strategies 2.8 (1.0) 2.6 (0.9) 1.0 (0.2) * * * Inadequate weight-bearing and weight-shifting patterns 2.9 (1.1) 2.4 (0.9) 1.0 (0.2) * * * Decreased postural control 2.6 (1.0) 2.2 (1.1) 1.1 (0.3) * * * Decreased feedback-related motor planning abilities 2.6 (0.8) 1.9 (0.9) 1.0 (0.2) * * * * Decreased feedforward-related motor planning abilities 3.4 (1.3) 3.0 (0.8) 1.0 (0.0) * * * Inefficient grading of force 3.0 (1.1) 2.8 (0.8) 1.0 (0.2) * * * Tiptoeing 2.0 (1.2) 1.1 (0.3) 1.0 (0.0) * * * Pushing others or objects 2.7 (1.3) 1.9 (1.0) 1.1 (0.3) * * * * Enjoyment when being pulled 3.0 (1.2) 3.2 (0.9) 1.1 (0.3) * * * Tendency to lean on others 3.3 (1.1) 2.8 (1.1) 1.1 (0.3) * * * Overactive 3.0 (1.4) 2.8 (1.3) 1.2 (0.4) * * * Overpassive 2.3 (1.3) 1.8 (0.9) 1.2 (0.4) * * * Crashing, falling, running 3.4 (1.0) 2.7 (1.3) 1.1 (0.3) * * * * COP total scores 44.3 (10.5) 37.9 (9.5) 17.2 (1.9) * * * * Factor 1, Tone and Joint Alignment 7.5 (2.4) 7.0 (2.9) 3.3 (0.5) * * * Factor 2, Behavior Manifestation 14.0 (4.0) 11.7 (3.6) 5.5 (0.9) * * * * Factor 3, Postural Motor 14.6 (4.1) 12.6 (4.0) 5.3 (0.9) * * Factor 4, Motor Planning 8.2 (2.6) 6.7 (1.9) 3.2 (0.5) * * * * Note. Blank cells indicate that the comparison was nonsignificant. ANOVA 5 analysis of variance; ASD 5 autism spectrum disorder; COP 5 Comprehensive Observations of Proprioception Scale; DD 5 developmental disability without ASD; SD 5 standard deviation; TYP 5 typically developing children.