evidence-based clinical practice

December 16, 2019

Susan L. Hyman, MD, FAAP, Susan E. Levy, MD, MPH, FAAP, Scott M. Myers, MD, FAAP

This clinical report focuses on the identification, evaluation and management of children with Autism Spectrum Disorder (ASD). This article discusses prevalence, clinical symptoms, screening and diagnosis, evaluation, intervention, working with families, research and service needs, and pediatric recommendations. The earlier that a child gets a diagnosis may be related to the severity of the signs and symptoms or increased access to services. Autism spectrum disorder can be classified with core deficits, DSM-5 diagnostic criteria and severity. Core deficits are identified in two domains: social communication/interaction and restrictive, repetitive patterns of behavior. The DSM-5, which establishes criteria for diagnosing mental and behavioral diagnoses, has further identified specific deficits within those two domains. A child must present with all three social communication deficits (social-emotional reciprocity; nonverbal communicative behaviors used for social interaction; developing, maintaining and understanding relationships) and two to four restrictive, repetitive behaviors (stereotyped or repetitive motor movements, use of objects, or speech; insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior; highly restricted, fixated interests that are abnormal in intensity or focus; Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment) to qualify for a diagnosis. Severity of diagnosis is then classified by the amount of support that is required for the core deficits. It’s important for pediatric clinicians to be aware of this classification system because it allows for clear communication across disciplines and a common language between a health care team when discussing progress and plans of care. 

There is significant research on the etiology of ASD, related to genetics, biomarkers and environmental exposure, especially due to the recent rise of the prevalence of the diagnosis. Reasons for increases in prevalence are related to increased awareness of the diagnosis, expansion of diagnosis criteria and increased early intervention services. As a pediatric clinician, being aware of the direction research is going in identifying causes or relationships with ASD allows for honest and educated communication with families. This information will continue to be important as the genetic relationship or biomarkers present for a child may influence long-term planning with treatment or future research may identify specific presentations that respond best to specific interventions. There are many different approaches of treatment for ASD, and the common factors across all these approaches should be included in a PT's plan of care, including: use of ABA principles for skill building, systematic approaches from training clinicians, individualized goals, child-initiated teaching, imitation and modeling, and fading adult prompts to increase independence. Medical management of co-occurring symptoms, including seizures, GI symptoms and feeding disorders, and co-occurring behavior health conditions, including ADHD, OCD and mood disorders, will influence the child's health, quality of life, and participation within therapy. Understanding the unique presentation and management of your patient outside of therapy, will help you provide the highest quality of care within therapy. Informed clinicians and collaboration across systems of care provide appropriate care and treatment for children and families with ASD.

February 21, 2020

Iona Novak, Catherine Morgan, Michael Fahey, Megan Finch-Edmondson, Claire Galea, Ashleigh Hines, Katherine Langdon, Maria McNamara, Madison CB Paton, Himanshu Popat, Benjamin Shore, Amanda Khamis, Emma Stanton, Olivia P Finemore, Alice Tricks, Anna te Velde, Leigha Dark, Natalie Morton, Nadia Badawi

This article synthesizes all the research, as of 2019, on interventions specific for patients with Cerebral Palsy (CP). The interventions identified in the article are divided based on the goals for therapy and label the specific goals for interventions across the top. Novak and colleagues use a traffic light system for intervention effectiveness, where red light interventions don't have high-quality evidence supporting effectiveness specific to that goal, green light interventions have high-quality evidence supporting effectiveness and yellow light interventions fall somewhere in-between. The charts from this article allow this research to be easily implemented into clinic, by identifying your goal on the top of the chart and then looking down the column of intervention bubbles for guidance about your intervention selection. The size of the bubbles is related to amount and quality of research associated with a specific intervention. 

This article is a great starting place when creating a plan of care for a patient, as it can guide intervention selection and family discussion for the highest quality of care. Once you have identified targeted interventions, the citations from this article can then be used to get more in-depth understanding of the interventions you have chosen for your specific patient. For example, AFOs are identified as a "probably do it" intervention for motor goals, as it specifically influences walking speed, gross motor skills, stride length and gait kinematics. If I have decided to choose this intervention for a patient, I could then use the reference section to read more about the research specific to AFOs for children with CP.
 

Important highlights of information from this article that I use in my daily practice focus on intervention selection for management of CP. Specifically, task-specific training or "targeted functional mobility training" is required to improve functional mobility. This means that for a child to get better at something they need to practice that specific activity or task. Practice of a task that incorporates "child-initiated problem solving" strengthens motor connections between the brain and body through movement. The importance of task-specific training is also seen with respect to contracture prevention, as standing and active movement is the best prevention for loss of ankle ROM, and with respect to physical activity, as exercise and active movement improves mobility but not a specific gross motor skill. 

Andolph et al 2012

Karen E. Adolph, Whitney G. Cole, Meghana Komati, Jessie S. Garciaguirre, Daryaneh Badaly, Jesse M. Lingeman, Gladys Chan, and Rachel B. Sotsky

This article utilized playroom observations of 20 crawlers and 116 walkers to study natural infant locomotion and what influences the transition into walking. This article highlights the differences between periodic gait, which is consecutive steps in a straight line, with natural locomotion of a child, which is more variable and accounts for changes in surface, speed and obstacles. They found that walkers took more steps and traveled longer distances faster than crawlers, supporting the idea that children transition into walking because they get somewhere faster. Fall rates were not different between walkers and crawlers, so children who walk have all the benefits of upright locomotion, without any increased risk. New walkers averaged 2368 steps per hour, equating to 7 football fields in that time, with 17 fall per hour. In natural locomotion for children, about 50% of walking was less than 3 steps and 25% was only 1 step. This shows how common it can be for children to pause when walking. Falls during play wasn't correlate to distance, time or steps walking, and even though children who walked more would have an increased likelihood of falling, they fell less. 

The quantity, distribution and variety of walking in these new walkers all support the importance of walking adaptability with learning to walk and why walking age doesn't equate to walking experience. Time distributed variable practice leads to maximal motor learning for new walkers, specifically avoiding mass practice and allow rest breaks for consolidation of learning and improved transfer of skills. In my clinical practice, I set up cruising and walking activities that facilitate this natural locomotion pattern, providing short distances between activities and allowing standing breaks in play compared to forced long distance walking for step counts. I focus on the number of times a child initiates stepping during a day instead of how far they are walking in each of those initiations. Once first steps happen, I like to include gait adaptability training to maximize independence, including obstacles, changes in speed, backwards stepping and dynamic surfaces. Maintaining variability in therapy sessions allows for improved transfer of walking skills at home and in the community.