Abnormalities of joint mobility and gait in children with autism spectrum disorders

Clinical gait analysis in older children with autism spectrum disorder

Individuals with autism spectrum disorder (ASD) often exhibit motor deficits that increase their risk of falls. There is a lack of understanding regarding gait biomechanics demonstrated by older children with ASD. The purpose of the study was to determine differences in gait patterns between older children with ASD and typically developing children. Eleven children with ASD and 11 age- and gender-matched typically developing children were recruited for the study. Participants walked on a force-instrumented treadmill at a constant speed (1.1 ​m/s ​- ​1.2 ​m/s) for five minutes (min). Participants performed maximal voluntary contractions to assess their knee muscular strength. Differences between individuals with ASD and matched control participants were examined through paired t-tests with a significance level of p ​≤ ​0.05. Individuals with ASD demonstrated a smaller knee extensor torque compared to controls (p ​= ​0.002). Participants with ASD exhibited a shorter stride length (p ​= ​0.04), a greater cadence (p ​= ​0.03), and a higher variation in stride width (p ​= ​0.04) compared to control participants. The individuals with ASD experienced a greater braking ground reaction force (p ​= ​0.03) during loading response. The results indicate older children with ASD develop a unique gait pattern signified by a reduced stride length, increased cadence, and an increase of variation in stride width. This unique gait pattern may represent a movement strategy used by the individuals with ASD to compensate for the weakness associated with their knee extensor muscles. Individuals with ASD who demonstrate these unique gait deviations may face reduced postural stability and an increased risk of fall-related injuries.

Quantitative assessment of tip-toe behavior in individuals with autism spectrum disorder and intellectual disability: A cross-sectional study

The term "toe walking" describes walking on the toes with a lack of heel strike upon initiation of the stance phase of gait. In individuals with autism spectrum disorder (ASD), this phenomenon, or "tip-toe behavior" (TTB), can be present in a substantial proportion of subjects even during standing. In this study, we investigated TTB in 50 persons with ASD (age range 4-26 years). We evaluated TTB through an observational/report-based assessment protocol. Subsequently, we employed a new structured video-based coding protocol based on standardized video recordings, focusing on static and dynamic conditions. Finally, the findings of the two protocols were compared. Twenty-four subjects with TTB were identified and classified according to three functional groups: TTB1, present only during running (6 subjects); TTB2, present during walking and running (11 subjects); and TTB3, present during standing, walking, and running (7 subjects). Moreover, we found that TTB3 subjects exhibited a significantly higher quantity of TTB compared with subjects in the TTB1 and TTB2 groups during both standing and walking tests. Additionally, a high quantity of TTB in the static test was found to be related to a high quantity of TTB in the dynamic test. Variables such as age, autism severity, intellectual disability, and gender were not significantly associated with the mean percent of TTB both in static and dynamic tests in multivariate analysis. This structured video-based coding approach appears feasible and useful for assessing TTB in individuals with ASD and it has the potential to provide insights into TTB trajectories and aid in designing possible interventions.

Relationship and New Prospectives in Joint Hypermobility in Children with Autism Spectrum Disorder: Preliminary Data

Autism spectrum disorder (ASD) and joint hypermobility (JH) are considered two different etiological and clinical entities that most often appear in childhood. Despite growing increased research showing a co-occurrence for both conditions, a link between them is rarely established in clinical settings, and the relationship between ASD and JH has not so far been completely investigated in all age groups of ASD children. This preliminary study examined a cohort of 67 non-syndromic ASD children aged 2-18 years (sex ratio M:F = 12:1) showing different degrees of cognitive impairment and autism severity, using the Beighton scale and its revised version. A total of 63% of ASD patients aged 2-4 years and 73% of ASD patients aged ≥5 years presented significant scores of hypermobility. No significant correlation was found comparing total laxity score and cognitive assessments and severity of autistic symptomatology (p > 0.05). The results suggest that JH could be considered as a clinical characteristic of ASD patients and it needs to be assessed in order to schedule a better rehabilitation program.

Corneal structural alterations in autism spectrum disorder: An in vivo confocal microscopy study

Individuals with autism spectrum disorder (ASD) often exhibit joint hypermobility and connective tissue disorders. However, it remains unclear if ASD individuals also have structural alterations in the connective tissue of the cornea. This study aims to determine whether the Kobayashi structure (K-structure) characteristics differ between adults with ASD and typically developing controls (TDC) and explore the clinical correlates of the K-structure abnormality. We recruited 30 ASD adults and 35 TDC. Corneal structures, particularly the K-structure in the Bowman's layer, of the participants were examined using in vivo confocal microscopy (IVCM), and a K-grading ranging from 1 to 4 was given to each eye based on the level of morphological mosaicism. The ASD participants' eyes received a significantly higher single-eye K-grading than that of the TDC eyes (p < 0.001), and the medians [25th, 75th percentile] of bilateral-eye summed K-grading were 8 [7, 8] and 5 [4, 6] in ASD and TDC, respectively (p < 0.001). A significantly higher K-grading in the ASD participants' eyes was still observed after adjusting for the within-subject inter-eye correlation (p < 0.001). Youden Index showed the optimal cutoffs to differentiate ASD from TDC by bilateral-eye summed K-grading and single-eye K-grading was >6 and >3, respectively. Additionally, a higher K-grading was associated with fewer visual sensation seeking in ASD (Spearman's correlation coefficient ρ = -0.518, p = 0.008) and low visual registration (i.e., higher sensory threshold) in TDC (ρ = 0.446, p = 0.023). This study provided novel evidence of corneal structural alterations in ASD by IVCM. Our findings may not only support the prior hypothesis of the association between ASD and connective tissue abnormalities but also shed light on the relationship between connective tissue disorder and neurodevelopmental disorders.

Efficacy of Motor Interventions on Functional Performance Among Preschool Children With Autism Spectrum Disorder: A Pilot Randomized Controlled Trial

IMPORTANCE

Motor ability plays an important role in overall developmental profiles. Preschool children with autism spectrum disorder (ASD) are at risk of motor skills deficits and delays. However, evidence of the efficacy of different motor interventions for the identification of optimal treatment types is lacking, especially for preschool children with ASD.

OBJECTIVE

To examine the efficacy of the Motor Skill Occupational Therapy Intervention ON ASD (MOTION-ASD) and Cognitive Orientation Exercise (CO-EXC) programs to improve motor skills performance, self-care performance, and adaptive behaviors among preschool children with ASD.

DESIGN

Randomized controlled trial, two-group, triple-blinded, repeated-measures design Setting: University laboratory.

PARTICIPANTS

Thirteen preschool children with ASD (M age = 4.91 yr).

OUTCOMES AND MEASURES

The Bruininks-Oseretsky Test of Motor Proficiency-Second Edition, Brief Form, Assessment of Motor and Process Skills, and Vineland Adaptive Behavior Scales-Third Edition.

RESULTS

Children in the MOTION-ASD group showed significantly greater improvements in manual coordination and overall gross and fine manual skills than those in the CO-EXC group immediately after the intervention. Significant improvements in fine manual control, body coordination, overall motor skills, and self-care performance were made throughout both interventions and were retained at the posttest and the 4-wk follow-up.

CONCLUSIONS AND RELEVANCE

These findings provide supporting evidence that motor skills interventions involving fundamental skills and cognitive training may be a viable therapeutic option for treating children with ASD. The results also suggest that practitioners may consider providing structured and strategic motor skills interventions for preschool children with ASD. What This Article Adds: This study's rigorous tests of motor skills interventions support ways to manage motor difficulties in children with autism spectrum disorder (ASD). An intervention based on motor learning theory could benefit preschool children with ASD, especially in terms of manual coordination ability and overall gross and fine motor skills.

Pediatric joint hypermobility: a diagnostic framework and narrative review

BACKGROUND

Hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD) are debilitating conditions. Diagnosis is currently clinical in the absence of biomarkers, and criteria developed for adults are difficult to use in children and biologically immature adolescents. Generalized joint hypermobility (GJH) is a prerequisite for hEDS and generalized HSD. Current literature identifies a large proportion of children as hypermobile using a Beighton score ≥ 4 or 5/9, the cut off for GJH in adults. Other phenotypic features from the 2017 hEDS criteria can arise over time. Finally, many comorbidities described in hEDS/HSD are also seen in the general pediatric and adolescent population. Therefore, pediatric specific criteria are needed. The Paediatric Working Group of the International Consortium on EDS and HSD has developed a pediatric diagnostic framework presented here. The work was informed by a review of the published evidence.

OBSERVATIONS

The framework has 4 components, GJH, skin and tissue abnormalities, musculoskeletal complications, and core comorbidities. A Beighton score of ≥ 6/9 best identifies children with GJH at 2 standard deviations above average, based on published general population data. Skin and soft tissue changes include soft skin, stretchy skin, atrophic scars, stretch marks, piezogenic papules, and recurrent hernias. Two symptomatic groups were agreed: musculoskeletal and systemic. Emerging comorbid relationships are discussed. The framework generates 8 subgroups, 4 pediatric GJH, and 4 pediatric generalized hypermobility spectrum disorders. hEDS is reserved for biologically mature adolescents who meet the 2017 criteria, which also covers even rarer types of Ehlers-Danlos syndrome at any age.

CONCLUSIONS

This framework allows hypermobile children to be categorized into a group describing their phenotypic and symptomatic presentation. It clarifies the recommendation that comorbidities should be defined using their current internationally accepted frameworks. This provides a foundation for improving clinical care and research quality in this population.

Effects of an 8-week multimodal exercise program on ground reaction forces and plantar pressure during walking in boys with autism spectrum disorder

BACKGROUND

Autism spectrum disorder is a developmental disability with first signs appearing in children aged 3 years and younger. Given that autism spectrum disorder is accompanied by a broad range of symptoms such as impaired sensory, neurological, and neuromotor functions, it appears plausible to argue that an intervention program focusing on multimodal exercise rather than single-mode exercise might be more effective in treating this wide variety of symptoms.

OBJECTIVE

The aim of this study was to evaluate the effects of a multimodal exercise program entitled Sports, Play, and Active Recreation for Kids on variables of ground reaction forces and plantar pressure during walking in boys with autism spectrum disorder.

METHODS

Twenty-four autism spectrum disorder boys aged 7-11 years were recruited and randomly allocated into an intervention or a waiting control group. Sports, Play, and Active Recreation for Kids was conducted over a period of 8 weeks with three weekly sessions. This training protocol includes aerobic dance and jump rope exercises as well as running games. Pre- and post-training, ground reaction forces and plantar pressure variables were recorded while walking at a constant walking speed of 0.9 m/s using a foot scan embedded in a 15-m walkway.

RESULTS

Significant group-by-time interactions were found for the first peak of vertical ground reaction force, loading rate, and peak pressure at the medial heel region (all p = 0.001-0.49, d = 0.89-1.40). Post-hoc analyses showed significant pre-post decreases for the first peak of vertical ground reaction force (p = 0.001, d = 1.27), loading rate (p = 0.009, d = 1.11), and peak pressure at the medial heel region (p = 0.021, d = 1.01).

CONCLUSIONS

Our results suggest that a joyful and multimodal exercise program has positive effects on kinetic walking characteristics of autism spectrum disorder boys. Accordingly, we recommend to implement this type of exercise in prepubertal autism spectrum disorder boys to improve gait kinetics.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20170806035517N4. Registered on November 8, 2021. This study was approved by the Ethical Committee of the University of Mohaghegh Ardabili, Ardabil, Iran (IR.UMA.REC.1400.019). The study was conducted in accordance with the latest version of the Declaration of Helsinki.

Association Between Autism Spectrum Disorders and Cardiometabolic Diseases: A Systematic Review and Meta-analysis

Importance

Although the increased risk of obesity among individuals with autism has been well established, evidence on the association between autism, cardiometabolic disorders, and obesity remains inconclusive.

Objective

To examine the association between autism spectrum disorders and cardiometabolic diseases in a systematic review and meta-analysis.

Data Sources

PubMed, Scopus, Web of Science, ProQuest, Embase, and Ovid databases were searched from inception through July 31, 2022, without restrictions on date of publication or language.

Study Selection

Observational or baseline data of interventional studies reporting the prevalence of cardiometabolic risk factors (ie, diabetes, hypertension, dyslipidemia, atherosclerotic macrovascular disease) among children and/or adults with autism and matched with participants without autism were included.

Data Extraction and Synthesis

Screening, data extraction, and quality assessment were performed independently by at least 2 researchers. DerSimonian-Laird random-effects meta-analyses were performed using the meta package in R.

Main Outcomes and Measures

Relative risks (RRs) of diabetes, hypertension, dyslipidemia, and atherosclerotic macrovascular disease among individuals with autism were the primary outcomes. Secondary outcomes included the RR of type 1 and type 2 diabetes, heart disease, stroke, and peripheral vascular disease.

Results

A total of 34 studies were evaluated and included 276 173 participants with autism and 7 733 306 participants without autism (mean [range] age, 31.2 [3.8-72.8] years; pooled proportion [range] of female individuals, 47% [0-66%]). Autism was associated with greater risks of developing diabetes overall (RR, 1.57; 95% CI, 1.23-2.01; 20 studies), type 1 diabetes (RR, 1.64; 95% CI, 1.06-2.54; 6 studies), and type 2 diabetes (RR, 2.47; 95% CI, 1.30-4.70; 3 studies). Autism was also associated with increased risks of dyslipidemia (RR, 1.69; 95% CI, 1.20-2.40; 7 studies) and heart disease (RR, 1.46; 95% CI, 1.42-1.50; 3 studies). Yet, there was no significantly associated increased risk of hypertension and stroke with autism (RR, 1.22; 95% CI, 0.98-1.52; 12 studies; and RR, 1.19; 95% CI, 0.63-2.24; 4 studies, respectively). Meta-regression analyses revealed that children with autism were at a greater associated risk of developing diabetes and hypertension compared with adults. High between-study heterogeneity was a concern for several meta-analyses.

Conclusions and Relevance

Results suggest that the associated increased risk of cardiometabolic diseases should prompt clinicians to vigilantly monitor individuals with autism for potential contributors, signs of cardiometabolic disease, and their complications.

[Motor impairments in children with autism spectrum disorders: causes and possibilities for correction]

Autism spectrum disorder (ASD) is characterized by triad of abnormalities in the form of developmental distortion with a lack of communicative abilities, behavioral and motor stereotypies. Etiology and pathogenesis of disease currently are unknown, but multifactorial causes of this pathology have been suggested. Although social disorders are considered a defining characteristic, motor disorders are a key feature of ASD. They are based on a postural control impairment, which is accompanied by delayed psychomotor development, reduced ability to motor synchronism in early childhood, modified arrangement of muscles, problems with balance and gait, postural instability, coordination deficiency, presence of motor dyspraxia and other abnormalities.

OBJECTIVE

To analyze current scientific data about motor disorders in ASD and their correction possibilities in children with this pathology.

MATERIAL AND METHODS

Analysis of publications, contained in PubMed and Google Scholar databases, which give consideration to motor disorders in children with ASD, was carried out. The search was done by keywords: motor disorders, children, autism spectrum disorder, causes, correction.

RESULTS AND CONCLUSION

Adaptive physical culture during individual training is one of the available and effective methods of physical rehabilitation in patients with ASD. Children with ASD need three levels of psychological support, each of which offers individual exercises, depending on the nature and severity of speech and cognitive impairment.

Children with autism display altered ankle strategies when changing speed during over-ground gait

BACKGROUND

Examining gait mechanics when altering speed has been used in various clinical populations to understand the pervasiveness of neurological impairments. Few studies have examined whether different gait mechanics exist when altering speed in children with Autism Spectrum Disorder, although autism may present as a movement disorder due to abnormalities in the central nervous system. Most autism gait-related research has used preferred walking speed, while different speeds may yield discernible patterns that can be used for future interventions. The purpose of this study was to examine kinematic strategies used by children with autism in preferred, fast, and slow walking speeds.

METHODS

Three-dimensional kinematic data were obtained on 14 children (aged 8-17 years) during preferred, fast, and slow walking. Hip, knee, and ankle angular joint positions were examined at loading response, pre-swing, and terminal swing sub-phases due to their importance on forward propulsion and weight transfer. Repeated measures analyses of variance (α = 0.05) were used to test for statistical differences and effect sizes were interpreted with Cohen's d.

FINDINGS

Although significant differences were observed for each joint and sub-phase, the left and right ankle joints during pre-swing displayed the most consistent differences among conditions (p < 0.001, and p < 0.001), respectively. Additionally, the left ankle displayed a moderate effect size (η² = 0.71) and the right ankle displayed a large effect size (η² = 0.80).

INTERPRETATIONS

These findings reveal that the ankle joint, during pre-swing, is the primary kinematic strategy used by children with autism when altering gait speed, whereas previous evidence suggests that the hip joint was the primary strategy.

The Management of Toe Walking in Children with Autism Spectrum Disorder: "Cast and Go"

Background: Toe walking is associated with autism spectrum disorders (ASD). Correction of this “behavior” is a health challenge. The toe walker is affected by the contact refusal with the outside world: touching the ground as little as possible, trying to avoid any contact. A structured equines foot is a possible consequence. Method: We present the “Cast and Go” protocol, used in 22 idiopathic toe walker children with ASD treated from 2015 to 2020. The treatment was performed by a single senior experienced doctor with botulinum injection, ankle casts and rehabilitative therapies. All patients underwent pre- and post-treatment clinical evaluation using ankle dorsiflexion angle and casting number as treatment. We aimed to identify the intervention with the shortest acquisition time for the management of toe walking. Results: Our findings demonstrated the baseline ankle dorsiflexion angle influenced the casting number (p < 0.01) and male patients had a higher baseline ankle dorsiflexion angle than female patients (p < 0.01). No adverse events were observed. Conclusions: These findings suggested that the “Cast and Go” protocol could be a promising, dynamic and effective practice for toe walking disease in ASD patients.

Sensory Profile of Children and Adolescents with Autism Spectrum Disorder and Tip-Toe Behavior: Results of an Observational Pilot Study

Atypical sensory processing is frequently reported in persons with autism spectrum disorders (ASD), and it is one of the described diagnostic criteria for ASD. There is also mounting literature supporting the presence of motor impairments in individuals with ASD. Among these motor signs, tip-toe behavior (TTB) is a possible clinical finding, but its etiology is not clearly understood. It is suggested that TTB in ASD could be a sign of a sensory modulation impairment, but evidence is lacking and controversial. The main aim of this pilot study is to explore sensory features in a sample (4 females; 28 males) of children and adolescents with ASD (age range: 7-18). All participants also presented Intellectual Disability. Participants were divided in two groups, matched for age and gender, on the basis of the presence or absence of TTB (16 ASD TTB group vs. 16 ASD NO-TTB group) and then evaluated by using the Short Sensory Profile. We found that both ASD groups tend to significantly present sensory-related behavioral symptoms, but ASD TTB individuals more frequently showed the specific pattern of "under responsive/seeks sensation" than ASD NO-TTB individuals. These preliminary findings support that sensory-motor features might be taken into consideration when rehabilitation for TTB in children and adolescents with ASD is necessary.

Comparison of Treadmill Gait Between a Pediatric-Aged Individual With SYNGAP1-Related Intellectual Disability and a Fraternal Twin

SYNGAP1-related Intellectual Disability (SYNGAP1-ID) is a rare neurodevelopmental condition characterized by profound intellectual disability, gross motor delays, and behavioral issues. Ataxia and gait difficulties are often observed but have not yet been characterized by laboratory-based kinematic analyses. This investigation identified gait characteristics of an individual with SYNGAP1-ID and compared these with a neurotypical fraternal twin. Lower limb kinematics were collected with a 12-camera motion capture system while both participants walked on a motorized treadmill. Kinematic data were separated into strides, and stride times calculated. Sagittal plane hip, knee, and ankle joints were filtered and temporally normalized to 100 samples. Minimum and maximum joint angles, range of motion (ROM) and angular velocities were obtained for each joint by stride and averaged for each participant. ROM symmetry between left and right joints was also calculated. Discrete relative phase (DRP) was used to assess coordination and variability between joints within a single limb and compared across limbs. Phase portraits were calculated by joint, and their areas were computed with a MATLAB script. Statistical parametric mapping (SPM) was used to assess differences in joint angle waveforms between participants. P1, the individual with SYNGAP1-ID, displayed significantly reduced stride times relative to the fraternal twin, i.e., P2. A majority of minimum, maximum angles, ROMs, and angular velocities were significantly different between P1 and P2. Phase portrait areas were consistently less in P1 relative to P2 and there were differences in knee and ankle symmetries. DRP showed no differences between individuals, suggesting that P1’s coordinative events remained similar to those observed during neurotypical gait (P2). SPM revealed significant differences between the left and right legs at the knee and ankle joints of P1 while P2 joint left and right waveforms were nearly identical for all joints. Additionally, SPM revealed there were significant differences between P1 and P2 for all joints. This investigation identified several major gait features of an individual with SYNGAP1-ID and provided a comprehensive characterization of these features by utilizing both linear and non-linear analyses. While limited in generalizability, this report provides a strong quantitative appraisal of gait in an individual with SYNGAP1-ID as well as an analysis pathway for future investigations.

Little Evidence for Conservative Toe Walking Interventions in Autism Spectrum Disorders: a Systematic Review

This systematic review summarizes the evidence about toe walking (TW) interventions in persons with autism. Following the PRISMA guidelines, a systematic search of MEDLINE, CINAHL, PsycINFO, The Cochrane Library, Google Scholar, and Opengrey was performed. Nine articles (all case reports or case series) were included. Methodological quality was assessed using the Mayo Evidence-Based Practice Centre tool. The included studies considered 17 subjects (16 males; age range: 4–15 years). All studies reported a reduction of TW frequency, but the follow-up was lacking in seven studies. There is a lack of high-quality studies with a sufficiently large and well-characterized sample to assess the effectiveness of TW interventions in autistic persons. These findings strongly support the need for further research in this area.

Autonomic Dysfunction in Autism Spectrum Disorder

Background: There have been previous reports of enhanced sympathoexcitation in autism spectrum disorder (ASD). However, there has been no formal investigation of autonomic dysfunction in ASD. Also, the joint hypermobile form of Ehlers-Danlos syndrome (hE-DS) that maybe overrepresented in ASD and orthostatic related autonomic dysfunction. This study examined the comorbidity of ASD, autonomic dysfunction and hE-DS in two UK autonomic national referral centers. Proven, documented and globally accepted clinical autonomic investigations were used to assess neuro-cardiovascular autonomic function in a cohort of ASD subjects and in age-matched healthy controls. Methods: Clinical data from 28 referrals with a confirmed diagnosis of ASD over a 10-year period were compared with 19 age-matched healthy controls. Autonomic function was determined using methods established in the centers previously described in detail. Results: 20/28 ASD had a diagnosed autonomic condition; 9 had the postural tachycardia syndrome (PoTS), 4 PoTS and vasovagal syncope (VVS), 3 experienced presyncope, 1 essential hyperhidrosis, 1 orthostatic hypotension, 1 VVS alone and 1 a combination of PoTS, VVS and essential hyperhidrosis. 16/20 ASD with autonomic dysfunction had hE-DS. In ASD, basal heart rate and responses to orthostatic tests of autonomic function were elevated, supporting previous findings of increased sympathoexcitation. However, sympathetic vasoconstriction was impaired in ASD. Conclusion: Intermittent neuro-cardiovascular autonomic dysfunction affecting heart rate and blood pressure was over-represented in ASD. There is a strong association with hE-DS. Autonomic dysfunction may further impair quality of life in ASD, particularly in those unable to adequately express their experience of autonomic symptoms.

Weighted Vest Loads Do Not Elicit Changes in Spatial-Temporal Gait Parameters in Children and Adolescents With Autism

Weighted vests have been used primarily as behavioral interventions for children and adolescents with autism. Contemporary research has begun to examine weighted vest effects on movement. Previous research in children with neurotypical development revealed 15% body mass loads modified spatial-temporal gait characteristics; however, a value applicable to children and adolescents with autism has not been established. The purpose of this study was to establish an appropriate mass value by examining spatial-temporal gait parameters in children and adolescents with autism with various loads in a weighted vest. Nine children and adolescents with autism, aged 8–17, walked without a weighted vest, with 5%, 10%, 15%, and 20% body mass while spatial-temporal data were captured. Repeated-measures analysis of variance (α = .05) were conducted among conditions for each variable, with a Holm–Bonferroni method correction. Analysis revealed significant decreases in right step length, but no differences in stride width, left step length, double-limb support time, or stride velocity were observed. Due to insignificant findings, an appropriate mass value could not be determined for weighted vests for children with autism. However, unchanged spatial-temporal gait parameters with increasing loads could be clinically relevant as weighted vest loads of 10% are typically used for behavioral interventions.

Neurodevelopmental atypisms in the context of joint hypermobility, hypermobility spectrum disorders, and Ehlers-Danlos syndromes

Joint hypermobility (JHM), defined as an increased range of joint motion, is a frequent somatic trait in the general population but also the hallmark of many of the hereditary disorders of connective tissue. Ehlers-Danlos syndromes (EDS) belong to this group of diseases and are characterized by tissue fragility, skin abnormalities, and JHM. Between JHM and EDS, there are the so-called hypermobility spectrum disorders (HSD), which is an umbrella term referring to people with symptomatic JHM who do not fulfill criteria for a syndromic connective tissue disorder such as EDS. Among the variety of clinical correlates of JHM/HSD/EDS, neurodevelopmental atypisms are common although often not screened for and identified in the clinical setting. This article reviews the pertinent literature concerning neurodevelopmental conditions for which there is some evidence of an association with JHM/HSD/EDS. These include hyperactivity and attention deficit, learning, communication, and motor problems including tic disorders such as Tourette syndrome and autism spectrum disorders. Underlying mechanism hypotheses for such interconnections are also reviewed. The coexistence of connective tissue-altered conditions and neurodevelopmental atypisms increases disability in patients from an early age. Thus, increased awareness among clinicians and researchers is necessary to promote assessment, diagnosis, and develop management strategies to meet the specific needs of those affected.

Connecting brain and body: Transdiagnostic relevance of connective tissue variants to neuropsychiatric symptom expression

The mind is embodied; thoughts and feelings interact with states of physiological arousal and physical integrity of the body. In this context, there is mounting evidence for an association between psychiatric presentations and the expression variant connective tissue, commonly recognised as joint hypermobility. Joint hypermobility is common, frequently under-recognised, significantly impacts quality of life, and can exist in isolation or as the hallmark of hypermobility spectrum disorders (encompassing joint hypermobility syndrome and hypermobile Ehlers-Danlos syndrome). In this narrative review, we appraise the current evidence linking psychiatric disorders across the lifespan, beginning with the relatively well-established connection with anxiety, to hypermobility. We next consider emerging associations with affective illnesses, eating disorders, alongside less well researched links with personality disorders, substance misuse and psychosis. We then review related findings relevant to neurodevelopmental disorders and stress-sensitive medical conditions. With growing understanding of mind-body interactions, we discuss potential aetiopathogenetic contributions of dysautonomia, aberrant interoceptive processing, immune dysregulation and proprioceptive impairments in the context of psychosocial stressors and genetic predisposition. We examine clinical implications of these evolving findings, calling for increased awareness amongst healthcare professionals of the transdiagnostic nature of hypermobility and related disorders. A role for early screening and detection of hypermobility in those presenting with mental health and somatic symptoms is further highlighted, with a view to facilitate preventative approaches alongside longer-term holistic management strategies. Finally, suggestions are offered for directions of future scientific exploration which may be key to further delineating fundamental mind-body-brain interactions.

Could Gait Biomechanics Become a Marker of Atypical Neuronal Circuitry in Human Development?-The Example of Autism Spectrum Disorder

This perspective paper presents converging recent knowledge in neurosciences (motor neurophysiology, neuroimaging and neuro cognition) and biomechanics to outline the relationships between maturing neuronal network, behavior, and gait in human development. Autism Spectrum Disorder (ASD) represents a particularly relevant neurodevelopmental disorder (NDD) to study these convergences, as an early life condition presenting with sensorimotor and social behavioral alterations. ASD diagnosis relies solely on behavioral criteria. The absence of biological marker in ASD is a main challenge, and hampers correlations between behavioral development and standardized data such as brain structure alterations, brain connectivity, or genetic profile. Gait, as a way to study motor system development, represents a well-studied, early life ability that can be characterized through standardized biomechanical analysis. Therefore, developmental gait biomechanics might appear as a possible motor phenotype and biomarker, solid enough to be correlated to neuronal network maturation, in normal and atypical developmental trajectories—like in ASD.

The Effectiveness of Serial Casting and Ankle Foot Orthoses in Treating Toe Walking in Children With Autism Spectrum Disorder

PURPOSE

This proof of concept study examined the effectiveness of serial casting (SC) and ankle foot orthoses (AFOs) in children with autism spectrum disorder (Ch-ASD) who toe walk (TW). Data collected determined effects of SC, followed by AFO intervention on ankle dorsiflexion (A-DF) passive range of motion and kinematics, and parent-reported functional outcomes for children with autism spectrum disorder who TW and have limited A-DF passive range of motion.

SUMMARY OF KEY POINTS

The 5 participants increased passive range of motion with SC, except for 1 participant's left ankle. Two of 4 participants had near typical A-DF kinematic patterns following SC. The 5 participants improved A-DF during walking following 6 months of AFO use.

CONCLUSIONS

Serial casting increased A-DF ROM and kinematics during walking. Consistent AFO use for walking training improved function and reduced toe walking. Serial casting followed by AFOs is a potential intervention for children with autism spectrum disorder who TW.

Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes

The Ehlers-Danlos syndromes (EDS) are a group of heritable, connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. There is phenotypic and genetic variation among the 13 subtypes. The initial genetic findings on EDS were related to alterations in fibrillar collagen, but the elucidation of the molecular basis of many of the subtypes revealed several genes not involved in collagen biosynthesis or structure. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. hEDS is the most common type of EDS and involves generalized joint hypermobility, musculoskeletal manifestations, and mild skin involvement along with the presence of several comorbid conditions. Variability in the spectrum and severity of symptoms and progression of patient phenotype likely depend on age, gender, lifestyle, and expression domains of the EDS genes during development and postnatal life. In this review, we summarize the current molecular, genetic, epidemiologic, and pathogenetic findings related to EDS with a focus on the hypermobile type.

Age-related gait development in children with autism spectrum disorder

BACKGROUND

A better understanding of gait development and asymmetries in children with autism spectrum disorder (ASD) may improve the development of treatment programs and thus, patient outcomes.

RESEARCH QUESTION

Does age affect walking kinematics and symmetry in children with ASD?

METHOD

Twenty-nine children (aged 6-14 years old) with mild ASD (level one) were recruited and assigned to one of the three groups based on their ages: 6-8 years (U8), 9-11 years (U11) and 12-14 years (U14). Walking kinematics were captured using an inertia measurement unit system placed bilaterally on participants' foot, lower leg, upper leg, upper arm, pelvis, and thoracic spine. Joint angles were computed and compared among the age groups. Symmetry angles were used to assess the gait symmetry and were compared among the age groups.

RESULTS

Older children exhibited less ankle dorsiflexion and knee flexion angles at heel-strike and greater plantarflexion angles at toe-off compared with younger children. In addition, a decreased pelvis and thorax axial rotation range of motion and increased shoulder flexion/extension range of motion were observed for older children. However, no age-related difference in gait symmetry was observed.

SIGNIFICANCE

These findings could suggest that older children with ASD may develop gait kinematics to a more energy-efficient walking pattern.

Joint Hypermobility Links Neurodivergence to Dysautonomia and Pain

OBJECTIVES

Autism, attention deficit hyperactivity disorder (ADHD), and tic disorder (Tourette syndrome; TS) are neurodevelopmental conditions that frequently co-occur and impact psychological, social, and emotional processes. Increased likelihood of chronic physical symptoms, including fatigue and pain, are also recognized. The expression of joint hypermobility, reflecting a constitutional variant in connective tissue, predicts susceptibility to psychological symptoms alongside recognized physical symptoms. Here, we tested for increased prevalence of joint hypermobility, autonomic dysfunction, and musculoskeletal symptoms in 109 adults with neurodevelopmental condition diagnoses.

METHODS

Rates of generalized joint hypermobility (GJH, henceforth hypermobility) in adults with a formal diagnosis of neurodevelopmental conditions (henceforth neurodivergent group, n = 109) were compared to those in the general population in UK. Levels of orthostatic intolerance and musculoskeletal symptoms were compared to a separate comparison group (n = 57). Age specific cut-offs for GJH were possible to determine in the neurodivergent and comparison group only.

RESULTS

The neurodivergent group manifested elevated prevalence of hypermobility (51%) compared to the general population rate of 20% and a comparison population (17.5%). Using a more stringent age specific cut-off, in the neurodivergent group this prevalence was 28.4%, more than double than the comparison group (12.5%). Odds ratio for presence of hypermobility in neurodivergent group, compared to the general population was 4.51 (95% CI 2.17-9.37), with greater odds in females than males. Using age specific cut-off, the odds ratio for GJH in neurodivergent group, compared to the comparison group, was 2.84 (95% CI 1.16-6.94). Neurodivergent participants reported significantly more symptoms of orthostatic intolerance and musculoskeletal skeletal pain than the comparison group. The number of hypermobile joints was found to mediate the relationship between neurodivergence and symptoms of both dysautonomia and pain.

CONCLUSIONS

In neurodivergent adults, there is a strong link between the expression of joint hypermobility, dysautonomia, and pain, more so than in the comparison group. Moreover, joint hypermobility mediates the link between neurodivergence and symptoms of dysautonomia and pain. Increased awareness and understanding of this association may enhance the management of core symptoms and allied difficulties in neurodivergent people, including co-occurring physical symptoms, and guide service delivery in the future.

Joint Hypermobility and Clinical Correlates in a Group of Patients With Eating Disorders

Background: The ability to move joints beyond the normal range of motion is called Joint Hypermobility (JHM). JHM has been associated with a plethora of physical problems and is a frequent sign of hereditary disorders of connective tissue. Neuropsychiatric conditions such as eating disorders (ED) have also been related to JHM. However, little is known about the clinical profile of people with ED and JHM. The aim of this study was to explore JHM in patients with ED and to compare the clinical characteristics of hypermobile ED patients with non-hypermobile ED patients. Method: Fifty-three outpatients diagnosed with ED were assessed using the Beighton score for JHM, the Eating Disorders Inventory 2, the Eating Disorder Examination, and the Detail and Flexibility Questionnaire. Information relating to patients' psychiatric and somatic comorbidities/symptoms was also collected. Results: Using the traditional Beighton score's cutoff of ≥4, 41.5% of the sample presented with JHM. Our results indicate that compared with non-hypermobile ED patients, those with JHM are significantly younger, suffer at a greater extent from joint pain and easy bruising, have a shorter duration of the ED, and have lower scores for cognitive rigidity. In addition, for those with anorexia nervosa, the restricting subtype represents a significantly lower proportion of hypermobile ED patients compared to non-hypermobile ED patients. Multivariate analyses showed that cognitive rigidity, age, and duration of the ED could predict the JHM status in this sample. Conclusion: These results suggest that JHM is frequent in patients with ED and is accompanied by signs of tissue fragility. Patients with ED and JHM seem to present a specific profile characterized by less cognitive rigidity and restricting behavior in the case of anorexia nervosa. Further research is needed in order to confirm these results.

The Relationship Between Generalised Joint Hypermobility and Autism Spectrum Disorder in Adults: A Large, Cross-Sectional, Case Control Comparison

Autism spectrum disorder (ASD) and generalised joint hypermobility (GJH) share a number of clinical manifestations including proprioceptive impairment, motor difficulties, sensory hypersensitivity, and autonomic dysfunction. Clinical observations suggest that GJH is overrepresented in ASD. However, there are currently few systematic studies available. Knowledge about comorbidities may unfold common aetiopathological pathways underlying the association and improve the clinical management. The aim of this large, cross-sectional comparative study is to evaluate the relationship between ASD and GJH in adults. Data on joint hypermobility, symptoms associated with both hypermobility spectrum disorders (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS), lifetime psychiatric diagnoses, psychiatric rating scales for ASD and attention deficit hyperactivity disorder (ADHD), and socio-demographics was collected for 199 individuals with ASD and 419 non-ASD community controls. Logistic regression models adjusting for covariates (age, sex, ethnicity) revealed a significant relationship between ASD and GJH and between ASD and symptomatic GJH, with adjusted odds ratios of 3.1 (95% CI: 1.9, 5.2; p < 0.001) and 4.9 (95% CI: 2.6, 9.0; p < 0.001), respectively. However, the high prevalence of comorbid ADHD in the study sample reduces the generalizability of the results among individuals with ASD without comorbid ADHD. Possibly, an additional ADHD phenotype is the primary driver of the association between ASD and GJH. Furthermore, GJH with additional self-reported symptoms, suggestive of HSD/hEDS, showed a stronger association with ASD than did non-specified GJH, indicating that symptomatic GJH plays a greater role in the relationship than non-specified GJH does. Therefore, the current study underscores the need of careful sample subclassifications. ASD with GJH may represent a novel subgroup of ASD in terms of aetiopathology and clinical presentation. Future research should elucidate the aetiological factors behind the association between ASD and GJH and evaluate how the comorbidity of GJH affects ASD outcomes.

Meta-Analysis Reveals Gait Anomalies in Autism

Gait abnormalities are frequently reported in autism. The empirical literature, however, is characterized by inconsistent findings concerning which aspects of gait are affected. We conducted a meta-analysis to summarize study findings that examined temporal and spatial (i.e., two-dimensional) gait parameters in pediatric and adult samples comprising individuals with autism and healthy controls. After searching electronic databases, a total of 18 studies were identified and included in this review. Results from the meta-analyses revealed autism is associated with a wider step width, slower walking speed, longer gait cycle, longer stance time and longer step time. Additionally, autism appears to be associated with greater intra-individual variability on measures of stride length, stride time and walking speed. Meta-regression analyses revealed cadence and gait cycle duration differences, between autism and control groups, become more pronounced with age. Overall, this review demonstrates that autism is associated with gait abnormalities. However, assessment of the methodological quality of the studies reveal, additional research is required to understand the extent that gait abnormalities are specifically linked to autism, or whether they may be secondary to other factors commonly found in this group, such as increased weight. LAY SUMMARY: It is often noted by clinicians that individuals with autism have an awkward or unusual walking style, which is also referred to as gait. In this report, we reviewed past studies that compared gait in individuals with and without autism. Our review indicates autism is associated with an abnormal gait. However, it is not yet clear whether gait abnormalities are caused by autism, or arise due to other factors such as heavier weight, which often co-occurs in this group.

Relationship between tip-toe behavior and soleus - gastrocnemius muscle lengths in individuals with autism spectrum disorders

BACKGROUND

About 20% of individuals with autism spectrum disorders (ASD) showed tip-toe behavior (TTB). This behavior may be related to a decreased ankle joint range of motion (ROM) in dorsiflexion. Physiologically, gastrocnemius (GM) and soleus (SM) muscles influence ankle ROM independently. However, no studies investigated the relationship between the amount of time individuals with ASD spend in TTB and GM and SM muscle lengths.

OBJECTIVE

To evaluate the relationship between three mutually exclusive clinical patterns of TTB i.e., during standing, walking and running (TTB Class 1), or during walking and running (TTB Class 2), or only when running (TTB Class 3), and GM and SM muscle lengths.

METHODS

Sixty-nine individuals with ASD (average age: 14.1 ± 3.6 years, 56 males) were enrolled. In a clinical setting, SM and GM muscle lengths of both legs were assessed through a manual goniometer. Measurements were performed by two trained assessors blinded to TTB classifications.

RESULTS

Individuals with ASD classified as TTB Class 1 demonstrated a shortening of both GM and SM compared with NO-TTB and TTB Class 3 individuals.

CONCLUSIONS

Our results support the relationship between TTB severity and GM and SM shortening assessed by a decreased ankle joint ROM in dorsiflexion. Further studies are needed to determine the factors associated with TTB and decreased ankle ROM.

IMOVE-An Intuitive Concept Mobility Systems for Perioperative Transfer and Induction of Anaesthesia for Special Needs Children

Children with autistic spectrum disorder (ASD) often exhibit uncontrollable disruptive behaviour during transfer to the operating room and operating table and at the induction of anaesthesia (sleep). This process often involves the physical restraining of children. These children are then lifted onto the operating table by healthcare staff after being anaesthetized. This predisposes children to fall risk and hospital staff to musculoskeletal injuries. We developed two concept mobility devices, IMOVE-I and -II, based on robotics systems comprising of restraint modules and multi-positional modality (sitting, supine, Trendelenburg). The aim was to intuitively secure children to facilitate the safe induction of sleep and ease of transfer onto operating tables upon sleep. IMOVE-I loads the child in standing position using a dual arm restraint module that is activated by trained healthcare staff. IMOVE-II loads the child in the sitting position by motivating the self-application of restraints. Opinions were obtained from 21 operating theatre healthcare staff with experience in the care of ASD children and parents with ASD children. The mean satisfaction rating of IMOVE-I was 5.62 (95% CI 5.00, 6.27) versus 8.10 (95% CI 7.64, 8.55) in IMOVE-II, p < 0.001. IMOVE-II is favoured over IMOVE-I in system operation and safety, ease of use and module functionality.

Comprehensive Behavioral Phenotyping of a 16p11.2 Del Mouse Model for Neurodevelopmental Disorders

The microdeletion of copy number variant 16p11.2 is one of the most common genetic mutations associated with neurodevelopmental disorders, such as Autism Spectrum Disorders (ASDs). Here, we describe our comprehensive behavioral phenotyping of the 16p11.2 deletion line developed by Alea Mills on a C57BL/6J and 129S1/SvImJ F1 background (Del^m ). Male and female Del^m mice were tested in developmental milestones as preweanlings (PND2-PND12), and were tested in open field activity, elevated zero maze, rotarod, novel object recognition, fear conditioning, social approach, and other measures during post-weaning (PND21), adolescence (PND42), and adulthood (>PND70). Developmentally, Del^m mice show distinct weight reduction that persists into adulthood. Del^m males also have reduced grasp reflexes and limb strength during development, but no other reflexive deficits whereas Del^m females show limb strength deficits and decreased sensitivity to heat. In a modified version of a rotarod task that measures balance and coordinated motor activity, Del^m males, but not females, show improved performance at high speeds. Del^m males and females also show age-specific reductions in anxiety-like behavior compared with WTs, but neither sex show deficits in a social preference task. When assessing learning and memory, Del^m males and females show age-specific impairments in a novel object or spatial object recognition, but no deficits in contextual fear memory. This work extends the understanding of the behavioral phenotypes seen with 16p11.2 deletion by emphasizing age and sex-specific deficits; important variables to consider when studying mouse models for neurodevelopmental disorders. LAY SUMMARY: Autism spectrum disorder is a common neurodevelopmental disorder that causes repetitive behavior and impairments in social interaction and communication. Here, we assess the effects of one of the most common genetic alterations in ASDs, a deletion of one copy of 29 genes, using a mouse model. These animals show differences in behavior between males and females and across ages compared with control animals, including changes in development, cognition, and motor coordination. Autism Res 2020, 13: 1670-1684. © 2020 International Society for Autism Research and Wiley Periodicals LLC.

Neonatal behavior and social behavior and sensory issues in 18-month toddlers

BACKGROUND

There has long existed a need for early detection and early intervention for children with autism spectrum disorder. Accordingly, the aim of this study was to demonstrate, in a prospective manner, the relationship between behavioral features during the neonatal period and social behavior and sensory issues at 18 months.

METHODS

Participants were 105 full-term infants considered "healthy" by an obstetrician. The behavioral features of the infants were evaluated using the Neonatal Behavioral Assessment Scale (NBAS) between 2 and 7 days after birth. Follow-up assessments were conducted 18 months later using a Japanese version of the Modified Checklist for Autism in Toddlers (M-CHAT-JV) and the Infant / Toddler Sensory Profile (ITSP).

RESULTS

Sixteen (15.2%) of the 105 infants were M-CHAT-JV-positive. There were significant differences between the M-CHAT-JV-positive and M-CHAT-JV-negative groups in two of the NBAS clusters: orientation and motor. We observed a significant negative correlation between the NBAS orientation cluster and the ITSP "low registration" and "auditory processing" sections, as well as between the NBAS motor cluster and the ITSP "sensation avoiding" and "tactile processing" sections. Logistic regression analysis showed that the NBAS orientation cluster and ITSP low registration were significantly associated with the M-CHAT-JV at 18 months.

CONCLUSIONS

The results suggest a relationship between the NBAS orientation cluster in full-term neonates and their social behavior and sensory features at 18 months.

The risk of overweight and obesity in children with autism spectrum disorders: A systematic review and meta-analysis

Multiple studies have suggested that autism spectrum disorders seem to increase the risk of overweight and obesity. We examined the pooled prevalence and relative risk of developing overweight or obesity among children with autism spectrum disorders in a systematic review and meta-analysis. We searched PubMed, Scopus, ProQuest, and Web of Science databases and subsequently screened the records to identify studies that reported prevalence of overweight and/or obesity in children with ASD and matched groups of neurotypical children. DerSimonian-Laird random-effects meta-analyses were performed to examine pooled prevalence and relative risk of obesity in children with autism spectrum disorders using the "meta" package in R software. Among children with autism spectrum disorders, the prevalence of obesity was 22.2%. Children with ASD had a 41.1% greater risk (P = .018) of development of obesity. Non-Caucasian race, increasing age, female sex, and living in the United States emerged as positive moderators of the association between autism spectrum disorders and prevalence of overweight or obesity. Autism spectrum disorders seem to increase the risk of childhood obesity. Increased awareness of this association may allow the implementation of early interventions to reduce obesity and prevent potential deterioration of quality-of-life in this population.

Autism and toe-walking: are they related? Trends and treatment patterns between 2005 and 2016

PURPOSE

This study quantified toe-walking trends and treatment decisions in patients with autism spectrum disorder (ASD) in the United States between 2005 and 2016 using a large national private-payer database.

METHODS

A retrospective database review was performed on paediatric patients with ASD, and for International Classification of Diseases-9/10 diagnosis codes for toe-walking. Patients were filtered based on treatment type by Current Procedural Terminology (CPT) code. Continued toe-walking rates were assessed for each patient population and treatment group. A Pearson's chi-squared test was used to evaluate differences in group characteristics.

RESULTS

Of 2 221 009 paediatric patients in the database, 5739 patients had a diagnosis of ASD, and 8.4% of patients with ASD also had a diagnosis of toe-walking (n = 484). For typically developing children in the database, 0.47% of patients had a diagnosis of persistent toe-walking. In all, 59.3% of ASD patients underwent physical therapy, 7.4% serial casting and 3.3% surgical correction, compared with 38.1%, 3.6% and 1.2% of normally developing children, respectively (chi-square 6.4031; p < 0.040699). Without intervention, 63.6% of patients with ASD continued to toe-walk within ten years of their diagnosis, with 19.3% of patients without ASD (chi-square 82.9762; p < 0.0001).

CONCLUSION

This study supports the association between a greater prevalence of toe-walking in children with ASD. We showed that patients with ASD and toe-walking receive surgical correction at nearly triple the rate of children without ASD who toe-walk. The continued rate of toe-walking is comparable between treatment groups as well as between ASD and typically developing children. Typically developing children have higher rates of toe-walking resolution without intervention than children with ASD.

LEVEL OF EVIDENCE

Level II.

Four Social Brain Regions, Their Dysfunctions, and Sequelae, Extensively Explain Autism Spectrum Disorder Symptomatology

Autism spectrum disorder (ASD) is a challenging neurodevelopmental disorder with symptoms in social, language, sensory, motor, cognitive, emotional, repetitive behavior, and self-sufficient living domains. The important research question examined is the elucidation of the pathogenic neurocircuitry that underlies ASD symptomatology in all its richness and heterogeneity. The presented model builds on earlier social brain research, and hypothesizes that four social brain regions largely drive ASD symptomatology: amygdala, orbitofrontal cortex (OFC), temporoparietal cortex (TPC), and insula. The amygdala's contributions to ASD largely derive from its major involvement in fine-grained intangible knowledge representations and high-level guidance of gaze. In addition, disrupted brain regions can drive disturbance of strongly interconnected brain regions to produce further symptoms. These and related effects are proposed to underlie abnormalities of the visual cortex, inferior frontal gyrus (IFG), caudate nucleus, and hippocampus as well as associated symptoms. The model is supported by neuroimaging, neuropsychological, neuroanatomical, cellular, physiological, and behavioral evidence. Collectively, the model proposes a novel, parsimonious, and empirically testable account of the pathogenic neurocircuitry of ASD, an extensive account of its symptomatology, a novel physiological biomarker with potential for earlier diagnosis, and novel experiments to further elucidate the mechanisms of brain abnormalities and symptomatology in ASD.

Moving Along and Beyond the Spectrum: Creative Group Therapy for Children With Autism

Group therapy for autism confronts the core of the syndrome. Non-directed dynamic approaches, in which moment-to-moment spontaneous expressions drive the content of group sessions, are even more intricate. The implementation of nonverbal creative techniques holds the key to self-expression and self-other exploration, promoting communication and play. This manuscript offers an integrative conceptual model and a case report regarding such mind-body therapeutic perspective. The creative arts intervention is presented via a small group of young minimally verbal children with autism, deprived of communicative language, offering an interdisciplinary perspective to delineate group challenges and rationale, process, and outcomes. Vignettes are provided to illustrate the group development. A thorough discussion follows, addressing three intertwining axes: firstly, the implications of nonverbal creative means are considered; secondly, the psychophysiological processes set in motion through sensory-motor experiences are deliberated; and thirdly, the emergence of "moments of meeting" and spontaneously generated playful group activities are enlightened.

Gait in children with infantile/atypical autism: Age-dependent decrease in gait variability and associations with motor skills

Gait and its associations with prewalking motor milestones, motor skills, and age were investigated in 32 children with infantile/atypical autism and 36 typically developing controls. Gait was assessed using GAITRite recordings of spatiotemporal and variability gait parameters. Parents reported their child's prewalking motor milestones. Motor skills were assessed using the Movement Assessment Battery for Children. Children with infantile/atypical autism showed higher gait variability than controls, indicating a less regular walking pattern. In children with infantile/atypical autism gait variability was negatively associated with motor skills, but there was no such association with prewalking motor milestones. The higher gait variability in children with infantile/atypical autism showed an age-dependent decrease, suggesting that their gait regularity converges toward that of typically developing children.

Autism, Joint Hypermobility-Related Disorders and Pain

Autism Spectrum Disorder (ASD) and Joint Hypermobility-Related Disorders are blanket terms for two etiologically and clinically heterogeneous groups of pathologies that usually appears in childhood. These conditions are seen by different medical fields, such as psychiatry in the case of ASD, and musculoskeletal disciplines and genetics in the case of hypermobility-related disorders. Thus, a link between them is rarely established in clinical setting, despite a scarce but growing body of research suggesting that both conditions co-occur more often than expected by chance. Hypermobility is a frequent sign of hereditary disorders of connective tissue (e.g., Ehlers-Danlos syndromes, Marfan syndrome), in which the main characteristic is the multisystem fragility that prone to proprioceptive and motor coordination dysfunction and hence to trauma and chronic pain. Considering the high probability that pain remains disregarded and untreated in people with ASD due to communication and methodological difficulties, increasing awareness about the interconnection between ASD and hypermobility-related disorders is relevant, since it may help identify those ASD patients susceptible to chronic pain.

Lower extremity joint stiffness during walking distinguishes children with and without autism

How children with Autism Spectrum Disorder (ASD) and peers with typical development (TD) modulate lower extremity stiffness during walking could identify a mechanism for gait differences between groups. We quantified differences in lower extremity joint stiffness and linear impulses, along the vertical and anterior/posterior axes during over-ground walking in children with ASD compared to age- and gender-matched children with TD. Nine age- and gender-matched pairs of children, aged 5-12 years, completed the current study. Joint stiffness and linear impulses were computed in four sub-phases of stance: loading response, mid-stance, terminal stance, and pre-swing. The Model Statistic technique (α = 0.05) was used to test for statistical significance between the matched-pairs for each variable and sub-phase. Furthermore, dependent t-tests (α = 0.05) were utilized, at the group level, to determine whether significant differences existed between sub-phases. Results indicate that children with ASD may exhibit greater stiffness in pre-swing, and thus, produce inefficient propulsive forces during walking. We attribute these differences to sensory processing dysfunction previously observed in children with ASD.

Lower-extremity rotational profile and toe-walking in preschool children with autism spectrum disorder

The aim of this study was to establish the torsional and toe-walking profiles of children with autism spectrum disorder (ASD), and to analyze the correlations between torsion, toe-walking, autism severity score, and age. In total, 79 consecutive children with autism were examined to determine their hip rotations, thigh-foot angle, degree of toe-walking, and autism severity. Femoral and tibial torsion values, of the preschool patients, were compared statistically with age-matched controls. The hip rotation profile of the patients was similar to the normal group. Nearly a half of the patients with ASD present excessive external tibial torsion. The difference in the tibial torsion between patients and normal children was statistically significant. A weak correlation was found only between tibial torsion and the autism severity score, but no correlation was found between the other parameters. External tibial torsion is the cardinal and persistent orthopedic manifestation among patients with ASD. Toe-walking is the second most common such manifestation and is an independent orthopedic feature in these patients. External tibial torsion may potentially contribute toward the described gait abnormalities in patients with ASD.

Toe Walking Assessment in Autism Spectrum Disorder Subjects: A Systematic Review

There is increasing evidence that autism spectrum disorder (ASD) subjects have also motor impairments. Toe walking (TW) is a phenomenon that can be found in ASD subjects during gait, even if this condition was found not to be necessarily related only to walking, since these children often also stand and run on their tiptoes. Since persistent TW in ASD subjects may contribute to secondary shortening of the Achilles's tendon, it becomes important to have an assessment tool and/or outcome measure for both the clinical and rehabilitative settings. The aim of this systematic review is to critically evaluate and describe the methods employed to assess toe walking in ASD subjects. The systematic review protocol was previously registered on PROSPERO. We conducted an extensive literature search in PubMed, CINAHL, PsycINFO, The Cochrane Library, and Scopus databases. There were no restrictions on the types of study design eligible for inclusion. Ten studies were included in the systematic review. Risk of bias of the included studies was conducted using the following instruments depending on the study types: STROBE Statement, Cochrane risk of bias tool, and CARE checklist. Almost all the included studies (8/10) proposed a tip-toe behavior (TTB) assessment only during walking. Nine out of ten of the included studies assessed TTB using a qualitative methodology. The results evidenced the heterogeneity of qualitative methods and a lack of a structured quantitative test to assess toe walking in ASD subjects. Autism Res 2018, 11: 1404-1415. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY ABSTRACT: Toe walking (TW) is a phenomenon that can be found during ASD subject's gait. The persistence of this behavior may contribute to secondary Achilles's tendon shortening. In this perspective it becomes important to have an assessment tool and/or outcome measure for both the clinical and rehabilitative settings. The current systematic review aimed to describe the methods employed to assess TW. The results evidenced the lack and the need of a structured quantitative test to assess TW in ASD subjects.

A Cohort Study Comparing Women with Autism Spectrum Disorder with and without Generalized Joint Hypermobility

Reports suggest comorbidity between autism spectrum disorder (ASD) and the connective tissue disorder, Ehlers-Danlos syndrome (EDS). People with EDS and the broader spectrum of Generalized Joint Hypermobility (GJH) often present with immune- and endocrine-mediated conditions. Meanwhile, immune/endocrine dysregulation is a popular theme in autism research. We surveyed a group of ASD women with/without GJH to determine differences in immune/endocrine exophenotypes. ASD women 25 years or older were invited to participate in an online survey. Respondents completed a questionnaire concerning diagnoses, immune/endocrine symptom history, experiences with pain, and seizure history. ASD women with GJH (ASD/GJH) reported more immune- and endocrine-mediated conditions than their non-GJH counterparts (p = 0.001). Autoimmune conditions were especially prominent in the ASD/GJH group (p = 0.027). Presence of immune-mediated symptoms often co-occurred with one another (p < 0.001–0.020), as did endocrine-mediated symptoms (p < 0.001–0.045), irrespective of the group. Finally, the numbers of immune- and endocrine-mediated symptoms shared a strong inter-relationship (p < 0.001), suggesting potential system crosstalk. While our results cannot estimate comorbidity, they reinforce concepts of an etiological relationship between ASD and GJH. Meanwhile, women with ASD/GJH have complex immune/endocrine exophenotypes compared to their non-GJH counterparts. Further, we discuss how connective tissue regulates the immune system and how the immune/endocrine systems in turn may modulate collagen synthesis, potentially leading to higher rates of GJH in this subpopulation.

Autism spectrum disorder in primary care

Nurse practitioners working in the primary care setting will commonly see children with autism spectrum disorder. It is important for clinicians to be vigilant for subtle developmental signs that can lead to early identification and diagnosis. This article presents information on assessment, screening, the responsibilities of coordinating services, and ways to support families.