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AN INTEGRATED AND HOLISTIC APPROACH TO AUTISM-THERAPEUTIC

CASE STUDY IN BANGALORE, INDIA
Buvana Ramesh*1, Laveena D’mello*2
*1Research Scholar, College Of Social Science & Humanities, Srinivas University, Mangalore, India.
*2Associate Professor, School Of Social Science & Humanities, Srinivas University,
Mangalore, India.
ABSTRACT
DSM-5 reduced social-related elements of autism into social communication impairment and
repetitive/restricted behaviors and termed it as Autism Spectrum Disorder. In India, there is a lack of evidence-
based estimate of the population prevalence of ASD. The rural study showed a prevalence of 0.11, and studies in
urban pool showed a prevalence of 0.09. Early diagnosis of ASD in children help them get appropriate care and
treatment. This case study highlights a scientific, systematic approach which is effective in reshaping the
children in both body and mind. Integration in a true sense for ASD consists of physiotherapy (PT), behavioral
therapy (BT), speech therapy (ST) and academic readiness. Children with autism have difficulty in following
instructions, maintaining eye contact, less attention span and are not typically socially responsive. Physical gait,
stance, walking, posture, body balance, strengthening of muscles and sensory tissues are some of the PT focus
and support techniques. BT directs its focus on stimming, attitude, tantrums and other cognitive development
techniques. ST techniques are applied to change from a non-verbal to a verbal child. Special educators play a
role in readying the kid with reading, writing and comprehension. This is a special concentration case study on
a child who has a carefully planned holistic program which has been successful. The implication of the study is,
it means hope for the ASD community when they plan on an early intervention for their children.
Keywords: Autism, Holistic, Integrated, Physiotherapy, Speech Therapy, Behavior Therapy, Intervention.
I. INTRODUCTION
DSM-5 reduced social-related elements of autism into social communication impairment and
repetitive/restricted behaviors and termed it as Autism Spectrum Disorder ASD. [1] In India, there is a lack of
evidence-based estimate of the population prevalence of ASD. The rural study showed a prevalence of 0.11, and
studies in urban pool showed a prevalence of 0.09. [2] Autism is a composite spectrum hiding an array of
autisms. Some originate before birth affecting the brain. There are various other factors like heredity, social and
environmental factors during pregnancy and after birth. There are a range of kaleidoscopic behaviors in
children with autism, bringing about range of emotions from their families. The spectrum ranges from mild to
severe and several shades in between [3]. Having different measures to find the extent of severity, it is yet not
consistent when professionals make the distinctions. Autism is an enigma that is yet to be comprehended
completely. As much an enigma, it is also stigmatized to a certain extent in India. In eastern India, based on an
article, it brings distress and has a negative impact on the caregivers and seekers lives [4]. Researches have
been carried out about how autism was being stigmatized and how they now fall under ‘neurodiversity’ [5]. It is
about time to have a mental shift about the stigma that is attached to this disorder. The growth in the increasing
number of diagnostic tools and methods worldwide is remarkable. The awareness is expanding and spreading
to the rural population in India.
It is pertinent to understand that every child is different and every autistic child is certainly unique in his or her
own way. There is no one single approach to make their lives better. Numerous practical methodologies have
been formalized and introduced by the therapists as treatments. Teachh [6], Functional developmental
approach [7], nutritional approach [8] are few of them. A well thought out integrated, systematic, scientific
approach helps in reshaping both their body and mind. Certain common behaviours of ASD are, almost normal
physical growth, mental immaturity, social introversion and basic communication problems making them non-
verbal, etc. They find it difficult to communicate because they perceive and process things differently. They
react unusually to loud sounds, people, and bright light and may not know to express in normal words or
actions. Stimming or self-stimulated behavior is another common symptom in ASD. Repetitiveness in hand,
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fingers or facial movements is a stereotyped behavior. [9] Echolalia is a repetition of others’ words in a
meaningless manner indicating some form of disorder
II. PURPOSE/OBJECTIVE
The purpose of this systematic case study is to highlight the effectiveness of holistic and integrated therapy
interventions in children with autism spectrum disorder (ASD).
III. NEED FOR THE STUDY
Several journal articles and research papers are published for behavioral therapy, speech therapy and play
therapy but fewer for an integrated and holistic approach. When all the therapies work in tandem, the program
becomes highly effective. Awareness of the presence of such therapeutic treatments is absent among parents of
ASD children. This case study was selected based on such comprehensive, systematic and well-designed
program that has helped many such children from this center in Bangalore, India. The objective is to bring
awareness and make the information available to a larger population.
IV. THERAPIES FOR TREATMENT
Physical therapists are healthcare professionals who help in improving, restoring and maintaining physical
health, fitness and wellbeing. Physiotherapy in autism helps in mobility, restores balance in areas of imbalance,
provide rehabilitation in areas of gross and fine motor skills [10].The effectiveness of physiotherapy was
measured with the dynamometer in such a research. Fine and Gross motor skills can be strengthened. The
therapists and doctors have their own screening practices and procedures. They keenly observe and assess the
neurological disorder if any, check for spinal strength, any other distinct imbalance issues. The motor
assessment, tests for the built, posture, muscle tone, gait, etc. The Muscle test is a measurement to assess, limbs,
knee, joints, foot and ankle in full detail. This is carried out in parallel to the neurological relation of the child for
assessing his equilibrium and co-ordination. Respiratory pattern, core muscles strength and pelvic bridging are
assessed. A thorough assessment evaluates the child of the core strength and weakness. [11] Proprioceptive,
vestibular, sensory afferents contribute to the complexity of maintenance of balance. A shortfall in one will
result in postural imbalance. Physiotherapists evaluate the balance and oscillations in children whilst silent
standing on the floor, staircase and stepstool. It is proved through research that certain exercise regimes reduce
stereotypical behavior providing room for future research. [12] Physical therapy has proven beneficial for
autism in the improvement of posture, eye contact and focus. Having a fitness regime is helpful. Any
musculoskeletal deficits in the bone structure can also be aligned. Functionality and motor co-ordination can
well be improved. [13] Given the mental age of an autistic child, pretend play would be less than expected, In
ASD children, the mental state does not have the capacity to understand or predict the behavior of another
state. This calls for the futuristic behavior of the pretend play concept, which cannot be fulfilled by them.
Many research papers have been published in applying cognitive behavior therapy for autism. After
neurological and psychological assessments, evaluation based therapy programs are designed for every child.
Some of the therapy sessions may look and sound play-centric in contrast to how an ASD child looks at it. ASD
children have their own set ways and the cognitive behavior therapy with Applied Behaviour Analysis break
their set ways. The children are extremely resilient and hence consistent measures with extreme patience is
required for socially acceptable mode of behavior. [14] Role plays and rehearsals could be mode of teaching.
Distortion and generalizations could be used about their general set ways and beliefs to handle their real life
situations.
V. INTERVENTION ROUTINES
The child is monitored from the entry into the center until it’s time to exit from the center. On this basis,
vestibular, proprioception, gait training, visual tracking, sensory activities are designed and applied. A thorough
examination and assessment is conducted and an individualized program is customized for the child based on
the results of the evaluation. A weekly program gets designed with the duration of each exercise routine per
day, the number of days per week and a simultaneous home program. If and when the child becomes therapist
centric, the pattern gets broken in order for the child to develop a social functioning and to break the fixation.
Each therapist has a special approach which will facilitate the child in adaptation and deconditioning and

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reconditioning the body and mind. When the mental setup of the child is set to function a certain way and
inflexible to changes, then the rotation of therapists help in training for mental flexibility.
Gross motor skills aids in holding, picking, grasping and movement of larger objects and fine motor helps in
smaller objects. [15] Stimming can be addressed by keeping their mind and body occupied with various
activities. Many of them are incapable of expressing their feelings because they don’t know how to. Behavior
therapy teaches them a constructive way of keeping their arms to themselves. Some minor physical deficits and
misalignments could hamper their mobility and speech. Treating them for respiratory malfunctions and gross
motor and sensory issues can help them reduce such behavior. There are a few setbacks of this problems.
Speech therapy may get hindered; cause for more stigmatization; becomes more challenging in behavioral
training. [16] Their research was carried out using a cue, pause, point theory. The child was asked to stay silent
by providing a visual cue and then point to the answer for the question. This was successful in reducing the
echolalia in a child with ASD for about 57 months.
VI. METHODOLOGY
This case study is about a child of two years and three months when he showed lack of attention, loss of eye
contact, speech delays and behavioral problems. He was taken to an occupational therapist where he was
assessed. The first administration of the Peabody test showed that except for grasping, the rest of the motor
skills like locomotion, stationary, object manipulation visual motor integration were almost behind by twelve
months. The child was not able to maintain position for a count of 5 seconds. His auditory and sensory profile
scores were of concern. He demonstrated tactile discomfort and had severe concern in this movement and
processing domain. His playing ability was within the 12-18 month range. He was recommended Speech
therapy, motor and cognitive therapy, instructions following, gross motor strengthening, etc. He was suggested
activities for vestibular input.
The child was assessed by the occupational therapist for Ages and Stages Questionnaire (ASQ) which indicated
that his gross, fine motor, problem solving, communication, personal and social scores were way below the
expected and age appropriate scoring and hence all the domains were of concern. The child was also assessed
for Child Behavior Checklist (CBCL) even before he was brought to this center. On the problem scales, his
internalizing and externalizing problem scales were within the normal range. His scores on the emotionally
reactive, sleep, somatic problems were in the normal range. However, his scores on the withdrawn and
attention problems syndromes were in the clinical range above the 97 th percentile. His score on the autism
spectrum problems and attention deficit/hyperactivity problems were again in the 97 th percentile. His findings
on AIIMS modified INDT-ASD indicated that ASD was present. His Developmental Assessment Scale for Indian
Infants (DASH) showed his motor age was at a 19.2 month scale and his mental age was at a 12.2 months. All of
this indicated that the child had overall delay in development. He was meeting the ASD criteria. Therapies for
improving speech and communication, interventions for social and play and communication skills were also
suggested. Strategies to improve gross and fine motor skills were suggested.
Although the above reports were perused, this center followed the protocol and re-evaluated the child. They
made a thorough examination of the child in self -stimulatory, self -injurious behaviors in addition to all other
aspects of daily living activities. Flapping hands, toe walking, banging head against stationary objects, short
attention span, hard to calm down when upset were some of the common traits of ASD that were found.
Despite his cheerful attitude while entering the clinic, he was poor in following instructions. Lacking social
smile and focus and eye tracking, he was an avoider of activities. His vestibular functioning skills like wobble
board standing, tandem standing and step stool standing were nil. He adapted ‘W’ sitting position and sitting
with abducted legs. Proprioception of finger eye, tip to tip, tip therapist finger, finger nose test were positive.
6.1 TOOLS USED: Peabody Developmental Motor Scale, Sensory Profile Questionnaire, AIIMS modified INDT-
ASD, DASH, CBCL.
6.2 Manual Testing for Muscle Grading for Muscle Power
Upper Limb

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Table 1: Shoulder Joint
Muscle Group Right Side Left Side
Flexors 3+ 3+
Extensors 3+ 3+
Adductors 3+ 3+
Abductors 3+ 3+
Internal Rotators 3+ 3+
External Rotators 3+ 3+
Table 2: Elbow Joint
Muscle Group Right Side Left Side

Flexors 3+ 3+

Extensors 3+ 3+

Table 3: Fore Arm (Radio-Ulnar Joint)

Muscle Group Right Side Left Side

Pronators 3 3

Supinators 3 3

Table 4: Wrist Joint

Muscle Group Right Side Left Side
Flexors 3 3
Extensors 3 3
Radial Deviators 3 3
Ulnar Deviators 3 3
Lower Limb
Table 5: Hip Joint
Muscle Group Right Side Left Side
Flexors 3 3
Extensors 3 3
Adductors 3 3
Abductors 3 3
Internal Rotators 3 3
External Rotators 3 3
Table 6: Knee Joint
Muscle Group Right Side Left Side

Flexors 3+ 3+

Extensors 3+ 3+

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Table 7: Ankle Joint
Muscle Group Right Side Left Side

Dorsi Flexors 3 3

Plantar Flexors 3 3

Table 8: Foot
Muscle Group Right Side Left Side
Invertors 3 3
Evertors 3 3
Table 9: Muscle Girth-Limb Circumference
Muscle Group Right Side Left Side
Arm 16cm 16cm
Forearm 14cm 14cm
Thigh 26cm 26cm
Calf 20cm 20cm
The above tables provide extensive details of the muscle power of the child’s limbic system. This contributes to
the inability in gross motor and fine motor activities. Postural and positioning issues, stiffness of muscles are
some of the resulting factors. The inability to perform certain equilibrium and non- equilibrium tasks were also
due to this. Having measurements in place, it facilitated in designing a comprehensive physiotherapeutic
program for the child. The Range of Motion (ROM) of the child can gradually be increased with repetitive
activities, exercises and daily sensory massages.
The Key to the above Testing method is as follows:
Grade 5 (Normal Range ; 100%) : This is a test position and it indicates how much the patient is able to
withstand pressure in that position. When the therapist applies maximum resistance, the patient has no
discomfort in withstanding the pressure. When there is a ROM against gravity, patient can complete the task
even with maximum resistance.
Grade 4 (Good range ; 75%) : This is a test position and it indicates how much the patient is able to withstand
pressure in moderate or medium to high strength. When the therapist applies medium resistance, the patient is
comfortable in withstanding the pressure. When there is a ROM against gravity, patient can complete the task
even with moderate resistance.
Grade 3+ (Fair+ range) : This is a test position and it indicates how much the patient is able to withstand
pressure in a minimal resistance against gravity.
Grade 3 (Fair range ; 50%) : The therapist cannot apply force in this testing. Otherwise the patient will fail the
test.
Grade 2+ (Poor +) : This is a test on an anti-gravity position and it indicates how much the patient is able to
move with roughly 50% motion or could hold a position without any gravity. When the patient is able to do a
full ROM easily, but immediately loses it with the slightest of pressure, then 2+ grade will be given.
Grade 1 (Trace) :
When there is a minute contraction but unable to move the body with or without resistance nor gravity. Then it
is graded as 1. When no tracing or action happens when they are being tested, then the grading is 0.. The
therapist examines visually or through touch which is termed as palpation.
6.3 LYMPHATIC DRAINAGE MASSAGE: Neuro Inflammation seems to be a hallmark in ASD [17]. This manual
massage helps in clearing the blocks or obstacles in the cervical nodes and provides free flow of the lymph
coming from the brain. This reduces the inflammation, resulting in tactile functioning, flexibility, loosening of
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muscles and focus and attention. The child was given this massage five days a week for the past few months.
The tolerance level increased in behavioral, physical and speech activities. His muscle stiffness was loosened.
Focus improved which resulted in less distraction during activities.
6.4 PARENTS FEEDBACK: Parents are encouraged to watch the therapies every month. They follow a well-
designed home program for the continuity and also to familiarize the children with the new therapies
introduced in the center. Parents of this case study have expressed their joy in the positive improvement in
their son’s attitude and behavior. They were able to notice some significant changes in doing multiple activities
with ease. He was following instructions and he started adapting a different sitting position, better focus, sitting
and standing tolerance were achieved.
In six months period of therapy, the child willingly and happily entered the center, greeting the therapist with
verbal prompts. He was sustaining eye contact but got distracted in an open environment. Although adapting W
sitting position, he was able to sit cross legged with instructions. His core muscles needed improvement in
order for sitting tolerance. His co-operation began to increase during transition although he was not very
flexible to changes. He exhibited social smile for the concerned therapist. Stimming was considerably reduced.
In spite of exhibiting weak muscle tone, he began climbing up the stairs without support and climbing down
with minimal support. This was possible with simultaneous interventions. Exercises to improve his flexors
which will improve his gait were implemented. Simple repetitive interventions like SLR, pelvic bridging were
carried out to improve his pelvic, upper and lower limb muscles. Exercises for strengthening his respiratory
system were applied. Sensory tactile resistance and seeking was approached through lymphatic drainage
massage and was tolerated. Vestibular functionalities like eye contact, perception, focus, attention showed
improvement. Activities were practiced through static and dynamic balance. Proprioception activities were
performed passively by the therapist to achieve awareness and control of the force and pressure. Specific gait
training, visual tracking and fine motor muscles were trained. The complexity of the activities increased as the
child was showing improvement.
The child was uttering small baby words when he was about 18 months of age and had a sudden noticeable
regression and became nonverbal and started expressing his feelings and emotions by crying, biting, banging
his head, etc. The provisional diagnosis was a delayed speech and language development with secondary to
ADHD with autistic features. He was unable to speak when brought to the center. With consistent efforts,
dedication and intensive stimulation, therapeutic intervention, the child showed tremendous progress. Before
intervention, the child was present with poor sitting tolerance, attention and eye contact. With consistent
efforts and intervention therapy for 7 months, the child was able to meet the functional communication needs
in 2-3 word sentences. Co-ordination with other therapies and co-operation from the parents, the child’s
receptive and expressive language skills have exceeded expectations. From Object matching and with verbal
prompts, the child started uttering very small sounds and then framed words. There was a baseline and goal
setting that the child had to achieve. Reducing the use of gestures and using words was an achievement.
Modelling, imitating and prompting with moderate assistance, expressing verbally were some interventions.
Mimicking the actions of the therapist, gradually with the basic functionalities, introducing the action words as
verbs, introducing nouns with flash cards, puzzles, matching boards, etc. the child was quick to grasp and retain
them. Prepositions and conjunctions were also introduced in a play-way method. The child was given polar
question with a yes/no answer. The child was able to perform with 90 percent accuracy with such polar
questions. His comprehension skills improved and he was introduced with ‘wh’ questions. Appreciation, verbal
praise, token reinforcements were means of achieving tasks.
The child was gradually exposed to group therapy. Initially, socializing and playing with other children was an
ordeal. For most children, play is a natural phenomenon. For ASD children, it is a complex phenomenon because
it is not a free flow of development, it develops in a fragmented manner [18]. Imitation, receptive and
expressive ways of communication are some of the hurdles they face during play. This child has been
exceptional in overcoming those hurdles, although gradually. He started to watch and observe and displayed
smiles. The children were monitored closely for their own and others’ safety. The holistic and well integrated
setup played a key role in the development of the child.

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Structured physiotherapy may seem like play way method. However the objective is to make the kids feel at
ease and comfortable which is also part of the treatment. Researchers found cross group training like yoga,
dance, simple, basic self-defense training would see improvements in functionalities like motor and behavioral
skills in ASD children. Activities for Daily living was inculcated through play therapy. Teaching them to use a
toothbrush and potty-training is part of their activities. Using color pencils, paints helped them for hand eye co-
ordination, motor strengthening, sitting tolerance, tactile training, etc.
One year of rigorous training for almost five days a week, an hour long every day of therapy increased the
parents’ confidence level of the child’s progress that they enrolled him in a typical preschool. The therapists
geared up to get him into academic readiness. So, the child alternated his therapy sessions with special
educator’s academic intervention by getting him introduced to Basic English alphabets, phonics and semantics.
Special educators integrate their sessions with word and picture familiarity gained from his other therapies.
In about 16 months of consistent efforts by the integrated method and a holistic approach by the
physiotherapy, occupational therapy, behavioural therapy, speech therapy, group therapy, play therapy and
home program, the child has shown remarkable progress. While entering the center, the child enters happily
and willingly. He greets the therapist independently and rarely needs prompting. His eye contact is good but
lacks while making conversation. His gaze eye movement and fixated movements have improved although
needs sustenance for longer duration. His focus, attention, sitting tolerance have shown improvement. He has
adapted well with therapist, environment and positional transitioning. He is able to follow a 3 step instruction
and distraction has reduced. His gross motor and fine motor muscles have strengthened and the focus began on
stabilizing the knee joint movement, scapula and humeral movements. Some of his fine motor skills like
buttoning his shirt are achieved with maximal assistance. His static vestibular activities are performed with
minimal assistance. His dynamic vestibular activities are performed independently and with less fear. His
cognition improved with dynamic activities. Duration sustenance in eye foot cognition, spatial awareness,
balance and co-ordination was posing a challenge. He progressed from poor to minimal support in bilateral
integration. He is independent in visual tacking and requires very minimal to no prompting.
6.5 CDC Scale
Table 10: Activities of Daily Living
Age Activity Achievem
ents
24-30 months  Pulls pant up with assistance 
 Able to hold spoon with fingers appropriately 
 Wipes nose if given towel 
30-36 months  Knows proper place for own things 
 Insists on doing things independently 
 Serves self at table with little spilling 
36-42 months  Wipes nose when reminded 
 Able to use hand to accomplish many self- help 
tasks
 Feeds self with little spilling 
Center for Disease Control (CDC) pediatric scale is a tool to make clinical observations about the growth and
functional profiles. The child accomplished the tasks or milestones for motor, cognition, emotional and social
skills based on the CDC scale. In addition to this, the child was able to progress in the speech profile too. His
structure and function of the child’s articulatory system is normal. Loudness and pitch is normal. The
pronunciation of words is accurate. Supra segmental features are used appropriately. The child has satisfactory
phonological awareness and is becoming intelligible in connected speech. He has good comprehension and
expression with respect to lexical categories such as common objects, animals, body parts, fruits, colors, shapes,
body parts, calendar months, and days of the week, months, clothes and family members.

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VII. LIMITATION
This was a case study and hence the sample size is small. There is no cure yet found for ASD, so only
intervention and therapy based treatments can be studied. Absence of a national database on autism makes it
difficult to generalize for the entire population, given the diversity of culture and social disparity. Variations in
the regional data could arise like China [19]. Owing to the financial burden of the specialized therapies, the
reach of such treatments may not be benefited by the less privileged. Rural population are less aware of the
existence of the diagnostic tools since they are not available in the local languages. Hence the logistics of
yielding the maximum result in diagnosis gets affected. The Rights of Persons with Disabilities (RPwD) Act of
2016 in India has called for an inclusive education. Until it is implemented as planned, the imbalance with
prevail which will affect and impact the impoverished.
VIII. ETHICAL COMPLIANCE
Proper consent procedure was followed as per the ethical standards.
IX. CONCLUSION
Manual Testing for Muscle Grading for Muscle Power has shown increase in its numbers. This shows that the
upper limb and lower limb have strengthened and the stiffness has lessened. The core muscles have
strengthened allowing the hip joints and pelvic muscles to function better. This aids the child in positioning. He
adapts different sitting and standing position. His jumping, climbing skills have vastly improved. His vestibular
strengthening helps in his spatial awareness, balance and cognition. His physical and mental components seems
to be relatively in better alignment. All these changes have brought about an overall physical, mental, social,
behavioral, speech changes in the child. It is quite evident that children with ASD benefit from these therapy
programs and learn skills useful in their daily living and helpful for school and future. It is uncertain whether
the learning would be continued in a less supported environment. The outcome is vague given the less
specialized home and family setup. Therefore, this case study may be a success story in the current date.
However, given ASDs heterogeneity and other social and environmental factors [20], it is hard to predict that
the present state would continue. Depending on the genetic sensitivity, the possibility for regression cannot be
ruled out. Nevertheless, there is hope for the ASD community with early intervention and comprehensive
treatment plan. Treatment of a holistic nature thus would have a positive impact.
ACKNOWLEDGEMENT
I am truly grateful for all the support and generous encouragement from Dr. Sunitha and team from CAPAAR
center in Bangalore.
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