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CASE REPORTS

Developing Overhand Throwing Skills for a Child With Autism With a Collaborative Approach in School-Based Therapy

Colebourn, Jennifer A. PT, DPT, MS; Golub-Victor, Ann C. PT, DPT, MPH; Paez, Arsenio PT, DPT, MS, CEIS

Author Information
doi: 10.1097/PEP.0000000000000405

INTRODUCTION

Autism spectrum disorder (ASD) is the fastest-growing developmental disorder in the United States, with an estimated 1.148% growth rate.1 One in 68 children in the US is now diagnosed with ASD.1 According to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), ASD is an inclusive term for a neurodevelopmental disorder sharing similar impairments in communication, social interactions, and restricted, repetitive behavior.2 Recent work has focused on describing the movement impairments of children with autism including clumsiness, poor upper and lower limb coordination, and postural instability.3–5 Collectively, these impairments may have an effect on the motor learning of children with ASD, as they often present with difficulties in planning and completing new motor skills.6–8 These motor struggles may affect a child's overall participation in gross motor activities and have potentially cascading consequences on a child's overall development. This may lead to fewer opportunities for social engagement, limited practice in developing new skills, and perpetuation of limitations. Although motor symptoms associated with ASD begin in early childhood and can last a lifetime, there is developing evidence for the effectiveness of exercise interventions in improving motor, social, and behavioral skills.9–11 Because of the effect of gross motor deficits in this population, physical therapists have become increasingly important members of teams providing services to children with ASD and their families, from early childhood, through the school years, and into adulthood.

Application of the International Classification of Functioning, Disability and Health (ICF) model12 in pediatric physical therapy emphasizes the child's ability to function in natural environments, enhancing participation of a child. School physical therapists serve as members of an educational team to foster the development of motor skills necessary for academic and social success. They work together with other instructional support personnel to address the needs of the whole child, with an emphasis on the skills required for functioning within the school setting. As school physical therapists are specially poised in a child's natural environment, they are well suited to evaluate the effects that their interventions may have on a child's participation.

Currently, no published clinical guidelines are available to direct physical therapy interventions for children with ASD. Physical therapy (PT) clinical decisions for children with ASD should be driven by the child's individual interests and level of participation, with careful attention to their preferred method of communication and level of understanding13 using evidence-based principles.

There are multiple reasons why children with autism may have difficulty enjoying the gross motor exploration of their environments and broadening their motor development. One force in motor learning is motivation. Generally, tasks and activities that learners associate with past successes tend to stimulate interest, whereas challenges that trigger memories of prior anxiety and failures may stimulate avoidance reactions. Thus, if the learner perceives the task as undesirable, learning of the task may be minimal.14 The inability of children with ASD to perform complex motor activities may lead to feelings of failure and decreased motivation for participation in gross motor activities, with a preference for more sedentary activities such as watching television or using the computer.15,16

Children with ASD may also demonstrate impairments in executive functioning, including difficulty planning and distributing attention, response inhibition, disorganized speech, and reduced flexibility in thought processes.17 This is evidenced by the increased time that children with ASD need to plan and execute goal-directed movements.18 As a result of these limitations, children may require learning environment modifications and specially designed instruction to maximize motor learning. Limiting excessive attentional demands may enhance cognitive strategies and improve a child's ability to maintain focus of attention and learn specific skills in the therapy setting.19 Strategies that some physical therapists use to limit distractions include use of quiet workspaces void of clutter, limiting gross motor materials, systematic motor instruction to allow the child to focus on 1 concept at a time, and creating predictable routines.

In pediatric motor learning, demonstration or modeling of a motor skill is effective for children who are developing typically.20 By contrast, numerous studies have found that children with ASD demonstrate poor motor imitation skills.21–24 These difficulties may impair a child's ability to learn by observation of others, especially when engaged in a complex series of movements. Therapists should consider alternate means of demonstration of motor skills, particularly ones that appear to improve visual attention and motivation. As many children with ASD are drawn to video images, video modeling may be an effective tool to improve learning in children with ASD.25 Some preliminary work demonstrated that video modeling can improve new skill acquisition and generalization of skills across environments for children with ASD11,25,26 and video modeling may be a useful component of motor skills demonstration for some children.

Although delays in fundamental movement skills are seen in children with ASD, motor development may follow typical patterns and children with ASD may benefit from increased opportunities for guided practice of motor skills.13 Current theories of motor learning for all children support high levels of self-produced practice, both within and between sessions and across varied environments. Although it appears that children with ASD are capable of implicit learning, or “a learn by doing approach,” their difficulties with executive functioning and motor problem solving may contribute to struggles to learn more complicated motor sequences.8 For a child with ASD, it may be particularly important to teach complex movement patterns by breaking down activities into smaller parts, using task analysis, as a component of a evidence-based approach to interventions for children with ASD.27

Research on motor learning in children developing typically and those with intellectual disabilities demonstrates that if attention is directed to the effect of the performers' movements on the environment, motor learning is generally enhanced.14 With this “knowledge of results,” a naturally occurring reinforcement may serve as an intrinsic motivator for the child and may promote motor learning through immediate visual and kinesthetic feedback.28 Thus, the external focus of attention can reduce the cognitive demands of a task and is associated with improved success. Chiviacowsky et al29 demonstrated that children with intellectual disabilities enhance motor learning through the use of an external focus of attention. For this reason, throwing, kicking, and other goal-directed ball games may be a useful therapeutic activity to improve coordination because of the immediate multisensory feedback and the inherent external focus of attention required for these skills.

When developing interventions to improve motor skills for a child with ASD, activities should be carefully designed so that the child experiences success within therapy sessions. Capio et al30 evaluated specific strategies related to overhand throwing skills for children with intellectual disabilities and have recommended interventions designed to constrain the environment to reduce the number of outcome errors. This has been termed “errorless motor learning.” Capio et al suggest that a child's motor learning might be improved when the learner initially engages in a throwing accuracy task within close proximity to the target so that it is difficult to miss. As the child's proficiency improves, the distance from the target is increased. This reduction in outcome errors may improve overall success during training.30 When possible, physical therapists should incorporate error reduction principles into their interventions for children with ASD.

Children with ASD present with multiple, complex developmental variations that are best addressed through a comprehensive team approach to interventions.3,4,31 Applied behavior analysis (ABA) is one of the current intervention standards for children with ASD and is an effective means for reducing negative behaviors while teaching new skills.32,33 The ABA approaches to learning new and socially significant skills involve behavioral shaping (the use of positive reinforcement and selective feedback to reward desired behaviors), task analysis (breaking down tasks into a series of simple steps), discrete trials (providing opportunities for engaging and repetitive practice), and specialized programming, which allows for generalization of skills into varied environments. As the principles of ABA interventions have overlapped with current motor learning approaches, it may be beneficial for physical therapists to collaborate with ABA practitioners when developing programs to address motor needs.

This case report presents an interdisciplinary approach for improving the motor skills of a child with ASD, integrating PT and ABA. The effect of the program on the child's overhand throwing skills is described. This report also examines whether the child's gains in overhand throwing ability reflect generalized, lasting motor learning and facilitates improved participation in recreational activities in the school setting. This study was approved by the Northeastern University's Institutional Review Board. Thomas' parents consented to the release of his health and educational information for this report.

Description of the Case

“Thomas” is a 9-year-old, third-grade student with ASD who attends a public elementary school. Thomas was born at full term, following an uncomplicated pregnancy and delivery. He has had a healthy childhood without hospitalizations. At the age of 3 years, Thomas' mother began noticing difficulties with his gross motor coordination and expressive language. Following neurological and developmental evaluations, Thomas was diagnosed with ASD, receptive/expressive language disorder, sensory integration dysfunction, and hypotonia. At 3 years 2 months, Thomas first received physical therapy, occupational therapy, speech therapy services, and ABA services in an integrated preschool setting, under an individualized education plan.

Thomas lives at home with both parents and his younger brother, who is developing typically. Both of the parents are college-educated and work full time. English is the primary language spoken at home, although Portuguese is also spoken. They have no family history for developmental or medical conditions. Thomas' teachers report that his family is engaged in his academic and social growth, with frequent and close communication with school staff and consistent carryover with home programs and teacher recommendations. At home, parents report that Thomas enjoys building Legos, playing with figurines, and playing outside with his brother. He does not participate in community-based recreational or social activities.

Thomas has fine motor, gross motor, and communication delays. He participates in the third-grade curriculum with a partial inclusion model, participating in his general education classroom for approximately half of his school day. Although Thomas initiates simple conversation with peers, he requires adult support to maintain a conversation and to respond to the initiations of others. Thomas struggles with age-appropriate play and the social and gross motor components of reciprocal peer play. In addition, Thomas exhibits repetitive movement behaviors that can interfere with his functioning, including self-stimulatory hand flapping, clapping, and occasional verbal outbursts.

Thomas receives 1-to-1 paraprofessional support in school from a staff member trained in ABA. A Board-Certified Behavior Analyst regularly consults with school staff to develop and update his behavior plan. Thomas' individualized education plan supports the development of academic skills, at a first-grade level for reading, writing, and math. Thomas follows classroom instructions with 1:1 teacher support and consistently communicates verbally using simple phrases. Thomas struggles with more complex language skills such as sequencing, expression of recently presented materials, and grammatical form and organization. In addition to the PT reported in this study, Thomas received consultative services through speech therapy and occupational therapy throughout the academic year. Thomas also participated in a weekly, 30-minute adapted physical education class conducted by the general education physical education teacher.

During a PT reevaluation in September 2014, Thomas' parents and teachers were interviewed and a thorough developmental and school function history was obtained. The PT examination included administration of standardized assessments as well as functional measures representative of skills needed for access to school curriculum and participation in activities in the school environment. Tests and measures were chosen on the basis of the demands of the school day, the ICF, and published work regarding tests and measures for children with ASD.34 Specific measures were selected on the basis of Thomas' needs, given his cognitive abilities, attention, and level of motor ability.

Outcome Measures/Standardized Tests

The following tests were used in Thomas' assessment: the Test of Gross Motor Development-2 (TGMD-2), The Bruininks-Oseretsky Test of Motor Proficiency-2 (BOT-2), and the School Function Assessment (SFA) (see Supplemental Digital Content 1 [http://links.lww.com/PPT/A156] for test references and details).

INTERVENTION

Initial Evaluation

Thomas was reevaluated in September 2014 upon return to school from his summer break. Baseline data were collected on school function and gross motor performance using the SFA, BOT-2, and TGMD-2. Student, parent, and teacher interviews were conducted to identify concerns and areas of needed growth. Thomas showed little interest in developing his throwing skills and requested to learn to gallop. Therefore, PT focused on these skills, without instruction or practice on overhand throwing. Periodic assessment of overhand throwing was completed but without specific intervention directed to those skills.

Overhand Throwing Intervention

Phase 1: Motor Planning

In December 2014, Thomas began to express interest in smaller balls and throwing activities. PT was directed at improving these skills. The PT consulted with the Board-Certified Behavior Analyst to develop a task analysis protocol for Thomas (verbal prompt hierarchy) and the Overhand Throwing Mechanics Task Analysis Data Sheet used during ABA training sessions. Supplemental Digital Content 2 (available at: http://links.lww.com/PPT/A157) is a sample data sheet for the motor planning phase of the program. The overhand throw was divided into 5 components: selecting the preferred throwing hand, demonstration of the correct “start posture” with feet in tandem stance identified by foot markers on the floor, establishing visual attention to the target by pointing to the target with the nonthrowing hand, positioning throwing arm behind body with 90° of flexion at elbow, and transferring weight to the front leg with a stepping motion/trunk and arm rotation diagonally across the body. The instruction was simple, “throw this ball to the target.” There was a 3- to 5-second delay to allow for processing of the tasks throughout the program. Following the demonstration of an undesired motor response, the ABA staff would use a second instruction: “Thomas, show me how you _____” (stating the next step in the procedure). If the student could not demonstrate the motor position, graded physical assistance was provided, starting with light physical guidance and increasing to full manual guidance as necessary to allow Thomas to develop the correct movement pattern. During each trial, the support was faded from the most support to least support until he was independence (I) with the skill. To reduce practice effects, data on the amount of support the student required were recorded for the first trial of the 10 minutes of practice. Simultaneously, the ABA staff implemented the student's school behavior plan to improve attention to task and to decrease interfering behaviors during sessions. Most often this included the use of a token board with tangible and/or activity reinforcers. Data sheets were reviewed with the PT during weekly PT sessions.

Thomas was offered the opportunity to watch a video demonstration of overhand throwing at every therapy session using the video created by Chatahoochee, Georgia Public Schools (Chatahoochee Video Minute, https://www.youtube.com/watch?v=-fPGb1elphc).

Thomas received 4 weeks of motor planning practice for overhand throwing: 3 PT sessions and 12 ABA sessions. These sessions emphasized motor planning and not throwing accuracy. Thomas participated in a 30-minute weekly adapted physical education class taught by the general education physical education teacher. This class included teaching of specific skills and activities required in the physical education. Activities varied weekly and had no overlap with PT.

Phase 2: Motor Learning/Target Practice

Following mastery of the motor sequence for overhand throw, the student began to throw to a target. Thomas, PT, and ABA staff were present in the room during PT sessions to facilitate common understanding of behavioral expectations and approaches in conjunction with gross motor goals. The video demonstration of overhand throwing was offered to Thomas before the start of every practice session (Chatahoochee Video Minute, https://www.youtube.com/watch?v=-fPGb1elphc).

Verbal cues and demonstration were given if Thomas exhibited difficulty with the motor sequence for throwing, using the Task Analysis Protocol discussed earlier. The proficiency of the throwing trials was measured using the overhand throw item in the Upper Limb Coordination Subtest of the BOT-2. This test item involves throwing a tennis ball to a 1′ target across a distance of 7′. To reduce errors in performance, initial practice involved throwing distances within close proximity to the target. Throwing began at 2′ away from the target and progressed in 1′ increments to the goal distance of 7′ away. Progression criteria were based on 80% accuracy at a given distance. Data were collected for 3 repetitions of 5 throws at the 7-ft distance at the end of every PT training session, regardless of the training distances.

Throughout the training sessions, the ABA staff implemented the student's school behavior plan to improve attention to task and decrease interfering behaviors. As noted earlier, this regularly included the use of a token board with tangible and/or activity reinforcers, including the use of self-selected gross motor activities for short breaks within the sessions, stickers, or other small toys and verbal gestures and/or “high fives.” Training was in 3 sets of 5 throws, and Thomas was rewarded for completion of the trials. In addition to weekly sessions with the PT and ABA staff, Thomas participated in daily practice with only the ABA staff, following this same protocol. In total, the student received 10 PT sessions and 63 ABA sessions for target practice during the study period.

Phase 3: Participation

A partner throwing game using a Velcro mitt and a tennis ball was gradually added to the intervention when Thomas began to demonstrate interest in the game and the equipment (Supplemental Digital Content 3, available at: http://links.lww.com/PPT/A158). This occurred at approximately 60% proficiency in throwing accuracy to the target, beginning on the third week of the target practice sessions. The throwing game was dedicated to improving Thomas' ability for reciprocal play and included instruction on the language and social skills needed for partner games. To reduce errors, initial practice sessions were conducted with student-teacher games using manual guidance for catching skills, with progression to independent play in peer-to-peer games. The partners in the game stood at a distance of approximately 5′ apart, progressing in distance to 10′ to 12′ as accuracy improved. The game consisted of a series of 20 throws. Throwing trials were considered successful if the child's partner was able to catch the ball without stepping off of the marker.

Posttesting/Retention Data Collection

Summer vacation provides a natural break in service delivery for children in school. The PT encouraged parents and school staff to continue play-based throwing games with Thomas during the summer.

Thomas did not participate in a formal gross motor program or recreational activity during the summer. Thomas was reevaluated in September 2015 using the same outcome measures. This reevaluation did not include additional instruction or review of the specific skills.

RESULTS

Thomas participated in a 24-week throwing intervention consisting of 13 30-minute PT sessions and 75 ABA sessions of 10 minutes in duration.Table 1 summarizes the data for the throwing trials using the protocol for Item 7 of the Upper Limb Coordination Subtest of the BOT-2. Each of the 3 sets of 5 throws is expressed as a percentage of the accuracy proficiency. Thomas missed 6 therapy sessions.

TABLE 1 - Summary of Clinical Measurements and Therapy Notes
Date Trial 1, % Trial 2, % Trial 3, % Total Trials, % Reciprocal Play, % Treatment Notes
Baseline October 6, 2014 0.00 0.00 20.00 6.67 For all baseline: Treatment focus on locomotor skills only, no throwing instruction, difficulty establishing handedness for throwing, balls thrown with inconsistent force, varied direction of throw, some 10 ft away from target, varied motor patterns
October 27, 2014 0.00 0.00 20.00 6.67
December 1, 2014 0.00 0.00 20.00 6.67
Test 1 January 12, 2015 0.00 20.00 0.00 6.67 Target practice distance 2-3 ft
Test 2 February 23, 2015 0.00 80.00 40.00 40.00 Target practice at 3 ft, video, instruct in stepping motion
Test 3 March 2, 2015 60.00 60.00 60.00 60.00 60 Target practice 4-5 ft, video, catching game with adult with manual guidance across 5 ft
Test 4 March 9, 2015 40.00 60.00 80.00 60.00 60 Target practice 5-6 ft, video, catching game with adult across 7 ft, required manual guidance for catching
Test 5 March 16, 2015 80.00 80.00 80.00 80.00 80 Stepping independently! Independent catching! Partner game with peer
Test 6 March 30, 2015 40.00 40.00 60.00 46.67 Refused play State-wide testing, increased repetitive behaviors, anxiety, difficulty sustaining attention
Test 7 April 6, 2015 80.00 100.00 100.00 93.33 90 No verbal prompts needed! Adult partner game 8 ft apart, no peer available
Test 8 April 27, 2015 80.00 80.00 100.00 86.67 Refused play Increased repetitive behaviors, difficulty sustaining attention
Test 9 May 4, 2015 40.00 40.00 80.00 53.33 80 Partner game with peer 8-9 ft apart
Test 10 May 18, 2015 100.00 80.00 100.00 93.33 100 Partner game with peer 8-9 ft apart
Retention September 11, 2015 80.00 80.00 100.00 86.67 90 Partner game with peer 8-9 ft apart
September 25, 2015 80.00 100.00 80.00 86.67 100 Partner game with peer 9-10 ft apart
October 16, 2015 100.00 80.00 80.00 86.67 100 Partner game with peer 9-10 ft apart

Thomas had statistically significant gains in throwing proficiency (P < .002). The testing during the retention phase indicated stability in Thomas' motor learning across a 5-month period, with maintenance of the skills learned. Figure 1 graphs the overhand throwing results indicating a stable baseline period before the onset of the intervention, followed by improved proficiency from 7% accuracy to 93% accuracy. Table 2 summarizes the results of the standardized assessments.

Fig. 1.
Fig. 1.:
Results of overhand throwing trials as measured by accuracy of throwing a tennis ball and hitting a 1-ft target across 7 ft (Item 7, Upper Limb Coordination Subtest, Bruininks-Oseretsky Test of Motor Proficiency-2).
TABLE 2 - Results of Standardized Assessments
BOT-2 Upper Limb Coordination Subtest TGMD-2 Object Control Subtest
Scaled Score 95% Confidence Interval Interpretation (Percentile) Scaled Score Interpretation (Percentile) School Function Assessment Recreational Movement Subtest Score
September 15, 2014 baseline 6 2-10 Below average (34%) 5 Poor (5%) Not assessed
December 1, 2014 pretest 8 4-12 Below average (36%) 5 Poor (5%) Score: 77, criterion: 100
June 1, 2015 posttest 11 7-15 Average (42%) 10 Average (50%) Not assessed
September 11, 2015 retention 13 9-17 Average (48%) 10 Average (50%) Score: 100, criterion: 100
Abbreviations: BOT-2, Bruininks-Oseretsky Test of Motor Proficiency-2; TGMD-2, Test of Gross Motor Development-2.

Comparison of baseline to retention scores indicates gains across all assessments with progression from poor to average on the TGMD-2, and similar improvement on the BOT-2 Upper Limb Coordination Test from below average to average. There were gains on the SFA with progression of Thomas' scores to above the criterion cutoff at the retention testing.

Descriptive reports from Thomas' parents and teachers indicate that Thomas was more willing to engage in gross motor throwing activities both at school and at home. These gains in participation matched those measured in the SFA. Notably, Thomas' mother reported that he enjoyed playing catching games with his brother and father over the summer break. His teachers and parents noted an improved confidence with his motor skills and reported he was less likely to refuse participation in ball games with his peers. This added participation may have contributed to the gains noted in retention scores as compared with posttesting on the Upper Limb Coordination test of the BOT-2.

DISCUSSION

Despite the motor difficulties experienced by children with ASD, there is scant information available on multidisciplinary strategies to improve motor performance and participation in physical activities. Rather than focusing on motor abilities, which describe the underlying capacities that contribute to movement performance, fundamental movement skills such as overhand throwing are goal-directed movements that serve as the foundations for participation in more advanced, social activities.13 Well-developed object-control skills may lead to greater participation in physical activity among children with intellectual disabilities.35 This is important for children with ASD because physical activity levels in this population of children are lower than their peers developing typically.15,36 The development of functional throwing abilities may be an important milestone for a developing child, as it may lead to improved participation in gross motor activities, play, and social interactions across the individual's lifespan.

Recent studies have detailed the motor difficulties in overhand throwing exhibited by children with ASD.13 Children with ASD have been described as demonstrating inappropriate or nonfunctional throwing patterns, with difficulty generating force and controlling the direction of the ball when throwing.13 Pretesting of Thomas indicated that his throwing capabilities matched those described in the literature, with zero success for target throwing, poorly controlled and poorly directed throwing, and avoidance of peer participation in throwing games.

This case report highlights key concepts in gross motor programming for children with ASD. Thomas' readiness and interest in learning to throw were important to his success. Despite preliminary data to support deficits in Thomas' throwing abilities, early therapy sessions focused on his request for locomotor skill development. The throwing intervention only began when Thomas expressed interest and demonstrated the motivation to learn to throw. Furthermore, this intervention highlights the importance of integrating motor learning principles into daily practice. Specific, tailored practice methodologies were developed to meet Thomas' individual learning needs. Careful selection of the location and type of instruction, the use of video modeling to augment visual demonstration, the inclusion of task analysis, discrete trials, and behavioral supports in therapy programming were used with particular focus on skills that would most significantly improve Thomas' participation.

The successful collaboration between the PT and ABA practitioners facilitated the development a gross motor program on the basis of motor learning and behavioral shaping that created a positive and rewarding learning experience for this child. Careful integration of ABA in the PT intervention improved Thomas' ability to maintain his attention to learn new gross motor skills, decreased interfering behaviors, and facilitated the development of his reciprocal play skills.

It is a challenge to provide high frequency of repetition required to learn a new motor skill within the limited time and frequency of PT sessions. Utilizing task analysis protocols and discrete trials under the guidance of ABA practitioners, daily throwing practice sessions were added to the child's gross motor program. This resulted in an increase in the child's opportunities for guided practice, adding 75 sessions of throwing instruction for over 12 additional hours of total training.

The selection of the most effective assessment tools to measure gross motor progress is especially difficult for the evaluation of children with ASD, as they often have complex and variable deficits in language, motor, and social skills. The assessment tools chosen in this study were based on a review of current research, as well as the abilities and needs of this particular child. Although the BOT-2 has been tested on the specific population of children with ASD with demonstrated reliability,38 this measure has limitations because of the complexity of the test criteria and the demand for significant cognitive skills. This test may not be well-suited for all children with ASD. In contrast, to date, there is limited research in support of the reliability for the clinical use of the TGMD-2 specifically for children with autism, although this measure has been used in a number of studies to document motor deficits with this population.13,37,39 The TGMD-2 may be a preferred measure for children with autism, especially in the school setting, as the items consist of familiar, functional skills that are required for participation in gross motor activities within the physical education classroom. In addition, given the observable nature of the TGMD-2, this measure may be an ideal tool for children with autism who often have limited language or communication abilities.

ACKNOWLEDGMENTS

The authors thank the teachers at the Child Development Program at Mulready Elementary School in Hudson, Massachusetts, for their willingness to share their expertise in applied behavior analysis and for their commitment to this gross motor program, and Jeananne Elkins, PT, PhD, DPT, MPH, Northeastern University, for her assistance with this article.

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Keywords:

applied behavior analysis; autism spectrum disorder; collaborative therapies; motor learning; overhand throwing; participation

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