EVALUATING AND TREATING BALANCE IMPAIRMENTS IN STUDENTS WITH AUTISM SPECTRUM DISORDERSusan Ronan PT, DPT, PCS

New York Medical College

THANK YOU

Mary Paolillo PT

Giant Steps

Devereux Millwood Learning Center

Nicholas Manente PT, DPT

Lauren Perillo PT, DPT

Jovan Ramirez PT, DPT

Nicole Robell PT, DPT

Nicole Sproviero PT, DPT

Ellen Morello PT, DPT

Sara Butler PT, DPT

Carolyn Kirkup PT, DPT

DISCLOSURE

Financial: Susan Ronan receives an honorarium from Education Resources.

Non-financial: She has no relevant non-financial relationships to disclose.

Objectives

Compare the neurological differences between children with autism and those with typical development.

Apply the evidence for gross motor dysfunction to the clinical presentation of children with autism.

Identify interventions for children with autism based on the science and evidence.

TOPICS

Diagnosis

Systems Review

Neurological Evidence

Clinical Presentation

Intervention Evidence

Nutrition

What do I do tomorrow?

Conclusion

AUTISM

ASD?

TEMPLE GRANDIN

“I can remember the frustration of not being able to talk. I knew what I wanted to say, but I could not get the words out, so I would just scream.”

“A treatment method or an educational method that will work for one child may not work for another child. The one common denominator for all of the young children is that early intervention does work, and it seems to improve the prognosis.”

ASD: PREVALENCE1

Incidence: 1: 88

Boys: Girls::4:1 (1 in 54 boys)

Prevalence: 1% in Asia, Europe, and

North America "Increased Prevalence?” Increased awareness

Earlier diagnosis

Changes in diagnostic practice (screening)

ETIOLOGY

Unknown

Theories:

“Refrigerator Mother” 1970s

Infectious

Immunological deficiency

Environmental toxins

Gastric Inflammatory Disease

Genetic- multiple genetic factors

Sperm (older fathers)

AUTISM AND ASD

AUTISM 2

“A developmental disorder that appears by age three and that is variable in expression but is recognized and diagnosed by impairment of the ability to form normal social relationships, by impairment of the ability to communicate with others, and by stereotyped behavior patterns especially as exhibited by a preoccupation with repetitive activities of restricted focus rather than with flexible and imaginative ones.”

DIAGNOSIS3

Diagnostic and Statistical manual of Mental Disorders (V) (2013)

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (V)3

(A) Persistent deficits in social communication and social interaction across multiple contexts.

Including:

social-emotional reciprocity.

nonverbal communicative behaviors used for social interaction.

developing, maintaining, and understanding relationships.

DSM (V)

(B) RESTRICTED, REPETITIVE PATTERNS OF BEHAVIOR, INTERESTS, OR ACTIVITIES.

Stereotyped or repetitive motor movements, use of objects, or speech

Inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior

Highly restricted, fixated interests that are abnormal in intensity or focus interest).

Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment

DSM (V)3

C. Symptoms must be present in the early developmental period

D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.

Questions

What are the main areas of impairment in the diagnosis of Autism?

EARLY DETECTIONWhen is the earliest time to detect autism?

WHEN CAN A DIAGNOSIS BE MADE?

“By 3 yrs.”

“As early as 18 mos.”

“12 mos.?”

“Earlier?”

PEDIATRICIANS

Pediatrician 82% routinely screening for general developmental delays, but only 8% screened for ASD.

Why? Insufficient time.

Lack of familiarity with screening tools

Reliance on referral to specialists.6

PARENTS

Early detection/ suspicion

Notice with peer interaction opportunities: Birthday part/ family event/ Play date

Medical professionals may disregard parental observations

Early detection/ suspicion

Notice with peer interaction opportunities: Birthday part/ family event/ Play date

Medical professionals may disregard parental observations

PRESENTATION

Social

Communication

Repetitive Behaviors/ play

Others

Sz (25- 33%)

Sensory- heightened sensory (smell/ taste?)

MR

PRESENTATION

Sleep difficulties

Self Injurious Behavior

Special Skills (Savant skills)

INDICATIONS7

Poor eye contact

Doesn't seem to know how to play with toys

Excessively lines up toys or other objects

Is attached to one particular toy or object

Doesn't smile

At times seems to be hearing impaired

BY 12 MOS.:

Red Flags: 10

Failure to orient to name

Lack of nonverbal showing

Lack of eye contact

Lack of initiative/ hypoactivity

Lack of emotional regulation

Poor social interaction

Orienting, smiling and vocalizing to objects.

Absolute Concern: 10

No babbling

No pointing/gesturing

Any loss of language

Any loss of social skills

SCREENING TOOLS

M-CHAT (toddlers)

Gilliam Autism Rating Scale 2 (GARS-2)

Autism Diagnostic Interview-Revised (ADI-R)

Autism Diagnostic Observation Schedule-Generic (ADOS)

Vineland Scale of Adaptive Behavior

EARLIER?

Dyadic interactions/ imitation

Emotional discrimination

Development of attachment11

Early asymmetry?12, 13

No early patterns identified14

Questions

Regarding the diagnosis of ASD

What would a parent report?

What would a teacher report?

ADDITIONAL CONSIDERATIONS

GI ISSUES

Constipation and Diarrhea, Chronic Abdominal pain15

Dysbiosis: Abnormal gastric flora

Abnormal gram-negative bacteria

Leaky Gut: increased intestinal permeability

Food Sensitivities/ Allergies15

Higher antigen specific antibodies for food proteins (IgA, IgG, IgM)

Glutens, Casein- may pass through the “leaky gut” and have neurological effects.

NUTRITIONAL DEFICIENCIES15

Omega -3 Fatty acids- lower in children with autism

Metabolism?

AUTOIMMUNITY15

Evidence for autoimmune antibodies

Cortex

Caudate nucleus (learning/ memory)

Cerebellum

Thalamic/ Hypothalamic

METABOLIC15

Impaired methylation

Increased oxidative stress

Lower antioxidants

Higher organic toxins/ heavy metals

Higher production of nitric acid (free radical)

HEAVY METAL TOXICITY15

Mercury

Thimerisol (Immunizations)

Do children with autism have an impairment in the ability to excrete mercury?

Not proved

Balance: NEUROLOGICAL EVIDENCE

NEUROANATOMICAL DIFFERENCES

Macrocephaly (first 2 years of life)

Enlarged

Frontal lobes

Amygdala (emotional learning, memory)

Cerebellar white matter

Underdevelopment

Cerebellar vermis (vestibular/ proprioception)

ASD: 3 PATHWAYS

Primary: frontal dysfunction

Second: brainstem dysfunction.

Tertiary: cerebellar dysfunction.

NEUROCHEMICAL

Alterations in16

Serotonergic (feelings of wellbeing)

Glutamatergic (cellular metabolism)

Cholinergic (PSN, SNS, Forebrain, Brainstem)

Gabaergic (inhibitory neurotransmitter)

Stress response

VISUAL SYSTEM

Normal retinal organization18

Visual Hyperacuity19*

Hypermetriopia (images reach the retina before focusing on the lens) 19

Astigmatism19

Strabismus/ optic disc Pallor19

Impaired oculomotor function19Difficulty with focusing on moving targets

Difficulty with skill acquisition

Communication

Social interaction

HYPERACUITY19

Individuals see all objects in the visual field with sharp resolution, making it difficult to focus on one.

Use of peripheral vision helps with selective attention to a visual target.

Head turn

HYPERACUSIS19

Decreased stapedial reflex

Results in:

Avoiding sounds

Covering ears

BASAL GANGLIA

? Dysfunction with Frontostriatal Basal Ganglia pathway

Results:

Saccadic dysfunction

Poor feed forward

SPECULATED LOSS OF PURKINJE CELLS

Purkinje Cells: Cortex of cerebellum

Control movement

GABA

Inhibitory- A decrease would decrease inhibition of the nerves

VESTIBULAR17

Semicircular canal deficits

Integration deficit between

Visual

Somatosensory

Vestibular system

Motor Planning20

Simple motor planning may be intact

Visual feedback, or external guidance is diminished

Difficulty with integration of visual and vestibular system

Decreases

Motor performance

Postural stability

Lack of effective sequencing

Question

What are the main motor impairments you have noticed in children with ASD?

CLINICAL PRESENTATION

POSSIBLE CLINICAL FINDINGS21

Low proximal tone

Delayed/ Poor postural reflexes

Poor integration of reflexes

Gross motor delays

Limited repertoire of play

Fine motor delays

Speech delays

POSSIBLE CLINICAL FINDINGS

Asymmetries

Difficulty crossing midline

Difficulty with visual tracking

Reliance on peripheral vision (Head posture?)

Difficulty with feed forward tasks (catching, kicking moving ball) Avoiding gaze

Echolalia

Movement Disorder

Dyspraxia

APRAXIA/ DYSPRAXIA21

Rinehart (2001): Children with autism ages 5- 19 yrs.: 22

Intact movement execution but atypical movement preparation.

Lack of anticipation

Related to motivation, and or attention?

Children with Asperger’s disorder:

Slower preparation (fronto striatal)

Oral:

Drooling

Open mouth at rest

Inability to pucker lips

Limb

Pen grasp, puzzle piece placement

ERRORS IN IMITATION23

Not related to memory or representing an action

Deficient activation of the mirror neuron cells

Deficit in mimicry

Visual attention- less attention to salient aspects of human interaction.

Difficulties perceiving biological motion.

STRENGTHS

Visual spatial perception

Better on tasks requiring acute visual perception

Visual search

SENSORY DYSFUNCTION24

Elevated sensory awareness.

Heightened sense of smell/ taste.

Gross Motor: 2 Theories25

Automatization Deficit Hypothesis:

Deficits in cerebellar function causes impairments skill learning/ and gaining automatic skills leading to poor motor and poor attention. (Visser 2003)

Disorder-Specific learning Theory:

Children who cannot cope with balance “threatening situations” (issues with motor learning and cerebellar function) develop anxiety. (Erez 2004)

Less Self Perceived Ability of Motor Performance?26

Deficits in:

Body Schema

Time/ Space awareness

Estimate Distance

Fear of intimate contact

Children with autism may view themselves as less capable than other children to perform gross motor tasks.

TYPICAL VESTIBULAR DEVELOPMENT27

Broad range of normal for children

Anatomically and functional at birth

VOR present in neonates and matures for the first 2 yrs of life.

Pursuit/ Optokinetic: 3-6 mos of age.

Same as an adult by 3-6 yrs of age.

VESTIBULAR SYSTEM28

Children with high functioning autism- normal post rotatory nystagmus in upright and with head tilt.

VESTIBULAR29

Vestibular processing is different for children with autism.

MOTOR STEREOTYPIES AND BALANCE

Suggestions that children with more severe motor stereotypies have worse balance.

Tested statically

? Dynamically

Radnovich KJ, Fournier KA, Hass CJ. (2013) Relationship between postural control and restricted, repetitive behaviors in autism spectrum disorders. Frontiers in Integrative Neuroscience. May, 7(28) pp 1-7.

BALANCE

Abnormal Proprioception.30,17

More difficulty with balance with eyes closed.17

Reliance on visual cues to reduce sway and maintain balance.17

Poor integration of visual, vestibular and somatosensory input for balance.17

GAIT

“Gait in children with autism: consistent with Cerebellar ataxia, difficulty walking on a line, variability in stride length and velocity, postural abnormalities in the head, trunk involvement in the fronto-striatial basal ganglia circuit.”31

GAIT CONTINUED

Increased stride length variability

No improvements with external cues (visual markers)

? Difficulty using environmental cues to modify movement once in action

Arm and head/ trunk posture asymmetries

TOE WALKING21

? Maybe

Related to: proprioception, kinesthesia, weight line shifted anterior in ambulation, difficulty with moving backward/ posterior in space.

INTERVENTION EVIDENCE

Supply and Demand of State EI programs (Respondents: 47 states, 4 territories)32

Services most used by children with ASD

Speech, OT

ABA

Psych/ Special Education

PT? not mentioned in study

Recommended Services: 25 or more services hrs./ week (National Research Council)

State EI: providing 5 hrs. (more than 1/ 2 states, with 4 statesproviding 20 hrs./ week)

Conclusion: EI does not have the resources for the increased demand

THE SEARCH

Physical Therapy, Physiotherapy, Gross Motor Skill, Gait, Balance, Vestibular System, SI, Autism, ASD, Asperger's, PDD, Motor Milestones, Developmental Reflexes, Gross Motor Function, Posture, Skill Acquisition.

SCOPUS, PEDro, CINAHL, OVID, Psych Info, PubMed, Specific Journals

Issues with Evidence- just to start

Lack of RCT

Small Sample sizes

Anecdotal

Non systematic

Did not quantify

Use of parental surveys

Use of child surveys

Heterogeneous population

Huge variety in function

Concurrent therapies/ treatments/ medications

Sackett’s Levels of Evidence33

1A = Systematic Review of Randomized

Controlled Trials (RCTs)

1B = RCTs with Narrow Confidence Interval

1C = All or None Case Series

2A = Systematic Review Cohort Studies

2B = Cohort Study/Low Quality RCT

2C = Outcomes Research

3A = Systematic Review of Case-Controlled

Studies

3B = Case-controlled Study

4 = Case Series, Poor Cohort Case Controlled

5 = Expert Opinion

Sensory Integration

Auditory Integration Training (AIT)

NDT

Vestibular Therapy

Brain Gym

Floor Time

Craniosacral

Greenspan

Brushing

Aquatic Therapy

“Traditional Therapy”

Massage

Interventions for Gross Motor Skills; WHERE IS THE EVIDENCE?

Sensory Integration

Most commonly used approach for individuals with autism34

Dr. Jean Ayres: Focus on processing of sensory information and the skill attainment. Hierarchical structure to development

Child centered approach

Just right challenge

Focus: Modulation

Integration

Sensory Integration:35

Meta Analysis

SI is as good as other therapies

May effect psychoeducational and motor skills

Ayers 1980:

Outcomes better for those with hyper sensory issues

Problems with literature:

Small sample size

Hard to differentiate effect of SI vs. other interventions

Characteristics of subjects heterogeneous and highly variable

Systematic approach

Anecdotal

Auditory Integration Training

Using headphones with music selected for different frequencies to improve attention, reticular activating and cerebellar performance.

Evidence:

Mixed findings

Weighted Vests36

Lack of well constructed studies

Treadmill training37

Article: Pitetti K, et al (2007) The Efficacy of a 9-Month Treadmill Walking Program on the Exercise Capacity and Weight Reduction for Adolescents with Severe Autism. Journal of Autism & Developmental Disorders, Jul, Vol. 37 Issue 6, p997-1006

Decreased BMI

Increased Exercise Capacity

Increased ability to walk on TM at a faster speed

AQUATIC THERAPY38

Benefits for children with Autism

Improved strength/ balance

Increased social participation

Vestibular stimulation

No studies

Massage

Calming effect

Improved responsiveness

Improved communication

Massage: Improves behavior/?Self regulation

Grandin’s Hug Machine

Decreased anxiety

Problems with literature:

Small sample size

NUTRITION: Socialization and language

NUTRITION15

Gluten/ Casein free diet (avoid for 60 days)

Changes in GI

Language

Socialization

SUPPLEMENTS15

Omega-3 Fatty Acids Improvements in reading

Probiotics Temporary results in GI (need more info)

Zinc ? Need more studies

Vitamin B6- ?

Multivitamin-?

OTHER INTERVENTIONS

Medications

Devices/ Orthotics/ Modifications:

Compression/ Weighted Vest

Foot orthotics

Communication Board/ Sign Language

“Wiggle seat”

THE CHALLENGE IN INTERVENTION:

Spectrum of abilities

Difficult to study because of a lack of homogeneity

No one intervention has been shown to be beneficial to balance

Studies tend to focus on children with higher functioning autism

WHAT DO I DO TOMORROW?

Learning strategies for children with autism39,40,41

Children with ASD: Focus on specific items in memory tasks rather than relational

processing or seeing the whole task.

Implicit learning is intact?

Children with Asperger's: Social Learning: SODA:

S: Stop; Where do I go to observe?

O: Observe; What is ___ doing?

D: Deliberate; What would I like to do?

A: Act; When I go to __ I plan

Plan/ Do/ Check/ Evaluate approach may be helpful with children who can participate

Sequencing, execution, using picture cards/ photos

CLINICAL QUESTION?

Do children with ASD have more difficulty with static or dynamic balance?

Suggestions from the evidence

Evaluate Eye tracking/ VOR

Functional use of vision

Test static vs. dynamic balance

Role of vision in balance

Vestibular/ Cerebellar training

Proprioceptive feedback

Feed forward activities (kicking a moving ball)

Sequencing activities

Bilateral integration

Proprioceptive/ Kinesthetic activities

Suggestions from the evidence

Aquatic Therapy

Increase self efficacy: gross motor tasks

Decrease fear of balance activities/ motor tasks

PILOT PROJECT

11 males: 9 - 20 years old

One subject excluded (n = 10)

Paraprofessional(s) were present

OTHER ASSESSMENTS

Romberg testing (tandem/ sharpened)

P-CTSIB

Eyes open

Eyes closed

Eyes open on foam pad

Eyes closed on foam pad.

BOTMP-2

Pediatric Balance Scale

Dynamic Gait Index

KEY FUNCTIONAL TASKS

Standing on one foot

Alternate step tapping

Turning to look over shoulder

What are you having success with?

CASE

GREG

Greg is 11 years old. He is receiving related services in 5th grade.

Greg is unable to stand still and will shift his weight back and forth whenever he is in standing. He requires a handrail to walk up and down stairs. He frequently miss steps when walking up or down a curb. He requires extra time to go up and down the steps of the bus.

Greg’s weight is shifted to the right in sitting and he has difficulty maintaining a midline position.

Greg frequently becomes distressed during the day and has a one on one para with him to assist with transitions and school activities.

CASE QUESTIONS

Evaluation:

What balance testing would be appropriate for Greg?

What kinds of functional activities would help to assess balance?

Intervention:

What approaches may be the most effective in working with Greg?

Case examples and problem solving

Psychosocial/ Environmental affordances and barriers

Systems review

Body structures/ functions

Strengths/ impairments

Activity

Participation

Coordination/ communication with others?

STG/ LTG

Create a treatment plan

Classroom instruction/ involvement

CONCLUSION

Team intervention is critical.

Each child and family must be approached on an individual basis.

Neuroanatomical/ functional differences in children with ASD may help guide intervention.

Functional assessment of balance may provide useful information

Consider dynamic vs. static control

THANK YOU!

Questions/ Comments?

REFERENCES

1. Kogen et al.(2007) Prevalence of Parent- Reported diagnosis of ASD Among Children in the US. Pediatrics 1124(4), 1-9.

2. Merriam-Webster (2013) Accessed September 27, 2013: http://www.merriam-webster.com/medical/autism.

3. Autism Speaks. DSM V Diagnostic Criteria: http://www.autismspeaks.org/what-autism/diagnosis/dsm-5-diagnostic-criteria accessed on 9/27/13

4. NIH: Rett’s Syndrome. Retrieved October 19, 2010. http://www.ninds.nih.gov/disorders/rett/detail_rett.htm

5. Mayo Clinic. (2010) Childhood disintegrative disorder. Retrieved October 19, 2010. http://www.mayoclinic.com/health/childhood-disintegrative-disorder/DS00801

6. Dosreis S, Weiner C, Johnson L, Newschaffer C. (2006) Autism spectrum disorder screening and management practices among general pediatric providers. Journal of Developmental and Behavioral Pediatrics, 27: 88-94.

7. NIH: ASD. 2010. Retrieved October 16, 2010. http://www.nimh.nih.gov/health/publications/autism/what-are-the-autism-spectrum-disorders.shtml

8. http://www.firstsigns.org/index.html. Retrieved October 10, 2010.

9. Robins et al. (2001) The MCHAT for Autism in Toddlers: An initial Study Investigating the Early detection of Autism and Pervasive Developmental Disorders. Journal of Autism and Developmental Disorder. 31(2); 131-144.

10. Nadel A, Poss J. (2007) Early detection of autism spectrum disorders: screening between 12 and 24 months of age. American Academy of Nurse Practitioners 19, 408-417.

11. Sigman M, Dijamco A, Gratier M, Rozga A. “Early Detection of Core deficits in Autism.” 2004. Mental Retardation and Developmental Disabilities Research Reviews 10: 221-233

12. Teitelbaum P, Teitelbaum O, Nye J, Fryman J, Maurer. (1998) Movement Analysis in infancy may be useful for early diagnosis. Proc. Ntl. Acad.Sci.USA 95: 13982-13987.

13. Esposito G, Venuti P, Maestro S, Muratori F. (2009) An exploration of symmetry in early autism spectrum disorders: Analysis of lying. Brain and Development31, 131-138.

14. Ozonoff S, Young G, Goldring S, Greiss-Hess L, Herrera A, Steele J, Macari S, Hepburn S, Rogers S. (2008) Gross Motor Development, Movement Abnormalities and Early Identification of Autism. Journal of Autism & Developmental Disorders. Vol. 38 Issue 4, 644-656.

15. Weber W. (2007) Complimentary and Alternative Medical Therapies for Attention-Deficit/ Hyperactivity Disorder and Autism. Pediatric Clinics of North America 54: 983-1006.

16. Anderson G. (2008) The Potential Role for Emergence in Autism. Autism Research 1: 18-30.

17. Molloy C, Dietrich K, Bhattacharya A. (2003) Postural Stability in Children with Autism Spectrum Disorder. Journal of Autism & Developmental Disorders. Dec, 33(6), 643-652.

18. Hadjikhani N, Chabris C, Joseph R, Clark J, Mc Grath L, Aharon I, Feczko E, Tager-Flusberg H, Harris G. (2001) Early visual cortex organization in autism: an fMRI study. Neurology Report 15(2): 267-270.

19. Gerrard S, Gordon R. (2009) Sensory Impairments and Autism: a Re-Examination of causal Modeling. Journal of Autism and Developmental Disorders. 39: 1449-1463

20. Baranek G. (2002) Efficacy of Sensory and Motor Interventions for Children with Autism. Journal of Autism and Developmental Disorders 32(5) 397- 422.

21. Ming X, Brimacombe M, Wagner G. (2007) Prevalence of Motor Development in ASD. Brain & Development.29; 565–570.

22. Rinehart N, Bradshaw J, Brereton A, Tonge B. (2001) Movement preparation in high- functioning autism and Asperger disorder: A serial choice reaction time task involving motor reprogramming. Journal of Autism and Developmental Disorders 31: 79-88.

23. Rogers S. (2007) Nature of motor imitation problems in school-aged males with autism. Developmental Medicine and Child Neurology 49: 5-5.

24. Rogers S, Hepburn S, Wehner. (2003) Parent Reports of Sensory Symptoms in Toddlers with Autism and Those with Other Developmental Disorders. Journal of Autism and Developmental Disorders. 33 (6); 631- 642.

25. Erez O, Gordon C, Sever J, Sadeh A, Mintz M. (2004) Balance dysfunction in child-hood anxiety: findings and theoretical approach. Journal of Anxiety Disorders; 18 341-356.

26. Eyck C, Bosscher R, Beek P, Doreleijers T. (2009) Gross motor performance and self-perceived motor competence in children with emotional, behavioral, and pervasive developmental disorder: a review. Developmental Medicine and Child Neurology. 51: 501-517.

27. Fife T, Tusa R, Furman J, Zee D, Frohman E, Baloh R, Hain T, Goebel J, Demer J, Eviatiar L. (2000) Assessment: Vestibular testing, techniques in adults and children. Neurology 55: 1431- 1441.

28. Goldberg M, Landa R, Lasker, A, Cooper L, Zee D. (2000) Evidence of Normal Cerebellar Control of Vestibulo-Ocular Reflex (VOR) in Children with High Functioning Autism. Journal of Autism and Developmental Disorders. 30(6) 519-524.

29. Kern J, Garver C, Grannemann B, Trivedi M, Carmody T, Andrews A, Mehta J. (2007) Response to Vestibular Sensory Events in Autism. Research in Autism Spectrum Disorders. 1 (1) 67-74.

30. Weimer A, Schatz A, Lincoln A, Ballantyne A, Trauner D. (2001) Motor impairment in Asperger Syndrome: evidence for a deficit in proprioception. Journal of Developmental and Behavioral Pediatrics. 22; 92-101.

31. Rhinehart N, Tonge B, Iansek R, et al. (2004) Gait function in newly diagnosed children wit autism: cerebellar and basal ganglia related motor disorder. Developmental Medicine and Child Neurology 48:819-24.

32. Wise M, Little A, Holliman J, Wise P, Wang J. (2010) Can State Early Intervention Programs Meet the Increased Demand of Children Suspected of having Autism Spectrum Disorders?” Journal of Developmental Behavior Pediatrics 31(6); 469- 472.

33. Sackett DL, Strauss SE, Richardson WS, et al. (2000) Evidence-Based Medicine: How to Practice and Teach EBM. Philadelphia, Pa: Churchill-Livingstone.

34. Hess K, Morrier M, Heflin LJ, Ivey M. (2008) Autism Treatment Survey: Services Received by Children with Autism Spectrum Disorders in the Public School System. Journal of Autism & Developmental Disorders, May, Vol. 38 Issue 5, p961-971

35. Vargas S, Camilli G. (1999) A meta-analysis of research on sensory integration treatment. American Journal of Occupational Therapy. 53(2): 189-198.

36. Stephenson J, Carter M. (2009) The Use of Weighted Vests with Children with Autism Spectrum Disorders and Other Disabilities. Journal of Autism & Developmental Disorders, Jan, Vol. 39 Issue 1, p105-114.

37. Pitetti K, Rendoff A, Grover T, Beets M. (2007)The Efficacy of a 9-Month Treadmill Walking Program on the Exercise Capacity and Weight Reduction for Adolescents with Severe Autism. Journal of Autism & Developmental Disorders, Vol. 37 Issue 6, p997-1006

38. Vonder Hulls D, Walker L, Powell J. (2006) Clinicians’Perceptions of the Benefits of Aquatic Therapy for young children with Autism: A Preliminary Study. Physical and Occupational Therapy in Pediatrics. 26(1/2) 13-22.

39. Bowler D, Motton L. (2009) Different Verbal Learning Strategies in Autism Spectrum Disorder: Evidence form the Rey Auditory Verbal Learning Test. Journal of Autism and Developmental Disorder. 39 : 910- 915.

40. Brown J, Aczel B, Jimenez L, Kaufman S, Grant K. (2010) Intact Implicit learning in Autism Spectrum Conditions. Quarterly Journal of Experimental Psychology. 63 (9), pp. 1789-1812

41. Bock M. (2007) The Impact of Social-Behavioral Learning Strategy Training on the Social Interaction Skills of Four Students with Asperger Syndrome. Focus on Autism and Other Developmental Disabilities. 22(2); 88-95.

42. Radnovich KJ, Fournier KA, Hass CJ. (2013) Relationship between postural control and restricted, repetitive behaviors in autism spectrum disorders. Frontiers in Integrative Neuroscience. May, 7(28) pp 1-7.