Research in Autism Spectrum Disorders 23 (2016) 179–187

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Research in Autism Spectrum Disorders

journal homepage: http://ees.elsevier.com/RASD/default.asp

Gross motor skills are related to postural stability and age in

children with autism spectrum disorder
Melissa A. Machea,* , Teri A. Toddb
a
Department of Kinesiology, California State University, Chico, 400 West 1st Street, Chico, CA 95929-0330, USA
b
Department of Kinesiology, California State University, Northridge, 18111 Nordhoff Street, Northridge, CA 91330, USA

A R T I C L E I N F O A B S T R A C T

Article history: Motor skill and postural stability deficits are commonly reported for children with autism
Received 4 October 2015 spectrum disorder (ASD), however the relationship between these variables is not well
Received in revised form 9 December 2015 established. We explored the relationship between motor skills, postural stability,
Accepted 2 January 2016
restricted and repetitive patterns of behavior, diagnosis, age, and sex. Children (11 with
Available online 11 January 2016
and 11 without ASD), 5–12 years of age, participated in the study. The Test of Gross Motor
Development-3 (TGMD-3) was used to assess fundamental motor skills. Postural sway was
Keywords:
measured on a force plate during quiet standing on a solid and compliant surface. Center of
Autism spectrum disorder (ASD)
Motor skills
pressure was calculated and used to compute sway area. Linear regression analysis showed
Postural control that sway area on a solid surface, age, and diagnosis were significant predictors of motor
Repetitive behaviors skill performance (R2 = .854). Severity of ASD, as assessed by the Repetitive Behavior Scale-
Balance Revised (RBS-R), was not predictive of motor skills. Children with ASD exhibited deficits in
Stability postural stability compared to children without ASD. Postural stability appears to influence
the ability of children to perform gross motor skills. However, the RBS-R does not seem to
be a useful tool for identifying those children with ASD who exhibit the greatest deficits in
motor skills.
ã 2016 Elsevier Ltd. All rights reserved.

1. Introduction

Autism spectrum disorder (ASD) is one of the most prevalent developmental disabilities in North America. The core
characteristics of ASD are deficits in social communication and restricted and repetitive patterns of behavior (American
Psychiatric Association [APA], 2013). In addition, children with ASD have been documented to exhibit motor skills which lag
behind those of their peers without ASD (Berkeley, Zittel, Pitney, & Nichols, 2001; Green et al., 2009; Staples & Reid, 2010).
Deficits in motor skills may prevent children and adolescents with ASD from engaging in play during recess, and leisure time,
and eventually adopting an active lifestyle as they mature. Indeed physical activity levels of children with ASD have been
found to be lower than the level of age-matched peers without disability (MacDonald, Esposito, & Ulrich, 2011). There is
increasing concern in the research community that sedentary lifestyles will negatively impact long-term health and
wellness among the growing population of individuals with ASD (Must et al., 2014).
In order to promote the health and wellness of individuals with ASD researchers have attempted to describe and
understand the commonly observed poor motor skill performance among these individuals. Over the past decade
researchers have studied the motor performance of individuals with ASD and found deficits in several areas of function

* Corresponding author at: Department of Kinesiology, California State University, Chico, Yolo 243, Chico, CA 95929-0330, USA. Fax: +1 530 898 4932.
E-mail addresses: mmache@csuchico.edu (M.A. Mache), teri.todd@csun.edu (T.A. Todd).

http://dx.doi.org/10.1016/j.rasd.2016.01.001
1750-9467/ã 2016 Elsevier Ltd. All rights reserved.
180 M.A. Mache, T.A. Todd / Research in Autism Spectrum Disorders 23 (2016) 179–187

including impairments in motor anticipation, dyspraxia, and postural control (Fournier et al., 2010; Schmitz, Martineau,
Barthelemey, & Assaiante, 2003). Though IQ has been linked to the severity of motor deficits for children with intellectual
disability, motor impairments are found in persons with ASD both with and without comorbid intellection disability (Green
et al., 2009). Thus, there is a general consensus in the literature that ASD is associated with specific motor impairments that
are not entirely due to intellectual function (Travers, Powell, Klinger, & Klinger, 2013).
Deficits in a wide array of motor function including gait, postural stability (i.e., balance), manual dexterity, object control,
and locomotor skills have been reported (Ghaziuddin and Butler, 1998; Staples & Reid, 2010). Postural stability, the ability to
maintain one's center of gravity within a given base of support, is a fundamental and early developing motor skill which
allows a person to maintain upright stance (Shumway-Cook & Horak, 1986). This skill is a prerequisite for the performance of
many motor tasks such as riding a bicycle, sitting on a swing, or throwing a baseball (Flatters et al., 2014). Recent studies
suggest that postural stability, as measured by postural sway area, sway path length, or sway velocity, is less developed in
children with ASD when compared to their peers without ASD (Fournier et al., 2010; Graham et al., 2015; Minshew, Sung,
Jones, & Furman, 2004; Molloy, Dietrich, & Bhattacharya, 2003; Travers, Powell, Klinger, & Klinger, 2013). Though a variety of
instruments (e.g., force plate, Neurocom Balance Masterã, Wii Balance Board, etc.) and variables have been used to assess
postural stability this does not seem to influence the observed differences between children with and without ASD reported
in the literature (Graham et al., 2015; Minshew et al., 2004; Radonovich, Fournier, & Hass, 2013; Stins, Emck, de Vries, Doop, &
Beek, 2015; Travers et. al., 2013). Minshew and colleagues evaluated postural stability in 79 individuals with and 61
individuals without ASD between the ages of 5 and 52 years. The results of this cross sectional study indicated that there was
a delay in the development of postural stability for individuals with ASD. Additionally, typical adult levels of postural
stability where not achieved among the adults with ASD in this cohort (Minshew et al., 2004). It is important to note that
participants in this study did not have an intellectual disability thus the observed impairments in postural stability were
linked with ASD. The authors hypothesized that impaired postural stability is one of the manifestations of the neural
abnormalities which cause problems with sensory integration and general neural circuitry among individuals with ASD.
In an effort to understand the nature of these observed deficits, and the role of the visual, vestibular, and somatosensory
systems, in the maintenance of postural stability, researchers can measure postural stability under a variety of conditions.
For example, researchers often assess postural sway while asking individuals to stand on two feet with eyes open and closed,
or stand on a firm and compliant surface. Several researchers have found that when balance tasks are simple, for example
standing on two feet with eyes open on a firm surface there is little difference between individuals with and without ASD.
However, as task difficulty increases individuals with ASD tend to show greater postural instability when compared with
their typically developing peers (Graham et al., 2015; Stins et al., 2015; Travers et al., 2013). For example, when sensory input
is altered by having an individual close their eyes or the size of their base of support is reduced, greater decreases in postural
stability are observed for those with ASD when compared to individuals without ASD. As many motor and sports skills are
performed under conditions that require limited vision or single leg weight bearing it is possible that these difficulties may
hamper the development of proficient motor skills in children with ASD.
Not only have deficits in motor skills been observed among children with ASD, but these deficits have also been related to
the characteristic deficits in social communication in this population of individuals. MacDonald and colleagues described an
association between fine and gross motor skills and severity of social communication deficits (MacDonald, Lord, & Ulrich,
2014). If this direct relationship between motor skills and social communication deficits holds true in the general population
of individuals with ASD it could be used as a simple tool for identifying those individuals who could most benefit from a
motor skill intervention. Similarly, if a relationship between motor skill deficits and restricted and repetitive patterns of
behavior is established this could also be used as a tool for efficiently and effectively identifying those individuals with the
greatest need for a motor skill intervention. However, to date the relationship between motor skills, postural stability, and
restricted and repetitive patterns of behavior remains unclear.
The Diagnostic and Statistical Manual of Mental Disorders [DSM-5] states that restricted and repetitive behaviors must be
manifested in at least two of the following ways in order to meet the diagnostic criteria for ASD: (1) stereotyped or repetitive
motor movements, use of objects, or speech, (2) insistence on sameness, inflexible adherence to routines, or ritualized
patterns or verbal or nonverbal behavior, (3) highly restricted, fixated interests that are abnormal in intensity or focus, or (4)
hyper- or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment (APA, 2013). The
pathology underlying the presence of these particular behaviors is not certain, and in fact could vary by the type of restricted
or repetitive behavior. However, it has been hypothesized that dysfunction in the basal ganglia, cerebellum, and associated
circuitry may play a role in the appearance of restricted or repetitive patterns of behavior (Lewis & Kim, 2009). Importantly,
these areas of the brain are also significant in motor control (Lopez, Lincoln, Ozonoff, & Lai, 2005), thus it is possible that
there is an association between motor control and restricted and repetitive behaviors (Radonovich et. al., 2013). Radonovich
et al. (2013) recently found that restricted and repetitive behaviors and postural stability were related in a group of 18
children 3–16 years of age with ASD, however the association between motor skills and restricted and repetitive behaviors
was not explored.
Though deficits in motor skills and postural stability have been reported among children with ASD at present it is not
known how these deficits are related to one another. In order to develop effective interventions for the improvement of
balance and motor skills among children with ASD it is imperative that we understand the factors that may influence these
deficits. Therefore the purpose of this study was to examine the relationship between gross motor skills, postural stability,
and restricted and repetitive behaviors in children with and without ASD. Specifically we sought to examine whether or not
 M.A. Mache, T.A. Todd / Research in Autism Spectrum Disorders 23 (2016) 179–187 181

the level of motor skill development, as assessed using the Test of Gross Motor Development-3rd Edition (TGMD-3) (Ulrich,
in press), was associated with the diagnosis of the child, postural sway area, and the Repetitive Behaviors Scale – Revised
(RBS-R) (Lam & Aman, 2007) overall intensity score. We hypothesized that a lower TGMD-3 score (i.e., poor motor skills)
would be associated with a greater postural sway area with eyes open on a solid and compliant surface, a greater overall
intensity score on the RBS-R, a diagnosis of ASD, and younger age. In addition, it was believed that children with ASD would
exhibit lower locomotor and object control scores on the TGMD-3 and greater postural sway area when compared to children
without ASD.

2. Methods

2.1. Participants

Elementary school aged children with and without ASD between the ages of 5 and 12 years were recruited through local
autism agencies, universities, and schools to participate in the present study. Study inclusion criteria for children with ASD
included a clinical diagnosis of ASD determined by a licensed professional (i.e., a psychologist or physician) using the Autism
Diagnostic Observation Schedule and DSM IV TR or DSM V criteria (APA, 2004; APA, 2013). Exclusion criteria for all children
included neurological disorder (e.g., seizures, tumors, traumatic brain injury, stroke, or lesions), presence of a chronic
medical disorder, visual impairment, gross sensory deficits, use of physical assistive devices, or significant physical
impairments that would prevent a child from fully participating in the study or cause significant impairments in balance. In
addition, children who were unable to follow the testing protocol, which required standing in a designated area for 20 s
without voluntary movement, were excluded from the study. Twenty-two children, eleven with and eleven without ASD,
met the inclusion criteria and participated in the present study (Table 1). All study procedures were approved by the
University Institutional Review Board. A parent or guardian of the child provided written informed consent and all children
provided verbal assent prior to participation in the study activities.

2.2. Measurements

The Test of Gross Motor Development-3rd Edition (TGMD-3) (Ulrich, in press) was used to assess gross motor skills. The
TGMD-3 is comprised of 6 locomotor skills and 7 object control skills. Locomotor skills include run, horizontal jump, gallop,
slide, skip, and hop. Object control skills include an overhand throw, underhand throw, two-hand catch, two-hand strike,
one-hand strike, dribble, and kick. The TGMD-3 breaks down each skill into 3 to 5 criteria. If a criteria is met the child receives
a 1, if the criteria is not met a 0 is recorded. Each skill is performed and scored twice. Scores for locomotor and object control
skills are obtained by adding the score from each skill in the respective subsection, an overall score is obtained by summing
the scores of the two subsection. Total TGMD-3 scores can range from 0 to 100 (i.e., the locomotor subset range is 0–46; the
object control subset range is 0–54). It should be noted that the TGMD-3 is currently in the process of being validated,
however, the TGMD-2 (i.e., the previous version of this instrument) was found to be a valid and reliable measure of motor
skills (Ulrich, 2000) and there are minimal changes to the current revision of this instrument. Changes include deletion of the
leap and underhand roll and addition of a one-hand strike with a racquet. In addition, the reliability of the two researchers
responsible for scoring the TGMD-3 in the present study was previously established at 85% with the test developer.
Postural sway was assessed by sampling ground reaction force (GRF) data at 60 Hz using a single force plate. GRF data
were sampled under two conditions in which the participants’ eyes were open: (1) with the participant standing on a solid
surface and (2) with the participant standing on a compliant surface (i.e., a foam pad). Quiet standing trials were 20 s in
duration similar to the methods of Radonovich et al. (2013) and Graham et al. (2015). The 20 s data collection began when the
participant was standing quietly and looking straight ahead. Six quiet standing trials were performed; three trials on the
solid surface and three trials on the compliant surface. The participants stepped off the force plate between trials and were
allowed to adopt a natural stance for each trial. The compliant surface was placed directly over the force plate and the force
plate was zeroed. In addition, the height of the compliant surface was accounted for in the computation of the COP data.
The presence and severity of repetitive behaviors and restricted interests were assessed using the RBS-R (Lam & Aman,
2007). The RBS-R is a 43 item questionnaire which is divided into five subscales according to the revised scoring formula. The
subscales are (a) ritualistic behavior/sameness, (b) self-injurious behavior, (c) stereotypic behavior, (d) compulsive behavior,
and (e) restricted interests. Statements under each section are rated on a scale from 0 to 3 with 0 indicating the behavior does
not occur and 3 indicating that the behavior occurs and is a severe problem for the child. The scale had been validated as a

Table 1
Participant group characteristics.

ASD Group Without ASD Group

Sex (boy:girl) 10:1 9:2
Mean age (months) (Mean
SD) 113.5
30.0 112.2
28.9
Age range (months) 60–152 63–142
182 M.A. Mache, T.A. Todd / Research in Autism Spectrum Disorders 23 (2016) 179–187

measure of repetitive behaviors in individuals with ASD (Esbensen, Seltzer, Lam, & Bodfish, 2009; Mirenda et al., 2010). The
RBS-R is intended to be completed by a parent or guardian of the child with direct knowledge of the child’s typical behavior.
The RBS-R provides two separate scores for each subscale and an overall score. One score is the intensity score, a sum of the
ratings for each item, while the other score is a frequency score that is a sum of the number of items endorsed. Lam and Aman
(2007) reported that the questionnaire has high internal consistency and good interrater reliability particularly with
individuals with mild to moderate autism.

2.3. Procedures

Children were in a quiet laboratory space with minimal distractions. After obtaining parental consent and child assent the
TGMD-3 was administered. Cones and tape were used to indicate start and stop points and appropriate paths for the various
motor skills. In addition to providing the child with verbal instructions for each motor skill, all skills were demonstrated to
the participant by the primary researcher as per the TGMD-3 protocol. Following the instructions and demonstration the
child performed two trials of the given skill. All TGMD-3 assessments were videoed and scored using the TGMD-3 guidelines
at a later time.
Following the TGMD-3 assessment postural sway was assessed through the completion of a series of quiet standing trials
on a force plate. Children were asked to stand quietly on the force plate with their hands at their side while looking straight
ahead at a happy face mounted at eye level approximately five meters in front of the participant. During the solid surface
trials the child stood directly on the force plate. During the compliant surface trials the child stood on a commercially
available three inch thick foam pad. Trials during which a child became distracted and moved voluntarily, for instance when
arm movements occurred, were repeated or dropped from the analysis.
While the child completed the TGMD-3 and postural sway testing the parent or guardian completed the RBS-R for the
child. Researchers were able to answer questions and provide clarification to the parent or guardian as needed as they
completed the RBS-R.

2.4. Data analysis

For the purpose of the present data analysis the locomotor and object control subset scores were summed to compute the
TGMD-3 total score. The GRF data from the force plate were used to compute center of pressure (COP) data for the postural
sway analysis. Postural sway area was computed for each quiet standing trial by calculating the area of a rectangle. The sides
of the rectangle were determined by finding the maximum range of COP movement in the antero-posterior and medio-
lateral directions, respectively. Sway area values were then averaged across trials of the same type. The intensity score for
each subset of the RBS-R was computed. The subset intensity scores were then summed and the overall intensity score was
used for the purpose of analysis in the present study.

2.5. Statistical analysis

Multiple linear regression was used to examine whether or not postural sway, restricted and repetitive behaviors,
diagnosis, age, and sex were associated with gross motor skills. Effects of condition on postural sway, as a function of
diagnosis, were examined using repeated measures analysis of variance (ANOVA). A condition (solid vs. compliant surface)
by diagnosis (ASD vs. without ASD) analysis was employed. Condition was a within-subject factor and diagnosis was a
between-subject factor. t-tests were used to examine group differences in the locomotor and object control scores on the
TGMD-3. The alpha level for all statistical analyses was set at 0.05. Descriptive data (Mean + SD) were calculated for TGMD-
3 scores, RBS-R overall intensity scores, and age for both children with and without ASD. All statistical analyses were
conducted in SPSS 22.0 (SPSS, Chicago, IL, USA).

Table 2
Standardized partial regression coefficients (b) and associated P values obtained from multiple
linear regression analysis.

b P value
Sex 0.149 0.165
Diagnosis 0.486 0.012a
Age 0.488 0.000a
RBS-R overall intensity score 0.014 0.934
Solid surface sway area 0.391 0.023a
Compliant surface sway area 0.061 0.717
a
Partial regression coefficient is significant at P < 0.05.
 M.A. Mache, T.A. Todd / Research in Autism Spectrum Disorders 23 (2016) 179–187 183

3. Results

The regression model results indicated that the TGMD-3 total score was significantly associated with postural sway area
in the solid surface condition, the diagnosis of the child, and the age of the child (F(5,16) = 18.638, P < 0.000, R2 = 0.854,
Adjusted R2 = 0.808) (Table 2). Specifically, a lower TGMD-3 total score was associated with a greater postural sway area, a
diagnosis of ASD, and a younger age of the child. TGMD-3 total scores were not associated with postural sway area in the
compliant surface condition, the RBS-R overall intensity score, or the sex of the child (Table 2).
Results of the ANOVA revealed main effects of both condition and group for the postural sway measures (Table 3). That is,
all children had significantly greater postural sway in the compliant condition when compared to the solid surface condition
(F(1,1) = 9.319, P = 0.006, h2 = 0.318). Additionally, children with ASD had significantly greater sway area than children
without ASD across conditions (F(1,1) = 4.538, P = 0.046, h2 = 0.185). Representative postural sway traces have been included
for a child with and without ASD in the both the solid and compliant surface conditions (Fig. 1).
Means and standard deviations for TGMD-3 locomotor, object control, and total scores are presented in Fig. 2. Children
with ASD scored significantly lower on the locomotor (t(20) = 3.92, P = 0.0008; d = 1.67) and object control subscales than
children without ASD (t(20) = 2.58, P = 0.018; d = 1.10). Not only were the differences between children with and without ASD
in locomotor and object control scores statistically significant but the effect sizes associated with these differences were
large. In addition, the regression analysis indicated differences existed between children with and without ASD for the
TGMD-3 total score (Table 2). That is, children with ASD scored lower than children without ASD on the TGMD-3.
Means and standard deviations for the RBS-R overall intensity scores are presented in Table 3. Statistical comparisons
were not made between children with and without ASD for this variable; however, there were large absolute differences
between children with and without ASD for the RBS-R overall intensity score.

4. Discussion

The majority of children with ASD display poor motor skills when compared to their typically developing peers. Though
recent research has shed light on the possible causes of the observed deficits in motor skill development, there has been little
research examining the relationship between factors that may influence motor skills, such as postural stability. This study
was designed to examine the relationship between motor skill performance and postural stability, as well as restricted and
repetitive patterns of behavior in children with and without ASD. Multiple linear regression analysis was used to examine if
postural sway area, the intensity of restricted and repetitive behaviors, a diagnosis of ASD, sex, or age were associated with
motor skill performance as measured by the TGMD-3. Our results indicate that motor skill performance was influenced by
postural sway area while standing on a solid surface, the diagnosis of ASD, and the age of the child. Postural sway area on a
compliant surface, intensity of restricted and repetitive behaviors, and sex were not predictors of motor skill performance.
Similar to previous studies we also observed greater postural sway area in the compliant surface condition when compared
to the solid surface condition and children with ASD exhibited greater sway area when compared to children without ASD.

4.1. Motor skills and ASD

It has been well established that children with ASD display poor motor skills when compared to same age peers without
ASD (Staples & Reid, 2010; MacDonald et al., 2014). Similar results were found in this study when the TGMD-3 was used to
assess gross motor skills, as a diagnosis of ASD was associated with lower TGMD-3 total scores, locomotor scores, and object
control scores. It should be pointed out that children with ASD scored an average of 28.6 points lower than their peers
without ASD on the TGMD-3 total score. As previously described the TGMD-3 total score is calculated by adding the scores of
the locomotor and object control subtests of the test. The large statistical differences in scores between children with and
without ASD for both the locomotor and object control subtests indicates that children with ASD lag behind their peers in a
vast array of motor skills.
A large percentage of children with ASD also have an intellectual disability (Charman et al., 2011), and it is accepted that
children with an intellectual disability score lower on tests of motor skills than age matched peers without an intellectual
disability (Westendorp, Houwen, Hartman, & Visscher, 2011). Though we did not obtain IQ scores for the children who
participated in this study all children were able to follow the given directions and complete the assessments without

Table 3
Postural sway area and restricted and repetitive behaviors (Mean
SD).

ASD Group Without ASD Group

RBS-R (overall intensity score) 32.9
20.1 1.5
1.9
Sway area solid surface (cm2) 31.6
34.1a,b 14.3
10.8a
Sway area compliant surface (m2) 49.9
39.3b 22.1
6.45

Note: The RBS-R scores were not statistically compared.

a
P = 0.006 vs. Sway Area Compliant Surface.
b
P = 0.041 vs. Without ASD Group.
184 M.A. Mache, T.A. Todd / Research in Autism Spectrum Disorders 23 (2016) 179–187

Fig. 1. Representative postural sway traces for a 7 year old boy with (A) and without ASD (B) in the solid (1) and compliant (2) surface condition.

assistance or visual cues which is a strong indication that only children with no or mild intellectual disability participated in
this study. It should also be noted that motor skills of children with ASD without an intellectual disability lag behind same
age peers without ASD (Staples & Reid, 2010). That being said, it is important to address postural stability and fundamental
motor skills in all children with ASD, not just those with intellectual disabilities. If children with ASD without intellectual
disability exhibit deficits in motor skills and balance then it would follow that the deficits are not solely associated with IQ
but may be related to other neurological issues associated with ASD.

Fig. 2. Means and standard errors for Test of Gross Motor Development-3rd Edition for locomotor, object control, and total scores for children with and
without ASD.
*P < 0.001 vs. Without ASD Group
y P < 0.05 vs. Without ASD Group
 M.A. Mache, T.A. Todd / Research in Autism Spectrum Disorders 23 (2016) 179–187 185

Though standardized scores for the TGMD-3 are not presently available, as data is still being collected to develop these
scores, age was a predictor of the TGMD-3 total score. Thus, despite the fact that children with ASD tend to exhibit motor
skills that lag behind those of their peers without ASD, children with ASD still appear to experience developmental
improvements in gross motor skills. This is a particularly important finding as it is indicative of the fact that motor skills are
potentially modifiable among children with ASD.

4.2. Motor skills, postural stability, and ASD

Postural stability is believed to be a prerequisite for the development of mature patterns of gross motor skill performance.
Observational data indicate that postural stability typically increases throughout childhood before reaching mature levels
around 16 years of age (Stiendl, Kunz, Schrott-Fischer, & Scholtz, 2006). This maturation of postural stability in children is
usually associated with a child's ability to master increasingly complex motor skills. For example, early one arm throwing
patterns consist primarily of upper limb actions, as a child matures the throwing pattern becomes more complex and
includes lower body actions such as a step with the contralateral foot and hip rotation. When the child begins to incorporate
lower body actions in the throwing motion postural control is challenged and postural stability becomes a more important
component of successfully completing the skill. In the present study, postural sway area when standing on a solid surface
with eyes open was associated with TGMD-3 scores, specifically a smaller sway area was associated with a higher TGMD-
3 total score.
There have been inconsistent findings when comparing balance during quiet standing with eyes open on a solid surface in
children with and without ASD. Several researchers have found less postural stability during conditions of normal vision on a
solid surface among children with ASD when compared to children without ASD (Chang, Wade, Stoffregen, Hsu, & Pan, 2010;
Memari, Ghanouni, Shayestehfar, & Ghaheri, 2014; Minshew et al., 2004), while others have found patterns of sway to be
comparable among children with and without ASD under similar conditions (Graham et al., 2015; Molloy et al., 2003; Stins
et al., 2015). In the present study children with ASD displayed significantly greater amounts of postural sway while standing
on a solid surface than children without ASD. The present population of children was slightly younger than the groups in
many of the other studies that we have cited, which may help explain the large differences observed for postural sway
between children with and without ASD in both the solid and compliant surface conditions. Minshew et al. (2004) found that
postural stability does not appear to begin to mature until after the age of 12 in individuals with ASD, therefore the postural
stability of the participants with ASD in this study, who ranged from 5 to 11 years of age, may not have begun to mature yet.
In the present study postural sway was measured during two conditions, quiet standing on a solid surface and quiet
standing on a compliant surface. The amount of postural sway was greater for children with ASD during both conditions, and
increased for all children during the trials on a compliant surface when compared to the solid surface. Recent studies that
have examined postural sway under multiple conditions have found a similar pattern; even if sway was similar between
children with and without ASD under simple conditions (i.e., eyes open on a solid surface), when task difficulty increased
children with ASD exhibited increased sway compared to those without ASD (Graham et al., 2015; Travers et al., 2013). For
example, when postural stability is assessed with eyes closed compared to eyes open, single leg stance compared to double
leg stance, and as in our case compliant surface compared to solid surface (Minshew et al., 2004; Molloy et al., 2003) the
difference in performance between children with and without ASD increases. In the present study this same phenomenon
was not observed. That is, postural sway area for children with ASD was 2.26 times greater in the compliant surface condition
when compared to the solid surface condition. Similarly, children without ASD exhibited a sway area 2.21 times greater in the
compliant surface condition compared to the solid surface condition. Though a diagnosis of ASD did not influence the
response to the compliant condition it is important to note that because children with ASD had greater sway than children
without ASD in the solid surface condition, they began at a postural stability deficit when compared to children without ASD
when task difficulty was increased. That is, the 226% increase in sway area for children with ASD meant that their sway area
increased to 49.9 cm2 whereas the 221% increase for children without ASD meant that their sway area was still only 22.1 cm2.
Though both groups of children exhibited similar responses (i.e., similar percent increases in sway area) to modified sensory
input, the absolute size of the sway area may be more relevant when considering the implications that these deficits may
have on a child's ability to perform complex motor skills. A sway area of 22.1 cm2 may not impede the execution of motor
skills to the extent of a sway area of 49.9 cm2.
If we wish to develop interventions that can help individuals with ASD learn to perform complex motor skills more
effectively we must identify the reasons balance deficits in children with ASD tend to become more severe when the balance
system is challenged. We know that the balance system depends on the integration of input from visual, vestibular, and
proprioceptors to maintain upright posture.
Previous research has suggested that children with ASD have a greater reliance on visual input to maintain balance than
children without ASD (Molloy et al., 2003; Travers et al., 2013; Stins et al., 2015). The fact that we did not challenge or modify
the visual information allowed us to better understand the response of children with ASD when proprioceptive information
is modified. It is possible that children with ASD do not integrate or rely on proprioceptive information when visual
information is available, thus when the proprioceptive information was modified they continued to use primarily visual
information to maintain postural stability resulting in greater postural sway. This would also help to explain why children
with and without ASD exhibited similar responses to the modified proprioceptive input. That is, the sway area for children
without ASD increased by a similar amount as it did for children with ASD when proprioceptive input was modified, however
186 M.A. Mache, T.A. Todd / Research in Autism Spectrum Disorders 23 (2016) 179–187

the absolute size of the sway area was more than double for children with ASD than it was for children without ASD. Children
with ASD may have still been relying on visual information and that visual information could not account for the increased
task difficulty presented by the compliant surface. Whereas children without ASD could still maintain a relatively small sway
area because they were able to effectively integrate all of the available sensory information to maintain postural stability.
This could have implications for activities of daily living and the performance of motor skills during physical activities. For
example, walking on a sidewalk or well-lit indoor hallway may be relatively simple for a child with ASD, but if the hallway
becomes busy and the child is attempting to look for room numbers, the challenges presented to the visual system under
such circumstances may compromise the child’s ability to maintain postural stability. It is possible, that any challenges
presented to the visual, vestibular, or proprioceptive system could inhibit the development and mature performance of
complex motor skills.

4.3. Restricted and repetitive patterns of behaviors

Not surprisingly parents in the present study reported a significantly greater intensity of restricted and repetitive
behaviors for children with ASD than they did for children without ASD. The practical significance of the difference in RBS-R
scores between children with and without ASD was expected. However, despite the apparently large differences in average
intensity scores on the RBS-R between children with (32.9
20.1) and without ASD (1.5
1.9) this variable was not predictive
of TGMD-3 total scores. The fact that RBS-R scores were not a significant predictor of TGMD-3 scores was not completely
unexpected when considered in light of other recent findings. For example, Graham and colleagues used a linear regression
model to investigate the relationship between balance and three core diagnostic features of ASD, including restricted and
repetitive patterns of behavior as measured by the RBS-R, (Graham et al., 2015). The regression model, which accounted for
age in addition to RBS-R scores did not show a significant association between RBS-R scores and balance control. As sufficient
postural stability is considered a crucial component in the acquisition of mature patterns of motor skills one could
hypothesize that a lack of relationship between RBS-R scores and postural control would also be associated with a lack of
relationship between RBS-R scores and motor skill scores, as was the case in the present study. This indicates that RBS-R
scores may not be an effective means of identifying those individuals with ASD that could most benefit from balance or
motor skills training. Based on the present results, it would appear that a simple test of balance may be a better tool for the
identification of individuals who could profit from a motor skills intervention.
The relationship between ASD severity, motor skills, and postural stability remains unclear given the present findings and
those of previous authors, Papadopoulos et al. (2011) found that ASD severity was not associated with all aspects of motor
skill performance, specifically ball skills. However, ASD severity was associated with measures of dynamic balance in this
same population of children with ASD. Similarly, Travers et al. (2013) found a direct relationship between RBS-R total scores
and postural waver (i.e., the standard deviation of pressure changes over time) and postural drift (i.e., the slope of the
pressure change over time). Radonovich et al. (2013) reported a similar relationship between ASD severity and postural
stability. Though we did not directly assess the relationship between ASD severity, as measured by RBS-R total score, postural
sway area in the solid surface condition was twice as large for children with ASD than for children without ASD, and more
than twice as large in the compliant condition. Given that the children with ASD in the present study scored higher than their
peers on the RBS-R provides further evidence that a diagnosis of ASD may influence postural stability.

4.4. Limitations

The present results should be interpreted in light of the limitations of the study. One limitation to the present work is the
relatively small sample size used to complete the multiple regression analysis. While the use of a small sample size may
make the present results more sample-specific, and the significance of the predictor variables less stable, we believe when
interpreted in light of previous findings the present results still offer valuable insight on the deficits in balance and motor
skills exhibited by children with ASD. Another possible limitation of the present study is that our sample of children with ASD
may not be representative of individuals with ASD as a population. That is, in order to participate in the present study
children needed to have the ability to follow directions and attempt to complete the tasks required of them. That being said,
we were still able to observe differences between children with and without ASD in all relevant measures, providing further
evidence that these differences do in fact exist. Furthermore, IQ was not assessed in this study however all children who
completed the study were able to follow the directions; this inclusion criteria likely eliminated some children with
potentially lower IQ scores than those who participated.
Another possible limitation of this study is the fact that only proprioceptive information was manipulated in the present
study. That is we did not modify visual input alone, or present children with combined modifications of visual and
proprioceptive information to develop a more complete understanding of the nature of postural stability deficits. Modifying
additional sensory input will likely improve our understanding of the nature of these deficits; however, it may also change
the population of individuals who are able to participate in such a study. That is, not all individuals with ASD will be
comfortable, or possibly understand, the concept of standing with their eyes closed. In light of this limitation we still believe
the modification of proprioceptive input in the present study yields valuable information related to the nature of the
observed postural stability deficits among children with ASD.
 M.A. Mache, T.A. Todd / Research in Autism Spectrum Disorders 23 (2016) 179–187 187

5. Conclusions

In the present study postural sway area under normal conditions was indicative of gross motor skills among children with
and without ASD. That is, individuals with less postural sway area when standing on a solid surface scored higher on the
TGMD-3. These results indicate that individuals with ASD may lack sufficient postural control to execute complex motor
skills. In order to address deficits in motor skills it may be necessary to first develop a more complete understanding of the
nature of the observed deficits in postural stability. Researchers should continue to work to tease out the nature of these
deficits in postural stability and gross motor skills among children with ASD, in order to develop effective intervention
strategies.

Acknowledgements

This work was partially supported by a grant from the Office of Research and Sponsored Programs at California State
University, Chico.

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