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Wednesday, March 22, 2017

Introduction to - From Flapping to Function: A Parent's Guide to Autism and Hand Skills

When I hear the word autism the image that pops into my mind is 4-year-old Gary. He is lining up cars, end to end, while children around him make their cars roll, beep, and drive over paper roads. Gary doesn’t seem to notice what they are doing, even as he crawls over another child’s leg to reach the bucket of toys.
Gary glances at a toy just long enough to reach for it before looking away. He sits with his knees bent and feet outside his hips, in a position called W- sitting because his legs form a “W” shape (see photograph 1). While picking up cars with his left hand Gary shifts his weight to his right side. His wrist is loose and floppy. He grasps the cars with his fingertips, as though they were slimy fish he was keeping from touching his palms. When another child jostles the perfectly aligned cars, Gary grunts and, without missing a beat, adjusts them. Then he stands up and flaps his hands while walking around in circles.

(photograph 1 Boy playing in W-sitting position)

You may have imagined a similar child—a child who does not play with toys the way most children do (or spends more time flapping hands than using them to play). A multidisciplinary team observing Gary would all contribute important findings. An occupational therapist (OT) would note that although his eye-hand coordination seems fairly normal, Gary does not look directly at objects, he avoids using his palms when grasping and seems unaware when his body moves into a space occupied by another child, signs of a sensory processing disorder (SPD). A physical therapist (PT) would note hypotonia (low muscle tone) and poor postural control, meaning his muscles seem weak and floppy and he leans on his hands to help hold himself up. A speech-language pathologist (SLP) would note his lack of social awareness—he doesn’t even protest when another child bumps his cars. He doesn’t use toys functionally or vocalize while playing, the way the other children are making their pretend cars drive and crash while saying “beep, beep.” Gary’s lack of eye contact with other children and the way he repetitively lines up his cars would draw a child psychologist’s attention. Gary’s preschool teacher would be concerned that he cannot name the colors of the cars or engage in pretend play, such as forming an imaginary steering wheel with his hands and pretending to drive.

As the team discusses their observations, the picture of Gary that emerges is typical of children on the autism spectrum. The way he grasps, manipulates, and uses the cars while ignoring his peers demonstrates difficulties with

·        Postural control: his body and hands seem to be floppy and weak.

·        Visual skills: he avoids looking directly at the objects in his hands.

·        Play skills: he lines up the cars rather than using them in pretend play.

·        Communication and social skills: he does not imitate other children or share the play experience with them.

·        Sensory processing: he has difficulty interpreting and responding to touch and other stimuli.

Challenges in all of these developmental areas contribute to Gary’s difficulty using his hands, which is my particular interest as an occupational therapist. This book explains how atypical development affects the way children with an autism spectrum disorder (ASD) use their hands. It also offers intervention strategies aimed at helping children to experience success and be as independent as possible in performing everyday tasks such as dressing, cutting paper, or writing their names.  In chapter I you will be introduced to how children use their vision, think, process sensory information and behave influence hand skill development and learning in general. 

The technical term for hand skills is fine-motor skills, because grasping and manipulating objects uses the small, or “fine,” muscles of the hands in delicate movements. Traditional examples of fine motor skills would be stringing small beads or stacking blocks. Effective hand use, however, requires much more than good motor control. In this book I take a comprehensive look at how children diagnosed with ASD typically use their hands, what challenges they face, and what strategies will help them reach their potential. I stress “reach their potential,” because there is currently no cure for autism or its associated challenges. There are, however, many effective and fun strategies that parents can implement.  

Who This Book Is For

I wrote this book first and foremost for parents. When I worked in early intervention and Head Start programs I saw how family education enabled caregivers to carry over OT strategies throughout the young child’s day and night, seven days a week, whether at home, in the community, or on vacation. Many of these strategies are easily integrated into everyday routines and continue to be useful as the young child grows to adulthood.
As an example, four-year-old Abdul preferred to line up objects rather than drop them into a container with a small opening. Inserting objects is an early skill that develops the eye-hand coordination to use shape sorters and push coins into a piggy bank. Abdul was motivated to insert magnets into the can shown in photograph 2 when an electric toothbrush was placed inside.
Caution: Use larger objects if there is a choking risk. Magnets are dangerous if swallowed.

photo 2 Vibrating container adaptation

The toothbrush created vibration and motor sounds that interested Abdul and made him want to hold the container. He had to use both hands together-an important skill that will be discussed later, in order to separate the magnets. Pulling magnets apart is an enticing activity by itself, but inserting them into a vibrating container is irresistible. This is one of my oh-so-simple, yet oh-so-effective strategies to help children to build hand skills. 
This activity is also suitable for older children or adults who are developmentally ready to learn insertion skills. Many of the strategies described in this book can help individuals with cognitive and/or motor delays to develop hand skills typically mastered at a younger age. However, it is important that the materials be age appropriate and the person have the prerequisite skills to learn them. For example, six-year-old Bonnie refused to touch gooey substances such as paint or glue and she had difficulty learning how to form letters. Her mother filled a sturdy zip locked bag with paint, and Bonnie imitated her mother using her index finger to  form lines and shapes by pressing. Bonnie had the prerequisite skills to use her index finger as a writing tool, visually attend and imitate the movements. Bonnie liked this activity because she didn’t have to struggle with controlling a pencil, it was fun to feel the paint move through the plastic and she felt like an artist. 
This adaptation is just one of many strategies provided that may be beneficial to children with or without an autism diagnosis. Many strategies may also help very young children who do  not yet have a diagnosis but perhaps the parents sense that they should be concerned.   Although children with ASD are typically not diagnosed until toddlerhood or older, some parents may notice developmental differences in their babies. Therefore, I include red flags and strategies relevant to babies. These may be especially important if the baby has older siblings diagnosed with ASD. If the descriptions in this book “resonate” with your child, speak to your pediatrician or local child development center to get further information specific to your child’s needs. 
Much of the current literature on autism focuses on the social, communication and behavioral aspects of the disorder. I have written From Flapping to Function: A Parent’s Guide to Autism and Hand Skills for the early childhood professionals, educators, counselors, therapists, and other professionals working in school, residential, community, or institutional settings who seek a comprehensive, one-stop resource that focuses on how developmental challenges impact building hand skills and the strategies that will enable children to reach their potential.