TH E A T RISK AU TISTIC CHILD AND HIS FAM ILIY 38 F I S I O T E R A P I E JUNIE 1981 M . V E R A B U H R M A N N , M .B . C h.B ., D P H , D P M .* S U M M A R Y A u tis m is a p o o rly u n d e rsto o d a n d o b sc u re con d itio n . T h is article c la rifies so m e o f the diverse causes a n d s y m p to m s o f the c o n d itio n . T h e role o f the p h y s io th e r a ­ p ist in the tr e a tm e n t o f the autistic c h ild h a s n o t been e x ­ p lo r e d in S o u th A fr ic a a n d the a u th o r o ffe r s so m e su g g e stio n s as to the areas in w hich p h y s io th e r a p y c o u ld be o f use. T h e a u tis tic c h ild c a n be seen as a n a t risk ch ild a n d he a n d h is fa m ily as an a t risk g ro u p to w hom sp e c ia l a tte n tio n sh o u ld b e p aid. F o r a n y k in d of m e a n in g fu l p ro fe s s io n a l in te rv e n tio n a im e d a t p re v e n ­ tio n o r e a rly a n d la te tre a tm e n t o f s u c h a g ro u p th o ro u g h k n o w le d g e o f th e c o n d itio n is e sse n tia l. I n th e c a s e o f a u tis m it m ust b e re c o g n ise d th a t it is n o t a c le a r-c u t c lin ic a lly defin ed c o n d itio n b u t a sy n ­ d ro m e w ith f a irly w ide v a ria tio n s a n d a m u ltifa c to ria l a etio lo g y . T h e a im o f th is a rtic le is to focus on so m e asp e cts o f th e sy n d ro m e w h ic h could be o f in te re s t to p h y s io ­ th e ra p is ts, a n d w h ic h m ight stim u la te th e m to e x p lo re th e ir ro le in th e tre a tm e n t of c e rta in f e a tu re s in th e b e h a v io u r o f a u tis tic c h ildren. T h e m a te ria l is d ra w n from th e w o rld lite r a tu r e a n d m y e x p e rie n c e w ith a u tistic c h ild ren o v e r a p e rio d of 20 years. I n C a p e T o w n th e p ro b lem o f a u tis tic c h ild re n a n d th e ir fa m ilie s b e ca m e so pressing in th e e a rly 196 0 ’s th a t m e e tin g s w ith p a re n ts a n d in te re s te d p ro fe s sio n a l p e o p le w e re s ta r te d in 1964. F ro m th is a S o c iety fo r A u tis tic C h ild re n w as fo rm ed in 1966 a n d a p riv a te sc h o o l fo r W h ite a u tis tic c h ild ren w as s ta rte d in 1970. S in c e 1973 th is sc h o o l has b ecom e a g o v e rn m e n t s u b ­ sid ize d sp e c ia l sc h o o l. F o r C o lo u re d c h ild re n a class w ith o n e te a c h e r w as sta rte d in 1973; th is h a s d e ­ v e lo p e d in to a re c o g n iz e d special sc h o o l su b sid iz e d by th e D e p a rtm e n t o f C o lo u re d A ffairs. D E F IN IT IO N A s a sy n d ro m e a u tism is d e fin e d ‘as a g ro u p o f c o n ­ c u r re n t s y m p to m s w h ic h to g e th e r a re in d ic a tiv e o f a d ise ase o r o f m a la d a p tiv e fu n c tio n in g ’. T h e C o m m itte e o f I n q u iry in to th e T re a tm e n t, E d u c a tio n a n d C a re of A u tis tic C h ild re n (D e p a rtm e n t o f N a tio n a l E d u c a tio n , 1971) laid d o w n th e follow ing m ain c rite ria : • T h e c o n d itio n m u st h a v e sta rte d b e fo re th e a g e of 3 years: • T h a t th e r e b e a fixed p a tte rn o f s e lf-a b s o rb e d a n d d e ta c h e d b e h a v io u r. • T h a t th e r e b e a lan g u a g e d istu rb a n c e . • T h a t th e r e b e p e rsiste n t ritu a listic a n d o b se ssiv e a n d c o m p u lsiv e b e h a v io u r. T h e d ia g n o s tic c rite ria used b y a u th o rs a n d re s e a rc h w o rk e rs v a ry c o n sid e ra b ly fro m c e n tre to c e n tre , a n d f ro m c o u n try to c o u n try . T h is m a k e s th e c o lle c tin g of c o m p a ra tiv e d a ta on incidence, m e th o d s o f tre a tm e n t a n d o u tc o m e d iffic u lt. I t has lead to a s s u m p tio n s w h ic h a re p o o rly s u p p o rte d . A t the 3rd W .H .O . S e m in a r on P s y c h ia tric D ia g n o sis (R u tte r, et a l , 1969) a n a tte m p t w as m a d e to c la rify criteria , b u t e v e n h e re d iffic u ltie s * S e n io r P s y c h ia tris t, V a lk en b e rg H o s p ita l, C a p e T ow n. R e ce iv e d 1 M a y 1981. O P S O M M IN G O u tis m e is ’n o n d u id e lik e to e s ta n d w at nie g o e d ver- sta a n w o rd nie. D ie a r tik e l k la a r van die u ite e n lo p e n d e o o rs a k e en s im p to m e van die to e s ta n d op. D ie ro l van die fis io te r a p e u t in die b e h a n d e lin g van d ie o u tistie se k in d is n o g nie in S u id - A fr ik a d e u r s o e k nie en die s k r y fs te r s te l v o o r in w e lk e areas fis io te ra p ie v an w aarde k an wees. w e re e x p e rie n c e d . I t is h o p e d , h o w e v e r, th a t th e h e lp fu l su g g e stio n s o f th e p a rtic ip a n ts w ill re c e iv e g e n e ra l s u p ­ p o r t, a n d th a t m o re u n ifo rm c r ite r ia w ill c o m e in to g e n e ra l use. B e ca u se o f th e s e d iffe re n c e s , in c id e n c e in d if f e r e n t c o u n trie s is d iffic u lt to assess. In th e U n i t e e t T . K in g d o m a n d th e U n ite d S ta te s o f A m e ric a 2 - 4 p e t . ; ' 10 0 00 o f th e sc h o o l-g o in g p o p u la tio n h a s b e e n r e p o rte d . O n e h a s th e im p re ss io n th a t in S o u th A fric a it is 2 o r less p e r 10 0 0 0 in th e W h ite s, m u c h less in th e C o lo u re d p o p u la tio n a n d m o re o r less u n k n o w n a m o n g s t th e B lac k p e o p le . N o s a tis fa c to ry e x p la n a tio n s a re a v a ila b le . A E T IO L O G Y T h e r e is little a g re e m e n t a b o u t a e tio lo g ic a l f a c ­ to rs. O p in io n s d e p e n d la rg e ly o n th e o r ie n ta tio n o f th e c lin ic ia n a n d th e re s e a rc h e r a n d th e p a r tic u l a r a re a o f th is p r o te a n s y n d ro m e o n w h ic h a tte n tio n is b e in g fo c u se d . In a d e ta ile d a n d p a in s ta k in g s tu d y o f 100 a u tis tic c h ild re n G a rc ia a n d S a rv is (1964) c le a rly t a b u ­ la te d th e a e tio lo g ic a l fa c to rs . T h e s e ra n g e f r o m fa m ily p s y c h o p a th o lo g y , c irc u m s ta n c e s a n d tr a u m a tic e v e n ts e x p e rie n c e d b y th e c h ild a n d h is fa m ily to o rg a n ic c o n ­ d itio n s su c h as i m p a irm e n t o f s e n s o ry p e rc e p tio n to m in o r o r g ro ss n e u ro lo g ic a l fa c to rs. B e c a u se th e a e tio lo g y is so o b s c u re , d iv e rs e a n d m u lti­ fa c to ria l, a ll c lues h a v e to b e fo llo w e d u p . A p a r t f r o m o rg a n ic n e u ro lo g ic a l fa c to rs , n e u ro p h y s io lo g ic a l m e c h a n ­ ism s c o u ld b e o f sp e c ia l in te re s t to th e p h y s io th e ra p is t. T h e s e m e c h a n is m s c o u ld c a u s e o r c o n tr ib u te to the d is tu rb e d p e rc e p tio n s , im p a ire d b o d y im a g e , d e v ia n t m o b ility , h a n d a n d a rm fla p p in g , fin g e r lic k in g and tw itc h in g a n d c o n to rtio n s o f th e lim b s a n d b o d ^ O rn itz e t al., (1968) w rite: ‘A f r u itf u l a p p ro a c h m igm b e to lo o k a t th e a u tis tic c h ild ’s b e h a v io u r as e x p re ss in g th e d isso c ia tio n o f n o rm a lly o c c u rrin g n e u r o p h y s io lo ­ g ica l s ta te s . . . p h a se s o f s ta te s o f h y p e r-e x c ita tio n a n d in h ib itio n a lt e r n a te ’, e.g. p o s tu rin g a n d w ild a n d a im le s s a c tiv ity as o p p o s e d to im m o b ility a n d u n r e ­ sp o n s iv e n e ss to se n so ry stim u li. T h e y a lso p o s tu la te th e p o ss ib le p a th o lo g ic a l in v o lv e m e n t o f th e v e s tib u la r sy ste m to a c c o u n t fo r th e w h irlin g a n d u n u s u a l re a c tiv ity to s itu a tio n s a ffe c tin g e q u ilib riu m , a n d by th e e x c ite ­ m e n t e v o k e d b y s p in n in g a n d m o v in g o b je c ts. T h e a e tio lo g y , w h a te v e r it is, m a k e s it im p o s sib le fo r th e i n f a n t to re s p o n d n o rm a lly o r to e x p e rie n c e in ­ fa n c y in a n o rm a l w ay. T h e p r im a r y re s u lt in a ll c ases is t h a t it le a d s to im p a ire d b o n d in g b e tw e e n m o th e r a n d in fa n t. B e tte lh e im (1967) d e sc rib e s th is as ‘b a s ic a lly a d is tu rb a n c e o f t h e a b ility to r e a c h o u t to th e w o r ld ’. I n th e first in s ta n c e ‘th e w o r ld ’ c o n sists o f th e m o th e r a n d in th is ‘m o th e r - w o r ld ’ b o n d in g is c ru c ia l. B o n d in g c a n b e d e fin e d as th e d e v e lo p m e n t o f p r i m ­ a ry a ffe c tio n a l tie s b e tw e e n a m o th e r a n d h e r n e w ­ b o r n in f a n t a n d to d d le r. H a rlo w (1963) h a s sh o w n h o w th is d e v e lo p s a n d c a n b e im p a ire d , b y e x p e rim e n ta l w o rk w h ic h h e d id u sin g r h e s u s m o n k e y s . C lo se o b ­ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNE 1981 P H Y S I O T H E R A P Y 39 se rv a tio n o f m o th e r - in fa n t c o u p le s, a n d d isc u ssio n s w ith m o th e rs, h a v e c o n firm e d a n d e la b o ra te d o n th e s e e x ­ p e rim e n ta l fin d in g s . S a n d e r (1964), w o rk in g a t th e B o sto n U n iv e rs ity S c h o o l o f M e d ic in e , h a s d e sc rib e d th e i n te ra c tio n b e tw e e n m o th e r a n d i n f a n t d u rin g th e b o n d in g p ro c ess. H e stu d ie d c o u p le s u p to 18 m o n th s , a n d h a s id e n tifie d 5 sta g es o f ‘a d a p tiv e i n te r a c tio n ’, w h e re b o th m o th e r a n d in f a n t m u s t trig g e r off a n d re sp o n d to a p p r o p ri a te b e h a v io u r in th e o th e r. In m y e x p e rie n c e I h a v e b e e n im p re ss e d b y th e o b s e rv a tio n s o f m o th e rs in g e n e ra l a b o u t th e ir re sp o n se s to th e ir n e w b o rn b a b ie s. T h e b a b ie s e ith e r im m e d ia te ly a ro u s e fe e lin g s o f re sp o n siv e n e ss a n d c lo sen e ss, o r m o th e rs e x p e rie n c e little in s tin c tiv e fe e lin g s fo r a p a r ­ tic u la r in fa n t. T h is e m o tio n a l re a c tio n seem s to b e th e first e v id e n c e o f th e p re se n c e o r a b se n c e o f b o n d in g . P h y s ic a l c o n ta c t im m e d ia te ly a f te r b i r th se e m s to fa c ili­ ta te a fe e lin g o f c lo sen e ss a n d a se n se o f b e lo n g in g n e ss w h ic h p ro m o te s b o n d in g . T h is p le a s u ra b le c o n ta c t sh o u ld re m a in a n u n d e r c u r r e n t o f th e i r re la tio n s h ip w h a te v e r th e ir p ro b le m s a n d fru s tr a tio n s d u rin g th e p r o ­ cess o f g ro w in g up. F o r e ffe c tiv e in te rv e n tio n e x te n siv e k n o w le d g e o f th e p h y sic a l a n d p sy c h o lo g ic a l d e v e lo p m e n t a n d b e ­ h a v io u r d u rin g e a rly in fa n c y a n d c h ild h o o d is e sse n tia l. A se n sitiv e a w a re n e ss o f th e m o th e r-c h ild a n d p a re n t- ch ild i n te ra c tio n m u s t a lso b e a c q u ire d . In th is field th e re is n o s u b s titu te fo r p a in s ta k in g h is to ry -ta k in g , n o t o n ly o f th e d e v e lo p m e n t a n d e v e n ts a ffe c tin g th e c h ild , b u t a lso o f h o w th e c h ild a n d th e s e e v e n ts a ffe c t th e m o th e r a n d h e r re la tio n s h ip w ith th is p a r tic u la r ch ild a n d w ith th e re s t o f th e fa m ily . D E V E L O P M E N T A L H IS T O R Y A N D A S S E S S M E N T In cases o f su s p e c te d a u tis m th e h is to ry o f th e m ile ­ sto n e s o f d e v e lo p m e n t h a v e to b e ta k e n in g re a te r d e ta il th a n is o rd in a rily d o n e w ith re la tiv e ly in ta c t c h ild re n . E v e ry e ffo rt m u s t b e m a d e to o b ta in a c c u ra te a n d f a c tu a l d a ta , b u t th e w ay in w h ic h th e in f o r m a tio n is given b y th e m o th e r o r p a re n ts is e q u a lly im p o rta n t. I n ­ a c c u ra te o r c o n flic tin g d a ta m u s t b e n o te d , a p p a r e n t ‘ir- re le v a n c ie s’ to a n sw e rs o r ‘ir r e le v a n t’ sp o n ta n e o u s ly g iven in fo rm a tio n m u s t b e e v a lu a te d as re le v a n t to th e re la tio n s h ip . C o m m o n f e a tu re s o f a u tis m a re th o se a lre a d y m e n ­ tio n e d in th e d e fin itio n . In a d d itio n th e lac k o f r e la ­ tio n s h ip c a n b e se e n by: • T h e d iffic u lty in m ix in g w ith a n d p la y in g w ith o th e r l c h ild re n . • N o t b e in g c u d d ly in th e re a l se n se o f th e w o rd . • T h e a v o id a n c e o f eye c o n ta c t. • T re a tin g p e o p le lik e o b jec ts, se e m in g to lo o k th ro u g h th em a n d w a lk o v e r them . • N o t tu rn in g to th e p a r e n ts fo r c o m fo rt w h e n h u r t o r d istre sse d . T h e se lf-a b so rb e d , d e ta c h e d b e h a v io u r is a lso p o r ­ tra y e d b y th e a b o v e tra its a n d in a d d itio n by: • T h e ir s ta n d -o ffis h m a n n e r — as th o u g h th e y d o n o t n e e d o th ers. • T h e o ft n o te d a b se n c e o f s e p a ra tio n a n x ie ty . • T h e ir te n d e n c y to a c t as th o u g h th e y a re d e af, e sp e c ia lly n o t re s p o n d in g to th e h u m a n voice. • T h e y u su a lly lac k fe a r a b o u t re a lis tic d a n g e rs, b u t c a n h a v e o b se ssiv e fe a rs a b o u t a p p a r e n tly o rd in a ry e v e n ts o r m in o r s itu a tio n s . T h e ir c o m p u lsiv e b e h a v io u r is se e n in: • T h e ir r e p e titiv e a n d s u s ta in e d o d d p la y , s u c h as sp in n in g o b je c ts, flic k in g p iec es o f strin g , etc. • T h e ir u n u s u a l a tta c h m e n t to p a r ti c u la r o b je c ts a n d th e ir a c u te e m o tio n a l re a c tio n w h e n th e s e a re ta k e n aw ay. • T h e ir re s is ta n c e to c h a n g e s in r o u tin e o f m a n a g e ­ m e n t, fo o d , s itu a tio n s , etc. N o sin g le c h a ra c te ris tic s h o u ld b e re g a rd e d as b e in g o f p a r a m o u n t im p o rta n c e , th e c lu s te rin g o f c h a r a c te ris ­ tics to g e th e r w ith th e h is to ry m a k e s a d ia g n o s is p o s ­ sible. B u t p e rh a p s th e m o s t im p o r ta n t fa c to r is th e su b tle a n d d iffic u lt-to -d e fin e q u a lity o f th e re la tio n s h ip s as e x p e rie n c e d b y th e d ia g n o s tic ia n in th e d ia g n o s tic ro o m o r a t th e h o m e . T o so m e e x te n t it is th e c o u n te r ­ tra n s fe re n c e , i.e. th e fe e lin g s w h ic h th e v a rio u s m e m ­ b e rs o f th e fa m ily e v o k e in th e e x a m in e r, w h ic h m u s t a ls o b e g iv en d u e w e ig h t. F r o m th e p o in t o f view o f th e p h y s io th e ra p is t sp e c ia l a tte n tio n s h o u ld b e p a id to g ro ss a n d f in e m o to r d e ­ v e lo p m e n t a n d c o -o rd in a tio n . A v a rie ty o f e x te rn a l a n d p h y sic a l c o n d itio n s c a n in te rfe re w ith th e s m o o th d e v e lo p m e n t o f th ese. If, f o r e x a m p le , a n in f a n t o r c h ild h a d to b e h o s p ita liz e d o r im m o b iliz e d fo r lo n g e r o r s h o r te r p e rio d s d u rin g c ritic a l p h a se s o f d e v e lo p ­ m e n t, w h a te v e r th e re a s o n , d e v ia tio n s in d e v e lo p m e n t a re lik e ly to o c c u r. I t m u s t b e k e p t in m in d t h a t th e s e will h a v e p sy c h o lo g ic a l a n d p h y sic al re p e rc u ssio n s w h ic h in tu rn w ill a ffe c t r e la tio n s h ip s a n d c o lo u r th e p ro c e ss o f b o n d in g . T h e a b o v e h a s p la y e d a ro le in a few o f th e cases I a m a c q u a in te d w ith , b u t it m u s t b e c le a rly u n d e rs to o d th a t s u c h tr a u m a tic e x p e rie n c e s d o n o t n e c e ssa rily lea d to a u tis m ; th e re m u s t b e o th e r fa c to rs in th e s e c ases also. T h e g ra sp o f th e p o te n tia lly a u tis tic c h ild is g e n e ra lly p o o r. E v e n d u rin g th e first y e a r o f life th is is e v id e n t. T h e a p p ro x im a tio n o f th u m b -fin g e r is p o o rly d e v e lo p e d a n d th e g ra sp r e m a in s th e w h o le h a n d o r ju s t th e fin g ers. T h e y e ith e r m o u th e v e ry th in g , o r th e y re fu s e to u se f in g e r fo o d . C h e w in g o f sem i-so lid s a n d solids o fte n p re s e n t d iffic u ltie s a n d su c k in g r e m a in s th e m a in m o d e o f im b ib in g n o u ris h m e n t. T h e y a re th u s re lu c ta n t a n d slow to u se th e s p o o n o r o th e r u te n s ils. T h is in ­ e ffe c tu a l use o f th e ir h a n d s le a d s to c o n s id e ra b le d if f i­ c u ltie s in th e a c q u is itio n o f m a n u a l skills, w ritin g a n d tra in in g in a rts a n d c ra fts. S e v e re ro c k in g a n d h e a d b a n g in g c a n d e v e lo p e a rly a n d c a n b e c o m e a se rio u s a n d d is tu rb in g p r o b le m in la te r y e ars. In ju rie s c a u s e d b y h e a d b a n g in g c a n b e so se v e re th a t c ra s h -h e lm e ts h a v e b e e n p re sc rib e d . S e rio u s s e lf-m u ltila tio n is n o t u n c o m m o n . T h is u su a lly o c c u rs d u rin g p e rio d s o f m a rk e d a n d a p p a r e n tly u n ­ p ro v o k e d h y p e re x c ite m e n t. T h is b e h a v io u r c a n b e a g e n e ra l f e a tu r e o f a p a r tic u la r c h ild o r it c an o c c u r in a c h ild w h o is o rd in a rily q u ie t a n d p a ssiv e . I t seem s as th o u g h in n e r te n s io n b u ild s u p w h ic h c a n o n ly fin d e x p re ss io n in n e a r v o lc a n ic e ru p tio n s . B iz a rre p o s tu rin g is n o t a n u n c o m m o n f e a tu re . M a r k e d b a c k w a rd a rc h in g to th e e x te n t th a t th ey sta n d o n th e ir h e a d a n d f e e t can o c c u r fro m th e second h a lf o f th e first y e a r — it is u su a lly tr a n s ito ry in n a tu re . L ess b iz a r r e b u t m o re p e rs is te n t is tw irlin g a n d sp in n in g o f th e b o d y a n d fla p p in g o f a rm s a n d h a n d s . F r o m th e first y e a r o f life, b u t p a rtic u la r ly n o tic e a b le la te r o n , is th e w a y th e b o d y is h e ld w h e n th e ch ild is p ic k e d up. It is e ith e r h e ld v e ry rig id ly a n d th e n th e ch ild is c a lle d ‘n o t c u d d ly ’, o r it m o u ld s to o n e ’s b o d y as th o u g h it is m a d e o f d o u g h , a n d th e c h ild is th en m is ta k e n ly c a lle d ‘c u d d ly ’ b y th e p a re n ts a n d o th e rs . F o r th e e x a m in e r it is im p o r ta n t to k n o w h o w th e b o d y o f th e a v e ra g e c h ild re s p o n d s to b e in g h e ld . T h e c h ild ’s b o d y relates a n d re sp o n d s as a s e p a ra te in d iv id u a l to th e b o d y o f a n o th e r s e p a ra te in d iv id u a l. T h e b o d y im a g e o f m o s t a u tis tic c h ild re n is ■ p o o rly d e v e lo p e d . I t seem s as th o u g h th e ir b o d ies a re as p o o rly in te g ra te d as th e ir e m o tio n a l a n d in te lle c tu a l asp e cts a n d th e ir social re la tio n s h ip s . A p a r t f r o m o rg a n ic c au ses th is c o u ld a c c o u n t f o r th e p o o r p o s tu re s w h ic h a re n o t u n ­ c o m m o n . A p a r t f r o m p o o r p o stu re s, m a n y h a v e c lu m sy a n d u n g a in ly gaits. S o m e , h o w e v e r, a re g ra ce fu l a nd agile. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 40 F I S I O T E R A P I E JUNIE 1981 T h e d ia g n o s is o f a u tism is th e re fo re n o sim p le p r o ­ c ed u re . In p s y c h ia try w e d istin g u ish be tw ee n ‘la b e llin g ’, giv in g a c o n d itio n a n a m e , a n d th e p sy c h o -d y n a m ic asse ssm e n t o f th e fa c to rs w h ich h a v e o r a re still c o n ­ trib u tin g to th e p ic tu r e as it p re se n ts a t th e tim e. T h is re q u ire s th e skill o f a v a rie ty o f d isc ip lin e s in th e case o f a u tis m . A fu ll p h y sic a l, n e u ro lo g ic a l a n d , a t tim e s, a b io c h e m ic a l in v e s tig a tio n is a lw ay s n e ce ssa ry . Several p s y c h ia tric in te rv ie w s m ay b e in d ic a te d ; th e p sy c h o m e tric a sse ssm e n t c a n b e e x tre m e ly difficult to e sta b lish a n d th e ir a tta in m e n ts c an sh o w a w ide s c a tte r. A t tim es it m ay b e n e c e ssa ry to, h a v e th e o p in io n o f sp e c ia lis ts in o th e r fields, p a rtic u la rly to assess h e a rin g a n d vision. T h e f o rm e r re q u ir e s sp e c ia l k n o w le d g e a n d te c h n iq u e s. In C a p e T o w n th e c hild is a lso se n t fo r o b se rv a tio n to th e a p p r o p ria te sc h o o l. T h e s e p a in s ta k in g d ia g n o s tic p ro c e d u re s a re re q u ire d b e c a u se ‘a u tis tic fe a tu re s ' c a n o c c u r in a w ide v a rie ty o f o th e r c o n d itio n s. T h e d e ta ile d p ro c e d u re is a lso re q u ire d so as to assess th e a e tio lo g ic a l fa c to rs as a c c u ra te ly as p o ssib le . T h e s e m u s t be k n o w n to th e e x te n t in w hich it is p o s s ib le so as to e n a b le th e te a m w h o w ill be d e a lin g w ith th e c h ild a n d his fa m ily to w o rk o u t a tre a tm e n t a n d e d u c a tio n a l p ro g ra m m e a im e d a t th e m a jo r c au ses o f th e c o n d itio n a n d to u se th e stre n g th s in the c h ild a n d his fa m ily to th e m ax im u m . C O N C L U S IO N I n th is c o u n tr y th e ro le o f th e p h y s io th e ra p is t h a s n o t b e e n e x p lo re d in a n y m e a n in g fu l w ay. I n m y o p in io n sh e c a n be o f g re a t h e lp w ith the s tim u la tio n a n d d e v e lo p m e n t o f th e se n so ry m o d a litie s. By th e v a rio u s te c h n iq u e s o f h e r s p e c ia lity sh e c o u ld a id th e d e v e lo p m e n t o f a b o d y im a g e , a n d th e im b a la n c e o f th e u se o f m u sc le s, so as to m in im iz e c lu m sy a n d b iz a rre g a its a n d th e p o s tu rin g m e n tio n e d e a rlie r. I t m ig h t a lso b e w o rth w h ile e x p lo rin g th e id e a s of O rn itz a n d , w ith re la x a tio n te c h n iq u e s a n d o th e r m e a n s, g e t a b e tte r u n d e r s ta n d in g o f th e p e rio d s o f h y p e r ­ e x c ita tio n . I n a b o o k (G o u w s, 1979) o n th e e d u c a tio n o f th e a u tis tic c h ild th e ro les o f p a ra m e d ic a l sta ff h a v e b e en b rie fly m e n tio n e d , b u t th e p h y s io th e ra p is t h a s been o m itte d . T h is co u ld be a n a c c id e n ta l o m is sio n , b u t it is m o re lik e ly th a t th e skills o f th e p h y s io th e ra p is t h a v e n o t y e t b e e n a p p lie d in th is a re a . U n til th e a u tistic c h ild is se e n as a n a t risk c h ild a n d u n til p h y s io th e ra ­ p ists h a v e a p p lie d th e ir sp e c ia l sk ills a n d k n o w le d g e in a p ra c tic a l s e ttin g a n d w o rk e d in a te a m w ith o th e r d isc ip lin e s , n o o n e is in a p o s itio n to give a n a u th o r i ­ ta tiv e o p in io n . T h e fa m ily is n o t th e c o n c e rn o f th e p h y s io th e ra p is t in te rm s o f p h y sic al p ro b le m s, b u t sh e will h a v e to w ork in close a ss o c ia tio n w ith th e m . F a m ilie s e x p e rie n c e ex ­ tre m e te n s io n s o f v a ry in g k in d s a n d th e h e lp in g p r o ­ fe ssio n s h a v e to k n o w a b o u t it a n d u n d e rs ta n d it as it c a n u n d o m u ch o f th e ir w ork. R eferen ces B e tte lh e im , B. (1967). T h e e m p ty fo rtre ss . F r e e Press. N e w Y o rk . D e p a r tm e n t o f N a tio n a l E d u c a tio n (1971). R e p o r t ofT th e c o m m itte e o f in q u iry in to th e tre a tm e n t, e d u \ ' c a tio n a n d c are o f a u tis tic c h ild re n . G o v e rn m e n t P rin te r. P re to ria . G a rc ia , B. a n d S arvis, M . A . (1964). E v a lu a tio n a nd tre a tm e n t p la n n in g fo r a u tistic c h ild re n . A r c h . G en. P sy c h ia t., 10, 530. G o u w s, M . (1979). O n d e rw y s v ir o u tis tie se kinders. S.A . R a a d v a n G e e s te sw e te n sk a p lik e N a v o rsin g . P re to ria . H a rlo w , H . F . (1963). I n D e te rm in a n ts o f i n f a n t b e ­ h a v io u r. E d . F o s s, B. M . M e th u e n . L o n d o n . O rn itz , E . M . a n d R itv o , E. R . (1968). N e u ro p h y sio lo g ic m e c h a n ism s u n d e rly in g p e rc e p tu a l in c o n s ta n c y in a u tistic a n d sc h iz o p h re n ic c h ild re n . A rc h . G en. P sy ch ia t., 19, 22. R u tte r , M ., L eb o v ici, S., E is e n b e rg , L. et al. (1969). A tria x ia l classifica tio n o f m e n ta l d iso rd e rs in c h ild h o o d . A n in te rn a tio n a l study. J. C h ild P sy ch o l. P sy c h ia t., 10, 41. S a n d e r, L. (1964). A d a p tiv e re la tio n s h ip s in e a rly m o th e r- c h ild in te ra c tio n . J. A m e r. A c a d . C h ild P sy ch ia t., 3, 231, KEEPING IN TOUCH TH E NEED FOR COMMUNICATION IN PHYSIOTHERAPY P . B O W E R B A N K M .C .S .P ., B A , D ip T e r t E d f (U N IS A ) S U M M A R Y T h e n e e d f o r c o m m u n ic a tio n , a t a ll lev els, in p h y s io ­ th era p y, is stressed. C o m m u n ic a tio n is d e fin e d a n d ch a ra c te ristics o f th e c o m m u n ic a tio n m o d e l are g iven, viz. o p e n n ess, e m p a th y , s u p p o r t, p o sitiv e n e s s, e q u a lity, c o n te n t a n d rela tio n sh ip s. A r e a s o f c o m m u n ic a tio n su c h a s v e rb a l c o m m u n ic a tio n , liste n in g , n o n v e r b a l c o m m u n i­ c a tio n , to u c h , p r o x im ity , fa c ia l e xp ressio n a n d w ritte n c o m m u n ic a tio n are discussed. T h e title o f th is p a p e r ‘th e n e e d fo r c o m m u n ic a tio n in p h y s io th e r a p y ’ su g g e sts t h a t th e r e is a c e rta in lack * C h ie f P h y s io th e ra p is t, G r o o te S c h u u r H o s p ita l. P a p e r d e liv e re d a t S A S P C o n g re ss h e ld in P re to r ia M a rc h 1981. R e c e iv e d 29 M a rc h 1981. O P S O M M IN G D ie b e h o e fte aan k o m m u n ik a s ie , o p a lle v la k k e , in fis io te ra p ie , w o r d b e k le m to o n . K o m m u n ik a s ie w o r d ge- d e fin ie e r cn k e n m e r k e van die k o m m u n ik a s ie m o d e l w o r d gegee, nl. o p e n lik h e id , e m p a tie , o n d e rste u n in g , p o si- tiw iteit, g e ly k h e id , in h o u d e n v erh o u d in g s. A r e a s van k o m m u n ik a s ie so o s m o n d e lin g e k o m m u n ik a s ie , luister, n ie -m o n d e lin g e k o m m u n ik a s ie , aa n ra k in g , nabyheicl, g e - sig s u itd r u k k in g en g e sk re w e k o m m u n ik a s ie w o r d be- s p r e e k ., o f c o m m u n ic a tio n o r th a t th e c o m m u n ic a tio n p ro c e ss is n o t b e in g effe c tiv e ly c a rrie d o u t b y p h y s io th e ra p is ts . A s tu d y o f th e l ite r a tu r e su g g ests th a t th is s ta te m e n t m ig h t p o ss ib le b e tru e . F ro m a n a rtic le by J u d ith L o rb e r (1975) I q u o te : W h e n a p a tie n t e n te rs h o s p ita l, h e o r sh e is a n o u ts id e r in th e h e a lth p r o f e s s io n a l’s p la c e o f w ork. L ik e a n y o th e r w o rk e rs, d o c to rs , n u rse s (p h y sio R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )