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A R T I C L E
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 deﬁcits 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 beneﬁt 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 speciﬁc functional limitations. (Pediatr Phys Ther 2012;24:2–20) 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 speciﬁed (PDD-NOS), or Asperger syndrome (AS) on the basis of medical and developmental history and clinical observations of behavior (see Table 1 for deﬁnitions).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 deﬁcits 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 child’s ability to fully participate in daily activities and routines. These deﬁcits 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 beneﬁt
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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 (firstname.lastname@example.org). 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 conﬂict 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
and October 31. Autism disordera Asperger syndromea. Asperger’s disorder. The term motor activity was selected by the authors in an attempt to capture and describe motor abnormalities. and stereotyped or repetitive behaviors. schizophrenia. and PDD not otherwise speciﬁed. PubMed. and PT (see Figure for search terms). There is no delay in language. and play prior to the age of 3 years. Pediatric Physical Therapy Motor Activity in Autism 3 . Care was given to be certain that each search yielded all possible evidence in the published literature. and Google Scholar search engines between January 1. METHODS A literature search was carried out using OVID.b Pervasive developmental disorder—not otherwise speciﬁed (PDD-NOS)a. 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. There must also have been a delay in social interaction. and general motor function of children with ASD. 2009. 2009.TABLE 1 Deﬁnitions and Abbreviations of Developmental Disorders Identiﬁed in the Literature and Associated With Autism Classiﬁcation Autism spectrum disorder (ASD)1 Pervasive developmental disorder (PDD)a Deﬁnition ASD is a neurodevelopmental disorder that is characterized by limitations in social interactions and communication. motor activity. or adaptive behaviors and activities of daily living skills. Rett’s disorder. restricted interest.b from the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV). delays. social or communicative language. PDD encompasses several disorders including autistic disorder. The diagnosis of autistic disorder is based on impaired social interaction and communication and the presence of repetitive or stereotyped behavior. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. schizotypical personality disorder. Seventeen search terms were used in an attempt to best capture the broad range of articles addressing children with autism or related diagnoses. The search was then updated during May 2010 using the same strategies with each of the 17 search terms. The diagnosis of Asperger syndrome is based on impaired social interaction and restricted or stereotyped interests that interfere with daily functioning.1 on proposed revisions of the DSM. these currently used diagnoses may be incorporated into one diagnosis (ASD) when the ﬁfth edition is published. PDD-NOS includes “atypical autism” (when the criteria have not been met for autism disorder). Further review of Fig. Search strategy. childhood disintegrative disorder. Unauthorized reproduction of this article is prohibited. These symptoms should not be accounted for by PDD. cognitive development. or avoidant personality disorder. In all. 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.3 b Based a Adapted children with autism. 90 searches were completed (Figure).
they were generated through the work of the ﬁrst author. In addition. No differences on the Mullen Scales of Early Learning were found in children with ASD and typical children at 6 months. Second Edition. 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. additional articles that would meet the search criteria may be found if a new search following the same strategy was conducted today. Two level 2 articles and 47 level 3 articles were identiﬁed and included in the analysis. In another study. increased clumsiness. Dewrang and Sandberg16 used retrospective parent reports to compare individuals with AS with a group of young adults who were developing typically. including sensorymotor symptoms. however. and poor coordination. . In another study. 14. Interestingly. These ﬁndings suggest that evaluation of motor activity may play a role in early prediction of ASD. These researchers found that the group with ASD had signiﬁcantly less static and dynamic symmetry in the supine position than the other groups. In contrast. Baraneck15 suggested that symptoms of autism. and articles that were not accessible in English (see Figure). including asymmetrical movement patterns. Studies that inform health care providers about children with ASD and addressed motor activity were analyzed and reviewed (see Appendix). Landa and GarrettMayer12 also prospectively studied 2 groups of infants: 4 Downey and Rapport 1 group was classiﬁed as low-risk for development of autism and the other as high-risk for development of autism.an article was dependent on the appearance of the search terms in the abstract of the article as identiﬁed by the ﬁrst author (Figure). are present at birth in children with ASD and may aid in the early identiﬁcation of ASD. and corroborated with the second author. The articles were grouped and analyzed on the basis of these themes. signiﬁcant differences were found between the group with ASD and the group developing typically in all domains. At the 24month visit. the following thematic categories emerged: early motor ﬁndings. further testing was administered to classify children who had typical development. Teitelbaum et al14 also suggested that motor abnormalities. Children were examined with the Mullen Scales of Early Learning at 6. They did. postural control. and dyspraxia. and children with typical development. on the basis of criteria from Sackett et al. These authors also suggested that more sensitive testing might be required to identify motor impairments. Review articles that did not include speciﬁc methods and inclusion criteria also were excluded from the analysis (see Figure). gestures and motor imitation. as well as between the group with ASD and the group with language delay. rather. articles in which the search terms were present in the abstract but did not include analysis of motor function. by 14 months. Unauthorized reproduction of this article is prohibited. during the process of sorting articles that met the search criteria. In another study by Loh et al. the children with ASD began to demonstrate a slowing in development compared with the other groups. children with ASD have difﬁculty with communication as well as difﬁculty using motor activity (eg. individuals with AS demonstrated impaired imitation. During the review process. gestures and imitation) as forms of communication to support social Pediatric Physical Therapy Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association.18 stereotyped behaviors and postures found in children with ASD were similar to those in the comparison group. The children with ASD demonstrated the slowest rate of increase in developmental skills over time. those with developmental delays not associated with ASD. Esposito et al13 retrospectively examined videotapes of 3 groups of infants aged 12 to 21 weeks: those diagnosed with ASD. would have qualiﬁed for early intervention services. however. 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. On the basis of video analysis. and 24 months. By 24 months. Articles that originally met the inclusion criteria but did not address motor activities as part of study criteria or outcomes also were not included. ﬁnd a slower rate of development in reaching mature motor patterns. might be present and identiﬁable between 9 and 12 months of age. ASD.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. or language delay. Based on recurring similarities in the content of the available literature as reviewed.10 Only articles that were found to be at Sackett levels 1-3B were used for this analysis. Gestures and Motor Imitation The ability to use gestures and motor imitation relies on motor activity to communicate with others. in a study by Provost et al. The themes were not derived through a speciﬁc qualitative methodological approach. They found that during the ﬁrst 2 years of life. Articles classiﬁed as levels 4 and 5 were identiﬁed but not used in the literature review. they suggested that more comprehensive motor evaluations might be useful in early detection of autism. Other exclusion criteria included systematic reviews that did not include speciﬁc research methods. No level 1 articles appropriate for analysis were identiﬁed during the search. Articles were then graded according to the level of evidence. As is the case with all searches of the literature.9. Early Motor Findings Several recent studies sought evidence of motor impairments to provide early motor identiﬁcation markers and characteristics of ASD. various themes related to the characteristics and concerns related to ASD arose in the literature. The search strategy used here yielded all articles meeting inclusion criteria as of May 2010. For example.
Other researchers have suggested a possible link between imitation impairments and the presence of motor activity abnormalities. this same level of control was not achieved in the group with ASD.32 Minshew et al31 found that individuals with autism have decreased postural stability. Stone et al21 suggested that imitation impairments in children with ASD are due to a delay in acquiring imitation skills. rather than tool use. 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. or ADHD only. Ben-Sasson et al30 examined gestural representations in 3 groups of children: children with HFA. errors were increased when gesturing on command and imitation. Spatiotemporal errors were more common in the group with AS.28 Dewey et al29 also found that when compared with children with both developmental coordination disorder (DCD) and attention-deﬁcit/hyperactive disorder (ADHD).27 children with ASD had more imitation errors on the Florida Apraxia Screening Test than children who were developing typically. children with ASD have signiﬁcantly lower motor and gestural performance Pediatric Physical Therapy scores. or dyspraxia in children with ASD. however. Although this may be related to praxis. Compared to a group of children who were developing typically and adults. More recently. abnormal weight distribution. Molloy et al34 also found that children with ASD had signiﬁcantly more sway in standing than a comparison group of children who are developing typically. particularly in circumstances where there is sensory conﬂict.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.31. They also found increased impairment on motor testing. children with autism fail more imitation tasks than a group of children with developmental delays and a group of children who were developing typically. children with language impairment. A “paradoxical stress response” was noted in individuals with autism. At the age of 15 years. particularly in relation to social communication. Instead of a “paradoxical stress response. The authors suggested that these impairments might be related to dyspraxia. these authors suggested that it might also be related to altered neural substrates or language deﬁcits. as well as in preschool-aged children. In a study by Mostofsky et al. Without this control. Van Vuchelen et al25 reported the presence of an imitation impairment. In a follow-up study. In another study. especially in nonmeaningful gestures. Smith and Bryson28 found that children with ASD have increased difﬁculty performing and naming both meaningful and nonmeaningful gestures but no difﬁculty understanding or identifying gestures. The authors hypothesized that performing motor actions might be more difﬁcult when the task is combined with verbal description. The authors concluded that children with HFA have increased difﬁculty with gestural representations. 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. Individuals with autism tend to have decreased postural control. Motor imitation has been identiﬁed as a significant impairment in previous literature on individuals with ASD. indicated by an increase in postural stability in stressful conditions (deﬁned as removal of vision). Based on the data from a bimanual lift task by Schmitz et al. the group that was developing typically appeared to have a plateau in postural stability. Although some improvement may be seen between the ages of 2 and 3 years. in children with ASD who have low-functioning autism and high-functioning autism (HFA).23 In another study. This may be related to a lack of integration between motor and language. children with regressive type autism continued to fail more tasks. rather than disordered sequencing. especially nonfunctional imitation tasks. BenSasson et al30 suggest that individuals with ASD may beneﬁt from further testing to examine motor planning and sequencing. this delay was apparent in young children.19-21 In a literature review by Williams et al. when compared with the other 2 groups. development of postural stability appeared to be delayed in children with autism. which they suggest may be related to a motor planning deﬁcit. Green et al26 also found an association between motor and imitation scores.interaction. with lower and more variable scores in children with AS than in children with speciﬁc developmental delays of motor function. and children who are developing typically. Postural Control Postural control requires a level of stability necessary prior to executing additional motor skills or activities. motor activity may be limited to more static positions. Postural stability did not appear to improve in individuals with autism until the age of 12 years. In the groups with ASD. In a more recent study. and the absence of typical ankle strategies in standing. language skills. These ﬁndings were especially meaningful in children with autism who were younger than 14 months.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. There appeared to be decreased quality of gesture performance as well as a discrepancy between gestures and verbal descriptions. In another study. In the older age group (older than 30 months). . Rogers et al24 noted that during a simple task. indicating that children with ASD rely on visual input for balance. For example. Spatial errors were the most common in both groups. No support was found for a relationship between imitation impairment and play skills. Unauthorized reproduction of this article is prohibited. Children with ASD demonstrated increased sway. DCD only.” they found that children with ASD experienced a larger increase in sway when visual input was removed and somatosensory input modiﬁed. Notably. no signiﬁcant difference was found in the number of total errors between individuals diagnosed with HFA and those with AS.22. This ﬁnding points to impaired processing Motor Activity in Autism 5 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association.
children with ASD had signiﬁcantly poorer Pediatric Physical Therapy Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Manjiviona and Prior36 found limits in motor activity and function in children with HFA and AS. This was further supported in another study by Rinehart et al. Unauthorized reproduction of this article is prohibited. individuals with HFA and AS are “strongly impaired” in dynamic balance and diadochokinesis. there is a trend toward higher cognitive limitations correlated to lower motor scores. AD. also suggesting that dyspraxia may be a core symptom of ASD. motor imitation may be linked to dyspraxia. In another study. indicating that motor impairments might be related to IQ level. While no level 1 research supporting the presence of limitations in motor activities was found. Individuals diagnosed with AD had higher levels of motor activity impairment. no signiﬁcant difference remained between groups. Glazebrook et al41 noted that individuals with ASD are able to use advance information. On the basis of an analysis of goal-directed gait. Glazebrook et al42 and Nazzarali et al43 noted that individuals with ASD required more time to plan and execute goal-directed movements. The authors found that deﬁcits were present on tests of apraxia. children with ASD have impaired motor planning and execution. The 3 typical groups were matched with children in the group with ASD by chronological age. They found that children with ASD have signiﬁcantly poorer motor scores than children who are developing typically and who are chronologically age matched and cognitively age matched. suggesting reliance on vision with a proprioceptive impairment. and dyspraxia has been noted when comparing children with ASD with children who are developing typically. 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 deﬁcits associated with autism. vision. AS. and dysrhythmia with timed hand and foot movements. A strong correlation existed between intelligence quotient (IQ) scores and test results. or movement skill development. while those with AS demonstrated less impairment on gross motor. In addition. In a study by Fuentes et al. The authors suggested that by late childhood. several lower-level studies indicate that impairments in motor activity may be common in children with ASD. In addition. Vernazza-Martin et al46 suggested that when compared with a typical comparison group. 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. and total battery scores. .abilities with sensory conﬂict in individuals with ASD.1 According to Dowell et al. Current research has demonstrated that there is no signiﬁcant difference in level of motor impairments among children with AS. When adjusted for level of intelligence. 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. Further support for impaired postural control in children with ASD was provided by Fournier et al. the alterations in patterns are unclear.40 praxis 6 Downey and Rapport score was correlated with the Autism Diagnostic Observation Schedule score. Staples and Reid48 compared a group of children diagnosed with ASD to 3 groups developing typically. Motor delay and motor variability have also been noted and described in some studies and refuted in others. particularly to a delay in spatial mapping. Researchers have sought to distinguish differences across individuals with ASD. Ghaziuddin and Butler37 noted that children with autism. ﬁne motor. however. or PDD-NOS. Rinehart et al44 also noted a slower preparation time in children with HFA and AS when compared with a cohort developing typically. and PDDNOS have motor impairments. gait.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. or consequence prediction. Freitag et al51 reported that when compared with a group developing typically. Several researchers have suggested that when compared with a comparison group developing typically. Speciﬁcally. Dowell et al40 reported that children with ASD have slower timed movements and score signiﬁcantly lower on postural knowledge testing. Mostofsky et al27 suggested that based on the Florida Apraxia Screening test. more time is required to plan movements. however. Jansiewicz et al49 noted that boys with HFA and AS have increased difﬁculty with balance. especially on measures where visual input was removed. as well as to compare those with ASD with individuals who are developing typically or have other developmental concerns. children with ASD have dyspraxia.45 where children with HFA demonstrated increased preparation time compared with a cohort developing typically. Although motor abnormalities were noted in individuals who were ﬁrst described with AS. Green et al38 found a similar correlation between IQ and motor scores in individuals with ASD. and integration between sensory and motor input may be also impaired. and children with AS demonstrated a trend toward a motor preparation deﬁcit. children with ASD had difﬁculty with bilateral coordination and performed at a similar motor level as children approximately of half their chronological age. cognitive development. Hughes47 suggested that individuals with autism demonstrate difﬁculty executing simple goaldirected motor tasks that might be related to sequencing. Whereas differences in motor planning are present in some individuals with ASD. They also noted a positive association of motor scores to the level of social withdrawal. Statistically signiﬁcant 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 Proﬁciency.52 the authors found that when compared with a group of children who were developing typically.8 these limitations have not been consistently identiﬁed in individuals with ASD. Dyspraxia Quality of movement may be altered in children with ASD. motor skills in children with ASD are signiﬁcantly delayed.
Balance in individuals with ASD may be decreased. No signiﬁcant differences were found between toddlers with PDD-NOS and children who are developing typically. evidence supports the presence of speciﬁc difﬁculties related to motor activity in individuals with ASD. note that scores of children with ASD were more variable than those with developmental delays. which. In another study. however. The authors suggested that motor impairments are present at a young age and beneﬁt may be obtained from early intervention. Motor scores of children with ASD did not differ when compared with children with developmental delay. The children with speech disorders had lower scores on all gross and ﬁne motor domains except coordination. They suggested that poor motor performance might be a sign of autism.1 In a study by Dewey et al. Matson et al56 also noted gross and ﬁne motor impairments in toddlers with AD when compared with toddlers with atypical development between 18 and 36 months of age. continued research is necessary to identify the severity and the pattern of deﬁcit. no difference was found between the group with typical development and the group with ASD. evidence is emerging that supports the identiﬁcation of impaired motor activity in children who have the diagnosis of autism. might be related to the type of preferred play. stance. 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. physical therapists should consistently be part of the team addressing all the needs of the child. This ﬁnding was further supported by Pan et al. and at least 68% of these children would have qualiﬁed for early intervention services based on a delay of 25% or more. van Swieten et al53 sought to differentiate between motor and executive planning abilities in 3 groups of children and adults: a group with ASD. and timed movement activities. Poor motor scores were related to poor activities of daily living and physical education participation. Based on what the authors suggested to be a pure motor planning test. The ability to understand and address the entire clinical picture of the child.motor and writing scores overall. Although we still have much to learn about the timing of motor development and the patterns of motor activity in children with ASD. they are considered a core deﬁcit of DCD and ADHD. handwriting scores would improve as a result of increased ability to control and manipulate arm movements. and low IQ. In this study. In another study by Provost et al. presence and severity of ASD symptoms. As children are being diagnosed earlier with ASD and receiving early intervention services. or ADHD and DCD. They found that a large percentage of girls with ASD also ﬁt the diagnosis for DCD. Kopp et al60 compared several groups of girls: girls who were developing typically.55 The authors did. No difference in motor proﬁle was found between children with ASD who were chronologically age matched and children with other developmental delays. Although impaired motor activity is not included in the diagnosis. impaired motor activity appears to be an observable trend. Predictors of poor motor scores included younger age. ADHD. except oral motor and coordination. In contrast. Speciﬁc limitations were noted on tests of locomotion and object manipulation. including all areas of function. 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.11 the authors evaluated 3 groups of children—children with ASD.57 Morin and Reid58 noted that although individuals with autism have poor motor performance. This supports the presence of difﬁculty with motor activity in children with ASD. Poor gross motor skills were correlated with poor handwriting scores. children with ASD had signiﬁcantly lower scores than children with DCD. whereas children with autism had signiﬁcantly poorer scores on all ﬁne and gross motor scores (including balance). A signiﬁcant difference was found between groups for manual dexterity scores. a group with DCD. none of the children in the group with ASD tested within normal limits. increased anxiety. These results suggest that there is a limitation in motor function in children with ASD. however. Questions Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. More speciﬁcally.59 who found that children with ASD performed signiﬁcantly lower on motor tests than children with ADHD and children who are developing typically. developmental delays. Unauthorized reproduction of this article is prohibited. Pediatric Physical Therapy Motor Activity in Autism 7 . Further research is needed to identify the speciﬁc type of dysfunction. girls with ASD. research indicates that there are limitations in motor imitation in children with ASD.29 the authors found that when tested on the Bruinink-Oseretsky Test of Motor Proﬁciency (short form) and a gestural performance test. The children with AS had a trend toward poorer ball skills. In a rare study with an all-female sample. with poor skills being related to a lack of social skills as well as lack of motivation to practice. They hypothesized that if therapies address overall motor control. and developmental concerns—on the basis of results from the Bayley Scales of Infant Development. scores were decreased on gait. The link between imitation and motor activity is still unclear. the authors hypothesized. however. and decreased social function. The authors encouraged clinicians to screen for motor impairments as poor motor skills were found to be correlated with poor self-esteem. Although impaired motor skills and function are not a core deﬁcit of ASD. and a group with typical development. and girls with ADHD. they can obtain higher balance scores than those with intel- lectual delay. becomes an essential component of any intervention plan. children with ASD were compared with children with speciﬁc speech and language disorders and a comparison group of children who were developing typically. especially those in the preschool-aged group. DISCUSSION Based on this review of literature.
2006. Esposito G.62 and further research is needed to examine the severity. 1988. J Autism Dev Disord. et al. 8. 2001. 1994. lack of evidence has not prohibited the PT profession from forging ahead with new research and ongoing intervention. et al. CONCLUSION Although there may be limitations in motor activity present in children with ASD. Annotation Asperger syndrome.31:131-138. 6. Travers et al63 reported that for simple tasks. et al. Motor activity delays have been observed in infants and toddlers with autism and may affect future motor development.16:228231.66 it may be useful to implement interventions and research their efﬁcacy based on activity limitation and 8 Downey and Rapport participation restrictions rather than solely by impairment and disability. Asperger syndrome: a clinical account. American Psychiatric Association DSM-5 Development. Ozonoff S. Stereotyped motor behaviors associated with autism in high-risk infants: a pilot videotape analysis of a sibling sample. Fryman J. 2000. Parental retrospective assessment of development and behavior in Asperger syndrome during the ﬁrst 2 years of life. 13. and a group developing typically. screening. Teitelbaum P. Brian J. No consistent measure was used in each of the reviewed studies.aspx. PT. ASD. 11. 2009.37:321-328. which limits generalization of the ﬁndings. Movement analysis in infancy may be useful for early diagnosis of autism. 3. 2009. ACKNOWLEDGMENT The authors thank Stephanie Lyle. Res Autism Spectrum Disord. Tantam D. early identiﬁcation leading to the initiation of early service delivery might have a positive beneﬁt on motor skills and long-term disability in individuals diagnosed with ASD. J Autism Dev Disord. . 19. Wing L. Accessed December 2010. Lopez BR. 12. Functional behavioral assessment and children with autism: working as a team. Nye J.gov/ncbddd/autism/addm.55:1129-1146.29:245-255. Richardson WS.38:644-656. Goldring S. 7.29:213-224. A comparison of motor delays in young children: autism spectrum disorder. Teitelbaum O. 2008. 5. Although the results of this literature review do indicate that motor activity impairments may be present in children with ASD. 4th ed.65 Since children with ASD are ambulatory. Although limited research related to interventions for motor activity impairments in children with ASD was found. which might inﬂuence therapeutic approach. 1981. Kogan MD. Young GS. Tuchman R. The presence of postural instability is also supported in the literature. http://www . 15. 17. As with many other diagnoses. 2007. Glaros S. Venuti P. Unauthorized reproduction of this article is prohibited. they previously would not have been thought to beneﬁt from PT. Travers et al63 did address motorlinked implicit learning in children with ASD. PT: Magazine of Phys Ther.37:25-36. Maurer RG.11:115-129. Soman T. Gross motor development. and early identiﬁcation of autism. Provost B.dsm5. DSM-5: The future of psychiatric diagnosis. Autism during infancy: a retrospective video analysis of sensory-motor and social behaviors at 9-12 months of age. The literature also lends support to difﬁculty with motor planning in children with ASD. J Autism Dev Disord.11:42-52. As with all developmental delays.21:107-119. 2007. Limitations in motor activity in children with ASD might decrease the opportunity for social interactions and learning opportunities. 9. Development in infants with autism spectrum disorders: a prospective study. Infant Young Child. or whether limitations in motor activity restrict social participation and adversely affect imitation. 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. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Psychol Med. Sandberg AD. Rapin I. cause. Accessed June 2011. J Child Psychol Psychiat. Pediatrics.html. 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. http://www. Future research is necessary to identify to what extent functional activities are limited in children with ASD. Muratori F. Autism and development disabilities monitoring (ADDM) network. Baraneck GT. All evidence is not created equal: a discussion of levels of evidence. Evidence-Based Medicine: How to Practice and Teach EBM. Garrett-Mayer E. Loh A. PA: Churchill-Livingstone. Published March 2011. movement abnormalities. diagnosis. An updated literature search may provide increased evidence supporting motor activity impairments as well as provide documentation for intervention strategies for children with ASD. Decreased postural stability can signiﬁcantly limit participation in activities since the simplest of movements require complex control61. there are limitations to this analysis. Landa R. motor-linked implicit learning might be intact in children with ASD. 2010. 14. 1999.47:629-638. J Autism Dev Disord. Focus Autism Dev Disord. Published 2010. 1998. Prevalence of parentreported diagnosis of autism spectrum disorder among children in the US. Proc Natl Acad Sci U S A. J Child Psychol Psychiat. et al. Research is also necessary to determine the underlying causes as well as the most appropriate interventions. Sackett DL. In a study comparing a group of individuals with HFA. Strauss SE. Ingersoll B.64. 2003. Philadelphia. The social role of imitation in autism implications for the treatment of imitation deﬁcits. Blumberg SJ. Autism: deﬁnition. Brain Dev-JPN. and developmental concerns. 2008. As physical therapists move toward consistent use of the ICF. Physical therapists need to consider how to address these impairments in motor activity within the child’s daily routines. An exploration of symmetry in early autism spectrum disorders: analysis of lying.124:1395-1403. 2007. developmental delay. DPT. 10. Dewrang P.4:461-473. 4. REFERENCES 1. Maestro S. Heimerl S. Washington.still remain as to whether restrictions in social behavior limit imitation. neurobiology. DC: American Psychiatric Association. 16. 2. Pediatric Physical Therapy Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association.cdc. 18. American Psychiatric Association. for her early contributions to this work. Pediatr Clin N Am.95:13982-13987. Rogers E. and functional outcomes related to postural control. Schieve LA. Centers for Disease Control and Prevention. 1998.org/ Pages/Default.
1990. 1990. et al. Assaiante C. Dev Med Child Neurol. 61. Tonge BJ. Morin B. Stimmell KE.73: 1532-1537. Lemanek KL. Green D. Kageyama H.36:493-499. Motor imitation in young children with autism: what’s the object? J Abnorm Child Psych. Fishel PT. Rogers SJ. Baird G. 55. Mildenberger K. Pan CY. Play and imitation skills in the diagnosis of autism in young children. Reid G. Littleford CD. 32. Altemeier WA. Gillberg C. Brief report: motor incoordination in children with Asperger syndrome and learning disabilities. Tsai CL. Coordination of posture and movement. Motor Control. J Autism Dev Disord.42:43-48. Cook I. Movement planning and reprogramming in individuals with autism. Sugiyama T. Ben-Sasson A. Van Vuchelen M. 38.23:563-570. Henderson L. Lopez BR. 1996. J Autism Dev Disord. Rinehart NJ. 2001. Home Health Care Manag Pract. “Motor” impairment in Asperger syndrome: evidence for a deﬁcit in proprioception. Weimer AK. Mahone EM. Movement preparation in high-functioning autism and Asperger disorder: a serial choice reaction time task involving motor reprogramming. Landa R. Elliott D. Vernazza-Martin S. Beckung E. Elliott D. Neuropsychology. Howells-Rankin D. Clumsiness in autism and Asperger syndrome: a further report. Hepburn SL. Unauthorized reproduction of this article is prohibited. 57. Ousley OY. 40. Hess JA. Green D. social. Postural stability in children with autism spectrum disorder.39:1964-1705. Sung MB. Wehner E. 59. 1997. Denckla MB. Adapt Phys Act Q. Symbolic gestures and pantomimed object use. Reid G. 2009. The severity and nature of motor impairment in Asperger syndrome: a comparison with speciﬁc developmental disorder of motor function.22:92-101.12:314-326. von Gontard A.39:1401-1411. 1985. 36.20. Dowell LR.43:655-668.86:267-272. 26.37:948959. Dev Med Child Neurol. 46. Smith IM. Martineau J. Furman JM. pervasive developmental disorder—not otherwise speciﬁed. Dev Psychopathol. 43. Postural control in children with autism. Kleser C. 52. 50. Huber J. Sequence of gestural representations in children with high functioning autism. Fundamental movement skills and autism spectrum disorders. Mahone EM. Gesture imitation in autism: II. 2004. 1995.32: 6-9. Bhattacharya A. Barth´ l´ my C. 29. Underdevelopment of the postural control system in autism. Pediatric Physical Therapy Motor Activity in Autism 9 . Radonovich KL. 60. Tonge BJ. Fuentes CT. 24.26:99-107.33:643-652. Glazebrook CM. and atypical development. 2007. J Int Neuropsych Soc. 31. 2009. Newschaffer CJ.34:285299. 2009.31:350-361. 2006.348:17-20. Schnieder M. J Autism Dev Disord. Children with autism show speciﬁc handwriting impairments. 2010. Stone WL. 1997. 21. J Autism Dev Disord. Jerath VK. Mahan S. Miyahara M. 2003. 53. Mostofsky SH. Mostofsky SH. 1992. Young GS. J Autism Dev Disord. Wallman HV. Vernazza A. Larson JC. Jones BL. Cohen DJ.27(3):21-36. Neal D. Dev Behav Ped. Comparison of Asperger syndrome and highfunctioning autistic children on a test of motor impairment. Israeli J Occup Ther. J Autism Dev Disord. Eur Child Adolesc Psychiatry. Lincoln A. Dietrich KN. Minow F. Trauner DA. Butler E. and/or attention deﬁcit hyperactivity disorder. 54. 25. Szatmari P. 41. Dewey D.25:23-39. Weerdt WD. Denckla MB. Henderson SE. 48.22:419-432. 2010. Provost B. Mostofsky SH.22:71-85. Giolzetti A. Res Autism Spectrum Dis. Imitation actions on objects in early-onset and regressive autism: effects and implications of task characteristics on performance. J Autism Dev Disord.2: 43-55. Bastian AJ. J Child Psychol Psychiat. Staples KL. Brief report: planning problems in autism at the level of motor control. Developmental coordination disorder and other motor control problems in girls with autism spectrum disorder and/or attention-deﬁcit/hyperactivity disorder. 2007. Singh T. Phys Ther. Stone WL. Lyons J. Associations of postural knowledge and basic motor skill with dyspraxia in autism: implication for abnormalities in distributed connectivity and motor learning. Noterdaeme M. Dubey P.35:91-102. Rogers SK. 2010.44:763-781. 30. Chu CH. Earl M. 45. 2007. J Int Neuropsych Soc. Glazebrook CM. Developmental dyspraxia is not limited to imitation in children with autism spectrum disorders. Fundamental movement skills in children diagnosed with autism spectrum disorders and attention deﬁcit hyperactivity disorder. Brereton AV. 34. Martin N.10:244-264. van Bergen E. Schmitz C. Motor control ee and children with autism: a deﬁcit of anticipatory function? Neurosci Lett. Bereton AV. Motor and gestural performance in children with autism spectrum disorders. An examination of movement kinematics in young people with high-functioning autism and Asperger’s disorder: further evidence for a motor planning deﬁcit. 39. Cantell M. Volkmar FR. Quantitative assessment of neuromotor function in adolescents with high functioning autism and Asperger syndrome. J Autism Dev Disord. 23. Matson JL. 28. Williams JHG. 2007. Fournier KA. Motor skill abilities in toddlers with autistic disorder. 2006.70:855-863.11:219-225. 2009. et al. Bradshaw JL. Kimberg CI. 2010.25:475-485. 2008. A kinematic analysis of how young adults with and without autism plan and control goal-directed movements. J Autism Dev Disord. Bradshaw JL. A test of motor (not executive) planning in developmental coordination disorder and autism. 2009. Nazzarali N. Kohen-Raz R. 2007.36:757-767. Pediatrics. 2010. J Intell Disabil Res.21:436-439. How do individuals with autism plan their movements? J Autism Dev Disord. 22.49:6-12. Tsujii M. 2001. J Autism Dev Disord. Hori M.63:20562061. Neurology. 2009. 2003. Pickles A. 58. 2006. Mostofsky SH. 2005. Barnett AL. J Autism Dev Disord. Phys Occup Ther Pediatr. Ozonoff S. Bellgrove MA. 2001. and communicative deﬁcits. 2002. 47. Dzuik MA. Roeyers H. Freitag CM. Cogn Neuropsychol.4:444-449. J Autism Dev Disord. Evaluation of neuromotor deﬁcits in children with autism and children with a speciﬁc speech and language disorder. 51. Cermak SA. Minshew NJ. Amorosa H.36:613-621. A systematic review of action imitation in autism spectrum disorder. Stackhouse T. 2007. 42.13:246-256. Elliott D. J Autism Dev Disord. Charman T. Res Dev Disabil. 1998. Apostu A. 44. Hughes C. Decreased static and dynamic postural control in children with autism spectrum disorders. Mostofsky SH.24:679700.27:595603. 33. Gait Posture. Fernandez MC. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. 35. Neurology. Heimerl S. 2003. van Swieten LM. Rinehart NJ.18:E57-E73. 37. A quantitative and qualitative assessment of autistic individuals on selected motor tasks. Kopp S. Dyspraxia in autism: association with motor. Williams JHG. 49. et al. Fodstad JC. Goldberg MC.40:209-217. 2006. Ballantyne AO. Whiten A. Glazebrook CM. J Exp Psychol Human.51:311-316. Goal directed locomotion and balance control in autistic children. Impairment in movement skills of children with autistic spectrum disorders.49:734-739.38: 114-126. Motor signs distinguish children with high functioning autism and Asperger syndrome from controls. 56. 2002. Prior M. 62. Bryson SE. Levels of gross and ﬁne motor development in young children with autism spectrum disorder. Jansiewicz EM. Nature of motor imitation problems in school-aged males with autism: how congruent are the error types? Dev Med Child Neurol. The basics of balance and falls. developmental coordination disorder. 27. Schatz AM. Manjiviona J. Ghaziuddin M. J Autism Dev Disord. J Child Psychol Psychiatry. Crawford SG. Frank JS. 2009. 2004. Molloy CA. Nakanishi K.31:79-88. Imitation performance in toddlers with autism and those with other developmental disorders.
crawling. Travers BG. sitting. social touch. Long-term outcomes of early childhood programs: analysis and recommendations. Unauthorized reproduction of this article is prohibited. response to name. Stevenson CS. Social deﬁcits were also noted.27:238-245. 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. and health. affect. and walking that could be identiﬁed within the ﬁrst few months of life. 2006. subtle sensory-motor deﬁcits were present in infants who were later diagnosed with AD. children with ASD had slowed in development in all domains except visual reception by 14 months. Review of test scores and clinical judgment led to categorization of these infants as unaffected. Motor-linked implicit learning in persons with autism spectrum disorders. 86:726-734. On the basis of MSEL scores. Behrman RE. signiﬁcant 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 of infants. 2010. Symmetry was noted in some children with ASD. The effectiveness of early intervention: examining risk factors and pathways to enhanced development. motor/object stereotypies. Larner MB. 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. Klinger MR. infants (12-21 weeks) who were later diagnosed with ASD had higher rates of asymmetry in supine static and dynamic lying postures. Future Child. Klinger LG. children with early onset ASD were more likely to demonstrate lower levels of symmetry. 1998. ASD. By 24 months. 65. 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 Retrospective comparison (video analysis) ASD (n = 17) TD (n = 15) Eschkol-Wachman Movement Notation Baraneck15 Retrospective comparison (video analysis) Autism disorder (AD) (n = 11) DD (n = 10) TD (n = 11) Video analysis and coding of behavioral categories: looking. Mussey JL. or language delayed. Berlin LJ. McCorminck MC. Based on retrospective video analysis of infants between 9 and 12 months’ corrected chronological age.63. Toward a common language for function. however. 1995. 66. Phys Ther. (continued) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Brooks-Gunn J. 10 Downey and Rapport Pediatric Physical Therapy . These scores were similar to those of a group of children diagnosed with DD. Prev Med. sensory modulation Participants were initially identiﬁed 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. most of the children with ASD demonstrated altered movement patterns in mouth shape and lying. Jette A. 64. 63% and 68% (respectively) of children with ASD would qualify for early intervention services on the basis of a 25% motor delay. Autism Res. McCarton C.5:6-24.3:68-77. disability. Gomby DS. anticipatory postures. righting. Based on retrospective video analysis.
On the basis of retrospective video analysis. At 18 months. (continued) Ozonoff et al17 Retrospective comparison (video analysis) 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 Retrospective comparison (video analysis) 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. Part 2: Motor imitation improved in children with ASD between the age of 2 and 3 years. and object scores) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Difﬁculties were similar across all groups. Unauthorized reproduction of this article is prohibited.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. or children developing typically. Difﬁculties were noted speciﬁcally with imitation of body movements and nonmeaningful actions. Parents did report difﬁculty with imitation of motor skills and coordination. and language ability. Pediatric Physical Therapy Motor Activity in Autism 11 . Videos were analyzed of children at 12 and 18 months of age. 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. suggesting that motor imitation skills in children with ASD may be delayed in acquisition and not disordered. DD. 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. 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. body. and no correlation was found between motor skills and imitation abilities in children diagnosed with AD. chronological age. 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. The arm wave posture was more commonly seen in children with ASD in both age groups. children who were later diagnosed with AD did not demonstrate higher rates of movement abnormalities or fewer protective responses before the age of 2. 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. individuals with AS demonstrated difﬁculties in the ﬁrst 2 years of life with several areas of development. including motor skills.
demonstrated increased errors with imitation tasks. More research is necessary to further delineate autism and dyspraxia. nor was there a difference in emulation of the task between groups.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) Speciﬁc developmental disorder of motor function (SDD-MF) (n = 9) PDMS-2. Children with ASD who have been diagnosed with LFA or HFA. Motor imitation scores strongly differentiated children with AD from children with other developmental delays and may be a useful screening tool. they may be due to mirror neuron network impairments or atypical brain mechanisms associated with the mirror neuron system. 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.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. All groups of older aged children demonstrated similar imitation skills except for the group with regressive-onset AD. and developmental level with a comparison cohort. imitation deﬁcits were present in children with ASD and more apparent in younger children (under the age of 4) and with nonmeaningful tasks. Based on the results. Unauthorized reproduction of this article is prohibited. In the group with AS. sex. are hearing or language impaired. (continued) Stone et al23 Comparison AD (n = 22) Intellectually delayed with an IQ less than 70 (n = 15) Hearing-impaired (n = 15) Language.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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. No differences were found between groups on error type or pattern. Preschool-aged children with AD had signiﬁcantly lower motor imitation scores compared with preschool-aged children who have an intellectual delay. 12 Downey and Rapport Pediatric Physical Therapy .” Although not statistically signiﬁcant. to which they were matched on the basis of nonverbal skill age. rather. when matched for age. The results suggest that imitation differences are not due to a motor impairment. All children with AS tested below the 15th percentile on the MABC. poor scores on the MABC were correlated with lower scores on the Gesture Test. Children in the group with ASD also demonstrated signiﬁcantly poorer motor scores than the comparison group. and children developing typically. who demonstrated impaired nonfunctional imitation skills. Children younger than 14 months in the combined AD group demonstrated increased errors on imitation tasks when compared with the other groups. the authors suggested that difﬁculties with imitation arise from a delayed “action production system.
Pediatric Physical Therapy . no other signiﬁcant differences existed. Gesture production and imitation Dewey et al29 Comparison Bruininks-Oseretsky Test of Motor Proﬁciency Short Form (BOT-SF) The Gestures Test Ben-Sasson et al30 Comparison HFA (n = 23) with IQ > 70 including -AD (n = 15) -Pervasive developmental disorder–not otherwise speciﬁed (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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. on motor testing. Overall. The authors suggested that this might be due to a praxis impairment with difﬁculty in mapping movements as well as the representation of movements. Increased difﬁculty was noted during the conditions of sensory conﬂict. Memory and comprehension of gestures 2.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. On testing to assess gesturing. children with HFA had signiﬁcantly more errors on the body-part-for-tool than the group with AS. Although this may be related to praxis. not just difﬁculty with imitation. these authors suggested that it might also be related to altered neural substrates or language deﬁcits. children with ASD demonstrated signiﬁcantly 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). Unauthorized reproduction of this article is prohibited. Children with AD demonstrated an increased use of reactive postural control. 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). this might be attributed to motor planning or language impairments. children with ASD had signiﬁcantly higher rates of errors than children in the other groups. They demonstrated increased difﬁculty naming and imitating gestures. Children with HFA or language impairment demonstrated signiﬁcantly lower levels of gesture representation than children developing typically on a demonstration task. 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. (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-deﬁcit/ hyperactivity disorder (ADHD) (n = 27) ADHD and DCD (n = 38) TD (n = 78) Tests of: 1. as well as the lack of natural environment. The authors suggested that these ﬁndings are indicative of a praxis issue in children with ASD. The authors suggested that in the group with HFA. however. Children with AD had no difﬁculty understanding or recognizing motor gestures. muscle latencies and increased unloading time found in children with AD suggest a decreased use of anticipatory control seen in a group with TD. In the group with ASD. During a bimanual load lift task. children with ASD demonstrated signiﬁcantly higher errors on the Florida Apraxia Screening Test than the comparison group. as errors were still present when motor deﬁcits were accounted for. Difﬁculties may have also been exacerbated by the requirement to speak and gesture.
Adolescent aged children with AD demonstrated decreased stability when compared to preschool-aged children with TD. as children had increased postural stability in stressful conditions (removal of vision). A signiﬁcant negative correlation was found between TOMI-H scores and IQ. This can cause a decrease in shift of the center of mass to the stance limb. (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) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. Fifty percent of the children with AS and 66. Notably. rather than its own diagnostic classiﬁcation. On the basis of motor testing. children with AS and HFA have variability in motor activities. demonstrated by increased sway with removal of visual cues regardless of somatosensory input. Children with ASD demonstrated signiﬁcantly higher levels of mediolateral and anteroposterior sway.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 scored signiﬁcantly lower on the BOT than those with AS. Children in all 3 age-matched groups demonstrated motor activity impairments when tested on the BOT. The authors also suggested that while the BOT does test for motor impairments. Children with ASD tended to rely on visual input. The authors also noted a decreased displacement of the center of pressure toward the swing leg during gait in the group with ASD. children with AD had increased variability in performance and abnormal weight distribution with less use of the typical anteroposterior sway. 14 Downey and Rapport Pediatric Physical Therapy . the authors also found a “paradoxical” response to stressful situations. a pattern of impairment is not yet clear for individuals with ASD. as well as sway area.7% of the children with HFA demonstrated motor impairments when compared with a normative sample data for the TOMI-H. creating an increased need for postural control. The authors suggested that the lack of difference between the group scores provides support for AS being included in ASD diagnoses. children with ASD had less postural stability than the children developing typically with removal of visual cues and deviation of somatosensory cues. Children were tested in 4 balance positions. On the basis of the results. The authors suggested that children with ASD demonstrate postural instability. Unauthorized reproduction of this article is prohibited. A strong correlation between IQ scores and motor scores was found. than children with TD during quiet stance. Authors reported that these results in a previous study might have been due to additional visual stimuli. A “paradoxical stress response” was not found. No signiﬁcant differences were noted between the 2 groups. and no other signiﬁcant differences were noted between groups.
IQ. praxis performance was signiﬁcantly related to diagnosis. 97. although age predicted praxis and IQ did not. Individuals with AD appeared to use results from the prior trial to assist in movement planning for the current trial. when age. Children with ASD demonstrated signiﬁcantly poorer scores on the Florida Apraxia Screening Test and the PANESS. (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 (modiﬁed for children) PANESS Postural knowledge test (modiﬁed 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 AD (n = 9) Without AD (n = 9) Part 2: Calculation of reaction time and movement times based on a rapid aiming task adopted from earlier research Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. however. as tested by the MABC (deﬁned by <5th percentile). whereas basic motor skill did not. suggesting poorer basic motor skills as well as praxis. were present in 79. The children in the group diagnosed with ASD had signiﬁcantly poorer scores on the PANESS. No signiﬁcant difference was noted between children with HFA and AS on the postural knowledge test. and the Florida Apraxia Screening Test. postural knowledge and basic motor score predicted praxis score. When IQ was accounted for. The authors found that praxis performance was signiﬁcantly associated with ADOS score. dyspraxia may actually be independent of motor skills and may be a core symptom of ASD. the postural knowledge test. Unauthorized reproduction of this article is prohibited. When age and IQ were accounted for. Part 1: Individuals with AD demonstrated lower and signiﬁcantly more variable reaction times than those without AD. Pediatric Physical Therapy Motor Activity in Autism 15 .7% of children with typical IQ (>70). those with AD were able to use advanced visual cues to plan movements and decrease reaction time. and basic motor score were all accounted for. Similar to individuals without AD. Group scores were similar with children in both groups having deﬁnite motor impairments. The authors suggested that although individuals with ASD may have impaired basic motor skills. postural knowledge.2% of all children (9-10 years old) in the study. as compared with 69. suggesting that praxis may be a core symptom of ASD. Scores on praxis testing signiﬁcantly predicted scores on the ADOS. Part 2: Individuals with AD demonstrated lower reaction times and longer times to execute movement than those without AD.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.1% of the children with low IQ (<70) had deﬁnite motor problems. The group with AD also demonstrated signiﬁcantly longer times to execute movement.
the underlying cause may be different and further research is necessary to examine these causes. sex. They also demonstrated signiﬁcantly increased times to perform movements with signiﬁcantly decreased peak velocities and peak accelerations than the group without AD. 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. Individuals with HFA demonstrated signiﬁcantly slowed preparation times when compared with a cohort with TD. individuals in the group with AD demonstrated poorer motor ability than individuals without AD. 16 Downey and Rapport Pediatric Physical Therapy . Overall. sex. Part 1: Individuals with AD demonstrated slower reaction and movement times than the group developing typically.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. the authors did note a trend toward increased preparation time in the group with AD. The authors further suggested that although motor impairments may be present in both groups. The authors suggested that this might be due to a slowed visual responsiveness for spatial attention or inefﬁcient connections between hemispheres of the brain. They were able to use advance cues to plan movements and decrease reaction times. Unauthorized reproduction of this article is prohibited. IQ) (n = 12) Upper extremity kinematic task to measure movement preparation and movement time Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. This deﬁcit is more predominant in individuals with ASD. (continued) Nazzarali et al43 Comparison Part 1 AD (n = 12) Without AD (n = 12) Part 1: Variation of protocol from Glazebrook et al41 Part 2 AD (n = 12) Without AD (n = 12) 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. This was more difﬁcult when the task required a change in hands than a change in directions. IQ) (n = 12) AS (n = 12) TD (matched on age. IQ) (n = 12) AS (n = 12) TD (matched on age. They suggested that there is a true planning deﬁcit. sex. rather than a slowed movement. 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. while the group with HFA demonstrated a lack of anticipation in preparation. Part 2: Individuals with AD demonstrated increased difﬁculty reprogramming an already-planned movement. The group with AS demonstrated slower preparation movements. Although no signiﬁcant difference was found between individuals with AD and a cohort with TD. Verbal ability was correlated to reaction and movement times and nonverbal ability was correlated with reaction times.
On the basis of comparison with children who were developmentally matched. No difference was found between the group with ASD and the developmental age matched. which was found to be shorter in children with AD. Pediatric Physical Therapy Motor Activity in Autism 17 . as they were matched on the basis of motor scores. The group with AD demonstrated difﬁculty with gait trajectory based on an imposed goal. children with ASD tended to have difﬁculty with balance. or consequence prediction. (continued) Hughes47 Comparison AD (n = 36) Moderate learning disabilities (n = 24) TD (n = 28) Reach. they were able to stabilize in the frontal plane. children with AD demonstrated increased oscillations of the head. suggesting difﬁculties with motor planning. Unauthorized reproduction of this article is prohibited. and string and stride length). They also hypothesized that the differences may be due to sequencing. shoulder. Based on hand positioning during a reach-and-grasp task. and trunk causing less stable and more variable posture. and place task (Bar Game) with examiner report of hand positions Staples and Reid48 Comparison ASD (n = 25) TD. children with ASD appear to be delayed rather than disordered. as arm movements were noted to be awkward. as skills aligned with children with TD approximately half their age. and timed movement of the hands and feet. Children with ASD demonstrated signiﬁcantly lower scores on locomotor and object control scores than children who were chronologically age matched and mental age matched. age matched (n = 25) TD. suggesting that development is delayed rather than altered. In the group with ASD. Overall. cadence.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 signiﬁcant difference between the group with AD and the group with TD on gait parameters (stride duration. except for stride length. On the basis of analysis. Although children with AD demonstrated increased oscillations. locomotion pattern was not maintained in the group with AD. In general. vision. grasp. children with ASD had increased difﬁculty coordinating both sides of the body for a task. Gait parameters and stability appeared similar between groups. The group with ASD demonstrated signiﬁcant differences from the group with TD on all variables of the PANESS. velocity. gait. no differences were found on the PANESS between individuals diagnosed with HFA or AS. except for impersistence and patterned timed movements (a trend toward signiﬁcant was present). 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 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. the authors suggested that individuals with AD have increased difﬁculty with executing even simple goal-directed tasks when compared with children with moderate learning disabilities or children with TD. step length. The authors suggested that the pattern seen in older children with AD is similar to that seen in preschool-aged children with TD. movement skill performance matched (n = 22) TD. however.
The group with ASD demonstrated increased difﬁculty with dynamic balance and diadochokinesis. The authors suggested that these impairments might be a result of poor integration of motor. which the authors reported as being 42-44 times higher than the typical population. Based on motor testing. The children with AS trended toward poorer ball skills. Children developing typically had signiﬁcantly higher scores on the PANESS when compared with children with ASD. Trail Making. as well as scores on the timed movement section. Children with ASD demonstrated similar grip selection to age-matched children developing typically on a task that the authors used to test motor planning. (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 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. the authors suggested that individuals with AS may have a reliance on visual input and a proprioceptive deﬁcit. Assessment of Apraxia. balance (tandem and single leg). and level of withdrawal was also found. and ﬁnger-thumb apposition. were found to be predictive of handwriting scores. Grooved Pegboard. particularly for the sections examining gait and timed movements. The balance scores were poorer with eyes closed. handwriting abilities may improve as a result of increased control and ease of manipulation.APPENDIX Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Comparison Examination Toolsb Motor testing: Finger Tapping. An association between motor scores. There was a signiﬁcant difference between groups for manual dexterity skills. Finger-Thumb Apposition. children with ASD did not demonstrate difﬁculty aligning or sizing letters. however. but did not demonstrate signiﬁcantly poorer scores on tests of basic motor function than a cohort with TD. The authors suggested that when overall motor skills are addressed in children with ASD. On the basis of these results and the lack of dizziness usually found with a vestibular dysfunction. the core symptoms of ASD. 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. Handwriting scores were lower in the group with ASD. The authors hypothesized that the need for motor planning was not strong enough to elicit a difference in the children with ASD. Assessment of Ataxia. and executive function. The authors suggested that this trend may be due to type of preferred play or decreased interpersonal skills in children with AS. sensory. 85% of the children with AS and 88% of the children with learning disabilities qualiﬁed for the diagnosis of SDD-MF. Overall scores on the PANESS. 18 Downey and Rapport Pediatric Physical Therapy .
there was an overall trend (not signiﬁcant) toward poorer motor scores in the group with AD than the group that was intellectually delayed. The group with AD demonstrated signiﬁcantly higher balance scores than the group that was intellectually delayed. Children with ADHD also demonstrated signiﬁcantly poorer scores on measures than children with TD. Qualitatively. Children with ASD demonstrated signiﬁcantly poorer scores on locomotion. gross motor. running Pan et al59 Comparison ASD (n = 28) ADHD (n = 29) TD (n = 34) Test of Gross Motor Development– Second Edition. 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: ﬁne motor. or children with PDD-NOS and children atypically developing on gross and ﬁne motor scores. results still indicated that children with ASD have poorer scores. (continued) Matson et al56 Comparison Battelle Developmental Inventory. and cognitive age. Children with AD had signiﬁcantly poorer scores than children with TD for all sections except for oral motor and coordination tasks.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. standing long jump (adapted from the BOT). The authors suggested that based on GMDQ. When children in the group with ASD who demonstrated attention deﬁcits were omitted from analysis. suggesting that motor ability is not related to attention. calculation of the Gross Motor Development Quotient (GMDQ) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association. throwing. statistically signiﬁcant 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. Motor impairments were present in all groups. object control. which the authors suggested may be due to slowed movements seen in functional play. Children with AD did have signiﬁcantly lower ﬁne and gross motor scores than children who were developing atypically. On motor testing. and oral motor for global neuromotor impairment score. The authors suggested that low motor scores in children with AD might be related to level of cognitive impairment. The authors suggested that motor impairments in children with AD are apparent at an early age and they may beneﬁt from early intervention services. The group that was intellectually delayed demonstrated superior target throwing skills. Pediatric Physical Therapy Motor Activity in Autism 19 . There was no signiﬁcant difference found between children with AD and PDD-NOS (differences did approach signiﬁcance). balance. similar gross and ﬁne motor proﬁles were found. performance times 5 test items: dynamic balance. rather than diagnosis alone. Unauthorized reproduction of this article is prohibited. gender. catching. coordination. and GMDQ than children with ADHD and children with TD. differences might be secondary to limited social skills.
On the basis of overall clinical picture. and girls with ADHD had lower overall scores than those with ASD. 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. girls with ASD and ADHD scored signiﬁcantly lower than girls with TD. and these tests were not included in the descriptions of each study in the table. In school-aged girls. Cailler-Asuza Scale (children below 4 years). low IQ. See speciﬁc studies for more details on tests used. a Articles are listed in the same order in which they appear in the article. 25% of those with ASD and 32% of those with ADHD were diagnosed with DCD. On the EB-test. 20 Downey and Rapport Pediatric Physical Therapy . b Tests related to motor and imitation skills were reported in the table. the authors suggested that younger age. High rates of DCD were found in the group with ASD and ADHD. In the preschool-aged girls. MABC. and autistic symptoms are predictors for lower motor scores. for diagnostic purposes. Unauthorized reproduction of this article is prohibited.APPENDIX Brief Summary of Each Article Revieweda (Continued) Study Design/ Methodology Comparison Examination Toolsb EB-test (used for children older than 6 years). Studies may have used other testing (such as the ADOS). 80% of girls with ASD were diagnosed with DCD. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association.