Characterizing Occupational Therapy Intervention for Children on the Autism Spectrum.

IMPORTANCE: Occupational therapy is one of the most used interventions for children on the autism spectrum. There is a critical need to develop an operationalized list of key treatment components of usual-care occupational therapy practice for children on the autism spectrum. OBJECTIVE: To identify and develop consensus on definitions and examples of key treatment components of usual-care occupational therapy for children on the autism spectrum, ages 6 to 13 yr. DESIGN: We conducted a Delphi study to obtain feedback from a panel of experts. SETTING: Electronic survey. PARTICIPANTS: 17 occupational therapy panelists with expertise in autism intervention. OUTCOMES AND MEASURES: Panelists rated the definition and example of each treatment component and provided feedback through multiple rounds of survey. RESULTS: On the basis of the panelists' feedback on Delphi Round 1, the criteria rating form was revised to include four questions for the definition and example of each treatment component. Through four Delphi rounds of consensus building, we developed an operationalized list of 20 treatment components with definitions and examples that incorporated elements of usual-care occupational therapy intervention for children on the autism spectrum. CONCLUSIONS AND RELEVANCE: This operationalized list of treatment components serves as a foundational framework to improve education, practice, and research of occupational therapy intervention for children on the autism spectrum. Plain-Language Summary: This study identified and developed consensus on definitions and examples of key treatment components used in usual-care outpatient occupational therapy for children on the autism spectrum. Through four rounds of consensus building with 17 occupational therapy experts in autism, we identified 20 key treatment components central to occupational therapy practice. Our results have the potential to serve as a framework to improve education, practice, and clinical research in autism.

Progress towards universal health coverage in the context of mental disorders in India: evidence from national sample survey data.

BACKGROUND: Universal health coverage (UHC) has emerged as one of the important health policy discourses under the current sustainable development goals in the world. UHC in individual disease conditions is a must for attaining overall UHC. This study measures progress towards UHC in terms of access to health care and financial protection among individuals with mental disorders in India. METHODS: Data from the 75th Round National Sample Survey (NSS), 2017-18, was used, which is the latest round on health in India. Data collected from 555,115 individuals (rural: 325,232; urban: 229,232), from randomly selected 8077 villages and 6181 urban areas, included 283 outpatient and 374 hospitalization cases due to mental disorders in India. Logistic regression models were used for analyses. RESULTS: Self-reporting of mental disorders was considerably lower than the actual disease burden in India. However, self-reporting of ailment was 1.73 times higher (95% CI: 1.18-2.52, p < 0.05) among the richest income group population compared to the poorest in India. The private sector was a major service provider of mental health services with a larger share for outpatient (66.1%) than inpatient care (59.2%). Over 63% of individuals with a mental disorder who reported private sector hospitalization noted unavailability or poor service quality at public facilities. Only 23% of individuals hospitalized had health insurance coverage at All India level. However, health insurance coverage among poorest economic class was a meagre 3.4%. Average out-of-pocket expenditure during hospitalization (public: 123 USD; private: 576 USD) and outpatient care (public: 8 USD; private: 37 USD) was significantly higher in the private sector than in the public sector. Chances of facing catastrophic health expenditure at 10% threshold were 23.33 times (95% CI: 10.85-50.17; p < 0.001) higher under private sector than public sector during hospitalization. Expenditure on medicine, as the share of total medical expenditure, was highest for hospitalization (public: 45%, private:39.5%) and outpatient care (public: 74.1%, private:39.7%). CONCLUSIONS: Social determinants play a vital role in access to healthcare and financial protection among individuals with mental disorders in India. For achieving UHC in mental disorders, India needs to address the gaps in access and financial protection for individuals with mental disorders. TRIAL REGISTRATION: Not applicable.

The Effect of Attention on Auditory Processing in Adults on the Autism Spectrum.

This study examined the effect of attention on auditory processing in autistic individuals. Electroencephalography data were recorded during two attention conditions (passive and active) from 24 autistic adults and 24 neurotypical controls, ages 17-30 years. The passive condition involved only listening to the clicks and the active condition involved a button press following single clicks in a modified paired-click paradigm. Participants completed the Adolescent/Adult Sensory Profile and the Social Responsiveness Scale 2. The autistic group showed delayed N1 latencies and reduced evoked and phase-locked gamma power compared to neurotypical peers across both clicks and conditions. Longer N1 latencies and reduced gamma synchronization predicted greater social and sensory symptoms. Directing attention to auditory stimuli may be associated with more typical neural auditory processing in autism.

Rethinking recovery in adolescent concussions: Network-level functional connectivity alterations associated with motor deficits.

Adolescents who are clinically recovered from concussion continue to show subtle motor impairment on neurophysiological and behavioral measures. However, there is limited information on brain-behavior relationships of persistent motor impairment following clinical recovery from concussion. We examined the relationship between subtle motor performance and functional connectivity of the brain in adolescents with a history of concussion, status post-symptom resolution, and subjective return to baseline. Participants included 27 adolescents who were clinically recovered from concussion and 29 never-concussed, typically developing controls (10-17 years); all participants were examined using the Physical and Neurologic Examination of Subtle Signs (PANESS). Functional connectivity between the default mode network (DMN) or dorsal attention network (DAN) and regions of interest within the motor network was assessed using resting-state functional magnetic resonance imaging (rsfMRI). Compared to controls, adolescents clinically recovered from concussion showed greater subtle motor deficits as evaluated by the PANESS and increased connectivity between the DMN and left lateral premotor cortex. DMN to left lateral premotor cortex connectivity was significantly correlated with the total PANESS score, with more atypical connectivity associated with more motor abnormalities. This suggests that altered functional connectivity of the brain may underlie subtle motor deficits in adolescents who have clinically recovered from concussion. More investigation is required to understand the persistence and longer-term clinical relevance of altered functional connectivity and associated subtle motor deficits to inform whether functional connectivity may serve as an important biomarker related to longer-term outcomes after clinical recovery from concussion.

Altered white matter diffusivity and subtle motor function in a pilot cohort of adolescents with sports-related concussion.

BACKGROUND AND OBJECTIVE: Adolescents with sports-related concussion (SRC) demonstrate acute and persistent deficits in subtle motor function. However, there is limited research examining related neurological underpinnings. This pilot study examined changes in motor-associated white matter pathways using diffusion tensor imaging (DTI) and their relationship with subtle motor function. METHODS: Twelve adolescents with SRC (12-17 years) within two-weeks post-injury and 13 never-injured neurotypical peers completed DTI scanning. A subset of 6 adolescents with SRC returned for a follow-up visit post-medical clearance from concussion. Subtle motor function was evaluated using the Physical and Neurological Examination of Subtle Signs (PANESS). RESULTS: Adolescents with SRC showed higher mean diffusivity (MD) of the superior corona radiata and greater subtle motor deficits compared to controls. Across all participants, greater subtle motor deficits were associated with higher (more atypical) MD of the superior corona radiata. Preliminary longitudinal analysis indicated reduction in fractional anisotropy of the corpus callosum but no change in the MD of the superior corona radiata from the initial visit to the follow-up visit post-medical clearance. CONCLUSIONS: These findings support preliminary evidence for a brain-behavior relationship between superior corona radiata microstructure and subtle motor deficits in adolescents with SRC that merits further investigation.

The Effect of Age and Competition Level on Subtle Motor Performance in Adolescents Medically Cleared Postconcussion: Preliminary Findings.

OBJECTIVE: The aim of this study was to examine the effect of age and level of competition on subtle motor performance in adolescents who have recently been medically cleared postconcussion and never-injured controls. DESIGN: Thirty adolescents who were recently medically cleared postconcussion (12-18 yrs) and 30 never-concussed, typically developing controls were examined using the Revised Physical and Neurological Examination of Subtle Signs (PANESS) and the Immediate Post-Concussion Assessment and Cognitive Testing. RESULTS: Older age was associated with better Immediate Post-Concussion Assessment and Cognitive Testing scores in both groups, whereas only the control group showed improved motor performance on the PANESS with increasing age. Adolescents across both groups participating at a higher level of competition (school or travel level) had better motor performance on the PANESS than those participating at a lower level of competition (recreational level or no sports participation). Adolescents medically cleared postconcussion had greater motor deficits on the PANESS than controls did. CONCLUSION: After medical clearance, adolescents with a history of recent concussion demonstrate alterations in the relationship between motor function and age. The PANESS merits further exploration as a measure that is sensitive to factors affecting motor performance, such as age and level of athletic competition, as well as to persistent subtle motor deficits in adolescents medically cleared postconcussion.

Expanding our understanding of sensory gating in children with autism spectrum disorders.

OBJECTIVE: This study examined sensory gating in children with autism spectrum disorders (ASD). Gating is usually examined at the P50 component and rarely at mid- and late-latency components. METHODS: Electroencephalography data were recorded during a paired-click paradigm, from 18 children with ASD (5-12 years), and 18 typically-developing (TD) children. Gating was assessed at the P50, N1, P2, and N2 event-related potential components. Parents of all participants completed the Short Sensory Profile (SSP). RESULTS: TD children showed gating at all components while children with ASD showed gating only at P2 and N2. Compared to TD children, the ASD group showed significantly reduced gating at P50, N1, and P2. No group differences were found at N2, suggesting typical N2 gating in the ASD group. Time-frequency analyses showed reduced orientation and neural synchronization of auditory stimuli. P50 and N1 gating significantly correlated with the SSP. CONCLUSION: Although children with ASD have impaired early orientation and filtering of auditory stimuli, they exhibited gating at P2 and N2 components suggesting use of different gating mechanisms compared to TD children. Sensory deficits in ASD may relate to gating. SIGNIFICANCE: The data provide novel evidence for impaired neural orientation, filtering, and synchronization in children with ASD.

Developmental trajectory of subtle motor signs in attention-deficit/hyperactivity disorder: A longitudinal study from childhood to adolescence.

This study examined the developmental trajectory of neurodevelopmental motor signs among boys and girls with attention-deficit/hyperactivity disorder (ADHD) and typically-developing (TD) children. Seventy children with ADHD and 48 TD children, aged 8-17 years, were evaluated on at least two time-points using the Physical and Neurological Assessment of Subtle Signs (PANESS). Age-related changes in subtle motor signs (overflow, dysrhythmia, speed) were modeled using linear mixed-effects models to compare the developmental trajectories among four subgroups (ADHD girls and boys and TD girls and boys). Across visits, both boys and girls with ADHD showed greater overflow, dysrhythmia, and slower speed on repetitive motor tasks compared to TD peers; whereas, only girls with ADHD were slower on sequential motor tasks than TD girls. Developmental trajectory analyses revealed a greater reduction in overflow with age among boys with ADHD than TD boys; whereas, trajectories did not differ among girls with and without ADHD, or among boys and girls with ADHD. For dysrhythmia and speed, there were no trajectory differences between the subgroups, with all groups showing similar reductions with age. Children with ADHD show developmental trajectories of subtle motor signs that are consistent with those of TD children, with one clear exception: Boys with ADHD show more significant reductions in overflow from childhood to adolescence than do their TD peers. Our findings affirm the presence of subtle motor signs in children with ADHD and suggest that some of these signs, particularly motor overflow in boys, resolve through adolescence while dysrhythmia and slow speed, may persist.

Sensory Processing and Attention Profiles Among Children With Sensory Processing Disorders and Autism Spectrum Disorders.

This study explores the differences in the profile of relationships between sensory processing and attention abilities among children with sensory processing disorder (SPD), autism spectrum disorder (ASD), and typically developing (TD) children. The Test of Everyday Attention for Children (TEA-Ch), a performance-based measure of attention, was administered to 69 children (TD: n = 24; SPD: n = 21; ASD: n = 24), ages 6-10 years. All participants' parents completed the Short Sensory Profile (SSP), a standardized parent-report measure of sensory-related behaviors. Discriminant analyses using the TEA-Ch and the SSP domains revealed two classification functions; the first revealed that both clinical groups significantly differed from the TD group with greater sensory processing challenges in the categories of auditory filtering, under-responsive/seeks sensation, low energy/weak, and taste/smell sensitivity subscales of the SSP. The second function discriminated between the two clinical groups, indicating that children with ASD had significantly greater control and sustained attention deficits and less sensory issues than did children with SPD. Together, the two functions correctly classified 76.8% of the participants as to their group membership. The different profiles of sensory processing and attention abilities in children with SPD and ASD may provide guidance in identifying appropriate individualized therapeutic strategies for these children.

Subtle Motor Signs and Executive Functioning in Chronic Paediatric Traumatic Brain Injury: Brief Report.

Background: Children with traumatic brain injury (TBI) are reported to have persistent deficits in executive functioning and subtle motor functionsAim: This study examined the relationship between subtle motor signs and executive functioning in children with TBIMethods: Eighteen children aged 13-18 years with mild to severe TBI at least one year before study participation and 16 age-matched typically-developing controls were examined using the Revised Physical and Neurological Examination of Subtle Signs (PANESS), a simplified Go/No-go task, portions of the Delis-Kaplan Executive Function System Verbal Fluency and Trail Making tests, and a Wechsler Coding testResults: There were significant associations between PANESS scores and executive functioning measures in children with TBI but not in controls. Conclusion: Results suggest that assessment of subtle motor signs may provide broader information regarding functioning after pediatric TBI.

Single-arm, open-label, dose escalation phase I study to evaluate the safety and feasibility of transcranial direct current stimulation with electroencephalography biomarkers in paediatric disorders of consciousness: a study protocol.

INTRODUCTION: Children with disorders of consciousness (DOC) represent the highest end of the acquired brain injury (ABI) severity spectrum for survivors and experience a multitude of functional impairments. Current clinical management in DOC uses behavioural evaluation measures and interventions that fail to (1) describe the physiological consequences of ABI and (2) elicit functional gains. In paediatric DOC, there is a critical need to develop evidence-based interventions to promote recovery of basic responses to improve rehabilitation and aid decision-making for medical teams and caregivers. The purpose of this investigation is to examine the safety, tolerability and feasibility of transcranial direct current stimulation (tDCS) in children with DOC. METHODS AND ANALYSIS: This study is an open-label dose escalation trial evaluating the safety, tolerability and feasibility of tDCS in 10 children (5-17 years) receiving inpatient rehabilitation for DOC. This study will follow a modified rule-based design, allowing for intrapatient escalation, where a cohort of patients will be assigned to an initial tDCS current of 0.5 or 1 mA based on participant's head circumference and according to the safety data available in other paediatric populations. The subsequent assignment of increased current (1 or 2 mA) according to the prespecified rules will be based on the clinical observation of adverse events in the patients. The study will include up to three, 20 min sessions of anodal tDCS (sham, 0.5 or 1 mA, 1 or 2 mA) applied over the dorsolateral prefrontal cortex. The primary outcomes are adverse events, pain associated with tDCS and intolerable disruption of inpatient care. Secondary outcomes are changes in electroencephalography (EEG) phase-locking and event-related potential components and the Coma Recovery Scale-Revised total score from prestimulation to poststimulation. ETHICS AND DISSEMINATION: The Johns Hopkins IRB (#IRB00174966) approved this study. Trial results will be disseminated through journals and conferences. REGISTRATION NUMBER: NCT03618849.

Assessing the Impact of Music Therapy on Sensory Gating and Attention in Children With Autism: A Pilot and Feasibility Study.

Children with autism spectrum disorder (ASD) frequently demonstrate atypical processing of sensory information and deficits in attentional abilities. These deficits may impact social and academic functioning. Although music therapy has been used to address sensory and attentional needs, there are no studies including physiologic indicators of sensory processing to determine the impact of music therapy. The objective of this study was to determine the feasibility of conducting study protocols, determine the adequacy of electroencephalography (EEG) and behavioral measures in identifying attentional differences in children with ASD compared with typically developing (TD) children, and to gather preliminary evidence of intervention effects on brain responses and attention outcomes. Seven children with high functioning ASD ages 5 -12 and seven age- and gender-matched TD completed procedures measuring brain responses (EEG) and behaviors (the Test of Everyday Attention for Children). Children with ASD then completed a 35-min individual music therapy attention protocol delivered by a board-certified music therapist ten times over 5 weeks. Children with ASD completed measures of brain responses and behavior post-intervention to determine pre- to post-test differences. Consent and completion rates were 100% for children who met the study criteria. Feasibility measures indicated that measures of brain responsivity could be used to determine attentional differences between children with ASD and typical children. Initial outcome data for brain responses and behavior indicated positive trends for the impact of music therapy on selective attention skills.

Transcranial Direct Current Stimulation in Pediatric Motor Disorders: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically examine the safety and effectiveness of transcranial direct current stimulation (tDCS) interventions in pediatric motor disorders. DATA SOURCES: PubMed, EMBASE, Cochrane, CINAHL, Web of Science, and ProQuest databases were searched from inception to August 2018. STUDY SELECTION: tDCS randomized controlled trials (RCTs), observational studies, conference proceedings, and dissertations in pediatric motor disorders were included. Two authors independently screened articles based on predefined inclusion criteria. DATA EXTRACTION: Data related to participant demographics, intervention, and outcomes were extracted by 2 authors. Quality assessment was independently performed by 2 authors. DATA SYNTHESIS: A total of 23 studies involving a total of 391 participants were included. There was no difference in dropout rates between active (1 of 144) and sham (1 of 144) tDCS groups, risk difference 0.0, 95% confidence interval (-.05 to .04). Across studies, the most common adverse effects in the active group were tingling (17.2%), discomfort (8.02%), itching (6.79%), and skin redness (4%). Across 3 studies in children with cerebral palsy, tDCS significantly improved gait velocity (MD=.23; 95% confidence interval [0.13-0.34]; P<.0005), stride length (MD=0.10; 95% confidence interval [0.05-0.15]; P<.0005), and cadence (MD=15.7; 95% confidence interval [9.72-21.68]; P<.0005). Mixed effects were found on balance, upper extremity function, and overflow movements in dystonia. CONCLUSION: Based on the studies reviewed, tDCS is a safe technique in pediatric motor disorders and may improve some gait measures and involuntary movements. Research to date in pediatric motor disorders shows limited effectiveness in improving balance and upper extremity function. tDCS may serve as a potential adjunct to pediatric rehabilitation; to better understand if tDCS is beneficial for pediatric motor disorders, more well-designed RCTs are needed.

Subtle Motor Signs in Children With Chronic Traumatic Brain Injury.

OBJECTIVE: The aim of the study was to characterize subtle motor signs in children with moderate-severe traumatic brain injury in the chronic phase of injury. DESIGN: Fourteen children with moderate (n = 6) or severe (n = 8) traumatic brain injury, ages 11-18 yrs, who had sustained their injury at least 1-yr before study participation (range 1-14 yrs since injury), and 14 matched typically developing controls were examined using the Physical and Neurological Examination of Subtle Signs (PANESS). To examine the neural correlates of subtle motor signs, measures of total cerebral volume and motor/premotor volume were derived from magnetic resonance imaging. RESULTS: Children with traumatic brain injury had significantly poorer PANESS performance than controls on the total timed subscore, proximal overflow, and the PANESS total score. Participants with severe traumatic brain injury had greater proximal overflow than those with moderate injury, after controlling for age at injury. Across all participants, greater proximal overflow correlated with reduced total cerebral volume, whereas within the traumatic brain injury group, reduced motor/premotor volume correlated with lower PANESS total score. CONCLUSIONS: The study highlights the importance of examining subtle motor signs including overflow during clinical evaluation of chronic pediatric traumatic brain injury and establishes the clinical utility of the PANESS as a measure sensitive to chronic subtle motor signs in this population. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Define subtle motor signs including motor overflow; (2) Identify subtle motor signs such as motor overflow during clinical evaluation of children with brain injury; and (3) Explain the relevance of examining subtle motor signs in chronic pediatric brain injury during clinical evaluations. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Auditory priming improves neural synchronization in auditory-motor entrainment.

Neurophysiological research has shown that auditory and motor systems interact during movement to rhythmic auditory stimuli through a process called entrainment. This study explores the neural oscillations underlying auditory-motor entrainment using electroencephalography. Forty young adults were randomly assigned to one of two control conditions, an auditory-only condition or a motor-only condition, prior to a rhythmic auditory-motor synchronization condition (referred to as combined condition). Participants assigned to the auditory-only condition auditory-first group) listened to 400 trials of auditory stimuli presented every 800 ms, while those in the motor-only condition (motor-first group) were asked to tap rhythmically every 800 ms without any external stimuli. Following their control condition, all participants completed an auditory-motor combined condition that required tapping along with auditory stimuli every 800 ms. As expected, the neural processes for the combined condition for each group were different compared to their respective control condition. Time-frequency analysis of total power at an electrode site on the left central scalp (C3) indicated that the neural oscillations elicited by auditory stimuli, especially in the beta and gamma range, drove the auditory-motor entrainment. For the combined condition, the auditory-first group had significantly lower evoked power for a region of interest representing sensorimotor processing (4-20 Hz) and less total power in a region associated with anticipation and predictive timing (13-16 Hz) than the motor-first group. Thus, the auditory-only condition served as a priming facilitator of the neural processes in the combined condition, more so than the motor-only condition. Results suggest that even brief periods of rhythmic training of the auditory system leads to neural efficiency facilitating the motor system during the process of entrainment. These findings have implications for interventions using rhythmic auditory stimulation.