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Hypotonia in Kids on the Autism Spectrum

“My 10 year-old child with high-functioning autism is very smart, but he is very, very poorly coordinated. He has difficulty riding his bike, bowling, catching, hitting a tennis ball, kicking, shooting a basketball, diving in a pool, swinging a bat, and throwing. He can't run fast without tripping, and he has terrible posture. As an infant, he was a later walker (almost 17 months). He was a very sloppy eater, and still has trouble cutting with a knife or the edge of his fork. Also, he had some speech articulation issues. We were hoping he would grow out of all this, but he hasn't. I wonder if there is anything we could do to help him be less awkward. Does what I've described sound "normal" for some children with autism? Or does it sound concerning? How physically uncoordinated should he be before we try to get professional help for him?”


Many children with High-Functioning Autism (HFA) and Asperger’s (AS) have a comorbid condition called Hypotonia, which is sometimes referred to as "floppiness." This is because the muscles are meant to help support the skeletal system and are designed to prevent certain kinds of motion. Because the muscles are not especially tight, children with Hypotonia frequently experience "hypermobility" (i.e., the ability to move limbs into awkward positions). They often find that they're able to very easily carry out feats that require flexibility, but not strength or balance (e.g., splits, back-bending, shoulder rotation, etc.). Also, they may display uncommon flexibility in other joints (e.g., fingers).

This kind of flexibility comes with a price. HFA and AS children are generally very uncoordinated and awkward. In running, this plays a role in the so-called "unusual gait." A myth is that muscle tone just impacts the large muscles, but this is not the case. Muscle tone impacts all activities requiring muscles (e.g., speech, pencil grip, writing, etc.).

Hypermobile joints are less stable than usual, which means that the HFA or AS youngster needs stronger muscles to support the body. The increased compliance (i.e., give) in the connective tissue also affects the blood vessels and internal organs, which can lead to constipation, trouble with bladder control and voiding, and low blood pressure.

Hypermobility affects the development of motor control in many ways. Since the joints are naturally less stable, more muscle strength is needed for proper posture and movement control. Young people with hypermobility have difficulty climbing, gripping a pencil for drawing and handwriting, hanging from monkey bars, managing stairs, running, sitting erect while working at a table, and walking long distances. Also, these kids often have tight muscles in the hips and shoulders, which affects shoulder movements needed for drawing and handwriting, as well as sitting comfortably on a chair or cross-legged on the floor.

Due to tightness in the hip muscles, the affected child will often experience pain in the legs following exercise, or when he or she is going through a growth spurt. The youngster often has an increased tendency to respond negatively to discomfort, which can make night pain related to exercise very troublesome. In addition, toe walking is often seen in these children, which is associated with tightness in the calf muscles and the muscles crossing over the back and sides of the hips and legs. In most cases, children who walk on the toes have hypermobile joints. 

Fine motor skills are hard to learn if you have autism. These fine skills are essential for drawing or coloring, grasping objects, riding a bike without training wheels, zipping-up jeans, and tying shoelaces. However, when muscle tone is low, these skills are much harder to perform properly.

When an HFA or AS child isn't proficient at something (e.g., riding a bike), but all his friends can do it, this deficiency can create a sense of isolation in the child. Imagine watching all the other kids in your neighborhood doing various activities very easily while you don’t appear to have the same abilities. Consequently, HFA and AS children can start thinking they're “dumb.” This is definitely not the case. Intelligence has nothing to do with it!

HFA and AS children often slump a great deal when seated or standing for long stretches. Occasionally, they'll stand with their legs crossed in what seems to be an uncomfortable manner. Even though this appears painful, this is really an extremely comfortable position for these kids. Additionally, they frequently sit with their head and shoulders rolled forward, and will often lean on walls, furniture, door frames and desks. Moms and dads of kids on the autism spectrum will probably be very familiar with being "leaned on."

Hypotonia doesn't prevent HFA and AS kids from enjoying themselves, however. They are able to run and have fun with other kids without feeling any harmful effects. The issue is that they are a little slower and tire easier. Consequently, team sports (e.g., soccer, basketball, football) are often not suitable to these children.

While the slumping and leaning habits are not necessarily good posture, they are not particularly harmful to the child, unless of course the position is adopted for very long intervals without proper breaks.

Usually, kids are believed to have Hypotonia because they have poor postural stability and poor performance on movement tasks. The presumption is made that these issues result from Hypotonia, but this isn't always the case. HFA and AS children may have problems with understanding movement skills and obtaining basic strength needed for action for a combination of reasons (e.g., joint hypermobility, a fearful temperament, difficulty with the thinking skills needed for learning, difficulty predicting what happens next, the inability to learn from watching other people and from their own experience, etc.). Thus, the real issue is not what you can do for an HFA or AS child with Hypotonia, but instead what you can do to improve overall performance on age-appropriate movement tasks. This depends on the underlying reasons for the child’s problems, which may or may not have anything to do with Hypotonia.

Children with HFA and AS can have a comprehensive assessment by a physiotherapist and/or occupational therapist to determine the nature and degree of the problem. Listed below are a few of the areas where motor clumsiness is evident, and some ways of improve specific skills:

1. Rapid Movements— Research has noted that, while engaged in activities that require motor coordination (e.g., cutting out shapes with a pair of scissors), a significant percentage of kids with HFA and AS were known to hurry through the task. They seemed to be impulsive, unable to take a slow and calculated approach. With such haste, errors occur. This is often infuriating for the child and the teacher. The child may require guidance and reassurance to work at a suitable pace, having time to correct mistakes. Occasionally the youngster can be asked to slow down by having to count between actions and using a metronome to indicate a suitable pace.

2. Manual Dexterity— This area of movement skills involves the ability to use both of your hands (e.g., learning to dress, tie shoelaces, eat with utensils, etc.). This may also extend to the coordination of feet and legs (e.g., learning to ride a bike). If the HFA or AS child has problems with manual dexterity, a good technique to help is "hands on hands" training (i.e., a parent or teacher physically patterns the child's hands or limbs through the required movements, gradually fading out physical support).

3. Locomotion— When the HFA or AS child walks or runs, the movements may seem awkward or "puppet" like, and many of these kids walk with no associated arm swing. There may be deficiencies in upper and lower limb control. This particular feature can be very noticeable, and other kids may mock the autistic child, resulting in his or her desire not to take part in running sports and physical education in school.

A physiotherapist or occupational therapist can develop a remedial plan to ensure the child’s movements are coordinated. Therapy can include the use of a large wall mirror, video recording, modeling, and imitating more "fluid" movements using music and dance. An intriguing fact is that the ability to swim seems least affected, and this exercise can be encouraged to allow HFA and AS kids to experience genuine proficiency with movement.

4. Handwriting— A teacher may invest a lot of time interpreting and correcting the HFA or AS youngster’s illegible “chicken scratches.” The child may also be aware of the poor quality of his handwriting and may be hesitant to take part in activities which involve extensive writing. Unfortunately, high school instructors and potential employers consider the neatness of handwriting a way of measuring intelligence and character. As a result, the young person on the spectrum may get embarrassed or upset at their own inability to write neatly and consistently. The child may need an assessment by an occupational therapist and remedial exercises, but today's technology can help reduce this issue.

Kids on the autism spectrum are often very competent at using computers and keyboards, and they may prefer typing over writing homework and exams. In this case, the presentation of their work is then similar to the other kids. A parent or teacher could also act as the youngster’s scribe to guarantee the legibility of her written answers or homework. The ability to write longhand may become a lot less important in the future.

5. Basic Skills— Catching and throwing precision seems to be especially affected in HFA and AS children. When catching a ball with two hands, the arm movements of the child are often badly coordinated and affected by problems with timing (e.g., the hands close in the correct position, but a fraction of a second too late). One study noted that children on the spectrum would frequently not look in the direction of the target prior to throwing. Clinical observation additionally indicates that they have poor coordination in their ability to kick a ball.

One consequence of not being proficient at ball games is the exclusion of the HFA or AS child from some of the most well-liked games on the playground (i.e., kick ball). These “special needs” children may avoid such games simply because they understand they lack proficiency, or are intentionally excluded since they're a liability to the team. As a result, they're much less able to improve ball skills with practice. From an early age, mothers and fathers should help their child practice ball skills in order to guarantee that he has fundamental proficiency to be included in the games. The child can be enrolled in a junior soccer or basketball team to enhance coordination and to learn to play specific games. It's also vital that you have your child’s eyesight examined to determine whether wearing glasses enhances hand-eye coordination.

6. Balance— In HFA and AS children, there can be an issue with balance, as tested by analyzing the ability to stand on one leg with eyes closed. A number of autistic youngsters are not able to balance when placing one foot in front of the other (i.e., tandem walking, which is the task of walking a straight line as though it were a tightrope). This may affect the child's ability to use some playground equipment and activities in the gym. The child may need practice and encouragement with activities that require balancing.

Here are some exercises for babies and younger children with Hypotonia to develop fine motor skills:
  • Use deep pressure massage on the hands and feet, focusing on the pad of the big toe and each of the fingertips.
  • Talk to your child often. Tell him what you're doing, especially when bathing, grooming, dressing or changing him. Verbally repeat each step in the process often. Play mimic games with your child, repeating the sounds he will naturally make. Encourage him to make sounds by making faces, singing, and talking nonsense syllables.
  • Rub the hands and feet together, first left hand to left foot, then right hand to right food, then across the body.
  • Resist any thrust of your child's legs while you're holding her, and hold her often in a standing position while supporting her well in the torso. 
  • Play patty cake and patty foot to bring hands and feet into the center of the body.
  • Place toys or objects at the midline of the body and encourage drawing the limbs in to pick these objects up successfully.
  • Use small beanbags for weights and movement training.
  • Place child-safe mirrors on crib walls or down near the floor where your child can see himself often. This helps increase his self-image and self-reflection.
  • Make a safe place for your child in every room of your house, and bring her along as you go about your normal routine. The frequent changes in environment and constant contact with you will help stimulate your child's mind and awareness.
  • Lightly brush from the heel to the toe on each foot and from the base up to the fingertips on each hand with light massage strokes or a soft 1-inch paintbrush.
  • Hold bright or desirable small objects out, encourage reaching for it and praise any attempt or success to do so.
  • Help your youngster to do occasional rounds of heel walking, where all of her weight is balanced on her heel and her toes stick in the air.
  • Give your baby a lot of smiles, hugs and cuddles. This both increases emotional bonding and stimulates his senses.
  • Use a backpack with books or toys in it for weight training.
  • Expose your child to as many different pleasant stimuli as you can think of (e.g., mobiles, wind chimes, patterned cloth for crib sheets and bumpers, musical or noise toys in bright primary colors, etc.). Primary colors are bright red, blue and yellow. Babies see high-contrast things the best, and love these colors. An effective tactic that some parents have used is to cut out suitable pictures from magazines and placing on the baby's walls, which allows the frequent change-out of pictures needed to give stimulation without breaking the bank.
  • Draw feet up to the baby's mouth, circling the mouth with each big toe. Repeat with hands and fingertips in order to increase awareness of extremities and oral motor control.
  • Create tape recordings of your child's own sounds, the sounds of your family, and appropriate music. Play these tapes often, and dance your child around rhythmically in your arms during music or sounds. This helps her to become aware of her own body.

Treatment—


Speech and language therapy: A speech and language therapist can assess your HFA or AS youngster’s feeding and swallowing, and help identify swallowing problems that can sometimes be associated with Hypotonia. The therapist will also be able to make recommendations about feeding support.

Occupational therapy: Occupational therapy teaches the child the skills needed to carry out day-to-day activities (e.g., the therapist may focus on improving your child’s hand and finger skills needed for dressing and feeding). Your child will also be taught exercises and tasks she can perform on a daily basis. Equipment to help her move around more easily may also be recommended (e.g., ankle or foot supports if the child’s ankles or feet are affected by Hypotonia).

Physiotherapy:
A physiotherapist will assess your youngster’s muscle tone and ask him to carry out a series of exercises and tasks. In treating Hypotonia, the main objectives of physiotherapy are to strengthen the muscles around the joints of the arms and legs so they provide more support and stability, and to improve posture and co-ordination to compensate for low-muscle tone. The therapist will design a program that includes a range of exercises for your youngster to do on a daily basis. Therapy will be integrated into your youngster’s daily routine and everyday activities, both at school and at home.

Parenting Children and Teens with High-Functioning Autism


COMMENTS:

•    Anonymous said…   Lots of kids with ASD have movement issues due to the lack of priopercepitation, the input from the environment to their bodies. Spatial awareness is often affected. Anytime you have an issue with sensory processing you will issues with the "body in space" concept. Lots of kids seem to have hypotonia but actually have a lack of sensory input from their body. Hypotonia can be comorbid. So can Dyspraxia (dyspraxia is on the Developmental Coordinator Disorder Spectrum), but Dyspraxia is literally the abscence of any other explainable reason for movement oddities, so most kids will only get that DX at an older age.
•    Anonymous said…   My son 9 is exactly the same he can't dress himself, ride a bike, swim do his own shoes etc even though we practice every night.
•    Anonymous said…  It's unfortunately normal. My 13 yr old son has HFA and still can't tie his shoes, prefers to eat with his hands (even with this he still uses what I call a "mitten hand" grasp), and just cannot play team sports. Being in middle school and having these difficulties is devastating, particularly because he is very intelligent and in all advanced classes. We are fortunate enough to have two boys right in our neighborhood who have accepted his quirks and give him a ton of leniency when they try to play kickball, but if anyone else joins he usually just quits rather than be embarrassed. He's always been a toe walker and routinely complains of pain in his hips too. I hate it but there isn't really anything I can do that I haven't already done...
•    Anonymous said…  Kids on the spectrum tend to have difficulties with bilateral coordination. The OT I spoke with about my daughter said she suspected its due to the limited communication between the two hemispheres in the brain.
•    Anonymous said…  My 19 year old struggles to spread peanut butter with a knife. He does his best, but it's a mess. Sometimes to anoint of frustration for him. We keep supporting him to be independent...meaning we clean up the counter often!!
•    Anonymous said…  My 27 month old daughter just started crawling (after lots of PT). Her hypotonia was diagnosed when she was 13 months old. Hypotonia can actually effect some parts of the body than other. She mostly has issues in her legs; her feeding and fine motor skills have not been affected whatsoever. There's a supportive Facebook group called Hypotonia Parents that has been useful.
•    Anonymous said…  My 9 year old daughter is HFA and just learned to tie shoes. She is also uncoordinated and seems to trip over her feet a lot. She did some OT and that helped her a lot.
•    Anonymous said…  My Aspie boy just finished 15 mo. of intense Occupational Therapy/Physical Therapy and Speech Therapy. He is showing some improvements in all areas. I've been told by both of his physical therapists that swimming and rock wall climbing next would continue to improve his balance, bilateral coordination and endurance. He's been given yoga ball activities for home maintenance.
•    Anonymous said…  My daughter is 10 and has the same issues. Sports, gymnastics, riding a bike, skating etc are all things she has no coordination to do. She can however swim. She is very clumsy, can't tie shoes or even a simple knot. Her vocabulary has always been extensive. And she is super smart. But exercise is simply not her thing...except for swimming. She does ride a bike now but just learned last year.
•    Anonymous said…  My son had some minimal improvements with OT and speech, but not a significant amount. These therapies aren't cure-alls... and I'm sure most of us have tried OT (for years). I'm hoping to hear other suggestions...
•    Anonymous said…  My son has asperbergers. Most of your issues fit however my son was an early Walker and taller with an extensive vocabulary. I had to pull him out of high school is junior year because of sensory issues. He's 22 and still can't ride a bike, tie his shoes or skip. He is in college this year with a 4.0 GPA. One thing to remember about these kids is that they don't fit into a box. They are all unique.
•    Anonymous said…  My son has had some of these delays. He still can't swim. He's finally riding a bike. I noticed that he was sort of like a wet noodle on his bike - very hunched over and all over the place and I kept talking to him about keeping his back straight. That concept seemed very foreign to him and I don't think it's something you typically have to tell kids. It made me wonder if something like horseback riding therapy would be or would have been helpful. I think balance and core strength could be a big issue. I haven't done it but I've heard wonderful things from other parents about it.
•    Anonymous said…  My son has this as well. He walked at 22 months and still struggles with sloppy eating, riding a bike, etc. He is almost 9
•    Anonymous said…  My son was advised to throw a tennis ball against the wall...this has really helped his coordination so much..
•    Anonymous said…  Occupational and Physical therapy can help address these issue. Please seek help as soon as you can. Sooner is better.
•    Anonymous said…  Occupational and physical therapy will help. Also, hitting a ball off a T, as in t-ball helped my son.
•    Anonymous said…  Occupational therapy for the coordination issues and speech therapy.
•    Anonymous said…  Read some stuff by sally Goddard. It helped me find a therapist that works on the mid line coordination as well as other things  :)
•    Anonymous said…  Team sports have been disastrous.
•    Anonymous said…  The definitions of disabilities changes more often than the public knows. There's actually a government handbook of these. Schools can provide speech, occupational therapy, and social skills class Three of my kids go to these. My daughter diagnosed with Aspergers is 11. She has none of those problems but my other two do. My son can't do buttons and lacks fine motor skills. I had always thought it was because he started video games at two and is obsessed with them. Other parents with gaming kids don't have that problem mostly. Speech helped a lot BC her teacher makes it fun n I didn't stop harassing school until they did it there too. All kids are different, that's why theirs a spectrum theory. Too many symptoms are available.
•    Anonymous said…  The Masgutova Method has saved my kid's life
•    Anonymous said…  We have spent the last year with frequent medical tests trying to find the reason why our 20 year old with HFA / Aspergers is having spine, joint issues... this describes her as a child exactly and now as an adult i am beginning to understand that the hypotonia has become a long term contributor to major issues she is now struggling with... we didn't get a clear diagnosis until a couple years ago!

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