Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the Spectrum of Autism

Abstract

In recent years, the autism spectrum in children has been increasingly recognized. Parental awareness and the knowledge of health professionals are critical to the early diagnosis of autistic disorders. The autism spectrum disorder (ASD) is a complex neurodevelopmental disorder. The diagnosis of autism spectrum disorders is made on the basis of observation of behavior in three areas: social interaction, communication, and behavioral rigidity. The most common diagnosis is in children around 2–5 years of age, but the autism spectrum can be diagnosed at any age, also in adulthood. As the spectrum of autism varies, symptoms of autism may differ slightly from person to person. In order to exclude the presence of ASD in a child or adult, it is necessary to diagnose with the use of various tools, in which both a psychologist-diagnostician and a psychiatrist are involved. After diagnosis, the next important step is to include therapeutic and rehabilitation activities aimed at improving the functioning of the individual in disturbed areas. Lack of proper rehabilitation may lead to profound functional disturbances at a later age.

1. Introduction

The word autism comes from the Greek autós, which means “alone.” The concept was introduced into psychiatry in 1911 by the Swiss psychiatrist Eugen Bleuler for the inability to maintain relations with the environment. The first description of a person with autism was made in 1943 by psychiatrist Leo Kanner. Autism spectrum disorders (ASDs) are characterized by disturbances in the ability to communicate feelings and build interpersonal relationships, impoverishment and stereotypical behavior, and difficulties in integrating sensory impressions. According to the ICD 11 classification in force in Poland since 2022, there is a wider diagnosis of autism spectrum disorders, which combines the categories of childhood autism, atypical autism, and Asperger syndrome described earlier in ICD-10 into one main category of Autism Spectrum Disorder (ASD) included in the chapter on neurodevelopmental disorders. ASD is described in seven different variants listed as follows:

1. 6A02 Autism Spectrum Disorder

2. 6A02.0 Autism spectrum disorder without intellectual development disorder and with mild or no functional language impairment

3. 6A02.1 Autism spectrum disorder with mental development disorder and mild or no functional language impairment

4. 6A02.2 Autism spectrum disorder without impaired intellectual development and with impaired functional language

5. 6A02.3 Autism spectrum disorder with impaired intellectual development and functional disorders

6. 6A02.4 Autism spectrum disorder without intellectual development disorder and lack of functional language

7. 6A02.5 Autism spectrum disorder with impaired intellectual development and lack of functional language

8. 6A02.Y Other specified autism spectrum disorders

9. 6A02.Z Autism spectrum disorder, unspecified [1]

Most people with ASD exhibit features that impair functioning in three areas: communication, social, and behavioral (the so-called autism spectrum triad). The triad of disorders distinguished by Wing and Gould [2] is reflected in the current DSM V classification, which lists the following symptoms important in the diagnosis of ASD:

1. shortcomings in human development, especially in the capacity to participate in alternating social interactions,

2. deficits and dysfunctions in communication (verbal and nonverbal),

3. the presence of rigid patterns of behavior, activity, and interests.

An important element added to the diagnostic criteria in DSM-5 is the inclusion of disturbances within the sensory profile.

Symptoms of autism are most often seen in early childhood, but may not be fully manifested until social expectations exceed the child’s limited abilities. It should be emphasized that autism is not a mental illness. It has been assumed that the underlying causes are errors in neurological development, i.e., abnormalities in the formation of the central nervous system, starting in the prenatal age.

For proper therapy, it is also important to determine the severity of symptoms and their impact on the daily functioning of people with ASD:

1. L1 —patient and family require support —problems mainly relate to social relations,

2. L2 —requires significant support —communication problems with people,

3. L3 —requires very significant support —incapable of verbal and nonverbal communication [3].

2. Diagnosing ASD

Autism spectrum disorders are multifactorial disorders, and its exact causes are not fully understood. Due to the very different manifestation of symptoms, diagnosing autism spectrum disorders is a complex process, consisting of several stages and requiring the cooperation of a team of specialists. The word “spectrum” means that each person with autism is different, and each person with autism manifests itself in a different set of characteristics and their severity. Despite the neurobiological basis of autism spectrum disorders, there are still no biological indicators that would allow them to be used in everyday clinical diagnosis [4]. The diagnosis of ASD remains a clinical diagnosis, based on the observation and assessment of the patient’s behavior and cognitive functions. The disorder long-term affects a person’s ability to take care of himself, participate in society. The diagnosis of ASD also affects other family members of a person with ASD [5, 6].

Although there is no single conclusive test or biological marker for ASD detection, there are many screening and diagnostic tools that can be used in the examination of children with suspected neurodevelopmental disorders [4].

2.1 Diagnostic tools

2.1.1 CHAT

Screening tools available include “first-level” tests that can be used during your primary care physician visit, including the Checklist for Autism in Toddlers (CHAT; parental assessment/physician observation; examination of children between 18 and 24 months of age) [4]. This tool is intended for testing 18-month-old children during pediatric follow-up visits, although it can also be used for older children—up to 24 and even 36 months of age. This tool consists of two parts: nine questions asked to parents and five short clinical trials. CHAT has a consistent and fairly well-documented theoretical basis. CHAT is recommended to pediatricians in Great Britain by National Autistic Society. One of the versions of CHAT is M-CHAT (Modified-CHAT) intended for testing children aged 16–30 months [7]. This questionnaire contains 23 questions (nine were taken directly from CHAT) and is completed by the parents. Another variation of CHAT is Q-CHAT (Quantitative CHecklist for Autism in Toddlers) intended for the study of children aged 18–24 months. In the questionnaire, the parent assesses the frequency of a given behavior or the severity of the problem on a five-point scale (not a dichotomous one, unlike M-CHAT) [8].

In Western countries and the United States, autism is the most frequently used interviewing tool Diagnostic Interview–Revised (ADI-R). The Polish version has been available recently thanks to Dr. Izabela Chojnicka, who is the author of the Polish language version [9].

2.1.2 ADI-R

It is a diagnostic tool used to conduct an interview. Its publisher is Western Psychological Services. Initially, it was used for research purposes. It is now a “Comprehensive, standardized, and partially structured interview that is conducted with parents or guardians people with ASD” [9].

During its development, the currently applicable diagnostic criteria ICD-10 and DSM-IV-TR were taken into account. It is recommended for children from 24 months of mental age. It consists of 93 items grouped into the following headings:

1. Introduction and introductory questions – a section consisting of six items concerning the family situation, the process of education and treatment, diagnosis.

2. Early development – a section of seven items concerning the onset of symptoms of milestones in development and purity training.

3. Acquisition and loss of skills, including language skills – section consisting of 20 items.

4. Language and functioning of communication – a department consisting of 21 items.

5. Social development and fun – a department consisting of 17 items.

6. Behaviors and interests – section consisting of 13 items.

7. General behavior – a section of 14 items.

8. Final comments – a section consisting of three items concerning incl. Impressions of the interviewer [9].

The interview lasts from 1.5 to 4 hours depending on the age of the child. The individual items refer to both the previous behavior and the current behavior. The interview also includes questions about the presence of some symptoms typical of other pervasive development disorders, some questions about behaviors that are less important in the diagnosis of the autism spectrum but show the specificity of development of many children. The questionnaire also includes questions about the family or previous diagnoses and the course of any previous therapy. The scoring is nine levels, each question is assessed, and the diagnosis is made on the basis of an algorithm.

ADI-R interview may differ from the clinical diagnosis, but it is a very helpful tool in making a diagnosis, and it helps to gather a large amount of information.

“When reading Western scientific publications, especially in the field of autism spectrum biology, there are no studies in which the diagnosis of the respondents would not be made on the basis of ADI-R and ADOS-G” [9].

2.2 Behavior observation scales

2.2.1 ADOS

It is a tool for direct observation of behavior. It is standardized and consists of four protocols differing in terms of age and stage of speech development. It is most often used with the ADI-R. This tool consists of a number of experimental situations in which the observer is also a participant.

2.2.2 CARS

This scale is useful for the observation of children from 0 to 16 years of age; however, it should be noted that its effectiveness is greater for children from 2 years of age. It includes 15 areas of behavioral behavior, information comes from parents or other people staying with the child. The CARS scale is commonly used for treatment planning and assessment of progress [10].

2.2.3 PEP-R

PEP-R is a useful and popular tool for the functional diagnosis of a child. It is used in designing the therapy of a child with developmental problems. Thanks to the PEP-R test, it is possible to assess the educational needs of the child and determine the baseline level for therapy.

The PEP-R test consists of two parts: the developmental scale and the behavioral scale.

The scale of development allows for the assessment of the child’s functioning in the following areas:

Limitation, perception, fine and gross motor skills, eye-hand coordination, cognitive activities, and communication. It consists of 131 tasks in total.

The behavior scale is designed to identify responses and behaviors. The degree of disorders and the areas in which these disorders appear are assessed. The behavior scale consists of 42 tasks divided into four areas: networking and emotional reactions, play and interest in objects, reactions to stimuli, and speech [10, 11, 12].

3. The multifactorial basis of autism spectrum disorders

The autism spectrum is much more than diagnostic criteria. So the difference between defining autism spectrum disorder (ASD) and developmental pattern (ASC) is analogous to the difference between negative and positive definitions of health. In the first case, we focus on deficits and looking for therapeutic measures to help mask them. In the second case, we focus on the resources of the individual, resulting from its proper development pattern, and we look for ways to strengthen it. According to Baron-Cohen, there are currently four narratives describing the autism spectrum: disorder, disability, difference, and disease. However, it was the terms “otherness” and “disability” that he indicated as fully compatible with the concept of neurodiversity understood as nature’s strategy aimed at ensuring the scope of the human species (human minds) with a variety of challenges inherent in different environments (Baron-Cohen 2020: 138). Thus, this position can be considered more akin to the treatment of the autism spectrum as a developmental pattern than as a disorder. It is worth quoting at this point the opinion of one of the Polish researchers: “The spectrum of autism is a borderline category in many respects, blurred and unclear, ephemeral and changeable, and thus constantly revealing its arbitrariness and more social than biological construction” [5].

The state of knowledge about autism does not give unequivocal answers as to the causes of this disorder. The development of neurobiology and neuroimaging prompted many researchers to seek answers to the question of where does autism come from in neurological areas. Intensive efforts are underway to elucidate the neurobiology of autism. The combination of neuroanatomical abnormalities revealed in children’s brain MRI studies with abnormalities in neuropsychic development and autistic symptoms seems to be of particular interest. Significant links were found between autism spectrum disorders and the presence of certain biomarkers. For example, functional resonance in children with autism shows that human facial image processing takes place in a different area than in healthy people; autistic people look at human faces, paying attention to the mouth area, not the eye area. In his works, Tuchmann [13] showed that various types of EEG abnormalities often occur in the group of ASD patients. About 20% of ASD patients in basal resting EEG display show epileptic activity mainly in the form of focal lesions (spikes). EEG tests performed during sleep show even more seizure disorders in children with ASD. The EEG test is a method that can be used to assess the work of the brain in children with autism. However, there are no typical EEG patterns that would be unambiguous and specific to an ASD image.

Another hypothesis that contributes to the search for the causes of ASD is the theory of mirror neurons. The broken mirror hypothesis assumes that there is abnormal mirror cell activity in the brain of autistic people. Mirror cells are responsible for the mental mapping of motor activities, emotions, and sensory experiences observed in other people. In people with autism spectrum disorders, decreased activity of these cells in the area of the inferior frontal gyrus may explain the inability to understand the intentions of other people, in the insula and anterior part of the cingulate gyrus—difficulties in understanding emotional states, and in the angular gyrus—language disorders [14]. Oberman et al. [15], by monitoring mi waves in the EEG record, proved that in people with the autism spectrum, the activity of mirror neurons in the premotor cortex is reduced. These waves are attenuated by the discharges of motor neurons when making conscious body movements and by discharging mirror neurons when observing these movements in others. In children on the autism spectrum, mu-wave suppression is not observed when observing the movements of other people, which confirms the low activity of mirror neurons [16].

It seems interesting to analyze the relationship between symptoms of autism and possible dysfunctions in various regions of the brain. It is known that the centers located in different lobes of the cerebral cortex are responsible for higher mental functions. The temporal lobe is responsible for speech, remembering, verbal memory, object recognition, musical hearing and sound sensation, and smell analysis. Damage to the temporal lobes results in impaired hearing, speech understanding and sound perception, impaired selective attention to auditory and visual stimuli, problems with recognizing and describing the seen objects, and difficulties in recognizing the face (prosopagnosia). Functional disorders in the left hemisphere impede the ordering and categorization of verbal information and are responsible for difficulties in understanding speech (Wernicke‘s aphasia). On the other hand damage to the right hemisphere can cause speech orthosis. Centers in the temporal lobe are responsible for problems related to recall, disorders of sexual behavior, and control of aggressive behavior. Speech abnormalities of various degrees are evident in people suffering from autism spectrum disorders. They are of various dimensions and quality, ranging from a complete lack of speech understanding, through speech that is exclusively echolalia and does not serve the communicative function, through semi-communicative speech, poor to almost normal active speech, characterized by impaired prosody, intonation and a weak pragmatic meaning of language. What is typical in the picture of autistic disorders is also frequent aggressive and auto-aggressive behaviors, which are an expression of the dysfunction of the right temporal lobe. Therefore, in people suffering from autism, dysfunctions of the frontal and prefrontal areas are typical, which is manifested in the presented symptoms: stereotypical behavior and interests, disturbed social interactions, lack of understanding and socioemotional reciprocity. An important function is also played by the limbic lobe, which is responsible not only for the analysis of olfactory sensations and pain, but also for controlling negative emotions, focusing attention, memory, and learning. The manifestation of dysfunction in this area of the brain in people on the autism spectrum is hyperactivity, psychomotor restlessness, severe attention and memory disorders, loss of control over emotions, as well as disorders in the area of sensory integration (hypersensitivity or hypersensitivity to pain, touch, sounds) [17].

F. Warren, director of the National Association for Children and Adults with Autism in the United States, describes the symptoms of autism spectrum disorder in this way, making the far-reaching thesis that autism is caused by damage to the brain. “The symptoms of autism are caused by damage to the brain and include: disturbances and delays in mastering the habits of daily living, social and language habits …. These children have an abnormal reaction. This applies to both individual senses and the entire group. This applies to sight, hearing, touch, pain, sense of balance, taste, smell, and also to body posture … Speech and linguistic development are delayed or completely absent in these children. There may also be specific thinking abilities. In speech, we observe an incorrect accent, a limited understanding of concepts, the use of words in such a way that they are not associated with things that mean (…) abnormal ways of contacting people, objects and situations (…) they do not react properly to adults as well as peers. They also do not use objects and toys in the usual way (…). Autism occurs as a single disorder or in combination with others that damage the functions of the brain: viral infections, metabolic disorders or epilepsy” [18].

4. The nutritional aspect of the autism spectrum

Etiopathogenesis of these disorders is multifactorial, and both predispositions are important genetic, factors environmental-like and factors related to answer layout immune system and functioning cable alimentary [19, 20]. With spectrum disorder autism, gastrointestinal symptoms often coexist. It is suspected that children with autism spectrum disorders may suffer from improper digestion of gluten proteins and casein, leading to the formation of peptides that may act as endogenous opioids (including milk caso–morphin- and gluten-based gliadomorphins), influencing the functioning of the central system nervous [21, 22]. Gastrointestinal symptoms in children with ASD may also be caused by hypochloridia and decreased secretion of gastric acid, less activity of amylolytic enzymes, intestinal disaccharidases, and inflammation of the esophagus, stomach or intestines. In this case, children with ASD suffer from autoimmune diseases and diseases, including celiac disease [23]. Increased permeability of the intestinal mucosa and imbalance of the intestinal microflora are also more frequent in patients with autism spectrum disorders occurrence increased permeability membranes mucous bowels and imbalance of the intestinal microflora [24, 25]. Research conducted in 2018, which drew attention to the importance of dietary ingredients and their impact on the somatic behavior of children with ASD, clearly documented positive changes in groups subjected to specific diets.

In children with ASD before the elimination diet, the parents more often observed gastrointestinal symptoms, especially flatulence, abdominal pain and diarrhea (p≤0.05) (Table 1), more often than in children who did not undergo dietary modification (Table 1). Most children experience these symptoms they gave way after introduction diets elimination [19, 26]. They write about the advantages and disadvantages of nutritional treatment of the autism spectrum disorder (based on their research) and emphasize that in some cases GFCF (gluten-free, casein-free) diets - ketogenic, low-phenol, low-oxalate may even cause the disappearance of disorders, symptoms characteristic of ASD. Parents of these children observe the beneficial effects: children sleep better, learn faster, blood results improve, rashes disappear. Perseverance behavior is also reduced. [27] Among ASD patients, deficiencies of vitamins B, C, K, and D3 and elements—calcium, potassium, and iron—are common. Deficiency of these ingredients may negatively affect the functioning of the neurological system. Adequate supply of omega-3 fatty acids and probiotics may have a positive effect on the condition of patients with ASD [28].

Symptoms			Children with ASD
	On elimination diet n = 27			On usual diet n = 23v
	In the past	At present		In the pastAt present
Reux	22			4
Vomiting	37	7		22
Atulence	59	30		13
Bellyache	30			22
Abdominal pain	59	22		13	9
Diarrhea	67	19		30
Constipation	48	22		61	39

Table 1.

Gastrointestinal tract symptoms in children with autism spectrum disorders in the past and at present (%).

Source: Probl Hig Epidemiol 2018, 99 (1): 12–20.

5. Relation of the therapist —the parent of a child from the autism spectrum

The assumptions of working with ASD people say, first of all, about establishing a good relationship with this person. A very important element in building such a relationship is creating a safe space in which we will work with a person with ASD, developing a way of communication and supporting the family of a person with ASD.

One of the most important elements of the development of a child with autism—apart from family adaptation—is properly selected and continued specialist and home therapy. A specialist or a group of specialists should work with the child, who will first of all give the correct diagnosis and repeat it, tracking the child’s development and adjusting the therapy to the changes in the child’s behavior and its health. It is very important that parents have a full understanding of current and changing techniques regarding the care, care and development of an autism spectrum child in everyday life. At this stage, the exchange of experiences between parents and mutual support both in sharing their perceptions and experiences, as well as the need to obtain help is very important. [29].

Cooperation in the parent-therapist relationship allows parents to participate in the child’s therapy and get to know them better, notice characteristic behaviors or progress that they do not notice in the home environment. The best results are achieved when the therapy starts in early childhood, when the child receives the most stimuli, develops the fastest, and the parents are strongly involved in cooperation to obtain the best results. Parents’ participation in the child’s therapy combines the specialist’s experience with parental care, which brings the best results [30].

Pisula illustrates this on the example of the TEACCH model, in which it was assumed that parents learn how to cooperate with a child from therapists, and therapists get to know the child through the prism of the parent. It is a model of mutual support in everyday functioning. The better prepared the parents are, the better the results are achieved by working with the child at home, which has a positive effect not only on the child, but also on the whole family. Parents finally take control of the situation and stop being helpless about the behavior of their autistic child [30].

The best results are to stick to a few basic rules, starting with the fact that it should be remembered that the family has the greatest influence on the child’s development and that it is the basis for his progress and should spend the most time on exercise, maintaining routine, rhythm, noting behavior changes. Certainly, a specialist or a group of specialists who exchange information and observations with parents on an ongoing basis should work with an autistic child. It is important to adjust the family’s capabilities and resources, to pay attention to how to cope with their situation, and to establish solid relationships with other families operating under similar circumstances.

In addition to the great role of the parent, it should be remembered that it is the specialist’s task to get to know the child and the conditions of his family, its strengths and weaknesses, and strive to cooperate with the child’s parents, enabling its development to the fullest extent. Developing a relationship with the parents is as important a goal for the therapist as the work with the child itself. Thanks to this, the therapist inspires confidence in parents, which has a positive effect on the proposals of various solutions on his part. Otherwise, with a poor relationship with the parents, they may react negatively to his methods [31].

6. Therapeutic methods and techniques

Autism is a way of human development different from the typical one, manifested by differences in the way of communication, establishing relationships, expressing emotions, learning, and a diverse pattern of behavior. Each person with autism is an individual, and the abovementioned features may be of varying intensity. Autism accompanies a person throughout his life. After 6 years of analyzes, the NAC (National Autism Center) report was published, summarizing the research on the therapy of children, adolescents, and adults with autism. Its main goal is to select those forms of therapy that are most effective based on reliable scientific evidence. 2015 NAC report prepared as a result of the analysis of 361 scientific studies on methods of therapy for people with ASD. The report divided the treatments used into three groups: established (scientifically proven with strong and abundant evidence for their effectiveness), promising (there is evidence for the effectiveness of the method, but too little research is conducted), and undefined (very little or no evidence of a positive effect of the method). The established therapeutic methods are: behavioral methods, cognitive-behavioral interventions, modeling, natural teaching models, social skills training, activity plans. The group of promising therapies includes: alternative and supportive communication, relationship therapy, desensitization training, rehabilitation, massage, language training (resource and understanding), interventions based on new technology, therapies based on Theory of Mind Training, PECS, and music therapy. The group of undetermined therapies includes auditory training, the method of facilitated communication, gluten-free and casein-free diets, sensory integration, and additionally zootherapies or electroconvulsive therapies.

6.1 Physiotherapy

Each child diagnosed with an autism spectrum disorder or other related pervasive development disorder also has its own individual range of problems and dysfunctions. Their degree of intensity is also varied, which results in an absolute need for individualization of therapy. The therapeutic program must take into account the personality of the patient, as well as his current abilities and needs. It is important that the working methods used do not eliminate each other, but work complementary and synergistically, only then can they effectively activate the child’s development. The current tendencies in the world’s leading autism spectrum therapy centers dictate the broadly understood complexity of the actions of specialized institutions on children affected by the autism spectrum. This means that institutions that deal with the treatment of pervasive disorders should create and implement comprehensive rehabilitation programs, which should be arranged in the field of rehabilitation, therapy, vocational and general education, and social care. Not only every child needs therapeutic support, but also his family (siblings, parents, grandparents, and other people) who have close contact with the child.

The impacts of specialized institutions on patients with the autism spectrum can be divided into:

• medical/medical: differential diagnosis (medical interview, examination, direct observation), symptomatological, causal (specialist examinations, including: EEG, CT, immunological panel, metabolic panel, genetic tests, endoscopic examinations, loads, deficiencies), biomedical therapy (elimination diets, detoxification, chelation, supplementation, strengthening the immune system), pharmacotherapy,

• psychological: psychometric tests, direct observation, analysis of video materials, functional diagnosis, therapeutic programs for work at home, psychoeducation, general rehabilitation programs, training, workshops, support groups and family psychotherapy, Video Home Training,

• educational/pedagogical: educational leveling, general education programs, implementation of programs based on various working methods (behavioral method, Doman’s method, Delacato method, activity albums method, TEACCH, options method and others),

• communication: proper speech therapy (speech evocation and articulation correction), facilitated communication (pictograms, PECES), nonverbal communication training,

• social: emergency care, 24-hour care (boarding house, hostel), living and financial support, legal support for the family,

• therapeutic: neurorehabilitation, manual techniques (cranial therapy, microkinesitherapy, classic surface, and deep massage), integration therapy (group music therapy, Sherborne developing movement, art therapy, creative therapy, occupational therapy, good start method), relational therapy (dog therapy, hippotherapy, therapy by contact with a horse or a dolphin or a cat), sensory revalidation/sensuum revalidatio (monosensory therapy, polysensory therapy, sensory integration, sequential therapy, individual music therapy, auditory training with the Tomatis method, therapy based on liquid and loose materials, Knill therapy, Masgut method, relaxation, hydrotherapy, work in the darkroom, therapy in the room for experiencing the world, Affolter assisted movement method [32].

In short, it can be said that medical interactions are primarily aimed at eliminating or minimizing the causes of disturbed CNS activity, as well as at improving the somatic state of the patient. Psychological support is needed to assess the level of a child’s functioning in various areas, to set directions for further influence, and to monitor the progress made. The work of psychologists in autism spectrum therapy is also used in a very important field, which is improving educational competences and counteracting the effects of chronic stress, as well as social exclusion of families who care for children with autism spectrum disorders.

Educational activities are aimed at modifying the child’s behavior, which will make it possible to obtain the effect of the student’s and therapist’s work, acquire the ability to carry out orders, eliminate undesirable disruptive, self-destructive, and aggressive behaviors. This impact zone is also aimed at assimilating the child with educational skills and knowledge necessary for the implementation of compulsory schooling, introducing a general improvement program, and consolidating all acquired skills. Communication interactions are the basis for building the little patient’s independence and the possibility of finding his own place in society, as well as the ability to communicate with him, if not verbally, then with the use of alternative methods of communication. Activities in the social sphere should provide care for the child as well as assistance and advice in dealing with official matters, as well as provide social support to the patient’s family.

The last group of interactions that should be applied by a facility that specializes in autism spectrum therapy is supportive treatment and physiotherapy. This type of activities is aimed at stimulating development in individual spheres of functioning, improving the tasks of individual senses, their compatibility and integration.

Social integration through therapeutic contact with the animal world and peers as well as occupational therapy also finds its place here. The interaction group based on supportive therapy is an appropriate field for physiotherapists to work with autistic children. In the autism spectrum therapy, the following are used among the physiotherapy departments: manual therapy, hydrotherapy, therapeutic massage, physical therapy, and ergotherapy.

6.2 Neurorehabilitation

It is an important type of individual therapy aimed at intensifying the level of concentration of attention, similar to quantitative indicators in terms of the ratio of beta waves to theta, as well as SMR to theta, as well as in quantitative indicators for functional tests. Neurorehabilitation can be divided into two types of impact:

• magnetostimulation —i.e., the use of slowly changing magnetic fields in the patient in order to influence the bioelectrical activity of the cerebral cortex, especially on such phenomena as: concentration of attention, feeling of physical and mental relaxation, and thus on many other functions and cognitive processes,

• EEG—biofeedback training—that is, work based on a biological feedback system, thanks to which the patient learns to emit brain waves at the frequency imposed on him by the therapist so that his body can be brought into the desired state of activity (concentration of attention, relaxation) [32].

Research shows that systematic EEG biofeedback training can be an effective form of therapy for autistic children in the areas of verbal, physical, and social communication. Scientific research also shows improved speech, balance, understanding, and facial expressions in children with autism. The trainings also turned out to be helpful in reducing sensory sensitivity and in improving the response to changes in the environment. Trainings should be conducted at least once a week. Greater and definitely faster effects of the therapy are obtained by training two or three times a week. The minimum number of trainings to achieve the goal and consolidate the achieved effects of the therapy is about 20 sessions. [33].

6.3 Sensory integration (SI)

Sensory integration is the stimulation of the neurological process so that it organizes the sensations flowing from the body so that they can be used for purposeful action. Sensory integration disorders consist in incorrect processing of stimuli within the sensory, vestibular, visual, auditory, olfactory, and taste systems. The function of the analyzers is correct. They are clinically manifested by increased or decreased sensitivity to stimuli, abnormal levels of attention, poor motor coordination, delayed speech development, and behavioral difficulties. Thanks to AI therapy, the child’s brain, after collecting information from all senses, leads to their recognition, segregation, interpretation, and integration with information already possessed in order to be able to prepare an answer in the form of an appropriate motor reaction. The basis for working with this method consists of three basic sensory systems: the surface/tactile sensing system (whose receptors are located on the skin and are responsible for the reception of tactile, pain, and thermal stimuli), the deep/proprioceptive sensing system (with receptors receiving stimuli coming from tendons and muscles), and the vestibular/vestibular system (in which the receptors are located in the inner ear and receive impulses that inform us about the position of the head in relation to the force of gravity). Therapy based on loose and liquid materials—in children with the autism spectrum, it aims to overcome the resistance which, due to their hypersensitivity in the area of superficial sensation, does not want to touch anything, which is wet, rough, slippery, warm, cold, etc., different structure, temperature, texture, or liquidity. Working in the darkroom, it is a method aimed at increasing the level of concentration of attention. Classes are conducted in a darkened room.

Working with an autistic child takes place in three stages:

1. focusing attention on a moving image (e.g., using a projector with thematic dials or liquid colors),

2. work with point and laser light,

3. task projections in ultraviolet light.

6.4 Auditory training

Auditory training using the Tomatis method—it is audio-psycho-linguistic stimulation carried out with the help of a device called the electronic ear. They make up her sessions, which consist in listening to appropriately configured sound material through special headphones, as well as additional consultations together with an audio-psycho-phonological assessment. Through appropriate training, this method allows to achieve good results when the child’s listening process is disturbed, i.e., processing and analyzing auditory stimuli through the nervous system. And in the case of hearing disorders, it does not apply, i.e., when the sound reception is incorrect due to organic hearing damage.

6.5 Movement-based therapeutic interventions

Relaxation—it is used during the occurrence of excessive muscle tension or strong psychomotor agitation often occurring in children with the autism spectrum.

The most commonly used relaxation techniques are:

• relaxation based on light and sound—as individual classes conducted on a waterbed in a darkened room, with a delicate play of lights from bubble columns and music from external speakers or mounted in a waterbed (which gives an additional effect in the form of gentle vibrations for the body),

• surface and deep massage—which is a full body massage that stimulates the surface and deep feeling, relaxes the muscles, and eliminates connective tissue adhesions,

• hydrotherapeutic massage—a treatment performed in a hydromassage bathtub,

• aquatherapy—in the form of treatments carried out through fabrics (wraps, wrapping, rubbing, washing),

• aromatic baths,

• pearl baths,

• water therapy—as group activities in a therapeutic pool, the aim of which is not only to achieve relaxation effects, but also to integrate with peers, play together, and learn to follow instructions [32]. Aspects of psychological therapies applied to children with autism spectrum disorders and their families are also taken into account [34].

Therapy using the Knill method—it is a therapy in the form of a session, which is always accompanied by similar rituals (preparing props, adopting similar positions, starting exercises when certain music is turned on, etc.). These types of classes allow you to establish contact with the child, develop its activity in time and space, teach the acquisition of planning and foresight skills, as well as develop hearing and motor coordination.

Sherborne Developmental Movement Method is a system of movement games and exercises, the main task of which is to develop the emotional and social sphere in a child, as well as to develop awareness of himself and other people. Groups of exercises thanks to which you can solve specific problems occurring in people with developmental disorders:

• exercises leading to getting to know your own body;

• exercises that help to gain self-confidence and trust in a partner as well as a sense of security in contact;

• exercises that teach how to establish contact and cooperate in a group. Here we distinguish different types of relational games: caring—“with” together against;

• exercises leading to cooperation in a group;

• creative exercises.

There is no competition-inducing exercise. Children are praised and encouraged to be active. By gaining self-confidence, children are more likely to participate in other forms of therapy [15].

Dennison’s method also known as The Brain Gym is a set of exercises aimed at integrating the cerebral hemispheres in order to work more effectively. Dennison’s method is teaching with activating methods to turn on the natural mechanisms of mind and body integration through specially organized movements. Through the use of exercise, all parts of the brain turn on and work together to improve each chosen skill. It is a method that improves the effectiveness of learning, communication, creativity, and work efficiency. A very important factor in using this form in working with an autistic person is learning how to relax, relieve tension, and cope with stress.

The method of a good start aims to improve and improve the interaction of motor and psyche in a child through correction as well as compensation of disturbed functions. This method has various aspects, both prophylactic and therapeutic, as well as an equally important diagnostic aspect that allows assessing the type, causes, and depth of dysfunction in a given patient. Scheme of therapeutic work with this method begins with introductory classes, then basic classes (motor, motor-auditory and motor-auditory-visual), and final classes (they are calming, relaxing).

Therapy according to Masgutova’s program consists in organizing neurosensory conditions for the proper functioning of schemas that are components of the reflex wheel, and they include the sensory organ, then the processing of the sensory-proprioceptive stimulus, and the motor organ. The techniques of this therapy are focused on re-patterning procedures, i.e., coordinating new relationships between the components of the reflex wheel. The results of reflex integration influence their maturation and the structure of planned and controlled movement. Their task is to improve the functioning of the sensor, motor coordination, and quality of movement. They improve the communication skills, concentration of attention as well as spatial organization.

6.6 Structured improvement

It is a group of activities included in the strictly defined framework of their course. They consist in providing the environment of a child with ASD with permanent structures: physical (including establishing permanent places to play, eat, move, didactic tasks, eliminate disruptive stimuli, no sudden radical changes); visual (visibility of materials and teaching aids, the use of clear, unambiguous pictures, symbols, visual organization of activities and tasks, day plan); visual marking of areas in the room with symbols, pictograms; structures in the form of fixed rules, rules and a fixed schema, e.g., daily schedule.

6.7 Relationship-based therapy

The Relationship Development Intervention (RDI) method is based on work with children performed by parents at home. It consists in providing parents with tools to effectively teach their child the skills that make up dynamic intelligence and increase his motivation to work. It focuses on changing what characterizes autism, i.e., thinking stiffness, reluctance to change, lack of motivation, inability to see someone else’s perspective, difficulties in communication. The RDI program was based on working on five basic skills, typical of the so-called dynamic intelligence, necessary for normal functioning in life, which are also the five basic deficits found in people with autism. These are:

• dynamic analysis—the ability to analyze information in terms of what is important at a given moment, what to focus on, setting priorities;

• experience sharing communication—using the so-called declarative speech that does not give ready-made answers, forces you to think, arouses curiosity;

• episodic memory—memory of events and emotions that accompanied the event. The memory necessary to create our personal history and build a sense of competence and motivation;

• flexible thinking—the ability to quickly adapt to the situation, openness to changes, the ability to act under the criterion: “good enough”;

• self-awareness—the basic skill to understand that everyone is different and that our interactions and behaviors affect other people. It is also an essential skill to build motivation.

7. Manual techniques (cranial therapy and microkinesitherapy)

They consist in the use of forms of minimal pressure on the patient’s body in specific places in order to relieve the remaining tensions and muscle or fascial blockages. In autistic children, the most important thing is to eliminate blockages that are located in the bones of the skull and the entire hyoid system (muscles of the neck, collarbones, skull base, palate, temporomandibular joint).

8. Ergotherapy

Ergotherapy is recognized as one of the branches of physiotherapy and is based mainly on medical, psychological, social, and craft knowledge. It is used in the case of movement, sensory, nerve conduction, and mental disorders in patients of all ages, including older children. Its aim is to restore or acquire mobility, overcome difficulties in performing self-service activities, as well as other activities of everyday life. The consequence of ergotherapy should be for the child to obtain the greatest possible independence, independence, and life activity. Among the ergotherapeutic forms of work used in the treatment of patients affected by the autism spectrum, it is worth mentioning: occupational therapy, creative therapy, art therapy, music therapy, culinary therapy, psychodrama, rock climbing, or therapeutic and recreational tourism.

9. TEACCH

The origins of the TEACCH program go back to the 1970s. Eric Schopler‘s research resulted in the creation of an unusual, for those times, program of work with autistic people. This program differed from previous methods of work by recognizing the role of the parent as a co-therapist, full involvement of parents in the therapy, which was a stark contrast to the earlier attitude of blaming them for the autism spectrum of the child. The TEACCH program was also a structured program as opposed to the widely used play therapy.

The most important assumption of the TEACCH program is the individualization of the therapy program for each child and the broadly understood cooperation between professional therapists and parents. Parents are treated as an invaluable source of knowledge about their children, they are treated on an equal footing with therapists, the parent and the therapist learn from each other by creating a therapeutic team. Parents bring dedication, commitment, motivation, knowledge of the child to the team, and professionals bring knowledge about professional techniques. PEP-R tools are used to individualize therapy.

The TEACCH program is a comprehensive program, it includes various types of therapy for autistic children, it uses, for example, behavioral therapy or sensory integration and many other programs that will prove effective for a given child. The diagnosis of the TEACCH program is divided into several stages. The first is the initial diagnosis, which is based on the individual assessment of the child by PEP-R, CARS, or AAPEP. With the help of these tools, the predisposition, skills, and potential of the child are established. The obtained results are supplemented with an environmental interview. Then the whole family is included in the program of meetings at the center, which aims to work with both the child and the parent. The child therapist works with the child, learns about its strengths and weaknesses, determines the initial therapy plan, while the family counselor looks after the parents, helps them find their way around the situation, helps them understand the nature of the impairment, and learns from it about the child. Then the therapy program is jointly established. Once this program is approved by the parents, the therapist arranges the exercises to be performed at home.

10. Option method

The option method was developed by a Kaufman couple through experiences with their own autistic child. They were looking for a therapy for their son before an official diagnosis was made. They knew that the earlier the therapy started, the greater the possibilities and chances for the child. They also realized that leaving their son in their own world without trying to understand and help them may result in the deepening of autistic behaviors, the consolidation of autistic patterns, and the resulting emotional problems. Barry Kaufman became interested in the Option Method derived from the Attitude of Options, that is, “To love someone and be happy with him” [35].

This method consisted in revising one’s own beliefs, which made a person unhappy. She assumed that you can choose your own beliefs, which affects your feelings and behavior. The starting point for therapy is therefore work with parents, its aim is to teach the parent to accept the child, understand his behavior, and the parent also learns educational techniques. The next stage of therapy is joining the child’s activity, imitating his behavior in order to show him that he is next to a presence full of love and approval and that he wants to make contact in a way that is possible for the child. The next stage is motivating the child to want to make contact, to want to go beyond the rigid framework of their behavior. At this stage, it is all the time important to imitate the child and constant presence, stimulate the child with himself, with his closeness, try to establish contact through various types of clever tricks, such as making the child meet with the eyes of the parent. Making eye contact is very important for the child to it acquired awareness of the existence of parents, acquired knowledge about parents so that it could learn through limitation. Eye contact is essential for significant progress to be made.

11. Behavioral interventions

Applied Behavior Analysis (ABA) is a scientific approach to understanding different behaviors. It uses many years of experience, numerous studies, theories, and principles of behavior understood very broadly [36]. SAZ is based on causal (also known as instrumental) conditioning. Behavioral interventions use, inter alia, proactive strategies, i.e., various techniques related to manipulating the stimuli that precede the behavior. The most frequently used of them are: adapting the program to the child’s abilities, interweaving difficult and easy tasks, presenting tasks at the right pace, allowing the child to make a choice, adjusting the environment to be the optimal place for learning, and using various types of prompts [36]. Behavior-related interventions are also included in this category, and reinforcement is of particular importance here. Reinforcement can be positive or negative. Positive reinforcement occurs when, after a child becomes involved in a behavior, he or she receives the desired stimulus. It is important to take care of the variety of reinforcements and to individualize them so as not to become saturated with them. These can be the child’s favorite treats, the therapist’s attention, attractive toys, or pleasant activity with the therapist. The second type of reinforcement, negative reinforcement, occurs when the child’s involvement in a given behavior causes the unwanted stimulus to be withdrawn. A particular type of enhancement is differential enhancement, where desired behaviors are enhanced and undesirable behaviors are suppressed. This results in the reduction of many undesirable behaviors of the child and teaching functional and desired responses in a given situation.

12. Modeling

Modeling is an effective way to teach a child how to do something by showing him or her. Children can learn a lot by observing and imitating the behavior of their parents, siblings, peers, and teachers. We distinguish between two types of modeling: “live” and video-modeling. The first type is that the therapist (model) presents a certain behavior to imitate and the child repeats it. It is important that the behavior to be imitated is well described and that each of the modelers presents it to the child in the same way. During modeling, the child should be focused in order to be able to observe the model’s behavior well. In the final stage, a method of withdrawing modeling should be developed so that the learned behavior occurs spontaneously and in appropriate situations without the participation of the model. The second type, video modeling, is where a certain behavior is prerecorded and the child imitates the behavior observed in the video [37].

13. Methods of supporting communication

Various forms of assisted communication are used in autistic children. The term Alternative and Supportive Methods of Communication (AAC) groups methods that enable people with speech disabilities to communicate with their environment.

13.1 Makaton

The Makaton method is one of many alternative communication tools. It uses signs, i.e., gestures and symbols. Gestures and symbols can be used along with speech, then they have an auxiliary function, reinforcing the message, or in the case of lack of speech they constitute an independent method of communication. Graphic symbols are used with Makaton‘s gestures. They are black and white, simple pictures that accurately reflect the concepts they represent. The basic vocabulary includes 450 symbols and approximately 7,000,000 supplementary symbols. Each country has its own set of graphic symbols. The Makaton program was originally developed in the United Kingdom by Margaret Walker, a speech therapist and psychiatrist. The Polish version of Makaton was developed by Bogusława Kaczmarek. The changes included both gestures and graphic symbols. The basic vocabulary is 350 words very similar in all countries in Europe, in addition, in Poland, 100 words characteristic of our culture or customs. It is also emphasized that the applied therapeutic methods are carried out under additional aggravating conditions of Covid-19 [38].

Makaton Program users can be children and adults with different communication disorders profiles. The use of the language of symbols and gestures does not pose a threat to the development of speech as speech is used together with symbols or gestures whenever possible, and when it develops on a level sufficient for communication, the language of signs and symbols is discontinued [39].

13.2 Therapeutic process in the event of a pandemic

The first case of the SARS-CoV-2 virus in Poland was recorded on March 4, 2020, and less than a week later, the World Health Organization granted COVID-19 pandemic status, which resulted in changes in the functioning of families around the world. People with autism as people with disabilities were included in the group at high risk of contracting the virus. A number of changes concerned not only education, but also care and rehabilitation [40].

When on March 11, the work of educational system institutions was limited, it was also associated with the closure of educational and upbringing institutions, special schools, as well as specialized training and revalidation and upbringing centers [41]. Even in the first half of March, some support centers were also closed, and the children had to stay at home, without specialist care, which certainly made it difficult functioning of the family and initiated the growing problems of parents [40]. Due to the fact that families with children were locked at home, it was extremely important that the child continued to develop properly and make progress despite the lack of treatment with a specialist. One of the examples of replacing sensory therapy is sensory-motor games that stimulate the senses and reduce irritability in a child:

1. creating a harp from a box of chocolates and recipe rubber bands—the child chooses the number of rubber bands on his own and puts them on the boxes, then he can pluck them like strings while humming his favorite songs, while the parent can help “tune the strings” by stretching or loosening the rubber bands in order to spend others sounds, this game affects touch, sight, and hearing,

2. “Jump cushion”—stacking all kinds of pillows, quilts, and other soft materials in a pile, preferably in the middle of the room, providing space around the top of the pillows, the child will be able to jump while plunging into a soft pile, this game exerts pressure on muscles and joints as well as tactile stimuli and proprioceptive,

3. hug combined with rolling—a game affecting the vestibular system and tactile stimuli, consisting in placing the child on the stomach of an adult lying on his back in a hug and slowly rolling over the couch or other soft surfaces,

4. “Listen and draw” – a game involving playing music and conveying emotions related to the sounds heard by the child by drawing, preferably using crayons in a standing or lying position, the game strengthens the receptors of hearing, sight, and touch,

5. “Hammer and nails” – admittedly, a game for larger children that develops hand coordination, visual skills and spatial orientation, consisting in hammering small nails into a piece of wood by the child, but it can be replaced by hammering a golf ball into, for example, polystyrene or other soft material.

These sensory games not only help children to cope with stress and isolation, but can also be used at home as an addition to sensory therapy classes [41]. An important aspect is to create an environment for the child to facilitate sensory processing. For a child with autism, the highest priority is a safe environment that makes it easier for them to focus. Parents should adapt the environment in which the child is to be with other household members on a continuous basis to his needs. The level of the child’s arousal depends on his environment. Any loud sounds should be eliminated by introducing soft background music, providing subdued colors and natural lighting, as well as organizing each room and clearly defining the passages. The apartment should be warm, but not too hot, and the smells should be subdued and controlled (no use or limitation of perfumes, disinfectants, cleaning products) [41].

Kashman and Mora created in their essay a sensory cheat sheet for the sense of touch, proprioceptive, and vestibular. And so, the sense of touch is best influenced by loose products such as rice or dry beans, modeling clay, or a massage with a balm. The sense of proprioception is influenced by e.g., walking, even in place, stomping, placing food cans (with a load). On the other hand, races, jumping on the floor or playing with a scarf are good examples of games that affect the vestibular sense [28].

Karen Simmons, based on a short sentence spoken by her friend: “Fear may be the most destructive and harmful virus known to mankind.” SARS-CoV-2 virus. These are:

1. “The essence of our being is love,

2. Health is inner peace, healing is Letting go of fear,

3. Giving and taking are the same

4. We can let go of the past and the future

5. Only now counts, every moment is dedicated to giving

6. We can learn to love ourselves and others by forgiving, not judging

7. We can become seekers of love, not seekers of wine

8. We can choose and focus on keeping our inner peace no matter what happens outside,

9. We are students and teachers for each other,

10. We can focus on all of life, not just parts of it,

11. Since love is Eternal, death need not be seen as something terrible

12. We can always see others as loving or fearful and extend the cry for help in love.” [41]

These so-called positive attitudes principles were intended to help, in these extremely difficult times, especially for parents to remain calm and pass it on to a child with autism spectrum disorder [41].

14. Discussion

Progress in research on the autism spectrum and its genesis results in more and more forms of development support therapy. However, since the causes of the autism spectrum disorder have not been clearly identified, there is no “cure” for the disorder. Educational, behavioral, and rehabilitation influences play the most important role in the treatment of autism. Therapy should be comprehensive and carried out in specialized centers. The nervous system is so plastic that when properly stimulated, it can make up for many deficits. The sooner a child is cared for, the better the results. Currently, there are many forms of therapy available to improve the functioning of an autistic child. Autism is not a fully curable disorder, but with the use of appropriate therapeutic programs, some people are able to achieve such an improvement that they can function independently.

Children with autism spectrum disorder (ASD) are less likely to participate in physical activity than their age-related peers, and it has been suggested that physical therapists (PT) have the potential to facilitate their participation. Currently, no study has investigated the potential role of PT in increasing participation in physical activity (PA). The purpose of this qualitative study was to investigate the experiences of PT and the outlook for working with children with ASD and to explore potential directions in which PT could potentially increase PA. Methods: Ten pediatric PTs in Canada were interviewed and the data analyzed by thematic analysis. Results: Three themes were identified: the role of PT, perceived lack of expertise, trust and training, and structural and systemic barriers. The accounts emphasize the social and institutional complexity and limitations of PT’s potential promotion of PA in children with ASD. Participants supported primarily a consultative role whereby physical therapists can educate themselves and collaborate with parents, teachers, and social service providers to improve gross motor development and individualize PA needs. Conclusions: These results indicate how PT may be involved in enhancing PA in children with ASD [7].

Stasolla, Boccasini, and Perilli (2017) presented a literature review on assistive technology-based programs supporting the adaptive behavior of children with autism spectrum disorders that are broadly understood and designed to bridge the gap between human/individual abilities and/or skills and requests for environment. In particular, AT builds a link that enables people with ASD to gain independence and self-determination. By using the AT configuration, individuals with ASD may be able to achieve an active role, positive participation, beneficial occupation, and/or performance of functional daily activities. Moreover, they could be enabled to improve their social image, attractiveness, and status, while reducing the burden on families and carers. In short, people with ASD would cope positively with their environment. At least two functional goals can be achieved through an AT-based intervention, namely (a) evaluation and (b) recovery. In the case of the autism spectrum, El Kaliouby and Robinson (2007, p. 3) indicated that assistive technologies can be “divided into two broad categories,” i.e. therapeutic and prosthetic, with therapeutic technologies aimed at helping people cope with disabilities or specific deficiencies through curricula and interventions [42].

The review of the abovementioned methods of therapy for people with ASD shows that there is no one method that would cover all the needs of a child with ASD and his family. It seems appropriate to select therapies and working methods in accordance with the child’s needs and based on his strengths.

The latest research (not published: E.Trylinska-Tekielska The sense of empathy and the sense of stress in the group of parents of children from the autism spectrum in the pandemic period, 2022) shows that the personality traits of the closest relatives are a very important rehabilitation factor for children from the autism spectrum disorder. The child’s caregivers show the greater stress they experience, certainly a very important factor in preparing the child to function in society. It is also important that the society understands and respects the child’s needs from the autism spectrum.

15. Conclusion

The assessment of the social functioning of a person with an autism spectrum disorder is in contradiction with the dominant image of the autism spectrum as an ailment that disrupts functioning in the social sphere.

Most people believe that an autistic person is capable of making friends, working professionally, and living independently; the general public believes that a person with ASD is able to start a family. At the same time, the dominant opinion is that a child with spectrum autism is not able to cope in an ordinary school.

Behind this contradiction may be the belief that autism is a predominantly childhood condition, out of which to some extent “outgrows,” and an adult on the spectrum copes better in society than a child.

The problems of families of children with the autism spectrum have remained unchanged for years: it is primarily the lack of professional help in childcare, social exclusion, lack of emotional support, lack of knowledge about the autism spectrum, and lack of funds for living.

A specialist or a group of specialists should work with the child, who will first of all give the correct diagnosis and repeat it, tracking the child’s development and adjusting the therapy to the changes in the child’s behavior and its health condition.

People with the autism spectrum disorder during the pandemic reported experiencing higher than usual anxiety, nervousness, and tension, as well as anger.

A very small group of people on the autism spectrum have benefited from therapeutic support for the pandemic; most people did not receive any form of therapy.

Due to the fact that families with children were locked at home, it was extremely important that the child continued to develop properly and make progress despite the lack of treatment with a specialist.

The entire burden of carrying out therapy rested with families.

The crumbs of autism reside in each of us.