Rehabilitasi pada Pasien dengan

Autistic Spectrum Disorder

dr. Luh Karunia Wahyuni SpKFR-K
Departemen Rehabilitasi Medik
FKUI-RSCM
Outline

• Sensory processing disorder

• Feeding problem
• Motor deficit …. postural control problem, tiptoe gait
• Management
 Sensory Intellectual Attention-
processing deficits deficit/hyperactivity
disorder (SPD) disorder (ADHD)

Impaired theory Obsessive-

of mind compulsive
Features disorder (OCD)
Associated Preservative and self-
with Autistic injurious behaviors
ASD
Depression
Spectrum
Disorder Seizures
Executive
dysfunction

Aggression and
Motor deficits
tantrums

Fogle P. Essentials of communication sciences & disorders. Burlington, MA: Jones & Bartlett Learning; 2019; pg 198-200
Sensory Processing Disorder in
ASD
 Sensory Integrative Processes
The Senses Integration of their inputs End products

Auditoy (hearing) Speech

Language
Vestibular
Eye movement Ability to concentrate
(gravity & movement)
Posture Body perception Ability to organize
Balance Coordination of two Self-esteem
Muscle tone sides of the body Self-control
Proprioceptive Eye-hand
Gravitational security Motor planning Self-confidence
(muscle & joints) coordination
Academic learning ability
Capacity for abstract
Activity level
Sucking Visual perception thought and reasoning
Tactile (touch) Attention span
Eating Purposeful activity Specialization of each side
Emotional stability
of the body and the
Mother-infant bond brain
Tactile comfort
Visual (seeing)

First level Second level Third level Fourth level

(Model by Jean Ayres)
Sensory Processing Disorder
(SPD)

Ketidakmampuan otak memproses informasi

sensoris secara efisien

Gangguan timbal balik antara input-

proses-output
 Summary of Interpretation Using Dunn’s Theoretical Model of Sensory Processing
Model category Associated factors Related section Behavior indicators
headings
Poor registration Low endurance or tone Sensory processing Uninterested
Poor registration related to endurance or Dull affect
Sedentary* tone Withdrawn
Modulation of “Overly tired”
movement affecting Apathetic
activity* Self-absorbed
Sensitivity to stimuli Oral sensory sensitivity Auditory processing Distractible
Inattention or Oral sensory processing Hyperactive
distractibility
Sensory sensitivity
Sensation seeking Sensory seeking Modulation related to Active
body position and Continuosly engaging
movement Fidgety excitable
Sensation avoiding Emotionally reactive Behavioral outcomes of Resistant to change
Sedentary* sensory processing Reliant on rigid rituals
Sumber: Bundy A, Lane S, Murray E. Sensory integration: Theory and Practice. 2nd ed. Philadelphia: F A Davis; 2002.
 Sensory Processing Disorder in ASD
• The greater the sensory dysfunction, the greater the severity of the autism
symptomatology
• Auditory filtering and tactile sensitivity is the most affected one. This impairment
has been found to influence the severity of the restricted and repetitive behaviors
• Usually present difficulties with praxis. Thus, motor skills requiring adjustments in
initiation, timing, sequencing, speed, and direction of movement are usually
difficult for them.
• Commonly have greater cognitive functioning limitations at high levels of
information processing, including social skills

Ashburner, J., Ziviani, J., and Rodger, S. (2008). Sensory processing and classroom emotional, behavioral, and educational outcomes in children with autism spectrum disorder. Am. J. Occup. Ther. 62, 564–573. doi: 10.5014/ajot.62.5.564
Sanz-Cervera, P., Pastor-Cerezuela, G., Fernández-Andrés, M. I., and Tárraga- Mínguez, R. (2015). Sensory processing in children with autism spectrum disorder: relationship with non-verbal IQ, autism severity and attention deficit/hyperactivity disorder symptomatology. Res. Dev. Disabil.
45, 188–201. doi: 10.1016/j.ridd.2015.07.031
Kargas, N., López, B., Reddy, V., and Morris, P. (2015). The relationship between auditory processing and restricted, repetitive behaviors in adults with autism spectrum disorders. J. Autism Dev. Disord. 45, 658–668. doi: 10.1007/s10803-014-2219-2
Fernández-Andrés, M. I., Pastor-Cerezuela, G., Sanz-Cervera, P., and Tárraga-Mínguez, R. (2015). A comparative study of sensory processing in children with and without autism spectrum disorder in the home and classroom environments. Res. Dev. Disabil. 38, 202–212. doi:
10.1016/j.ridd.2014.12.034
Feeding Problem in ASD
 Sensory
Processing
Disorder

Behavior Motor
Difficulties Disorder
Feeding
Difficulties

Communicat
Learning
ion
Differences
Difficulties

Marshall, J., Ware, R., Ziviani, J., Hill, R. J., & Dodrill, P. (2014). Efficacy of interventions to improve feeding difficulties in children with autism spectrum disorders: a systematic review and
meta-analysis. Child: Care, Health and Development, 41(2), 278–302. doi:10.1111/cch.12157 (https://doi.org/10.1111/cch.12157)
 Common feeding problem and mealtime behavior
Refusal Colour, texture, packaging, temperature, smell, food group

Ritualistic Restricted dietary variety, insist on same utensils/setting, insist food to be

prepared the same, picky eating, food neophobia, ritualistic eating habits,
Behaviors eliminated food they used to eat

Feeding Oral hypersensitivity, oral motor difficulties, poor self-feeders, gagging

skills
Maladaptive Leave table frequently, throwing food, tantrums at mealtimes, food cravings,
gorging on food, eating too quickly, pica
behaviours

Marshall, J., Hill, R. J., Ziviani, J., & Dodrill, P. (2013). Features of feeding difficulty in children with Autism Spectrum Disorder. International Journal of Speech-Language
Pathology, 16(2), 151–158. doi:10.3109/17549507.2013.808700 (https://doi.org/10.3109/17549507.2013.808700)
ASD Motor Difficulties
 Pathomechanism postural control abnormalities in ASD

Dysfunction in sensory Reduced purkinye and Deficit in smooth pursuit

Focal cortical dysplasia
integration granule cells and saccadic eye movement

Abnormal migration of
daughter cells to target
regions Basal ganglia Vermal dysfunction in
Cerebellar deficits
involvement cerebellum
Circumscribed foci of thin
cortical area (frontal lobe
containing smaller pyramid
neurons and interneurons)
Impaired vestibular control, fine and gross motor
Sensory & motor deficits in ASD abnormalities in ASD

Kindregan D., Gallagher L., Gormley J. Gait deviations in children with autism spectrum disorders: A review. Autism Research and Treatment. 2015.
Samsam M, Ahangari R, Naser S.A. Pathophysiology of autism spectrum disorders: Revisiting gastrointestinal involvement and immune imbalance.
World J Gastroenterol. 2014. 20 (2): 9942-9951.
 Postural Control Development in ASD
• Asymmetrical posture in lying on the stomach
4 mo - 1 yo

• Some autistic infants cannot perform

Rolling stage • Others are only unable to follow motor sequence deviated patterns compared with TD

• some achieve the ability of sitting later than 6 months

6 mo • asymmetrical weight distribution on both sides falling forward or backward

• show asymmetry and asynchronization of weight shifting

Crawling • unable to perform diagonal patterns of legs and arms required in crawling
stage
Motor findings in ASD
Main motor findings include:
• stereotypies
• toe walking
• low muscle tone
• increased joint laxity
• clumsiness/ dyspraxia
• motor coordination
abnormalities
• sensory deprivation

Silver, WG. Rapin I. Neurobiological Basis of Autism. Pediatr Clin North Am 2012. V0l 59 (1): 45-61
 Tip Toe Walking

Occur in 50% of 5-year-old children with Autism

Potentially effect of decreased vibration threshold

Dysfunction in vestibular system, which is normally provide

feedback regarding body motion & position

Consider to be a residua of primitive walking pattern reflex or

tonic labyrinthine (TL) reflex

Contribute secondary motor deformity by producing a

shortening tendon Achilles

Accardo, P.J, Monasterio E. Oswald Donald. Toe Walking in Autism. V.B. Patel et al. (eds.) Comprehensive Guide to Autism. 2014
Communication Problem in ASD
 Communication Impairments in Children with ASD
• Impaired working memory • Interpret messages literally
• Not understand abstract words and
• Lack of initiation of verbal interaction thoughts
• Echolalia • Difficult to interpret “wh-” questions
• Receptive Language • Using the adult as a tool to get simple
tasks performed
• Understand a message only when
• Struggle to learn to read and write; some
spoken by one person in one way in children read early without understanding
one place (hyperlexia)
• Without generalization of word to • Idiosyncratic language
other contexts • Neologisms

Fogle P. Essentials of communication sciences & disorders. Burlington, MA: Jones & Bartlett Learning; 2019; pg 198-200
 Social (Pragmatic) Communication Disorder In ASD
• Difficulty using language for social purposes
• Difficulty following rules of the communication context (ex. turn-taking in
conversation)
• Difficulty understanding nonliteral language (ex jokes, idioms, metaphors)
• Difficulty integrating language with nonverbal communicative behaviors
• Unusual nonverbal behaviors (lack of sustained eye contact, inappropriate facial
expression, general body language, gesture or mime spontaneously)

Fogle P. Essentials of communication sciences & disorders. Burlington, MA: Jones & Bartlett Learning; 2019; pg 200
 Predict Good Outcome
• Early diagnosis and intervention programs are effective in changing the natural
outcome for many individuals with autism1
• Comorbidities will alleviate difficulties on treatment2
• Severity of ASD, level of general intelligence, and change in symptom expression
overtime are the basis parameters to predict the prognosis of ASD3
• Acquisition of language before 6 years4
• IQ level above 504
• Having a special skill, such as expertise in computers5
• Independent Living5

1. Woolfenden, S., Sarkozy, V., Ridley, G. and Williams, K. (2012). A systematic review of the diagnostic stability of Autism Spectrum Disorder. Research in Autism Spectrum Disorders, 6(1), pp.345-354
2. Tidmarsh, L. and Volkmar, F. (2003). Diagnosis and Epidemiology of Autism Spectrum Disorders. The Canadian Journal of Psychiatry, 48(8), pp.517-525.
3. Coplan, J. (2000). Counseling Parents Regarding Prognosis in Autistic Spectrum Disorder. PEDIATRICS, 105(5), pp.e65-e65.
4. Howlin P. Prognosis in autism: do specialist treatments affect long-term out- come? Eur Child Adolesc Psychiatry 1997;6:55–72.
5. Gillberg C. Outcome in autism and autistic-like conditions. J Am Acad Child 
Adolesc Psychiatry 1991;30:375– 82.
 Prognosis komunikasi pada ASD
• Wetherby et al : yang dapat berbicara lancar sebelum usia 5 tahun : prognosis lebih
baik untuk melanjutkan akademik dan perkembangan sosial
• Intervensi awal (identifikasi dan penegakan diagnosis) : faktor signifikan untuk
prognosis jangka panjang : kemampuan komunikasi lebih berkembang dan perilaku
out of control lebih minimal
• Kemampuan bahasa dan permainan simbolik yang telah berkembang sebelum usia
5 tahun : luaran lebih baik pada pendidikan dan komunikasi

• Wetherby AM, Prizant BM, Schuler AL. Understanding the nature of communication and language impairments. In: Wetherby AM, Prizant BM, editors, Autism
spectrum disorders: a transactional developmental perspective (communication and language intervention series), vol. 9. Baltimore (MD): Brookes; 2000.
p. 109–41.
• Prelock PJ, Nelson NW. Language and communication in ASD : An integrated view. Pediatr Clin North Am. 2012
 Prognosis komunikasi pada ASD
• Meskipun telah mendapatkan intervensi bertahun-tahun dan mengikuti
pendidikan : diperkirakan 30% mencapai kemampuan verbal minimal
• Sekitar 50% diperkirakan gagal berkomunikasi verbal (National Research Council,
2001)
• Target : useful speech by age 5 : fungsi sosial dan adaptasi ke depan akan lebih baik
• Interagency Autism Coordinating Committee  long term goal  90% anak akan
mencapai kemampuan berbicara bermakna pada usia 5 tahun
• Department of Health and Human Services (2004) : terapi untuk meningkatkan
komunikasi verbal berfokus pada anak usia < 5 tahun

1. Flusberg HT, Kasari C. Minimally Verbal School-Aged Children with ASD : The Neglected End of the Spectrum). Autism Res. 2013 December ; 6(6): . doi:10.1002/aur.1329
General Intervention Principles for Children With ASD

• Provide structure and consistency • Provide a quiet setting

• Keep the same routine • Allow the child to play with other
• Read the child’s nonverbal as well as children
verbal cues • Use positive behavioral reinforcers
• Communicate through signs, pictures, • Use sensory integration techniques
communication boards, and/or singing • Tactile
• Work with the child at his or her level • Vestibular
• Proprioceptive
• Follow the child’s cues • Olfactory
• Redirect when the child begins self- • Gustatory (Children with autism may
stimulation enjoy very spicy or sour tastes instead of
bland tastes.)
• Listen to the parent(s) to learn about • Provide the child with choices (may
the child’s preferences have to start with only two).

Solomon J, O'Brien J. Pediatric Skills for Occupational Therapy Assistants. Saint Louis: Elsevier Health Sciences; 2015. pg 212-
Intervensi Berbasis Sensori Integrasi
• Ayres Sensory Integration (OT- ASI) Intervention
• Pendekatan Wilbarger untuk mengatasi
hipersensitivitas sensori
• Aplikasi klinis sensory diet
• The alert program
• Water-based
• Hippotherapy
• Kontrol okulomotor
• Therapeutic listening
• Craniosacral Therapy dan Myofascial Release
• Lingkungan peternakan sebagai media terapi
• Snoezelen therapy
 Intervention: feeding problems
• Obtain and maintain the calm-alert state
• Oral motor program
• Minimize anxiety
• Provide gentle, steady, deep proprioceptive input, counting to 10 with the
child
• Deep-touch pressure
• Face, Mouth, Jaw and Teeth, Cheek and Lips, Respiratory control
(inhalation, exhalation, strength, duration, coordination)
• Food as tactile and sensory experience
• Chewing -> resistive and organizing
• Crunching -> alerting
• Sour foods -> alerting, arousing, and organizing
• Hot, spicy, or bitter flavors -> more alerting
• Cold food -> decrease sensitivity, increase low tone and arousal
• Make schedule to exercise
• 5 to 10 minutes before meals, also before or at the beginning of a speech
therapy session

• Enhanced sensory activities

 Intervention : communication problems

• The overall objectives are to improve social function, communication,

cognitive abilities, reduce repetitive and obsessional behaviors
• Including early multidisciplinary approach : i.e More Than Words, EIBIs
(Early Intensive Behavioral Intervention), TEACCH (Treatment and
Education of Autistic and Related Communication Handicapped Children)

Woolfenden, S., Sarkozy, V., Ridley, G. and Williams, K. (2012). A systematic review of the diagnostic stability of Autism Spectrum Disorder. Research in Autism
Spectrum Disorders, 6(1), pp.345-354
Komunikasi non-verbal pada ASD

• Bahasa isyarat
• PECS (Picture Exchange Communication System)
• VOCA (Voice Output Communication Aids)
• Tulisan

Flusberg HT, Kasari C. Minimally Verbal School-Aged Children with ASD : The Neglected End of the Spectrum). Autism Res.
2013 December ; 6(6): . doi:10.1002/aur.1329
 Treatment Tip Toe Walking in ASD
Range of motion (ROM) ankle and foot

Normal ROM, (-) contracture Reduced ROM, (+) contracture

plantar flexion

(-) foot deformity (-) foot deformity <5° 5-10° >10°

(-) pain (-) pain
(-) ↑ fall frequency (+) ↑ fall frequency

Ankle brace, Surgical

Strecthing AFO + physical strecthing
serial casting intervention
gastrocnemius therapy, such stair
soles climbing

Accardo, P.J, Monasterio E. Oswald Donald. Toe Walking in Autism. V.B. Patel et al. (eds.) Comprehensive Guide to Autism. 2014
Conclusion
• Early detection and intervention could improve child skills to optimize functional
and social skills in daily living, to minimize the core features of autism, and
eliminate behaviors that are unhelpful or disruptive
• The management of autism spectrum disorder requires a multidisciplinary team
(MDT) comprising parents, therapists, psychologists, special educators, and
medical specialists