Motor Activity in Children With Autism A Review.2

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Motor Activity in Children With Autism: A Review of Current Literature

Rebecca Downey, PT, DPT; Mary Jane K. Rapport, PT, DPT, PhD Physical Therapy Program, School of Medicine, University of Colorado, Denver, Colorado. Physical therapists have expanded their role and visibility in the treatment of children with autism spectrum disorders (ASD). Limitations in motor activity have not been considered in the assessments of core decits of this population; however, physical therapists should be prepared to discuss and address these limitations in children with ASD. Purpose: The primary purposes of this review were to summarize current evidence for motor activity limitations in children with ASD and suggest further areas of research in physical therapy and autism while considering how physical therapy may benet children with autism. Method: A literature search was carried out in 2009 and 2010 by using multiple search engines. Results: Forty-nine articles met inclusion criteria and were included in the review. Conclusion: Findings indicate that limitations in motor activity may be present in individuals with ASD, and further research is needed to identify specic functional limitations. (Pediatr Phys Ther 2012;24:220) Key words: Asperger syndrome, autism spectrum disorder, child, female, male, motor activity, pervasive developmental disorder, systematic review INTRODUCTION Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is characterized by limitations in social interactions and communication, restricted interest, and stereotyped or repetitive behaviors.1 The term autism spectrum disorder is often used to describe individuals who have been diagnosed with autism disorder (AD), pervasive development disorder not otherwise specied (PDD-NOS), or Asperger syndrome (AS) on the basis of medical and developmental history and clinical observations of behavior (see Table 1 for denitions).2,3 Recent research supported by the Centers for Disease Control and Prevention4 indicates that based on parent report, the incidence of autism is 110 per 10 000, with a higher incidence in males than in females.5 The approach to evaluation and treatment of children with ASD is frequently a multidisciplinary team approach.6 Although the term clumsiness has been used in describing individuals with AS, limitations in motor activity are not considered to be core decits of individuals with ASD.7,8 Historically, physical therapists have not been involved in the evaluation and treatment process of individuals with ASD; the role of the physical therapist is evolving with regard to both the evaluation and intervention processes. There is an increasing body of literature related to ASD, but evidence regarding physical therapy (PT) and intervention with this population continues to be limited in scope. To best understand PT intervention in children with autism, physical therapists need to assess the effect of motor activity limitations including motor anomalies, delays, or weaknesses on a childs ability to fully participate in daily activities and routines. These decits in motor activity inform physical therapists clinical decision making. The purposes of this review were to summarize current evidence for limitations in motor activity in children with ASD and suggest further areas of research related to PT and autism while considering how PT may benet
0898-5669/110/2401-0002 Pediatric Physical Therapy Copyright C 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and Section on Pediatrics of the American Physical Therapy Association
Correspondence: Mary Jane K. Rapport, PT, DPT, PhD, Physical Therapy Program, School of Medicine, University of Colorado, 13121 E 17th Avenue, C244, Aurora, CO 80045 (maryjane.rapport@ucdenver.edu). Grant Support: This study was funded by Leadership Education in Neurodevelopmental and Related Disorders Training (LEND), Health Resources and Service Administration (HRSA), and Maternal Child Health Bureau (MCHB), Award T73 MC11044. The authors declare no conict of interest. DOI: 10.1097/PEP.0b013e31823db95f
Copyright 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
2 Downey and Rapport
Pediatric Physical Therapy
TABLE 1
Denitions and Abbreviations of Developmental Disorders Identied in the Literature and Associated With Autism Classication Autism spectrum disorder (ASD)1 Pervasive developmental disorder (PDD)a Denition ASD is a neurodevelopmental disorder that is characterized by limitations in social interactions and communication, restricted interest, and stereotyped or repetitive behaviors. There is a continuum of behaviors represented within the ASD diagnosis The PDD diagnosis includes impaired social interaction and communication skills or the presence of stereotyped behaviors or restricted interests that are not congruent with developmental or cognitive ages. PDD encompasses several disorders including autistic disorder, Retts disorder, childhood disintegrative disorder, Aspergers disorder, and PDD not otherwise specied. The diagnosis of autistic disorder is based on impaired social interaction and communication and the presence of repetitive or stereotyped behavior. There must also have been a delay in social interaction, social or communicative language, and play prior to the age of 3 years. The diagnosis of Asperger syndrome is based on impaired social interaction and restricted or stereotyped interests that interfere with daily functioning. There is no delay in language, cognitive development, or adaptive behaviors and activities of daily living skills. The diagnosis of PDD-NOS is used when there is impairment in social interaction that is associated with communication skills or is present with stereotyped behavior and restricted interest. These symptoms should not be accounted for by PDD, schizophrenia, schizotypical personality disorder, or avoidant personality disorder. PDD-NOS includes atypical autism (when the criteria have not been met for autism disorder).
Autism disordera
Asperger syndromea,b
Pervasive developmental disordernot otherwise specied (PDD-NOS)a,b
from the Diagnostic and Statistical Manual of Mental DisordersFourth Edition (DSM-IV).1 on proposed revisions of the DSM, these currently used diagnoses may be incorporated into one diagnosis (ASD) when the fth edition is published.3
b Based
a Adapted
children with autism. The term motor activity was selected by the authors in an attempt to capture and describe motor abnormalities, delays, and general motor function of children with ASD. METHODS A literature search was carried out using OVID, PubMed, and Google Scholar search engines between
January 1, 2009, and October 31, 2009. Seventeen search terms were used in an attempt to best capture the broad range of articles addressing children with autism or related diagnoses, motor activity, and PT (see Figure for search terms). Care was given to be certain that each search yielded all possible evidence in the published literature. The search was then updated during May 2010 using the same strategies with each of the 17 search terms. In all, 90 searches were completed (Figure). Further review of
Fig. Search strategy.
Motor Activity in Autism
an article was dependent on the appearance of the search terms in the abstract of the article as identied by the rst author (Figure). Articles were then graded according to the level of evidence, on the basis of criteria from Sackett et al.9,10 Only articles that were found to be at Sackett levels 1-3B were used for this analysis. Other exclusion criteria included systematic reviews that did not include specic research methods, articles in which the search terms were present in the abstract but did not include analysis of motor function, and articles that were not accessible in English (see Figure). RESULTS The search strategy and inclusion criteria resulted in a total of 49 articles that were acceptable for this literature review of motor activity in children with ASD. No level 1 articles appropriate for analysis were identied during the search. Two level 2 articles and 47 level 3 articles were identied and included in the analysis. Articles classied as levels 4 and 5 were identied but not used in the literature review. Articles that originally met the inclusion criteria but did not address motor activities as part of study criteria or outcomes also were not included. Review articles that did not include specic methods and inclusion criteria also were excluded from the analysis (see Figure). As is the case with all searches of the literature, additional articles that would meet the search criteria may be found if a new search following the same strategy was conducted today. The search strategy used here yielded all articles meeting inclusion criteria as of May 2010. Studies that inform health care providers about children with ASD and addressed motor activity were analyzed and reviewed (see Appendix). During the review process, various themes related to the characteristics and concerns related to ASD arose in the literature. The articles were grouped and analyzed on the basis of these themes. The themes were not derived through a specic qualitative methodological approach; rather, they were generated through the work of the rst author, and corroborated with the second author, during the process of sorting articles that met the search criteria. Based on recurring similarities in the content of the available literature as reviewed, the following thematic categories emerged: early motor ndings, gestures and motor imitation, postural control, and dyspraxia. Early Motor Findings Several recent studies sought evidence of motor impairments to provide early motor identication markers and characteristics of ASD. For example, in a study by Provost et al,11 68% of children with ASD who were tested on the Bayley Scales of Infant Development II Motor Scale and 63% of children who were tested on the Peabody Developmental Motor Scales, Second Edition, would have qualied for early intervention services. Landa and GarrettMayer12 also prospectively studied 2 groups of infants:
1 group was classied as low-risk for development of autism and the other as high-risk for development of autism. Children were examined with the Mullen Scales of Early Learning at 6, 14, and 24 months. At the 24month visit, further testing was administered to classify children who had typical development, ASD, or language delay. No differences on the Mullen Scales of Early Learning were found in children with ASD and typical children at 6 months; however, by 14 months, the children with ASD began to demonstrate a slowing in development compared with the other groups. By 24 months, signicant differences were found between the group with ASD and the group developing typically in all domains, as well as between the group with ASD and the group with language delay. The children with ASD demonstrated the slowest rate of increase in developmental skills over time. In another study, Esposito et al13 retrospectively examined videotapes of 3 groups of infants aged 12 to 21 weeks: those diagnosed with ASD, those with developmental delays not associated with ASD, and children with typical development. These researchers found that the group with ASD had signicantly less static and dynamic symmetry in the supine position than the other groups. Teitelbaum et al14 also suggested that motor abnormalities, including asymmetrical movement patterns, are present at birth in children with ASD and may aid in the early identication of ASD. On the basis of video analysis, Baraneck15 suggested that symptoms of autism, including sensorymotor symptoms, might be present and identiable between 9 and 12 months of age. In another study, Dewrang and Sandberg16 used retrospective parent reports to compare individuals with AS with a group of young adults who were developing typically. They found that during the rst 2 years of life, individuals with AS demonstrated impaired imitation, increased clumsiness, and poor coordination. These ndings suggest that evaluation of motor activity may play a role in early prediction of ASD. In contrast, Ozonoff et al17 reported that infants who are later diagnosed with ASD do not demonstrate an increased number of movement abnormalities or a lack of protective reactions when compared with a group of children who are developing typically. They did, however, nd a slower rate of development in reaching mature motor patterns. In addition, they suggested that more comprehensive motor evaluations might be useful in early detection of autism. In another study by Loh et al,18 stereotyped behaviors and postures found in children with ASD were similar to those in the comparison group. These authors also suggested that more sensitive testing might be required to identify motor impairments. Gestures and Motor Imitation The ability to use gestures and motor imitation relies on motor activity to communicate with others. Interestingly, children with ASD have difculty with communication as well as difculty using motor activity (eg, gestures and imitation) as forms of communication to support social
interaction. Motor imitation has been identied as a significant impairment in previous literature on individuals with ASD, particularly in relation to social communication.19-21 In a literature review by Williams et al,22 the authors suggested that imitation impairments are present in children with ASD and are more apparent in younger age groups (below the age of 4 years) when compared with other children. Stone et al21 suggested that imitation impairments in children with ASD are due to a delay in acquiring imitation skills, rather than disordered sequencing. Although some improvement may be seen between the ages of 2 and 3 years, this delay was apparent in young children, as well as in preschool-aged children.22,23 In another study, Rogers et al20 found that children with ASD have impaired imitation skills on sequential imitation tasks when compared with a group of children with developmental delays. No support was found for a relationship between imitation impairment and play skills, language skills, or dyspraxia in children with ASD. In a more recent study, Rogers et al24 noted that during a simple task, children with autism fail more imitation tasks than a group of children with developmental delays and a group of children who were developing typically. These ndings were especially meaningful in children with autism who were younger than 14 months. In the older age group (older than 30 months), children with regressive type autism continued to fail more tasks, especially nonfunctional imitation tasks. Other researchers have suggested a possible link between imitation impairments and the presence of motor activity abnormalities. For example, Van Vuchelen et al25 reported the presence of an imitation impairment, especially in nonmeaningful gestures, in children with ASD who have low-functioning autism and high-functioning autism (HFA). They also found increased impairment on motor testing. Green et al26 also found an association between motor and imitation scores, with lower and more variable scores in children with AS than in children with specic developmental delays of motor function. Spatiotemporal errors were more common in the group with AS. In a study by Mostofsky et al,27 children with ASD had more imitation errors on the Florida Apraxia Screening Test than children who were developing typically. Spatial errors were the most common in both groups. In the groups with ASD, errors were increased when gesturing on command and imitation, rather than tool use. Notably, no signicant difference was found in the number of total errors between individuals diagnosed with HFA and those with AS. In another study, Smith and Bryson28 found that children with ASD have increased difculty performing and naming both meaningful and nonmeaningful gestures but no difculty understanding or identifying gestures. The authors suggested that these impairments might be related to dyspraxia.28 Dewey et al29 also found that when compared with children with both developmental coordination disorder (DCD) and attention-decit/hyperactive disorder (ADHD), DCD only, or ADHD only, children with ASD have signicantly lower motor and gestural performance
scores. Although this may be related to praxis, these authors suggested that it might also be related to altered neural substrates or language decits. More recently, Ben-Sasson et al30 examined gestural representations in 3 groups of children: children with HFA, children with language impairment, and children who are developing typically. The authors concluded that children with HFA have increased difculty with gestural representations, which they suggest may be related to a motor planning decit. There appeared to be decreased quality of gesture performance as well as a discrepancy between gestures and verbal descriptions, when compared with the other 2 groups. The authors hypothesized that performing motor actions might be more difcult when the task is combined with verbal description. This may be related to a lack of integration between motor and language. BenSasson et al30 suggest that individuals with ASD may benet from further testing to examine motor planning and sequencing. Postural Control Postural control requires a level of stability necessary prior to executing additional motor skills or activities. Without this control, motor activity may be limited to more static positions. Individuals with autism tend to have decreased postural control.31,32 Minshew et al31 found that individuals with autism have decreased postural stability, particularly in circumstances where there is sensory conict. Compared to a group of children who were developing typically and adults, development of postural stability appeared to be delayed in children with autism. Postural stability did not appear to improve in individuals with autism until the age of 12 years. At the age of 15 years, the group that was developing typically appeared to have a plateau in postural stability; however, this same level of control was not achieved in the group with ASD. Based on the data from a bimanual lift task by Schmitz et al,32 children with ASD rely on reactive postural control rather than on the typical anticipatory postural control seen in the comparison group when performing lifting tasks. In another study, Kohen-Raz et al33 examined postural stability in various standing positions between a group of children with ASD and a group of children who were developing typically. Children with ASD demonstrated increased sway, abnormal weight distribution, and the absence of typical ankle strategies in standing. A paradoxical stress response was noted in individuals with autism, indicated by an increase in postural stability in stressful conditions (dened as removal of vision). In a follow-up study, Molloy et al34 also found that children with ASD had signicantly more sway in standing than a comparison group of children who are developing typically. Instead of a paradoxical stress response, they found that children with ASD experienced a larger increase in sway when visual input was removed and somatosensory input modied, indicating that children with ASD rely on visual input for balance. This nding points to impaired processing
Motor Activity in Autism 5
abilities with sensory conict in individuals with ASD. Molloy et al34 argued that the presence of a paradoxical response found in the Kohen-Raz et al33 study might have been the result of additional visual and auditory input used in their methods. Further support for impaired postural control in children with ASD was provided by Fournier et al,35 who reported that children with ASD have increased postural sway in quiet stance without manipulation of sensory input as well as altered center of pressure shifts during gait initiation. Dyspraxia Quality of movement may be altered in children with ASD, and dyspraxia has been noted when comparing children with ASD with children who are developing typically. Motor delay and motor variability have also been noted and described in some studies and refuted in others. Although motor abnormalities were noted in individuals who were rst described with AS,8 these limitations have not been consistently identied in individuals with ASD. While no level 1 research supporting the presence of limitations in motor activities was found, several lower-level studies indicate that impairments in motor activity may be common in children with ASD. Researchers have sought to distinguish differences across individuals with ASD, as well as to compare those with ASD with individuals who are developing typically or have other developmental concerns. Manjiviona and Prior36 found limits in motor activity and function in children with HFA and AS. Ghaziuddin and Butler37 noted that children with autism, AS, and PDDNOS have motor impairments. Statistically signicant differences were found only between those with AS and those with AD (children with AD were noted to be more clumsy) as measured by the Bruinink-Oseretsky Test of Motor Prociency. Individuals diagnosed with AD had higher levels of motor activity impairment, while those with AS demonstrated less impairment on gross motor, ne motor, and total battery scores. A strong correlation existed between intelligence quotient (IQ) scores and test results. When adjusted for level of intelligence, no signicant difference remained between groups. Green et al38 found a similar correlation between IQ and motor scores in individuals with ASD, indicating that motor impairments might be related to IQ level. Current research has demonstrated that there is no signicant difference in level of motor impairments among children with AS, AD, or PDD-NOS; however, there is a trend toward higher cognitive limitations correlated to lower motor scores. Several researchers have suggested that when compared with a comparison group developing typically, children with ASD have dyspraxia. Mostofsky et al27 suggested that based on the Florida Apraxia Screening test, motor imitation may be linked to dyspraxia, particularly to a delay in spatial mapping. Dzuik et al39 proposed that dyspraxia may be separate from other motor skills in children with ASD and may be strongly correlated to the core decits associated with autism.1 According to Dowell et al,40 praxis
score was correlated with the Autism Diagnostic Observation Schedule score, also suggesting that dyspraxia may be a core symptom of ASD. In addition, Dowell et al40 reported that children with ASD have slower timed movements and score signicantly lower on postural knowledge testing. Glazebrook et al41 noted that individuals with ASD are able to use advance information; however, more time is required to plan movements. Glazebrook et al42 and Nazzarali et al43 noted that individuals with ASD required more time to plan and execute goal-directed movements. Rinehart et al44 also noted a slower preparation time in children with HFA and AS when compared with a cohort developing typically. This was further supported in another study by Rinehart et al,45 where children with HFA demonstrated increased preparation time compared with a cohort developing typically, and children with AS demonstrated a trend toward a motor preparation decit. On the basis of an analysis of goal-directed gait, Vernazza-Martin et al46 suggested that when compared with a typical comparison group, children with ASD have impaired motor planning and execution. Whereas differences in motor planning are present in some individuals with ASD, the alterations in patterns are unclear. Hughes47 suggested that individuals with autism demonstrate difculty executing simple goaldirected motor tasks that might be related to sequencing, vision, or consequence prediction. Staples and Reid48 compared a group of children diagnosed with ASD to 3 groups developing typically. The 3 typical groups were matched with children in the group with ASD by chronological age, cognitive development, or movement skill development. They found that children with ASD have signicantly poorer motor scores than children who are developing typically and who are chronologically age matched and cognitively age matched. Specically, children with ASD had difculty with bilateral coordination and performed at a similar motor level as children approximately of half their chronological age. The authors suggested that by late childhood, motor skills in children with ASD are signicantly delayed. Jansiewicz et al49 noted that boys with HFA and AS have increased difculty with balance, gait, and dysrhythmia with timed hand and foot movements. In another study, Weimer et al50 examined tests of apraxia and basic motor function in a group of children and young adults with AS and a comparison group. The authors found that decits were present on tests of apraxia, especially on measures where visual input was removed, suggesting reliance on vision with a proprioceptive impairment. In addition, Freitag et al51 reported that when compared with a group developing typically, individuals with HFA and AS are strongly impaired in dynamic balance and diadochokinesis, and integration between sensory and motor input may be also impaired. They also noted a positive association of motor scores to the level of social withdrawal. In a study by Fuentes et al,52 the authors found that when compared with a group of children who were developing typically, children with ASD had signicantly poorer
motor and writing scores overall. More specically, scores were decreased on gait, stance, and timed movement activities. Poor gross motor skills were correlated with poor handwriting scores. They hypothesized that if therapies address overall motor control, handwriting scores would improve as a result of increased ability to control and manipulate arm movements. In contrast, van Swieten et al53 sought to differentiate between motor and executive planning abilities in 3 groups of children and adults: a group with ASD, a group with DCD, and a group with typical development. Based on what the authors suggested to be a pure motor planning test, no difference was found between the group with typical development and the group with ASD. Miyahara et al54 found high rates of motor delay in 2 groups of children: a group of children with AS and a group of children with a learning disability. A signicant difference was found between groups for manual dexterity scores. The children with AS had a trend toward poorer ball skills, which, the authors hypothesized, might be related to the type of preferred play. No difference in motor prole was found between children with ASD who were chronologically age matched and children with other developmental delays.55 The authors did, however, note that scores of children with ASD were more variable than those with developmental delays. In another study by Provost et al,11 the authors evaluated 3 groups of childrenchildren with ASD, developmental delays, and developmental concernson the basis of results from the Bayley Scales of Infant Development. In this study, none of the children in the group with ASD tested within normal limits, and at least 68% of these children would have qualied for early intervention services based on a delay of 25% or more. Motor scores of children with ASD did not differ when compared with children with developmental delay. These results suggest that there is a limitation in motor function in children with ASD. Further research is needed to identify the specic type of dysfunction. Matson et al56 also noted gross and ne motor impairments in toddlers with AD when compared with toddlers with atypical development between 18 and 36 months of age. No signicant differences were found between toddlers with PDD-NOS and children who are developing typically. The authors suggested that motor impairments are present at a young age and benet may be obtained from early intervention. In another study, children with ASD were compared with children with specic speech and language disorders and a comparison group of children who were developing typically. The children with speech disorders had lower scores on all gross and ne motor domains except coordination, whereas children with autism had signicantly poorer scores on all ne and gross motor scores (including balance), except oral motor and coordination.57 Morin and Reid58 noted that although individuals with autism have poor motor performance, they can obtain higher balance scores than those with intel-
lectual delay. Balance in individuals with ASD may be decreased; however, continued research is necessary to identify the severity and the pattern of decit. Although impaired motor skills and function are not a core decit of ASD, they are considered a core decit of DCD and ADHD.1 In a study by Dewey et al,29 the authors found that when tested on the Bruinink-Oseretsky Test of Motor Prociency (short form) and a gestural performance test, children with ASD had signicantly lower scores than children with DCD, ADHD, or ADHD and DCD. This supports the presence of difculty with motor activity in children with ASD. This nding was further supported by Pan et al,59 who found that children with ASD performed signicantly lower on motor tests than children with ADHD and children who are developing typically. Specic limitations were noted on tests of locomotion and object manipulation. They suggested that poor motor performance might be a sign of autism, with poor skills being related to a lack of social skills as well as lack of motivation to practice. The authors encouraged clinicians to screen for motor impairments as poor motor skills were found to be correlated with poor self-esteem, increased anxiety, and decreased social function. In a rare study with an all-female sample, Kopp et al60 compared several groups of girls: girls who were developing typically, girls with ASD, and girls with ADHD. They found that a large percentage of girls with ASD also t the diagnosis for DCD, especially those in the preschool-aged group. Predictors of poor motor scores included younger age, presence and severity of ASD symptoms, and low IQ. Poor motor scores were related to poor activities of daily living and physical education participation. DISCUSSION Based on this review of literature, evidence is emerging that supports the identication of impaired motor activity in children who have the diagnosis of autism. Although impaired motor activity is not included in the diagnosis, impaired motor activity appears to be an observable trend. The ability to understand and address the entire clinical picture of the child, including all areas of function, becomes an essential component of any intervention plan. The majority of current evidence does support the presence of motor activity abnormalities prior to 2 years of age in children who are later diagnosed with ASD that persists into early childhood. As children are being diagnosed earlier with ASD and receiving early intervention services, physical therapists should consistently be part of the team addressing all the needs of the child. Although we still have much to learn about the timing of motor development and the patterns of motor activity in children with ASD, evidence supports the presence of specic difculties related to motor activity in individuals with ASD. The link between imitation and motor activity is still unclear; however, research indicates that there are limitations in motor imitation in children with ASD. Questions
still remain as to whether restrictions in social behavior limit imitation, or whether limitations in motor activity restrict social participation and adversely affect imitation. The presence of postural instability is also supported in the literature. Decreased postural stability can signicantly limit participation in activities since the simplest of movements require complex control61,62 and further research is needed to examine the severity, cause, and functional outcomes related to postural control. The literature also lends support to difculty with motor planning in children with ASD. Limitations in motor activity in children with ASD might decrease the opportunity for social interactions and learning opportunities. Although limited research related to interventions for motor activity impairments in children with ASD was found, Travers et al63 did address motorlinked implicit learning in children with ASD. In a study comparing a group of individuals with HFA, ASD, and a group developing typically, Travers et al63 reported that for simple tasks, motor-linked implicit learning might be intact in children with ASD, which might inuence therapeutic approach. Motor activity delays have been observed in infants and toddlers with autism and may affect future motor development. As with all developmental delays, early identication leading to the initiation of early service delivery might have a positive benet on motor skills and long-term disability in individuals diagnosed with ASD.64,65 Since children with ASD are ambulatory, they previously would not have been thought to benet from PT. Physical therapists need to consider how to address these impairments in motor activity within the childs daily routines. Although the results of this literature review do indicate that motor activity impairments may be present in children with ASD, there are limitations to this analysis. An updated literature search may provide increased evidence supporting motor activity impairments as well as provide documentation for intervention strategies for children with ASD. No consistent measure was used in each of the reviewed studies, which limits generalization of the ndings. CONCLUSION Although there may be limitations in motor activity present in children with ASD, much research is still needed to identify the age at which these limitations in motor activity are present and to what extent they differ from children who are developing typically. As with many other diagnoses, lack of evidence has not prohibited the PT profession from forging ahead with new research and ongoing intervention. Future research is necessary to identify to what extent functional activities are limited in children with ASD. Research is also necessary to determine the underlying causes as well as the most appropriate interventions. As physical therapists move toward consistent use of the ICF,66 it may be useful to implement interventions and research their efcacy based on activity limitation and
participation restrictions rather than solely by impairment and disability. Physical therapists can and should play a unique role in promoting functionally based intervention strategies to enhance motor activity and improve function in children with ASD.
ACKNOWLEDGMENT The authors thank Stephanie Lyle, PT, DPT, for her early contributions to this work. REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994. 2. Rapin I, Tuchman R. Autism: denition, neurobiology, screening, diagnosis. Pediatr Clin N Am. 2008;55:1129-1146. 3. DSM-5: The future of psychiatric diagnosis. American Psychiatric Association DSM-5 Development. http://www.dsm5.org/ Pages/Default.aspx. Published 2010. Accessed December 2010. 4. Centers for Disease Control and Prevention. Autism and development disabilities monitoring (ADDM) network. http://www .cdc.gov/ncbddd/autism/addm.html. Published March 2011. Accessed June 2011. 5. Kogan MD, Blumberg SJ, Schieve LA, et al. Prevalence of parentreported diagnosis of autism spectrum disorder among children in the US, 2007. Pediatrics. 2009;124:1395-1403. 6. Rogers E. Functional behavioral assessment and children with autism: working as a team. Focus Autism Dev Disord. 2001;16:228231. 7. Wing L. Asperger syndrome: a clinical account. Psychol Med. 1981;11:115-129. 8. Tantam D. Annotation Asperger syndrome. J Child Psychol Psychiat. 1988;29:245-255. 9. Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. Philadelphia, PA: Churchill-Livingstone; 2000. 10. Glaros S. All evidence is not created equal: a discussion of levels of evidence. PT: Magazine of Phys Ther. 2003;11:42-52. 11. Provost B, Lopez BR, Heimerl S. A comparison of motor delays in young children: autism spectrum disorder, developmental delay, and developmental concerns. J Autism Dev Disord. 2007;37:321-328. 12. Landa R, Garrett-Mayer E. Development in infants with autism spectrum disorders: a prospective study. J Child Psychol Psychiat. 2006;47:629-638. 13. Esposito G, Venuti P, Maestro S, Muratori F. An exploration of symmetry in early autism spectrum disorders: analysis of lying. Brain Dev-JPN. 2009;31:131-138. 14. Teitelbaum P, Teitelbaum O, Nye J, Fryman J, Maurer RG. Movement analysis in infancy may be useful for early diagnosis of autism. Proc Natl Acad Sci U S A. 1998;95:13982-13987. 15. Baraneck GT. Autism during infancy: a retrospective video analysis of sensory-motor and social behaviors at 9-12 months of age. J Autism Dev Disord. 1999;29:213-224. 16. Dewrang P, Sandberg AD. Parental retrospective assessment of development and behavior in Asperger syndrome during the rst 2 years of life. Res Autism Spectrum Disord. 2010;4:461-473. 17. Ozonoff S, Young GS, Goldring S, et al. Gross motor development, movement abnormalities, and early identication of autism. J Autism Dev Disord. 2008;38:644-656. 18. Loh A, Soman T, Brian J, et al. Stereotyped motor behaviors associated with autism in high-risk infants: a pilot videotape analysis of a sibling sample. J Autism Dev Disord. 2007;37:25-36. 19. Ingersoll B. The social role of imitation in autism implications for the treatment of imitation decits. Infant Young Child. 1998;21:107-119. Pediatric Physical Therapy
20. Rogers SJ, Hepburn SL, Stackhouse T, Wehner E. Imitation performance in toddlers with autism and those with other developmental disorders. J Child Psychol Psychiat. 2003;44:763-781. 21. Stone WL, Ousley OY, Littleford CD. Motor imitation in young children with autism: whats the object? J Abnorm Child Psych. 1997;25:475-485. 22. Williams JHG, Whiten A, Singh T. A systematic review of action imitation in autism spectrum disorder. J Autism Dev Disord. 2004;34:285299. 23. Stone WL, Lemanek KL, Fishel PT, Fernandez MC, Altemeier WA. Play and imitation skills in the diagnosis of autism in young children. Pediatrics. 1990;86:267-272. 24. Rogers SK, Young GS, Cook I, Giolzetti A, Ozonoff S. Imitation actions on objects in early-onset and regressive autism: effects and implications of task characteristics on performance. Dev Psychopathol. 2010;22:71-85. 25. Van Vuchelen M, Roeyers H, Weerdt WD. Nature of motor imitation problems in school-aged males with autism: how congruent are the error types? Dev Med Child Neurol. 2007;49:6-12. 26. Green D, Baird G, Barnett AL, Henderson L, Huber J, Henderson SE. The severity and nature of motor impairment in Asperger syndrome: a comparison with specic developmental disorder of motor function. J Child Psychol Psychiatry. 2002;43:655-668. 27. Mostofsky SH, Dubey P, Jerath VK. Developmental dyspraxia is not limited to imitation in children with autism spectrum disorders. J Int Neuropsych Soc. 2006;12:314-326. 28. Smith IM, Bryson SE. Gesture imitation in autism: II. Symbolic gestures and pantomimed object use. Cogn Neuropsychol. 2007;24:679700. 29. Dewey D, Cantell M, Crawford SG. Motor and gestural performance in children with autism spectrum disorders, developmental coordination disorder, and/or attention decit hyperactivity disorder. J Int Neuropsych Soc. 2007;13:246-256. 30. Ben-Sasson A, Stimmell KE, Cermak SA. Sequence of gestural representations in children with high functioning autism. Israeli J Occup Ther. 2009;18:E57-E73. 31. Minshew NJ, Sung MB, Jones BL, Furman JM. Underdevelopment of the postural control system in autism. Neurology. 2004;63:20562061. 32. Schmitz C, Martineau J, Barth l my C, Assaiante C. Motor control ee and children with autism: a decit of anticipatory function? Neurosci Lett. 2003;348:17-20. 33. Kohen-Raz R, Volkmar FR, Cohen DJ. Postural control in children with autism. J Autism Dev Disord. 1992;22:419-432. 34. Molloy CA, Dietrich KN, Bhattacharya A. Postural stability in children with autism spectrum disorder. J Autism Dev Disord. 2003;33:643-652. 35. Fournier KA, Kimberg CI, Radonovich KL, et al. Decreased static and dynamic postural control in children with autism spectrum disorders. Gait Posture. 2010;32: 6-9. 36. Manjiviona J, Prior M. Comparison of Asperger syndrome and highfunctioning autistic children on a test of motor impairment. J Autism Dev Disord. 1995;25:23-39. 37. Ghaziuddin M, Butler E. Clumsiness in autism and Asperger syndrome: a further report. J Intell Disabil Res. 1998;42:43-48. 38. Green D, Charman T, Pickles A. Impairment in movement skills of children with autistic spectrum disorders. Dev Med Child Neurol. 2009;51:311-316. 39. Dzuik MA, Larson JC, Apostu A, Mahone EM, Denckla MB, Mostofsky SH. Dyspraxia in autism: association with motor, social, and communicative decits. Dev Med Child Neurol. 2007;49:734-739. 40. Dowell LR, Mahone EM, Mostofsky SH. Associations of postural knowledge and basic motor skill with dyspraxia in autism: implication for abnormalities in distributed connectivity and motor learning. Neuropsychology. 2009;23:563-570. 41. Glazebrook CM, Elliott D, Szatmari P. How do individuals with autism plan their movements? J Autism Dev Disord. 2008;38: 114-126.
42. Glazebrook CM, Elliott D, Lyons J. A kinematic analysis of how young adults with and without autism plan and control goal-directed movements. Motor Control. 2006;10:244-264. 43. Nazzarali N, Glazebrook CM, Elliott D. Movement planning and reprogramming in individuals with autism. J Autism Dev Disord. 2009;39:1401-1411. 44. Rinehart NJ, Bradshaw JL, Bereton AV, Tonge BJ. Movement preparation in high-functioning autism and Asperger disorder: a serial choice reaction time task involving motor reprogramming. J Autism Dev Disord. 2001;31:79-88. 45. Rinehart NJ, Bellgrove MA, Tonge BJ, Brereton AV, Howells-Rankin D, Bradshaw JL. An examination of movement kinematics in young people with high-functioning autism and Aspergers disorder: further evidence for a motor planning decit. J Autism Dev Disord. 2006;36:757-767. 46. Vernazza-Martin S, Martin N, Vernazza A, et al. Goal directed locomotion and balance control in autistic children. J Autism Dev Disord. 2005;35:91-102. 47. Hughes C. Brief report: planning problems in autism at the level of motor control. J Autism Dev Disord. 1996;26:99-107. 48. Staples KL, Reid G. Fundamental movement skills and autism spectrum disorders. J Autism Dev Disord. 2010;40:209-217. 49. Jansiewicz EM, Goldberg MC, Newschaffer CJ, Denckla MB, Landa R, Mostofsky SH. Motor signs distinguish children with high functioning autism and Asperger syndrome from controls. J Autism Dev Disord. 2006;36:613-621. 50. Weimer AK, Schatz AM, Lincoln A, Ballantyne AO, Trauner DA. Motor impairment in Asperger syndrome: evidence for a decit in proprioception. Dev Behav Ped. 2001;22:92-101. 51. Freitag CM, Kleser C, Schnieder M, von Gontard A. Quantitative assessment of neuromotor function in adolescents with high functioning autism and Asperger syndrome. J Autism Dev Disord. 2007;37:948959. 52. Fuentes CT, Mostofsky SH, Bastian AJ. Children with autism show specic handwriting impairments. Neurology. 2009;73: 1532-1537. 53. van Swieten LM, van Bergen E, Williams JHG, et al. A test of motor (not executive) planning in developmental coordination disorder and autism. J Exp Psychol Human. 2001;36:493-499. 54. Miyahara M, Tsujii M, Hori M, Nakanishi K, Kageyama H, Sugiyama T. Brief report: motor incoordination in children with Asperger syndrome and learning disabilities. J Autism Dev Disord. 1997;27:595603. 55. Provost B, Heimerl S, Lopez BR. Levels of gross and ne motor development in young children with autism spectrum disorder. Phys Occup Ther Pediatr. 2007;27(3):21-36. 56. Matson JL, Mahan S, Fodstad JC, Hess JA, Neal D. Motor skill abilities in toddlers with autistic disorder, pervasive developmental disordernot otherwise specied, and atypical development. Res Autism Spectrum Dis. 2010;4:444-449. 57. Noterdaeme M, Mildenberger K, Minow F, Amorosa H. Evaluation of neuromotor decits in children with autism and children with a specic speech and language disorder. Eur Child Adolesc Psychiatry. 2002;11:219-225. 58. Morin B, Reid G. A quantitative and qualitative assessment of autistic individuals on selected motor tasks. Adapt Phys Act Q. 1985;2: 43-55. 59. Pan CY, Tsai CL, Chu CH. Fundamental movement skills in children diagnosed with autism spectrum disorders and attention decit hyperactivity disorder. J Autism Dev Disord. 2009;39:1964-1705. 60. Kopp S, Beckung E, Gillberg C. Developmental coordination disorder and other motor control problems in girls with autism spectrum disorder and/or attention-decit/hyperactivity disorder. Res Dev Disabil. 2010;31:350-361. 61. Frank JS, Earl M. Coordination of posture and movement. Phys Ther. 1990;70:855-863. 62. Wallman HV. The basics of balance and falls. Home Health Care Manag Pract. 2009;21:436-439.
63. Travers BG, Klinger MR, Mussey JL, Klinger LG. Motor-linked implicit learning in persons with autism spectrum disorders. Autism Res. 2010;3:68-77. 64. Gomby DS, Larner MB, Stevenson CS, Behrman RE. Long-term outcomes of early childhood programs: analysis and recommendations. Future Child. 1995;5:6-24.
65. Berlin LJ, Brooks-Gunn J, McCarton C, McCorminck MC. The effectiveness of early intervention: examining risk factors and pathways to enhanced development. Prev Med. 1998;27:238-245. 66. Jette A. Toward a common language for function, disability, and health. Phys Ther. 2006; 86:726-734.
APPENDIX
Brief Summary of Each Article Revieweda Study Design/ Methodology Comparison Examination Toolsb Bayley Scales of Infant Development II Motor Scale (BSID II) Peadbody Developmental Motor Scales, 2nd Edition (PDMS-2)
Author(s) Provost et al11
Study Groups Autism spectrum disorder (ASD) (n = 19) Developmental delay (DD) with concerns for motor delay chronologically aged matched within 3 months (n = 19) Developmental concerns without motor delay chronologically aged matched within 3 months (NMD) (n = 18) High risk for autism (n = 60) Low risk for autism (n = 27)
Summary of Findings According to scores on the BSID II and the PDMS-2, 63% and 68% (respectively) of children with ASD would qualify for early intervention services on the basis of a 25% motor delay. These scores were similar to those of a group of children diagnosed with DD.
Landa and GarrettMayer12
Prospective comparison
Mullen Scales of Early Leaning (MSEL)
Esposito et al13
Retrospective comparison (video analysis)
ASD (n = 18) Typical development (TD) (n = 18) DD (n = 12)
Eschkol-Wachman Movement Notation static and dynamic symmetry
Teitelbaum et al14
ASD (n = 17) TD (n = 15)
Eschkol-Wachman Movement Notation
Baraneck15
Autism disorder (AD) (n = 11) DD (n = 10) TD (n = 11)
Video analysis and coding of behavioral categories: looking, affect, response to name, anticipatory postures, motor/object stereotypies, social touch, sensory modulation
Participants were initially identied from 2 groups: infants considered to be at high risk of autism because they were siblings of children with autism and infants considered at low risk because there was no family history of autism. Review of test scores and clinical judgment led to categorization of these infants as unaffected, ASD, or language delayed. On the basis of MSEL scores, children with ASD had slowed in development in all domains except visual reception by 14 months. By 24 months, signicant differences were found between the group with ASD and the group of children developing typically on all domains of the MSEL. Based on retrospective video analysis, infants (12-21 weeks) who were later diagnosed with ASD had higher rates of asymmetry in supine static and dynamic lying postures. Symmetry was noted in some children with ASD; however, children with early onset ASD were more likely to demonstrate lower levels of symmetry. Based on retrospective video analysis of infants, most of the children with ASD demonstrated altered movement patterns in mouth shape and lying, righting, sitting, crawling, and walking that could be identied within the rst few months of life. Based on retrospective video analysis of infants between 9 and 12 months corrected chronological age, subtle sensory-motor decits were present in infants who were later diagnosed with AD. Social decits were also noted.
(continued)
10
Downey and Rapport
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Retrospective comparison (parent questionnaire) Examination Toolsb Parent questionnairesymptoms of autism before the age of 2 years (SAB-2)
Author(s) Dewrang and Sandberg16
Study Groups Asperger syndrome (AS) (n = 23) TD (n = 12)
Summary of Findings According to results from retrospective parent questionnaire, individuals with AS demonstrated difculties in the rst 2 years of life with several areas of development, including motor skills. Parents did report difculty with imitation of motor skills and coordination. On the basis of retrospective video analysis, children who were later diagnosed with AD did not demonstrate higher rates of movement abnormalities or fewer protective responses before the age of 2. There were slower rates of motor development noted in the group with At(NR) in early skills and in the group with At(R) in walking. Videos were analyzed of children at 12 and 18 months of age. The arm wave posture was more commonly seen in children with ASD in both age groups. At 18 months, the hand-to-ear posture was noted in both the group with ASD and the nondiagnosed siblings of children with ASD. Overlap between all groups was present for stereotyped behaviors. Children with AD had decreased imitation performance when compared with children with DD or children developing typically. No differences were found in motor skills between children with AD, DD, or children developing typically, and no correlation was found between motor skills and imitation abilities in children diagnosed with AD. Part 1: Children with ASD under 31/2 years old have poorer imitation skills than children without ASD but with developmental delays when matched on mental age, chronological age, and language ability. Difculties were noted specically with imitation of body movements and nonmeaningful actions. Difculties were similar across all groups, suggesting that motor imitation skills in children with ASD may be delayed in acquisition and not disordered. Part 2: Motor imitation improved in children with ASD between the age of 2 and 3 years. (continued)
Ozonoff et al17
AD (n = 54) including -Autism: no regression (At(NR)) (n = 26) -Autism: regression (At(R)) (n = 28) DD (n = 25) TD (n = 24)
Infant Motor Maturity and Atypically Coding Scales
Loh et al18
ASD (from a population of children with siblings diagnosed with ASD) (n = 8) Nondiagnosed siblings of children with ASD (n = 9) TD (n = 15)
Coding of motor mannerisms during standardized testing
Rogers et al20
Comparison
Stone et al21
AD (n = 24) DD (mixed etiology) (n = 20) Fragile Syndrome (FXS) (n = 18, not included in group comparison analysis) including: -FXS without AD (n = 13) -FXS with AD (n = 5) TD (n = 15) Part 1 ASD (n = 18) DD (n = 18) TD (n = 18)
Imitation battery Praxis battery
Part 1: Motor Imitation Scale
Part 2 ASD (n = 26)
Part 2: Motor Imitation Scale (only total, body, and object scores)
11
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Systematic review Examination Toolsb
Author(s) Williams et al22
Study Groups
Summary of Findings Based on a literature review of 21 studies, imitation decits were present in children with ASD and more apparent in younger children (under the age of 4) and with nonmeaningful tasks. More research is necessary to further delineate autism and dyspraxia. Preschool-aged children with AD had signicantly lower motor imitation scores compared with preschool-aged children who have an intellectual delay, are hearing or language impaired, and children developing typically. Motor imitation scores strongly differentiated children with AD from children with other developmental delays and may be a useful screening tool. Children younger than 14 months in the combined AD group demonstrated increased errors on imitation tasks when compared with the other groups, to which they were matched on the basis of nonverbal skill age. All groups of older aged children demonstrated similar imitation skills except for the group with regressive-onset AD, who demonstrated impaired nonfunctional imitation skills. No differences were found between groups on error type or pattern, nor was there a difference in emulation of the task between groups. The results suggest that imitation differences are not due to a motor impairment; rather, they may be due to mirror neuron network impairments or atypical brain mechanisms associated with the mirror neuron system. Children with ASD who have been diagnosed with LFA or HFA, when matched for age, sex, and developmental level with a comparison cohort, demonstrated increased errors with imitation tasks. Children in the group with ASD also demonstrated signicantly poorer motor scores than the comparison group. Based on the results, the authors suggested that difculties with imitation arise from a delayed action production system. Although not statistically signicant, children with AS performed more poorly and variably on the MABC and the Gesture Test when compared with children with SDD-MF of similar age. All children with AS tested below the 15th percentile on the MABC. In the group with AS, poor scores on the MABC were correlated with lower scores on the Gesture Test. (continued)
Stone et al23
Comparison
AD (n = 22) Intellectually delayed with an IQ less than 70 (n = 15) Hearing-impaired (n = 15) Language- impaired (n = 19) TD (n = 20) Early onset AD (n = 17) Regressive-onset AD (n = 24) DD (n = 22) TD (n = 22)
Imitation motor tasks (12 total)
Rogers et al24
Comparison
Motor imitation in 2 conditions: functional and nonfunctional
Van Vuchelen et al25
Comparison
Green et al26
Comparison
Cognitive impairment (n = 21) with IQ < 80 including -Low functioning ASD (LFA) (n = 8) -Cognitive impairment without ASD (n = 13) No cognitive impairment with IQ > 80 (n = 34) including -High functioning ASD (HFA) (n = 17) -TD (n = 17) AS (n = 11) Specic developmental disorder of motor function (SDD-MF) (n = 9)
PDMS-2- administered to those in the group with a cognitive impairment Movement assessment battery for children (MABC)administered to those with high functioning IQ Motor imitation test
MABC The Gesture Test
12
Downey and Rapport
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology al27 Comparison Examination Toolsb Florida Apraxia Screening Test (Revised)
Author(s) Mostofsky et
Study Groups ASD (n = 21) including -HFA (n = 13) -AS (n = 8) Gender and age matched TD (n = 24) Inclusion for all subjects: IQ > 80
Summary of Findings While error type was similar between the 2 groups, children with ASD demonstrated signicantly higher errors on the Florida Apraxia Screening Test than the comparison group. In the group with ASD, children with HFA had signicantly more errors on the body-part-for-tool than the group with AS; however, no other signicant differences existed. The authors suggested that these ndings are indicative of a praxis issue in children with ASD, not just difculty with imitation. Children with AD had no difculty understanding or recognizing motor gestures. They demonstrated increased difculty naming and imitating gestures. The authors suggested that this might be due to a praxis impairment with difculty in mapping movements as well as the representation of movements. On testing to assess gesturing, children with ASD had signicantly higher rates of errors than children in the other groups. Overall, on motor testing, children with ASD demonstrated signicantly poorer scores with increased variability in scores than children in any of the other groups (41% of children with ASD did not meet criteria for motor impairment based on the BOT-SF). Although this may be related to praxis, these authors suggested that it might also be related to altered neural substrates or language decits, as errors were still present when motor decits were accounted for. Children with HFA or language impairment demonstrated signicantly lower levels of gesture representation than children developing typically on a demonstration task. The authors suggested that in the group with HFA, this might be attributed to motor planning or language impairments. Difculties may have also been exacerbated by the requirement to speak and gesture, as well as the lack of natural environment. Individuals between the ages of 5 and 52 years with HFA demonstrated decreased postural control when tested on the EquiTest compared to a sample with TD. Increased difculty was noted during the conditions of sensory conict. Postural control did not improve until the age of 12 and individuals with HFA never achieved adult levels (plateau seen at approximately 20 years of age in comparison group). During a bimanual load lift task, muscle latencies and increased unloading time found in children with AD suggest a decreased use of anticipatory control seen in a group with TD. Children with AD demonstrated an increased use of reactive postural control. (continued) Motor Activity in Autism 13
Smith and Bryson28
Comparison
AD (n = 20) Language impairment chronologically and receptive age matched (n = 20) TD receptive age matched (n = 20) ASD (n = 49) Developmental coordination disorder (DCD) (n = 46) Attention-decit/ hyperactivity disorder (ADHD) (n = 27) ADHD and DCD (n = 38) TD (n = 78)
Tests of: 1. Memory and comprehension of gestures 2. Gesture production and imitation
Dewey et al29
Comparison
Bruininks-Oseretsky Test of Motor Prociency Short Form (BOT-SF) The Gestures Test
Ben-Sasson et al30
Comparison
HFA (n = 23) with IQ > 70 including -AD (n = 15) -Pervasive developmental disordernot otherwise specied (PDD-NOS) (n = 11) Language impairment (n = 23) TD (n = 30) HFA (n = 79) TD group matched (n = 61) Inclusion for all subjects: full scale and verbal IQ > 70
Demonstration task portion of the Autism Diagnostic Observation Schedule (ADOS)
Minshew et al31
Comparison
Dynamic posturography (EquiTest)
Schmitz et al32
Comparison
AD (n = 8) (right-hand dominance) TD (n = 16) (right-hand dominance)
Bimanual load lift task with kinematic and electromyographic analysis
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Comparison Examination Toolsb Tetra-ataxiametry method for postural control during posturographic testing
Author(s) Kohen-Raz et al33
Study Groups AD (n = 91) TD (n = 166)
Summary of Findings With posturographic testing, children with AD had increased variability in performance and abnormal weight distribution with less use of the typical anteroposterior sway. Adolescent aged children with AD demonstrated decreased stability when compared to preschool-aged children with TD. Notably, the authors also found a paradoxical response to stressful situations, as children had increased postural stability in stressful conditions (removal of vision). Children were tested in 4 balance positions. On the basis of the results, children with ASD had less postural stability than the children developing typically with removal of visual cues and deviation of somatosensory cues. Children with ASD tended to rely on visual input, demonstrated by increased sway with removal of visual cues regardless of somatosensory input. A paradoxical stress response was not found. Authors reported that these results in a previous study might have been due to additional visual stimuli. Children with ASD demonstrated signicantly higher levels of mediolateral and anteroposterior sway, as well as sway area, than children with TD during quiet stance. The authors also noted a decreased displacement of the center of pressure toward the swing leg during gait in the group with ASD. This can cause a decrease in shift of the center of mass to the stance limb, creating an increased need for postural control. The authors suggested that children with ASD demonstrate postural instability. On the basis of motor testing, children with AS and HFA have variability in motor activities. Fifty percent of the children with AS and 66.7% of the children with HFA demonstrated motor impairments when compared with a normative sample data for the TOMI-H. No signicant differences were noted between the 2 groups. A signicant negative correlation was found between TOMI-H scores and IQ. The authors suggested that the lack of difference between the group scores provides support for AS being included in ASD diagnoses, rather than its own diagnostic classication. Children in all 3 age-matched groups demonstrated motor activity impairments when tested on the BOT. Children with AD scored signicantly lower on the BOT than those with AS, and no other signicant differences were noted between groups. A strong correlation between IQ scores and motor scores was found. The authors also suggested that while the BOT does test for motor impairments, a pattern of impairment is not yet clear for individuals with ASD. (continued)
Molloy et al34
Comparison
ASD (n = 8) TD chronologically age matched (n = 8)
Posturographic testing
Fournier et al35
Comparison
ASD (n = 13) TD chronologically age matched (n = 12)
Posturographic testing
Manjiviona and Prior36
Comparison
AS (n = 12) HFA (n = 9) Inclusion for all subjects: normal or near normal IQ
Test of Motor ImpairmentHenderson Revision (TOMI-H)
Ghaziuddin and Butler37
Comparison
AD (n = 12) AS (n = 12) PDD-NOS (n = 12)
Bruininks-Oseretsky Test (BOT)
14
Downey and Rapport
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Comparison Examination Toolsb MABC Developmental Coordination Disorder Questionnaire
Author(s) Green et al38
Study Groups AD (n = 45) ASD (broad) (n = 56)
Summary of Findings Motor impairments, as tested by the MABC (dened by <5th percentile), were present in 79.2% of all children (9-10 years old) in the study. Group scores were similar with children in both groups having denite motor impairments. When IQ was accounted for, 97.1% of the children with low IQ (<70) had denite motor problems, as compared with 69.7% of children with typical IQ (>70). Children with ASD demonstrated signicantly poorer scores on the Florida Apraxia Screening Test and the PANESS, suggesting poorer basic motor skills as well as praxis. Scores on praxis testing signicantly predicted scores on the ADOS, whereas basic motor skill did not. The authors suggested that although individuals with ASD may have impaired basic motor skills, dyspraxia may actually be independent of motor skills and may be a core symptom of ASD. The children in the group diagnosed with ASD had signicantly poorer scores on the PANESS, the postural knowledge test, and the Florida Apraxia Screening Test. No signicant difference was noted between children with HFA and AS on the postural knowledge test, although age predicted praxis and IQ did not. When age and IQ were accounted for, postural knowledge and basic motor score predicted praxis score, however; when age, IQ, postural knowledge, and basic motor score were all accounted for, praxis performance was signicantly related to diagnosis. The authors found that praxis performance was signicantly associated with ADOS score, suggesting that praxis may be a core symptom of ASD. Part 1: Individuals with AD demonstrated lower and signicantly more variable reaction times than those without AD. The group with AD also demonstrated signicantly longer times to execute movement. Similar to individuals without AD, those with AD were able to use advanced visual cues to plan movements and decrease reaction time. Part 2: Individuals with AD demonstrated lower reaction times and longer times to execute movement than those without AD. Individuals with AD appeared to use results from the prior trial to assist in movement planning for the current trial. (continued)
Dzuik et al39
Comparison
ASD (n = 47) TD (n = 47)
Florida Apraxia Screening Test (Revised) Physical and Neurological Assessment of Subtle Signs (PANESS)
Dowell et al40
Comparison
ASD (n = 37) TD (n = 50)
Florida Apraxia Screening Test (modied for children) PANESS Postural knowledge test (modied for children)
Glazebrook et al41
Comparison
Part 1 AD (n = 18) Without AD (n = 18)
Part 1: Calculation of reaction and movement times during an adapted precue paradigm
Part 2: Calculation of reaction time and movement times based on a rapid aiming task adopted from earlier research
15
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Comparison Examination Toolsb Calculation of reaction time and movement times based on a rapid aiming task adopted from earlier research
Author(s) Glazebrook et al42
Study Groups AD (n = 9) Age-matched individuals without AD (n = 9)
Summary of Findings The group with AD required more time to plan movements. They also demonstrated signicantly increased times to perform movements with signicantly decreased peak velocities and peak accelerations than the group without AD. Verbal ability was correlated to reaction and movement times and nonverbal ability was correlated with reaction times. Overall, individuals in the group with AD demonstrated poorer motor ability than individuals without AD. Part 1: Individuals with AD demonstrated slower reaction and movement times than the group developing typically. They were able to use advance cues to plan movements and decrease reaction times. Part 2: Individuals with AD demonstrated increased difculty reprogramming an already-planned movement. This was more difcult when the task required a change in hands than a change in directions. The authors suggested that this might be due to a slowed visual responsiveness for spatial attention or inefcient connections between hemispheres of the brain. Although individuals with HFA and AS demonstrated similar errors in a serial-choice task, both groups demonstrated increased preparation time when compared with a cohort with TD. The group with AS demonstrated slower preparation movements, while the group with HFA demonstrated a lack of anticipation in preparation. Individuals with HFA demonstrated signicantly slowed preparation times when compared with a cohort with TD. Although no signicant difference was found between individuals with AD and a cohort with TD, the authors did note a trend toward increased preparation time in the group with AD. They suggested that there is a true planning decit, rather than a slowed movement. This decit is more predominant in individuals with ASD. The authors further suggested that although motor impairments may be present in both groups, the underlying cause may be different and further research is necessary to examine these causes. (continued)
Nazzarali et al43
Comparison
Part 1: Variation of protocol from Glazebrook et al41
Part 2: Measurement of reaction and movement times during a reaching task that was hand manipulated or direction manipulated
Rinehart et al44
Comparison
HFA with performance and verbal IQ >70 (n = 12) TD (matched on age, sex, IQ) (n = 12) AS (n = 12) TD (matched on age, sex, IQ) (n = 12)
Measurement of preparation and movement time with a serial-choice button-pressing apparatus
Rinehart et al45
Comparison
HFA with performance and verbal IQ > 70 (n = 12) TD (matched on age, sex, IQ) (n = 12) AS (n = 12) TD (matched on age, sex, IQ) (n = 12)
Upper extremity kinematic task to measure movement preparation and movement time
16
Downey and Rapport
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Comparison Examination Toolsb Gait analysis
Author(s) Vernazza-Martin et al46
Study Groups AD (n = 9) TD (n = 6)
Summary of Findings The authors found no signicant difference between the group with AD and the group with TD on gait parameters (stride duration, step length, velocity, cadence, and string and stride length), except for stride length, which was found to be shorter in children with AD. On the basis of analysis, children with AD demonstrated increased oscillations of the head, shoulder, and trunk causing less stable and more variable posture. Although children with AD demonstrated increased oscillations, they were able to stabilize in the frontal plane. Gait parameters and stability appeared similar between groups; however, locomotion pattern was not maintained in the group with AD. The group with AD demonstrated difculty with gait trajectory based on an imposed goal, suggesting difculties with motor planning. Based on hand positioning during a reach-and-grasp task, the authors suggested that individuals with AD have increased difculty with executing even simple goal-directed tasks when compared with children with moderate learning disabilities or children with TD. The authors suggested that the pattern seen in older children with AD is similar to that seen in preschool-aged children with TD, suggesting that development is delayed rather than altered. They also hypothesized that the differences may be due to sequencing, vision, or consequence prediction. Children with ASD demonstrated signicantly lower scores on locomotor and object control scores than children who were chronologically age matched and mental age matched. No difference was found between the group with ASD and the developmental age matched, as they were matched on the basis of motor scores. In general, children with ASD had increased difculty coordinating both sides of the body for a task, as arm movements were noted to be awkward. On the basis of comparison with children who were developmentally matched, children with ASD appear to be delayed rather than disordered, as skills aligned with children with TD approximately half their age. In the group with ASD, no differences were found on the PANESS between individuals diagnosed with HFA or AS. The group with ASD demonstrated signicant differences from the group with TD on all variables of the PANESS, except for impersistence and patterned timed movements (a trend toward signicant was present). Overall, children with ASD tended to have difculty with balance, gait, and timed movement of the hands and feet. (continued)
Hughes47
Comparison
AD (n = 36) Moderate learning disabilities (n = 24) TD (n = 28)
Reach, grasp, and place task (Bar Game) with examiner report of hand positions
Staples and Reid48
Comparison
ASD (n = 25) TD, age matched (n = 25) TD, movement skill performance matched (n = 22) TD, mental age matched (n = 19)
Test of Gross Motor Development
Jansiewicz et al49
Comparison
ASD (n = 40) TD with no neurologic or psychiatric diagnoses (n = 55)
PANESS
17
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Comparison Examination Toolsb Motor testing: Finger Tapping, Grooved Pegboard, Trail Making, Assessment of Apraxia, Finger-Thumb Apposition, Assessment of Ataxia, Assessment of Visuomotor Integration
Author(s) Weimer et al50
Study Groups AS (n = 10) TD age matched (n = 10)
Summary of Findings Individuals with AS demonstrated poorer scores on tests of apraxia, balance (tandem and single leg), and nger-thumb apposition, but did not demonstrate signicantly poorer scores on tests of basic motor function than a cohort with TD. The balance scores were poorer with eyes closed. On the basis of these results and the lack of dizziness usually found with a vestibular dysfunction, the authors suggested that individuals with AS may have a reliance on visual input and a proprioceptive decit. The group with ASD demonstrated increased difculty with dynamic balance and diadochokinesis. The authors suggested that these impairments might be a result of poor integration of motor, sensory, and executive function. An association between motor scores, the core symptoms of ASD, and level of withdrawal was also found. Children developing typically had signicantly higher scores on the PANESS when compared with children with ASD, particularly for the sections examining gait and timed movements. Handwriting scores were lower in the group with ASD; however, children with ASD did not demonstrate difculty aligning or sizing letters. Overall scores on the PANESS, as well as scores on the timed movement section, were found to be predictive of handwriting scores. The authors suggested that when overall motor skills are addressed in children with ASD, handwriting abilities may improve as a result of increased control and ease of manipulation. Children with ASD demonstrated similar grip selection to age-matched children developing typically on a task that the authors used to test motor planning. The authors hypothesized that the need for motor planning was not strong enough to elicit a difference in the children with ASD. Based on motor testing, 85% of the children with AS and 88% of the children with learning disabilities qualied for the diagnosis of SDD-MF, which the authors reported as being 42-44 times higher than the typical population. There was a signicant difference between groups for manual dexterity skills. The children with AS trended toward poorer ball skills. The authors suggested that this trend may be due to type of preferred play or decreased interpersonal skills in children with AS. (continued)
Freitag et al51
Comparison
ASD with Full Scale IQ >70 (n = 16) including AS (n = 4) HFA (n = 12) TD IQ matched (n = 16)
Zurich Neuromotor Assessment
Fuentes et al52
Comparison
ASD (n = 14) TD (n = 14)
Minnesota Handwriting Assessment Revised PANESS
van Swieten et al53
Comparison
DCD (n = 27) ASD (n = 20) TD (n = 70)
Grasp and turn task to measure preferred grip
Miyahara et al54
Comparison
AS (n = 26) Learning disabilities (n = 16)
MABC
18
Downey and Rapport
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Comparison Examination Toolsb PDMS-2
Author(s) Provost et al55
Study Groups ASD (n = 19) DD (n = 19) AD (n = 117) PDD-NOS (n = 112) Atypically developing without ASD (n = 168)
Summary of Findings When children with ASD were matched with children with DD based on age, gender, and cognitive age, similar gross and ne motor proles were found. There was no signicant difference found between children with AD and PDD-NOS (differences did approach signicance), or children with PDD-NOS and children atypically developing on gross and ne motor scores. Children with AD did have signicantly lower ne and gross motor scores than children who were developing atypically. Motor impairments were present in all groups. The authors suggested that motor impairments in children with AD are apparent at an early age and they may benet from early intervention services. Qualitatively, statistically signicant differences were found on motor performance between the children with TD and the children with expressive and receptive language disorders in all areas except for coordination. Children with AD had signicantly poorer scores than children with TD for all sections except for oral motor and coordination tasks. On motor testing, there was an overall trend (not signicant) toward poorer motor scores in the group with AD than the group that was intellectually delayed. The group with AD demonstrated signicantly higher balance scores than the group that was intellectually delayed, which the authors suggested may be due to slowed movements seen in functional play. The group that was intellectually delayed demonstrated superior target throwing skills. The authors suggested that low motor scores in children with AD might be related to level of cognitive impairment, rather than diagnosis alone. Children with ASD demonstrated signicantly poorer scores on locomotion, object control, and GMDQ than children with ADHD and children with TD. Children with ADHD also demonstrated signicantly poorer scores on measures than children with TD. When children in the group with ASD who demonstrated attention decits were omitted from analysis, results still indicated that children with ASD have poorer scores, suggesting that motor ability is not related to attention. The authors suggested that based on GMDQ, differences might be secondary to limited social skills. (continued)
Matson et al56
Comparison
Battelle Developmental Inventory, 2nd Edition
Noterdaeme et al57
Comparison
AD (n = 11) Expressive language disorder age and IQ matched (n = 11) Receptive language disorder age and IQ matched (n = 11) TD age and IQ matched (n = 11) AD (n = 8) Intellectually delayed (n = 8)
Morin and Reid58
Comparison
Standardized neurological examination: ne motor, gross motor, coordination, balance, and oral motor for global neuromotor impairment score, performance times 5 test items: dynamic balance, catching, standing long jump (adapted from the BOT), throwing, running
Pan et al59
Comparison
ASD (n = 28) ADHD (n = 29) TD (n = 34)
Test of Gross Motor Development Second Edition, calculation of the Gross Motor Development Quotient (GMDQ)
19
APPENDIX
Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Comparison Examination Toolsb EB-test (used for children older than 6 years), Cailler-Asuza Scale (children below 4 years), MABC, motor-neurologicalperceptual assessment
Author(s) Kopp et al60
Study Groups ASD (n = 20) ADHD (n = 34) TD age and IQ matched (n = 57)
Summary of Findings All study participants were female. High rates of DCD were found in the group with ASD and ADHD. In school-aged girls, 25% of those with ASD and 32% of those with ADHD were diagnosed with DCD. In the preschool-aged girls, 80% of girls with ASD were diagnosed with DCD. On the EB-test, girls with ASD and ADHD scored signicantly lower than girls with TD, and girls with ADHD had lower overall scores than those with ASD. On the basis of overall clinical picture, the authors suggested that younger age, low IQ, and autistic symptoms are predictors for lower motor scores.
a Articles
are listed in the same order in which they appear in the article.
b Tests related to motor and imitation skills were reported in the table. Studies may have used other testing (such as the ADOS), for diagnostic purposes,
and these tests were not included in the descriptions of each study in the table. See specic studies for more details on tests used.
20
Downey and Rapport

Motor Activity in Children With Autism A Review.2

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R E V I E W

Motor Activity in Children With Autism: A Review of Current Literature

2 Downey and Rapport

Pediatric Physical Therapy

Pervasive developmental disordernot otherwise specied (PDD-NOS)a,b

Fig. Search strategy.

Pediatric Physical Therapy

Motor Activity in Autism

Pediatric Physical Therapy

Motor Activity in Autism

Pediatric Physical Therapy

Motor Activity in Autism

Author(s) Provost et al11

Landa and GarrettMayer12

Mullen Scales of Early Leaning (MSEL)

Retrospective comparison (video analysis)

ASD (n = 18) Typical development (TD) (n = 18) DD (n = 12)

Eschkol-Wachman Movement Notation static and dynamic symmetry

Retrospective comparison (video analysis)

ASD (n = 17) TD (n = 15)

Eschkol-Wachman Movement Notation

Retrospective comparison (video analysis)

Autism disorder (AD) (n = 11) DD (n = 10) TD (n = 11)

Downey and Rapport

Pediatric Physical Therapy

Author(s) Dewrang and Sandberg16

Study Groups Asperger syndrome (AS) (n = 23) TD (n = 12)

Retrospective comparison (video analysis)

Infant Motor Maturity and Atypically Coding Scales

Retrospective comparison (video analysis)

Coding of motor mannerisms during standardized testing

Imitation battery Praxis battery

Part 1: Motor Imitation Scale

Part 2 ASD (n = 26)

Pediatric Physical Therapy

Motor Activity in Autism

Author(s) Williams et al22

Imitation motor tasks (12 total)

Motor imitation in 2 conditions: functional and nonfunctional

Van Vuchelen et al25

MABC The Gesture Test

Downey and Rapport

Pediatric Physical Therapy

Smith and Bryson28

Demonstration task portion of the Autism Diagnostic Observation Schedule (ADOS)

Dynamic posturography (EquiTest)

AD (n = 8) (right-hand dominance) TD (n = 16) (right-hand dominance)

Bimanual load lift task with kinematic and electromyographic analysis

Pediatric Physical Therapy

Author(s) Kohen-Raz et al33

Study Groups AD (n = 91) TD (n = 166)

ASD (n = 8) TD chronologically age matched (n = 8)

ASD (n = 13) TD chronologically age matched (n = 12)

Manjiviona and Prior36

AS (n = 12) HFA (n = 9) Inclusion for all subjects: normal or near normal IQ

Test of Motor ImpairmentHenderson Revision (TOMI-H)

Ghaziuddin and Butler37

AD (n = 12) AS (n = 12) PDD-NOS (n = 12)

Bruininks-Oseretsky Test (BOT)

Downey and Rapport

Pediatric Physical Therapy

Author(s) Green et al38