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Introduction

The Children’s Center is a community-based, mental health organization that works with

children up to the age of seven (The Children’s Center, 2017). The center works with children

that have emotional regulation and behavior difficulties, autism, ADHD, depression, whose

parents have been divorced, or those that have suffered from trauma (The Children’s Center,

2017). This center provides a therapeutic preschool to address emotional and behavioral issues

and to facilitate social participation (The Children’s Center, 2017). Autism spectrum disorder

(ASD) will be the focus of this literature review as it represents a portion of the clients treated at

The Children’s Center’s preschool.

Public Health Needs

ASD is considered a developmental delay that ranges in severity and can impact

communication, social participation, cognition, behavior, and emotional regulation (Centers for

Disease Control and Prevention [CDC], 2020a). According to the Centers for Disease Control

and Prevention, about one in fifty-four children are diagnosed with ASD and it is four times

more common in males (CDC, 2020a; CDC, 2020b). It occurs across all racial, ethnic, and

socioeconomic groups and does not have a known cause (CDC, 2020a; Mayo Foundation for

Medical Education and Research, 2018). Symptoms of ASD occur on a spectrum of severity and

can greatly differ by the individual (CDC, 2020a). Symptoms may include avoiding eye contact,

lack of facial expressions, echolalia, repetitive behaviors, preferring to play alone, and delayed

movement, language, and learning (CDC, 2020a; Mayo Foundation for Medical Education and

Research, 2018). Around forty to ninety percent of children with ASD may also present with

difficulties in sensory processing and be over or under-reactive to sensory stimuli including

auditory, visual, olfactory, tactile, vestibular, proprioceptive, and gustatory senses (Crasta et al.,
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2020; Hatch-Rasmussen, 2020; Roley et al., 2015). The proprioceptive and vestibular systems

are part of the sensory system that children with autism may have difficulties integrating (Hatch-

Rasmussen, 2020). Difficulties processing proprioceptive information can display as being

clumsy, poor body awareness, poor fine motor skills, and poor posture, while difficulties with

processing vestibular information can look like gravitational insecurity or jumping, spinning, and

running (Hatch-Rasmussen, 2020).

A literature review found that postural impairments are common in children with ASD

from infancy and do not show improvements until the age of twelve (Memari et al., 2014). It

highlighted that gross motor control, postural stability, motor planning, motor coordination,

functional balance, and praxis deficits are common in ASD (Memari et al., 2014). This article

also discussed that literature has found that postural stability deficits occur with sensory

integration challenges, including visual input (Memari et al., 2014).

In relation to postural stability, another article discussed that previous research has shown

that children with ASD have decreased postural control and motor planning due to deficits in

proprioception and demonstrate behaviors such as running (Blanche et al., 2012). This article

studied proprioception difficulties in children with ASD using the Comprehensive Observations

of Proprioception assessment, and found that children with ASD have difficulties with

proprioceptive processing, specifically in motor planning (Blanche et al., 2012). These

proprioceptive deficits influence postural stability, motor planning, and negative behaviors,

which limits participation in day-to-day activities (Blanche et al., 2012). Another research article

focused on sensory integration discussed that postural-ocular control deficits can make it

challenging to use tools, sit-upright, and sit still, which can impact a child’s participation (Roley

et al., 2015). When researching sensory integration and praxis characteristics in children with
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ASD, this article found that the children in their study had deficits in somatosensory perception,

vestibular bilateral functions, imitation praxis, and sensory reactivity with somatosensory,

vestibular, and imitation praxis significantly correlating with social participation (Roley et al.,

2015).

Lastly, another article discussed Ayers’ sensory integration theory (Crasta et al., 2020).

This theory encompasses the idea that attention is necessary for sensory processing (Crasta et al.,

2020). Children with autism have been shown to have difficulties in selective, sustained, and

attention control (Crasta et al., 2020). These challenges in both sensory processing and attention

can limit participation in daily activities, including academic participation (Crasta et al., 2020).

The results demonstrated deficits in both attention and sensory processing in children with ASD

compared to their typically developing peers (Crasta et al., 2020). Overall, the public health

needs of children with ASD include postural stability, gross motor, motor planning, praxis,

sensory integration, and attention as these deficits can impact academic and social participation

(Blanche et al., 2012; Crasta et al., 2020; Hatch-Rasmussen, 2020; Memari et al., 2014; Roley et

al., 2015).

Gaps in Services and Interventions

For children receiving community-based mental health services, interventions are focused

on three tiers (Arbesman et al., 2013). The first tier is services provided to children both with and

without a mental health or behavioral diagnoses (Arbesman et al., 2013). The second tier is for

children that are at risk for mental health and behavioral challenges (Arbesman et al., 2013). The

third tier includes services provided to children that have identified or diagnosed disorders

related to mental health and behavior (Arbesman et al., 2013). Health interventions for this

population can take place in a wide variety of settings including schools, special education,
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community, home health, early intervention, mental health service systems, and health care

(Arbesman et al., 2013; Brookman-Frazee, 2010). The common interventions among all three

tiers include social skills, emotional skills, health promotion including stress management and

yoga, and various recreational activities (Arbesman et al., 2013). For children with ASD, tier

three interventions typically focus on social skill interventions (Arbesman et al., 2013).

Brookman-Frazee et al. (2010) focused on identifying services provided to children with

autism spectrum disorder in community mental health clinics, and discussed that mental health

services primarily use psychosocial interventions in conjunction with medication. This article

identified that community-based mental health services are often not meant to target

developmental disabilities and typically target behavior problems (Brookman-Frazee et al.,

2010). Common behavioral techniques included in this article are social skills, problem-solving,

anger management, modeling, positive reinforcement, setting limits, psychoeducation, affect

education, teaching techniques, and role-play (Brookman-Frazee et al., 2010).

Mental health related services in general, as well as those related to ASD, primarily focus

on social interaction skills, emotional regulation, and behavior (Arbesman et al., 2013;

Brookman-Frazee et al., 2010). However, while research addressing the public health needs of

ASD in regards to postural stability, sensory integration, motor planning and praxis, and

attention exists, there is no research targeting those deficits in a mental health setting (Blanche et

al., 2012; Crasta et al., 2020; Hatch-Rasmussen, 2020; Memari et al., 2014; Roley et al., 2015).

This is the current gap in research as children who are seen in mental health clinics also may

have sensory and motor deficits that impact participation that are not currently being addressed.

Current Programming
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Current programming to address the public health needs exist outside of mental health

clinics. The first program is Sports, Play, and Active Recreation for Kids, otherwise known as

SPARK (Najafabadi et al., 2018). This program targets both motor and social participation skills

in children with ASD through a skill-fitness activity and a health fitness activity (Najafabadi et

al., 2018). Running, frisbee, dance, and soccer are a portion of the selected activities (Najafabadi

et al., 2018). For children with ASD, this program found significant improvement in motor skills

including coordination, and static and dynamic balance (Najafabadi et al., 2018). They also

showed improvement in social interaction (Najafabadi et al., 2018).

Yoga programs have also been developed to address the public health needs of children

with ASD (Semple, 2018). A review of literature found that one implemented yoga program had

increased sitting tolerance and improved imitative behaviors (Semple, 2018). Overall, results of

the yoga programs in this review primarily focused on social skills and negative behaviors

(Semple, 2018). A creative yoga program identified that yoga impacts motor and perceptual

processes including proprioception, attention, and social interaction skills in children (Kaur &

Bhat, 2019). This study focused on the effectiveness of yoga intervention in children with ASD

(Kaur & Bhat, 2019). The results of this study found that children that participated in the yoga

intervention improved in bilateral coordination, gross motor skills, and had a reduction in

imitation errors (Kaur & Bhat, 2019). However, they did not demonstrate improvement in

balance, which includes postural control (Kaur & Bhat, 2019).

A limitation and gap of these available programs is that research did not focus on whether

the improvements of motor skills impacted learning participation and whether the interventions

specifically improved proprioceptive input in the form of body awareness. There was also little
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to no evidence that clearly demonstrated an improvement in postural control. It also did not

provide evidence of these interventions being used in mental health settings and services.

Basic et al. (2021) conducted a review on sensory integration interventions for children

with ASD. The authors documented that sensory integration interventions improved attention

and alternate seating improved participation for children that had vestibular-proprioceptive

sensory integration difficulties (Basic et al., 2021). Both the improvement in attention and

participation were based on learning environments (Basic et al., 2021). However, there is no

research regarding how often these interventions are implemented in mental health services and

if they are beneficial to the children with ASD within these services.

A preschool intervention program called Mighty Moves focused on improving gross

motor skills and physical activity participation (Bellows et al., 2013). The results of this study

indicated that the preschool children’s gross motor skills significantly improved (Bellows et al.,

2013). While this program was not focused on ASD or mental health, it demonstrates that gross

motor intervention improves gross motor skills in preschool children (Bellows et al., 2013).

While this literature review is focused on children with ASD, The Children’s Center focuses on

preschool age children and similar intervention could be effective.

Conclusion

From the information gathered in this literature review, it is clear that children with ASD

have multiple public health needs. While current programs exist that improve gross motor skills

in preschool children and children with ASD, there is a disconnect between how these programs

influence school and academic participation, which is required of the children receiving services

at The Children’s Center. These programs will be important factors to consider in designing a

program that targets the public health needs of children with ASD in mental health settings.
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References

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American Journal of Occupational Therapy, 67(6).

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Basic, A., Petrovic, D. M., Pantovic, L., Parezanovic, R. Z., Gajic, A., Arsic, B., & Nikolic, J.

(2021). Sensory integration and activities that promote sensory integration in children with

autism spectrum disorders. Institute for Human Rehabilitation , 11(1), 28-38.

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