R E V I E W 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.
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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 by the Centers for Disease Control and Prevention4 indi-

Autism spectrum disorder (ASD) is a neurodevelop-
mental disorder that is characterized by limitations in so-
cial 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 de-
velopmental history and clinical observations of behavior
(see Table 1 for definitions).2,3 Recent research supported
0898-5669/110/2401-0002
Pediatric Physical Therapy
Copyright C 2012 Wolters Kluwer Health | Lippincott Williams &
Wilkins and Section on Pediatrics of the American Physical Therapy
Association
Correspondence: Mary Jane K. Rapport, PT, DPT, PhD, Physical Ther-
apy Program, School of Medicine, University of Colorado, 13121 E 17th
Avenue, C244, Aurora, CO 80045 (maryjane.rapport@ucdenver.edu).
Grant Support: This study was funded by Leadership Education in Neu-
rodevelopmental and Related Disorders Training (LEND), Health Re-
sources 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
cates 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 inter-
vention 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 par-
ticipate in daily activities and routines. These deficits in
motor activity inform physical therapists’ clinical decision
making.
The purposes of this review were to summarize cur-
rent 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

2 Downey and Rapport Pediatric Physical Therapy

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 TABLE 1
Definitions and Abbreviations of Developmental Disorders Identified in the Literature and Associated With Autism

Classification Definition

Autism spectrum disorder
(ASD)1
Pervasive developmental
disorder (PDD)a
Autism disordera
Asperger syndromea,b
Pervasive developmental
disorder—not otherwise
specified (PDD-NOS)a,b
ASD is a neurodevelopmental disorder that is characterized by limitations in social interactions and
communication, restricted interest, and stereotyped or repetitive behaviors. There is a continuum of
behaviors represented within the ASD diagnosis
The PDD diagnosis includes impaired social interaction and communication skills or the presence of
stereotyped behaviors or restricted interests that are not congruent with developmental or cognitive ages.
PDD encompasses several disorders including autistic disorder, Rett’s disorder, childhood disintegrative
disorder, Asperger’s disorder, and PDD not otherwise specified.
The diagnosis of autistic disorder is based on impaired social interaction and communication and the presence
of repetitive or stereotyped behavior. There must also have been a delay in social interaction, social or
communicative language, and play prior to the age of 3 years.
The diagnosis of Asperger syndrome is based on impaired social interaction and restricted or stereotyped
interests that interfere with daily functioning. There is no delay in language, cognitive development, or
adaptive behaviors and activities of daily living skills.
The diagnosis of PDD-NOS is used when there is impairment in social interaction that is associated with
communication skills or is present with stereotyped behavior and restricted interest. These symptoms should
not be accounted for by PDD, schizophrenia, schizotypical personality disorder, or avoidant personality
disorder. PDD-NOS includes “atypical autism” (when the criteria have not been met for autism disorder).

a Adapted from the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition (DSM-IV).1
b Basedon proposed revisions of the DSM, these currently used diagnoses may be incorporated into one diagnosis (ASD) when the fifth edition is
published.3

children with autism. The term motor activity was selected
by the authors in an attempt to capture and describe mo-
tor abnormalities, delays, and general motor function of
children with ASD.
METHODS
A literature search was carried out using OVID,
PubMed, and Google Scholar search engines between
January 1, 2009, and October 31, 2009. Seventeen search
terms were used in an attempt to best capture the broad
range of articles addressing children with autism or re-
lated diagnoses, motor activity, and PT (see Figure for
search terms). Care was given to be certain that each search
yielded all possible evidence in the published literature.
The search was then updated during May 2010 using the
same strategies with each of the 17 search terms. In all,
90 searches were completed (Figure). Further review of

Fig. Search strategy.

Pediatric Physical Therapy Motor Activity in Autism 3

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 an article was dependent on the appearance of the search
terms in the abstract of the article as identified by the first
author (Figure). Articles were then graded according to
the level of evidence, on the basis of criteria from Sackett
et al.9,10 Only articles that were found to be at Sackett levels
1-3B were used for this analysis. Other exclusion criteria
included systematic reviews that did not include specific
research methods, articles in which the search terms were
present in the abstract but did not include analysis of motor
function, and articles that were not accessible in English
(see Figure).
RESULTS
The search strategy and inclusion criteria resulted in
a total of 49 articles that were acceptable for this literature
review of motor activity in children with ASD. No level
1 articles appropriate for analysis were identified during
the search. Two level 2 articles and 47 level 3 articles were
identified and included in the analysis. Articles classified as
levels 4 and 5 were identified but not used in the literature
review. Articles that originally met the inclusion criteria
but did not address motor activities as part of study criteria
or outcomes also were not included. Review articles that
did not include specific methods and inclusion criteria also
were excluded from the analysis (see Figure). As is the
case with all searches of the literature, additional articles
that would meet the search criteria may be found if a new
search following the same strategy was conducted today.
The search strategy used here yielded all articles meeting
inclusion criteria as of May 2010.
Studies that inform health care providers about chil-
dren with ASD and addressed motor activity were ana-
lyzed and reviewed (see Appendix). During the review
process, various themes related to the characteristics and
concerns related to ASD arose in the literature. The articles
were grouped and analyzed on the basis of these themes.
The themes were not derived through a specific qualita-
tive methodological approach; rather, they were generated
through the work of the first author, and corroborated with
the second author, during the process of sorting articles
that met the search criteria. Based on recurring similarities
in the content of the available literature as reviewed, the
following thematic categories emerged: early motor find-
ings, gestures and motor imitation, postural control, and
dyspraxia.
Early Motor Findings
Several recent studies sought evidence of motor im-
pairments to provide early motor identification markers
and characteristics of ASD. For example, in a study by
Provost et al,11 68% of children with ASD who were tested
on the Bayley Scales of Infant Development II Motor Scale
and 63% of children who were tested on the Peabody De-
velopmental Motor Scales, Second Edition, would have
qualified for early intervention services. Landa and Garrett-
Mayer12 also prospectively studied 2 groups of infants:
4 Downey and Rapport
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1 group was classified as low-risk for development of
autism and the other as high-risk for development of
autism. Children were examined with the Mullen Scales
of Early Learning at 6, 14, and 24 months. At the 24-
month visit, further testing was administered to classify
children who had typical development, ASD, or language
delay. No differences on the Mullen Scales of Early Learn-
ing were found in children with ASD and typical children
at 6 months; however, by 14 months, the children with
ASD began to demonstrate a slowing in development com-
pared with the other groups. By 24 months, significant
differences were found between the group with ASD and
the group developing typically in all domains, as well as
between the group with ASD and the group with language
delay. The children with ASD demonstrated the slowest
rate of increase in developmental skills over time.
In another study, Esposito et al13 retrospectively ex-
amined videotapes of 3 groups of infants aged 12 to 21
weeks: those diagnosed with ASD, those with develop-
mental delays not associated with ASD, and children with
typical development. These researchers found that the
group with ASD had significantly less static and dynamic
symmetry in the supine position than the other groups.
Teitelbaum et al14 also suggested that motor abnormalities,
including asymmetrical movement patterns, are present at
birth in children with ASD and may aid in the early identi-
fication of ASD. On the basis of video analysis, Baraneck15
suggested that symptoms of autism, including sensory-
motor symptoms, might be present and identifiable be-
tween 9 and 12 months of age. In another study, Dewrang
and Sandberg16 used retrospective parent reports to com-
pare individuals with AS with a group of young adults who
were developing typically. They found that during the first
2 years of life, individuals with AS demonstrated impaired
imitation, increased clumsiness, and poor coordination.
These findings suggest that evaluation of motor activity
may play a role in early prediction of ASD.
In contrast, Ozonoff et al17 reported that infants who
are later diagnosed with ASD do not demonstrate an in-
creased number of movement abnormalities or a lack of
protective reactions when compared with a group of chil-
dren who are developing typically. They did, however, find
a slower rate of development in reaching mature motor pat-
terns. In addition, they suggested that more comprehen-
sive motor evaluations might be useful in early detection of
autism. In another study by Loh et al,18 stereotyped behav-
iors and postures found in children with ASD were similar
to those in the comparison group. These authors also sug-
gested that more sensitive testing might be required to
identify motor impairments.
Gestures and Motor Imitation
The ability to use gestures and motor imitation relies
on motor activity to communicate with others. Interest-
ingly, children with ASD have difficulty with communica-
tion as well as difficulty using motor activity (eg, gestures
and imitation) as forms of communication to support social
Pediatric Physical Therapy
 interaction. Motor imitation has been identified as a signif-
icant impairment in previous literature on individuals with
ASD, particularly in relation to social communication.19-21
In a literature review by Williams et al,22 the authors sug-
gested that imitation impairments are present in children
with ASD and are more apparent in younger age groups
(below the age of 4 years) when compared with other
children.
Stone et al21 suggested that imitation impairments in
children with ASD are due to a delay in acquiring imita-
tion skills, rather than disordered sequencing. Although
some improvement may be seen between the ages of 2 and
3 years, this delay was apparent in young children, as
well as in preschool-aged children.22,23 In another study,
Rogers et al20 found that children with ASD have impaired
imitation skills on sequential imitation tasks when com-
pared with a group of children with developmental delays.
No support was found for a relationship between imitation
impairment and play skills, language skills, or dyspraxia in
children with ASD. In a more recent study, Rogers et al24
noted that during a simple task, children with autism fail
more imitation tasks than a group of children with devel-
opmental delays and a group of children who were devel-
oping typically. These findings were especially meaningful
in children with autism who were younger than 14 months.
In the older age group (older than 30 months), children
with regressive type autism continued to fail more tasks,
especially nonfunctional imitation tasks.
Other researchers have suggested a possible link be-
tween imitation impairments and the presence of motor ac-
tivity abnormalities. For example, Van Vuchelen et al25 re-
ported the presence of an imitation impairment, especially
in nonmeaningful gestures, in children with ASD who
have low-functioning autism and high-functioning autism
(HFA). They also found increased impairment on motor
testing. Green et al26 also found an association between
motor and imitation scores, with lower and more variable
scores in children with AS than in children with specific
developmental delays of motor function. Spatiotemporal
errors were more common in the group with AS. In a
study by Mostofsky et al,27 children with ASD had more
imitation errors on the Florida Apraxia Screening Test than
children who were developing typically. Spatial errors were
the most common in both groups. In the groups with ASD,
errors were increased when gesturing on command and
imitation, rather than tool use. Notably, no significant dif-
ference was found in the number of total errors between
individuals diagnosed with HFA and those with AS.
In another study, Smith and Bryson28 found that chil-
dren with ASD have increased difficulty performing and
naming both meaningful and nonmeaningful gestures but
no difficulty understanding or identifying gestures. The
authors suggested that these impairments might be related
to dyspraxia.28 Dewey et al29 also found that when com-
pared with children with both developmental coordination
disorder (DCD) and attention-deficit/hyperactive disorder
(ADHD), DCD only, or ADHD only, children with ASD
have significantly lower motor and gestural performance
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scores. Although this may be related to praxis, these au-
thors suggested that it might also be related to altered
neural substrates or language deficits.
More recently, Ben-Sasson et al30 examined gestural
representations in 3 groups of children: children with HFA,
children with language impairment, and children who are
developing typically. The authors concluded that children
with HFA have increased difficulty with gestural repre-
sentations, which they suggest may be related to a motor
planning deficit. There appeared to be decreased quality
of gesture performance as well as a discrepancy between
gestures and verbal descriptions, when compared with the
other 2 groups. The authors hypothesized that perform-
ing motor actions might be more difficult when the task
is combined with verbal description. This may be related
to a lack of integration between motor and language. Ben-
Sasson et al30 suggest that individuals with ASD may ben-
efit from further testing to examine motor planning and
sequencing.
Postural Control
Postural control requires a level of stability neces-
sary prior to executing additional motor skills or activities.
Without this control, motor activity may be limited to more
static positions. Individuals with autism tend to have de-
creased postural control.31,32 Minshew et al31 found that
individuals with autism have decreased postural stability,
particularly in circumstances where there is sensory con-
flict. Compared to a group of children who were develop-
ing typically and adults, development of postural stability
appeared to be delayed in children with autism. Postural
stability did not appear to improve in individuals with
autism until the age of 12 years. At the age of 15 years,
the group that was developing typically appeared to have
a plateau in postural stability; however, this same level of
control was not achieved in the group with ASD. Based
on the data from a bimanual lift task by Schmitz et al,32
children with ASD rely on reactive postural control rather
than on the typical anticipatory postural control seen in
the comparison group when performing lifting tasks.
In another study, Kohen-Raz et al33 examined postu-
ral stability in various standing positions between a group
of children with ASD and a group of children who were
developing typically. Children with ASD demonstrated in-
creased sway, abnormal weight distribution, and the ab-
sence of typical ankle strategies in standing. A “paradoxi-
cal stress response” was noted in individuals with autism,
indicated by an increase in postural stability in stressful
conditions (defined as removal of vision). In a follow-up
study, Molloy et al34 also found that children with ASD
had significantly more sway in standing than a compari-
son group of children who are developing typically. Instead
of a “paradoxical stress response,” they found that chil-
dren with ASD experienced a larger increase in sway when
visual input was removed and somatosensory input modi-
fied, indicating that children with ASD rely on visual input
for balance. This finding points to impaired processing
Motor Activity in Autism 5
 abilities with sensory conflict in individuals with ASD.
Molloy et al34 argued that the presence of a paradoxical
response found in the Kohen-Raz et al33 study might have
been the result of additional visual and auditory input used
in their methods. Further support for impaired postural
control in children with ASD was provided by Fournier
et al,35 who reported that children with ASD have increased
postural sway in quiet stance without manipulation of sen-
sory input as well as altered center of pressure shifts during
gait initiation.
Dyspraxia
Quality of movement may be altered in children with
ASD, and dyspraxia has been noted when comparing chil-
dren with ASD with children who are developing typically.
Motor delay and motor variability have also been noted and
described in some studies and refuted in others. Although
motor abnormalities were noted in individuals who were
first described with AS,8 these limitations have not been
consistently identified in individuals with ASD. While no
level 1 research supporting the presence of limitations in
motor activities was found, several lower-level studies indi-
cate that impairments in motor activity may be common in
children with ASD. Researchers have sought to distinguish
differences across individuals with ASD, as well as to com-
pare those with ASD with individuals who are developing
typically or have other developmental concerns.
Manjiviona and Prior36 found limits in motor activ-
ity and function in children with HFA and AS. Ghaziuddin
and Butler37 noted that children with autism, AS, and PDD-
NOS have motor impairments. Statistically significant dif-
ferences 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 Pro-
ficiency. Individuals diagnosed with AD had higher levels
of motor activity impairment, while those with AS demon-
strated less impairment on gross motor, fine motor, and
total battery scores. A strong correlation existed between
intelligence quotient (IQ) scores and test results. When
adjusted for level of intelligence, no significant difference
remained between groups. Green et al38 found a similar
correlation between IQ and motor scores in individuals
with ASD, indicating that motor impairments might be re-
lated to IQ level. Current research has demonstrated that
there is no significant difference in level of motor impair-
ments among children with AS, AD, or PDD-NOS; how-
ever, there is a trend toward higher cognitive limitations
correlated to lower motor scores.
Several researchers have suggested that when com-
pared with a comparison group developing typically, chil-
dren with ASD have dyspraxia. Mostofsky et al27 suggested
that based on the Florida Apraxia Screening test, motor im-
itation may be linked to dyspraxia, particularly to a delay
in spatial mapping. Dzuik et al39 proposed that dyspraxia
may be separate from other motor skills in children with
ASD and may be strongly correlated to the core deficits as-
sociated with autism.1 According to Dowell et al,40 praxis
6 Downey and Rapport
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score was correlated with the Autism Diagnostic Obser-
vation Schedule score, also suggesting that dyspraxia may
be a core symptom of ASD. In addition, Dowell et al40
reported that children with ASD have slower timed move-
ments and score significantly lower on postural knowledge
testing.
Glazebrook et al41 noted that individuals with ASD
are able to use advance information; however, more time
is required to plan movements. Glazebrook et al42 and Naz-
zarali et al43 noted that individuals with ASD required more
time to plan and execute goal-directed movements. Rine-
hart et al44 also noted a slower preparation time in children
with HFA and AS when compared with a cohort developing
typically. This was further supported in another study by
Rinehart et al,45 where children with HFA demonstrated
increased preparation time compared with a cohort de-
veloping typically, and children with AS demonstrated a
trend toward a motor preparation deficit. On the basis of
an analysis of goal-directed gait, Vernazza-Martin et al46
suggested that when compared with a typical comparison
group, children with ASD have impaired motor planning
and execution. Whereas differences in motor planning are
present in some individuals with ASD, the alterations in
patterns are unclear. Hughes47 suggested that individuals
with autism demonstrate difficulty executing simple goal-
directed motor tasks that might be related to sequencing,
vision, or consequence prediction.
Staples and Reid48 compared a group of children di-
agnosed with ASD to 3 groups developing typically. The
3 typical groups were matched with children in the group
with ASD by chronological age, cognitive development,
or movement skill development. They found that children
with ASD have significantly poorer motor scores than chil-
dren who are developing typically and who are chronolog-
ically age matched and cognitively age matched. Specifi-
cally, children with ASD had difficulty with bilateral coor-
dination and performed at a similar motor level as children
approximately of half their chronological age. The authors
suggested that by late childhood, motor skills in children
with ASD are significantly delayed.
Jansiewicz et al49 noted that boys with HFA and AS
have increased difficulty with balance, gait, and dysrhyth-
mia with timed hand and foot movements. In another
study, Weimer et al50 examined tests of apraxia and ba-
sic motor function in a group of children and young adults
with AS and a comparison group. The authors found that
deficits were present on tests of apraxia, especially on mea-
sures where visual input was removed, suggesting reliance
on vision with a proprioceptive impairment. In addition,
Freitag et al51 reported that when compared with a group
developing typically, individuals with HFA and AS are
“strongly impaired” in dynamic balance and diadochokine-
sis, and integration between sensory and motor input may
be also impaired. They also noted a positive association of
motor scores to the level of social withdrawal.
In a study by Fuentes et al,52 the authors found that
when compared with a group of children who were devel-
oping typically, children with ASD had significantly poorer
Pediatric Physical Therapy
 motor and writing scores overall. More specifically, scores
were decreased on gait, stance, and timed movement ac-
tivities. Poor gross motor skills were correlated with poor
handwriting scores. They hypothesized that if therapies
address overall motor control, handwriting scores would
improve as a result of increased ability to control and ma-
nipulate arm movements. In contrast, van Swieten et al53
sought to differentiate between motor and executive plan-
ning abilities in 3 groups of children and adults: a group
with ASD, a group with DCD, and a group with typical
development. Based on what the authors suggested to be
a pure motor planning test, no difference was found be-
tween the group with typical development and the group
with ASD.
Miyahara et al54 found high rates of motor delay in
2 groups of children: a group of children with AS and a
group of children with a learning disability. A significant
difference was found between groups for manual dexterity
scores. The children with AS had a trend toward poorer ball
skills, which, the authors hypothesized, might be related
to the type of preferred play.
No difference in motor profile was found between
children with ASD who were chronologically age matched
and children with other developmental delays.55 The au-
thors did, however, note that scores of children with ASD
were more variable than those with developmental delays.
In another study by Provost et al,11 the authors evaluated
3 groups of children—children with ASD, developmen-
tal delays, and developmental concerns—on the basis of
results from the Bayley Scales of Infant Development. In
this study, none of the children in the group with ASD
tested within normal limits, and at least 68% of these chil-
dren would have qualified for early intervention services
based on a delay of 25% or more. Motor scores of children
with ASD did not differ when compared with children
with developmental delay. These results suggest that there
is a limitation in motor function in children with ASD.
Further research is needed to identify the specific type of
dysfunction.
Matson et al56 also noted gross and fine motor impair-
ments in toddlers with AD when compared with toddlers
with atypical development between 18 and 36 months of
age. No significant differences were found between tod-
dlers with PDD-NOS and children who are developing
typically. The authors suggested that motor impairments
are present at a young age and benefit may be obtained
from early intervention. In another study, children with
ASD were compared with children with specific speech
and language disorders and a comparison group of chil-
dren who were developing typically. The children with
speech disorders had lower scores on all gross and fine mo-
tor domains except coordination, whereas children with
autism had significantly poorer scores on all fine and gross
motor scores (including balance), except oral motor and
coordination.57 Morin and Reid58 noted that although in-
dividuals with autism have poor motor performance, they
can obtain higher balance scores than those with intel-
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lectual delay. Balance in individuals with ASD may be
decreased; however, continued research is necessary to
identify the severity and the pattern of deficit.
Although impaired motor skills and function are not
a core deficit of ASD, they are considered a core deficit
of DCD and ADHD.1 In a study by Dewey et al,29 the au-
thors found that when tested on the Bruinink-Oseretsky
Test of Motor Proficiency (short form) and a gestural per-
formance test, children with ASD had significantly lower
scores than children with DCD, ADHD, or ADHD and
DCD. This supports the presence of difficulty with motor
activity in children with ASD. This finding was further sup-
ported by Pan et al,59 who found that children with ASD
performed significantly lower on motor tests than children
with ADHD and children who are developing typically.
Specific limitations were noted on tests of locomotion and
object manipulation. They suggested that poor motor per-
formance might be a sign of autism, with poor skills being
related to a lack of social skills as well as lack of motivation
to practice. The authors encouraged clinicians to screen for
motor impairments as poor motor skills were found to be
correlated with poor self-esteem, increased anxiety, and
decreased social function.
In a rare study with an all-female sample, Kopp et al60
compared several groups of girls: girls who were develop-
ing typically, girls with ASD, and girls with ADHD. They
found that a large percentage of girls with ASD also fit the
diagnosis for DCD, especially those in the preschool-aged
group. Predictors of poor motor scores included younger
age, presence and severity of ASD symptoms, and low IQ.
Poor motor scores were related to poor activities of daily
living and physical education participation.
DISCUSSION
Based on this review of literature, evidence is emerg-
ing that supports the identification of impaired motor ac-
tivity in children who have the diagnosis of autism. Al-
though impaired motor activity is not included in the di-
agnosis, impaired motor activity appears to be an observ-
able trend. The ability to understand and address the entire
clinical picture of the child, including all areas of function,
becomes an essential component of any intervention plan.
The majority of current evidence does support the pres-
ence of motor activity abnormalities prior to 2 years of age
in children who are later diagnosed with ASD that per-
sists into early childhood. As children are being diagnosed
earlier with ASD and receiving early intervention services,
physical therapists should consistently be part of the team
addressing all the needs of the child.
Although we still have much to learn about the timing
of motor development and the patterns of motor activity in
children with ASD, evidence supports the presence of spe-
cific difficulties related to motor activity in individuals with
ASD. The link between imitation and motor activity is still
unclear; however, research indicates that there are limita-
tions in motor imitation in children with ASD. Questions
Motor Activity in Autism 7
 still remain as to whether restrictions in social behavior
limit imitation, or whether limitations in motor activity
restrict social participation and adversely affect imitation.
The presence of postural instability is also supported in
the literature. Decreased postural stability can significantly
limit participation in activities since the simplest of move-
ments require complex control61,62 and further research is
needed to examine the severity, cause, and functional out-
comes related to postural control. The literature also lends
support to difficulty with motor planning in children with
ASD.
Limitations in motor activity in children with ASD
might decrease the opportunity for social interactions and
learning opportunities. Although limited research related
to interventions for motor activity impairments in children
with ASD was found, Travers et al63 did address motor-
linked implicit learning in children with ASD. In a study
comparing a group of individuals with HFA, ASD, and a
group developing typically, Travers et al63 reported that
for simple tasks, motor-linked implicit learning might be
intact in children with ASD, which might influence thera-
peutic approach.
Motor activity delays have been observed in infants
and toddlers with autism and may affect future motor de-
velopment. As with all developmental delays, early iden-
tification 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.64,65 Since
children with ASD are ambulatory, they previously would
not have been thought to benefit from PT. Physical ther-
apists need to consider how to address these impairments
in motor activity within the child’s daily routines.
Although the results of this literature review do in-
dicate that motor activity impairments may be present in
children with ASD, there are limitations to this analysis.
An updated literature search may provide increased evi-
dence supporting motor activity impairments as well as
provide documentation for intervention strategies for chil-
dren with ASD. No consistent measure was used in each
of the reviewed studies, which limits generalization of the
findings.
CONCLUSION
Although there may be limitations in motor activ-
ity present in children with ASD, much research is still
needed to identify the age at which these limitations in
motor activity are present and to what extent they differ
from children who are developing typically. As with many
other diagnoses, lack of evidence has not prohibited the PT
profession from forging ahead with new research and on-
going intervention. Future research is necessary to identify
to what extent functional activities are limited in children
with ASD. Research is also necessary to determine the un-
derlying causes as well as the most appropriate interven-
tions. As physical therapists move toward consistent use
of the ICF,66 it may be useful to implement interventions
and research their efficacy based on activity limitation and
8 Downey and Rapport
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.
participation restrictions rather than solely by impairment
and disability. Physical therapists can and should play a
unique role in promoting functionally based intervention
strategies to enhance motor activity and improve function
in children with ASD.
ACKNOWLEDGMENT
The authors thank Stephanie Lyle, PT, DPT, for her
early contributions to this work.
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APPENDIX
Brief Summary of Each Article Revieweda

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Provost et al11 Comparison Autism spectrum disorder Bayley Scales of Infant According to scores on the BSID II and the
(ASD) (n = 19) Development II PDMS-2, 63% and 68% (respectively) of
Developmental delay (DD) Motor Scale (BSID II) children with ASD would qualify for early
with concerns for motor Peadbody intervention services on the basis of a 25%
delay chronologically Developmental motor delay. These scores were similar to
aged matched within 3 Motor Scales, 2nd those of a group of children diagnosed
months (n = 19) Edition (PDMS-2) with DD.
Developmental concerns
without motor delay
chronologically aged
matched within 3 months
(NMD) (n = 18)
Landa and Prospective High risk for autism Mullen Scales of Early Participants were initially identified from
Garrett- comparison (n = 60) Leaning (MSEL) 2 groups: infants considered to be at high
Mayer12 Low risk for autism (n = 27) risk of autism because they were siblings
of children with autism and infants
considered at low risk because there was
no family history of autism. Review of test
scores and clinical judgment led to
categorization of these infants as
unaffected, ASD, or language delayed. On
the basis of MSEL scores, children with
ASD had slowed in development in all
domains except visual reception by 14
months. By 24 months, significant
differences were found between the group
with ASD and the group of children
developing typically on all domains of the
MSEL.
Esposito et al13 Retrospective ASD (n = 18) Eschkol-Wachman Based on retrospective video analysis, infants
comparison Typical development (TD) Movement Notation (12-21 weeks) who were later diagnosed
(video (n = 18) static and dynamic with ASD had higher rates of asymmetry
analysis) DD (n = 12) symmetry in supine static and dynamic lying
postures. Symmetry was noted in some
children with ASD; however, children
with early onset ASD were more likely to
demonstrate lower levels of symmetry.
Teitelbaum et al14 Retrospective ASD (n = 17) Eschkol-Wachman Based on retrospective video analysis of
comparison TD (n = 15) Movement Notation infants, most of the children with ASD
(video demonstrated altered movement patterns
analysis) in mouth shape and lying, righting, sitting,
crawling, and walking that could be
identified within the first few months of
life.
Baraneck15 Retrospective Autism disorder (AD) Video analysis and Based on retrospective video analysis of
comparison (n = 11) coding of behavioral infants between 9 and 12 months’
(video DD (n = 10) categories: looking, corrected chronological age, subtle
analysis) TD (n = 11) affect, response to sensory-motor deficits were present in
name, anticipatory infants who were later diagnosed with AD.
postures, Social deficits were also noted.
motor/object
stereotypies, social
touch, sensory
modulation
(continued)

10 Downey and Rapport Pediatric Physical Therapy

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.
 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Dewrang and Retrospective Asperger syndrome (AS) Parent questionnaire- According to results from retrospective
Sandberg16 comparison (n = 23) symptoms of autism parent questionnaire, individuals
(parent TD (n = 12) before the age of with AS demonstrated difficulties in
questionnaire) 2 years (SAB-2) the first
2 years of life with several areas of
development, including motor
skills. Parents did report difficulty
with imitation of motor skills and
coordination.
Ozonoff et al17 Retrospective AD (n = 54) including Infant Motor Maturity On the basis of retrospective video
comparison -Autism: no regression and Atypically analysis, children who were later
(video (At(NR)) (n = 26) Coding Scales diagnosed with AD did not
analysis) -Autism: regression (At(R)) demonstrate higher rates of
(n = 28) movement abnormalities or fewer
DD (n = 25) protective responses before the age
TD (n = 24) of 2. There were slower rates of
motor development noted in the
group with At(NR) in early skills
and in the group with At(R) in
walking.
Loh et al18 Retrospective ASD (from a population of Coding of motor Videos were analyzed of children at 12
comparison children with siblings mannerisms during and 18 months of age. The arm wave
(video diagnosed with ASD) standardized testing posture was more commonly seen in
analysis) (n = 8) children with ASD in both age
Nondiagnosed siblings of groups. At 18 months, the
children with ASD hand-to-ear posture was noted in
(n = 9) both the group with ASD and the
TD (n = 15) nondiagnosed siblings of children
with ASD. Overlap between all
groups was present for stereotyped
behaviors.
Rogers et al20 Comparison AD (n = 24) Imitation battery Children with AD had decreased
DD (mixed etiology) Praxis battery imitation performance when
(n = 20) compared with children with DD or
Fragile × Syndrome (FXS) children developing typically. No
(n = 18, not included in differences were found in motor
group comparison skills between children with AD,
analysis) including: DD, or children developing
-FXS without AD typically, and no correlation was
(n = 13) found between motor skills and
-FXS with AD (n = 5) imitation abilities in children
TD (n = 15) diagnosed with AD.
Stone et al21 Part 1 Part 1: Motor Imitation Part 1: Children with ASD under 31/2
ASD (n = 18) Scale years old have poorer imitation
DD (n = 18) skills than children without ASD but
TD (n = 18) with developmental delays when
matched on mental age,
chronological age, and language
ability. Difficulties were noted
specifically with imitation of body
movements and nonmeaningful
actions. Difficulties were similar
across all groups, suggesting that
motor imitation skills in children
with ASD may be delayed in
acquisition and not disordered.
Part 2 Part 2: Motor Imitation Part 2: Motor imitation improved in
ASD (n = 26) Scale (only total, children with ASD between the age
body, and object of 2 and 3 years.
scores)
(continued)

Pediatric Physical Therapy Motor Activity in Autism 11

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.
 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Williams et al22 Systematic Based on a literature review of 21 studies,

review imitation deficits were present in
children with ASD and more apparent
in younger children (under the age of
4) and with nonmeaningful tasks. More
research is necessary to further
delineate autism and dyspraxia.
Stone et al23 Comparison AD (n = 22) Imitation motor tasks Preschool-aged children with AD had
Intellectually delayed with (12 total) significantly lower motor imitation
an IQ less than 70 scores compared with preschool-aged
(n = 15) children who have an intellectual delay,
Hearing-impaired (n = 15) are hearing or language impaired, and
Language- impaired children developing typically. Motor
(n = 19) imitation scores strongly differentiated
TD (n = 20) children with AD from children with
other developmental delays and may be
a useful screening tool.
Rogers et al24 Comparison Early onset AD (n = 17) Motor imitation in 2 Children younger than 14 months in the
Regressive-onset AD conditions: combined AD group demonstrated
(n = 24) functional and increased errors on imitation tasks
DD (n = 22) nonfunctional when compared with the other groups,
TD (n = 22) to which they were matched on the
basis of nonverbal skill age. All groups
of older aged children demonstrated
similar imitation skills except for the
group with regressive-onset AD, who
demonstrated impaired nonfunctional
imitation skills. No differences were
found between groups on error type or
pattern, nor was there a difference in
emulation of the task between groups.
The results suggest that imitation
differences are not due to a motor
impairment; rather, they may be due to
mirror neuron network impairments or
atypical brain mechanisms associated
with the mirror neuron system.
Van Vuchelen Comparison Cognitive impairment PDMS-2- administered Children with ASD who have been
et al25 (n = 21) to those in the group diagnosed with LFA or HFA, when
with IQ < 80 including with a cognitive matched for age, sex, and
-Low functioning ASD impairment developmental level with a comparison
(LFA) (n = 8) Movement assessment cohort, demonstrated increased errors
-Cognitive impairment battery for children with imitation tasks. Children in the
without ASD (n = 13) (MABC)- group with ASD also demonstrated
No cognitive impairment administered to those significantly poorer motor scores than
with IQ > 80 (n = 34) with high the comparison group. Based on the
including functioning IQ results, the authors suggested that
-High functioning ASD Motor imitation test difficulties with imitation arise from a
(HFA) (n = 17) delayed “action production system.”
-TD (n = 17)
Green et al26 Comparison AS (n = 11) MABC Although not statistically significant,
Specific developmental The Gesture Test children with AS performed more
disorder of motor poorly and variably on the MABC and
function (SDD-MF) the Gesture Test when compared with
(n = 9) children with SDD-MF of similar age.
All children with AS tested below the
15th percentile on the MABC. In the
group with AS, poor scores on the
MABC were correlated with lower
scores on the Gesture Test.
(continued)

12 Downey and Rapport Pediatric Physical Therapy

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Association. Unauthorized reproduction of this article is prohibited.
 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Mostofsky et al27 Comparison ASD (n = 21) including Florida Apraxia While error type was similar between the 2
-HFA (n = 13) Screening Test groups, children with ASD demonstrated
-AS (n = 8) (Revised) significantly higher errors on the Florida
Gender and age matched Apraxia Screening Test than the
TD (n = 24) comparison group. In the group with ASD,
Inclusion for all subjects: children with HFA had significantly more
IQ > 80 errors on the body-part-for-tool than the
group with AS; however, no other
significant differences existed. The authors
suggested that these findings are indicative
of a praxis issue in children with ASD, not
just difficulty with imitation.
Smith and Comparison AD (n = 20) Tests of: Children with AD had no difficulty
Bryson28 Language impairment 1. Memory and understanding or recognizing motor
chronologically and comprehension of gestures. They demonstrated increased
receptive age matched gestures difficulty naming and imitating gestures.
(n = 20) 2. Gesture production The authors suggested that this might be
TD receptive age matched and imitation due to a praxis impairment with difficulty
(n = 20) in mapping movements as well as the
representation of movements.
Dewey et al29 Comparison ASD (n = 49) Bruininks-Oseretsky On testing to assess gesturing, children with
Developmental coordination Test of Motor ASD had significantly higher rates of
disorder (DCD) (n = 46) Proficiency Short errors than children in the other groups.
Attention-deficit/ Form (BOT-SF) Overall, on motor testing, children with
hyperactivity disorder The Gestures Test ASD demonstrated significantly poorer
(ADHD) (n = 27) scores with increased variability in scores
ADHD and DCD (n = 38) than children in any of the other groups
TD (n = 78) (41% of children with ASD did not meet
criteria for motor impairment based on the
BOT-SF). Although this may be related to
praxis, these authors suggested that it
might also be related to altered neural
substrates or language deficits, as errors
were still present when motor deficits
were accounted for.
Ben-Sasson et al30 Comparison HFA (n = 23) with IQ > 70 Demonstration task Children with HFA or language impairment
including portion of the Autism demonstrated significantly lower levels of
-AD (n = 15) Diagnostic gesture representation than children
-Pervasive developmental Observation developing typically on a demonstration
disorder–not otherwise Schedule (ADOS) task. The authors suggested that in the
specified (PDD-NOS) group with HFA, this might be attributed
(n = 11) to motor planning or language
Language impairment impairments. Difficulties may have also
(n = 23) been exacerbated by the requirement to
TD (n = 30) speak and gesture, as well as the lack of
natural environment.
Minshew et al31 Comparison HFA (n = 79) Dynamic Individuals between the ages of 5 and
TD “group matched” posturography 52 years with HFA demonstrated
(n = 61) (EquiTest) decreased postural control when tested on
Inclusion for all subjects: full the EquiTest compared to a sample with
scale and verbal IQ > 70 TD. Increased difficulty was noted during
the conditions of sensory conflict. 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).
Schmitz et al32 Comparison AD (n = 8) (right-hand Bimanual load lift task During a bimanual load lift task, muscle
dominance) with kinematic and latencies and increased unloading time
TD (n = 16) (right-hand electromyographic found in children with AD suggest a
dominance) analysis decreased use of anticipatory control seen
in a group with TD. Children with AD
demonstrated an increased use of reactive
postural control.
(continued)

Pediatric Physical Therapy Motor Activity in Autism 13

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.
 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Kohen-Raz et al33 Comparison AD (n = 91) Tetra-ataxiametry With posturographic testing, children with AD
TD (n = 166) method for postural had increased variability in performance and
control during abnormal weight distribution with less use of
posturographic the typical anteroposterior sway. Adolescent
testing aged children with AD demonstrated
decreased stability when compared to
preschool-aged children with TD. Notably,
the authors also found a “paradoxical”
response to stressful situations, as children
had increased postural stability in stressful
conditions (removal of vision).
Molloy et al34 Comparison ASD (n = 8) Posturographic testing Children were tested in 4 balance positions. On
TD chronologically age the basis of the results, children with ASD
matched (n = 8) had less postural stability than the children
developing typically with removal of visual
cues and deviation of somatosensory cues.
Children with ASD tended to rely on visual
input, demonstrated by increased sway with
removal of visual cues regardless of
somatosensory input. A “paradoxical stress
response” was not found. Authors reported
that these results in a previous study might
have been due to additional visual stimuli.
Fournier et al35 Comparison ASD (n = 13) Posturographic testing Children with ASD demonstrated significantly
TD chronologically age higher levels of mediolateral and
matched (n = 12) anteroposterior sway, as well as sway area,
than children with TD during quiet stance.
The authors also noted a decreased
displacement of the center of pressure toward
the swing leg during gait in the group with
ASD. This can cause a decrease in shift of the
center of mass to the stance limb, creating an
increased need for postural control. The
authors suggested that children with ASD
demonstrate postural instability.
Manjiviona and Comparison AS (n = 12) Test of Motor On the basis of motor testing, children with AS
Prior36 HFA (n = 9) Impairment- and HFA have variability in motor activities.
Inclusion for all subjects: Henderson Revision Fifty percent of the children with AS and
“normal or near (TOMI-H) 66.7% of the children with HFA
normal IQ” demonstrated motor impairments when
compared with a normative sample data for
the TOMI-H. No significant differences were
noted between the 2 groups. A significant
negative correlation was found between
TOMI-H scores and IQ. The authors
suggested that the lack of difference between
the group scores provides support for AS
being included in ASD diagnoses, rather than
its own diagnostic classification.
Ghaziuddin and Comparison AD (n = 12) Bruininks-Oseretsky Children in all 3 age-matched groups
Butler37 AS (n = 12) Test (BOT) demonstrated motor activity impairments
PDD-NOS (n = 12) when tested on the BOT. Children with AD
scored significantly lower on the BOT than
those with AS, and no other significant
differences were noted between groups. A
strong correlation between IQ scores and
motor scores was found. The authors also
suggested that while the BOT does test for
motor impairments, a pattern of impairment
is not yet clear for individuals with ASD.
(continued)

14 Downey and Rapport Pediatric Physical Therapy

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 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Green et al38 Comparison AD (n = 45) MABC Motor impairments, as tested by the

ASD (broad) (n = 56) Developmental MABC (defined by <5th percentile),
Coordination were present in 79.2% of all children
Disorder (9-10 years old) in the study. Group
Questionnaire scores were similar with children in
both groups having definite motor
impairments. When IQ was accounted
for, 97.1% of the children with low IQ
(<70) had definite motor problems, as
compared with 69.7% of children with
typical IQ (>70).
Dzuik et al39 Comparison ASD (n = 47) Florida Apraxia Children with ASD demonstrated
TD (n = 47) Screening Test significantly poorer scores on the
(Revised) Florida Apraxia Screening Test and the
Physical and PANESS, suggesting poorer basic motor
Neurological skills as well as praxis. Scores on praxis
Assessment of Subtle testing significantly predicted scores on
Signs (PANESS) the ADOS, whereas basic motor skill
did not. The authors suggested that
although individuals with ASD may
have impaired basic motor skills,
dyspraxia may actually be independent
of motor skills and may be a core
symptom of ASD.
Dowell et al40 Comparison ASD (n = 37) Florida Apraxia The children in the group diagnosed with
TD (n = 50) Screening Test ASD had significantly poorer scores on
(modified for the PANESS, the postural knowledge
children) test, and the Florida Apraxia Screening
PANESS Test. No significant difference was
Postural knowledge test noted between children with HFA and
(modified for AS on the postural knowledge test,
children) although age predicted praxis and IQ
did not. When age and IQ were
accounted for, postural knowledge and
basic motor score predicted praxis
score, however; when age, IQ, postural
knowledge, and basic motor score were
all accounted for, praxis performance
was significantly related to diagnosis.
The authors found that praxis
performance was significantly
associated with ADOS score, suggesting
that praxis may be a core symptom of
ASD.
Glazebrook Comparison Part 1 Part 1: Calculation of Part 1: Individuals with AD demonstrated
et al41 AD (n = 18) reaction and lower and significantly more variable
Without AD (n = 18) movement times reaction times than those without AD.
during an adapted The group with AD also demonstrated
precue paradigm significantly longer times to execute
movement. Similar to individuals
without AD, those with AD were able
to use advanced visual cues to plan
movements and decrease reaction time.
Part 2 Part 2: Calculation of Part 2: Individuals with AD demonstrated
AD (n = 9) reaction time and lower reaction times and longer times
Without AD (n = 9) movement times to execute movement than those
based on a rapid without AD. Individuals with AD
aiming task adopted appeared to use results from the prior
from earlier research trial to assist in movement planning for
the current trial.
(continued)

Pediatric Physical Therapy Motor Activity in Autism 15

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 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Glazebrook Comparison AD (n = 9) Calculation of reaction The group with AD required more

et al42 Age-matched individuals
without AD (n = 9)
Nazzarali et al43 Comparison Part 1
AD (n = 12)
Without AD (n = 12)
Part 2
AD (n = 12)
Without AD (n = 12)
Rinehart et al44 Comparison HFA with performance and
verbal IQ >70 (n = 12)
TD (matched on age, sex,
IQ) (n = 12)
AS (n = 12)
TD (matched on age, sex,
IQ) (n = 12)
Rinehart et al45 Comparison HFA with performance and
verbal IQ > 70 (n = 12)
TD (matched on age, sex,
IQ) (n = 12)
AS (n = 12)
TD (matched on age, sex,
IQ) (n = 12)
time and movement time to plan movements. They also
times based on a demonstrated significantly increased
rapid aiming task times to perform movements with
adopted from earlier significantly decreased peak
research velocities and peak accelerations
than the group without AD. Verbal
ability was correlated to reaction
and movement times and nonverbal
ability was correlated with reaction
times. Overall, individuals in the
group with AD demonstrated poorer
motor ability than individuals
without AD.
Part 1: Variation of Part 1: Individuals with AD
protocol from demonstrated slower reaction and
Glazebrook movement times than the group
et al41 developing typically. They were able
to use advance cues to plan
movements and decrease reaction
times.
Part 2: Measurement of Part 2: Individuals with AD
reaction and demonstrated increased difficulty
movement times reprogramming an already-planned
during a reaching movement. This was more difficult
task that was hand when the task required a change in
manipulated or hands than a change in directions.
direction The authors suggested that this
manipulated might be due to a slowed visual
responsiveness for spatial attention
or inefficient connections between
hemispheres of the brain.
Measurement of Although individuals with HFA and AS
preparation and demonstrated similar errors in a
movement time with serial-choice task, both groups
a serial-choice demonstrated increased preparation
button-pressing time when compared with a cohort
apparatus with TD. The group with AS
demonstrated slower preparation
movements, while the group with
HFA demonstrated a lack of
anticipation in preparation.
Upper extremity Individuals with HFA demonstrated
kinematic task to significantly slowed preparation
measure movement times when compared with a cohort
preparation and with TD. Although no significant
movement time difference was found between
individuals with AD and a cohort
with TD, the authors did note a
trend toward increased preparation
time in the group with AD. They
suggested that there is a true
planning deficit, rather than a
slowed movement. This deficit is
more predominant in individuals
with ASD. The authors further
suggested that although motor
impairments may be present in both
groups, the underlying cause may be
different and further research is
necessary to examine these causes.
(continued)

16 Downey and Rapport Pediatric Physical Therapy

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 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Vernazza-Martin Comparison AD (n = 9) Gait analysis The authors found no significant difference

et al46 TD (n = 6) between the group with AD and the group
with TD on gait parameters (stride duration,
step length, velocity, cadence, and string and
stride length), except for stride length, which
was found to be shorter in children with AD.
On the basis of analysis, children with AD
demonstrated increased oscillations of the
head, shoulder, and trunk causing less stable
and more variable posture. Although children
with AD demonstrated increased oscillations,
they were able to stabilize in the frontal
plane. Gait parameters and stability appeared
similar between groups; however, locomotion
pattern was not maintained in the group with
AD. The group with AD demonstrated
difficulty with gait trajectory based on an
imposed goal, suggesting difficulties with
motor planning.
Hughes47 Comparison AD (n = 36) Reach, grasp, and Based on hand positioning during a
Moderate learning place task (Bar reach-and-grasp task, the authors suggested
disabilities (n = 24) Game) with that individuals with AD have increased
TD (n = 28) examiner report of difficulty with executing even simple
hand positions goal-directed tasks when compared with
children with moderate learning disabilities
or children with TD. The authors suggested
that the pattern seen in older children with
AD is similar to that seen in preschool-aged
children with TD, suggesting that
development is delayed rather than altered.
They also hypothesized that the differences
may be due to sequencing, vision, or
consequence prediction.
Staples and Comparison ASD (n = 25) Test of Gross Motor Children with ASD demonstrated significantly
Reid48 TD, age matched (n = 25) Development lower scores on locomotor and object control
TD, movement skill scores than children who were
performance matched chronologically age matched and mental age
(n = 22) matched. No difference was found between
TD, mental age matched the group with ASD and the developmental
(n = 19) age matched, as they were matched on the
basis of motor scores. In general, children
with ASD had increased difficulty
coordinating both sides of the body for a task,
as arm movements were noted to be awkward.
On the basis of comparison with children
who were developmentally matched, children
with ASD appear to be delayed rather than
disordered, as skills aligned with children
with TD approximately half their age.
Jansiewicz et al49 Comparison ASD (n = 40) PANESS In the group with ASD, no differences were
TD with no neurologic or found on the PANESS between individuals
psychiatric diagnoses diagnosed with HFA or AS. The group with
(n = 55) ASD demonstrated significant differences
from the group with TD on all variables of the
PANESS, except for impersistence and
patterned timed movements (a trend toward
significant was present). Overall, children
with ASD tended to have difficulty with
balance, gait, and timed movement of the
hands and feet.
(continued)

Pediatric Physical Therapy Motor Activity in Autism 17

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 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Weimer et al50 Comparison AS (n = 10) Motor testing: Finger Individuals with AS demonstrated poorer
TD age matched (n = 10) Tapping, Grooved scores on tests of apraxia, balance
Pegboard, Trail (tandem and single leg), and
Making, Assessment finger-thumb apposition, but did not
of Apraxia, demonstrate significantly poorer scores
Finger-Thumb on tests of basic motor function than a
Apposition, cohort with TD. The balance scores were
Assessment of Ataxia, poorer with eyes closed. On the basis of
Assessment of these results and the lack of dizziness
Visuomotor usually found with a vestibular
Integration dysfunction, the authors suggested that
individuals with AS may have a reliance
on visual input and a proprioceptive
deficit.
Freitag et al51 Comparison ASD with Full Scale IQ >70 Zurich Neuromotor The group with ASD demonstrated
(n = 16) including AS Assessment increased difficulty with dynamic balance
(n = 4) HFA (n = 12) and diadochokinesis. The authors
TD IQ matched (n = 16) suggested that these impairments might
be a result of poor integration of motor,
sensory, and executive function. An
association between motor scores, the
core symptoms of ASD, and level of
withdrawal was also found.
Fuentes et al52 Comparison ASD (n = 14) Minnesota Handwriting Children developing typically had
TD (n = 14) Assessment Revised significantly higher scores on the
PANESS PANESS when compared with children
with ASD, particularly for the sections
examining gait and timed movements.
Handwriting scores were lower in the
group with ASD; however, children with
ASD did not demonstrate difficulty
aligning or sizing letters. Overall scores
on the PANESS, as well as scores on the
timed movement section, were found to
be predictive of handwriting scores. The
authors suggested that when overall
motor skills are addressed in children
with ASD, handwriting abilities may
improve as a result of increased control
and ease of manipulation.
van Swieten Comparison DCD (n = 27) Grasp and turn task to Children with ASD demonstrated similar
et al53 ASD (n = 20) measure preferred grip selection to age-matched children
TD (n = 70) grip developing typically on a task that the
authors used to test motor planning. The
authors hypothesized that the need for
motor planning was not strong enough
to elicit a difference in the children with
ASD.
Miyahara et al54 Comparison AS (n = 26) MABC Based on motor testing, 85% of the children
Learning disabilities with AS and 88% of the children with
(n = 16) learning disabilities qualified for the
diagnosis of SDD-MF, which the authors
reported as being 42-44 times higher
than the typical population. There was a
significant difference between groups for
manual dexterity skills. The children
with AS trended toward poorer ball
skills. The authors suggested that this
trend may be due to type of preferred
play or decreased interpersonal skills in
children with AS.
(continued)

18 Downey and Rapport Pediatric Physical Therapy

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 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Provost et al55 Comparison ASD (n = 19) PDMS-2 When children with ASD were matched with
DD (n = 19) children with DD based on age, gender,
and cognitive age, similar gross and fine
motor profiles were found.
Matson et al56 Comparison AD (n = 117) Battelle Developmental There was no significant difference found
PDD-NOS (n = 112) Inventory, 2nd between children with AD and PDD-NOS
Atypically developing Edition (differences did approach significance), or
without ASD (n = 168) children with PDD-NOS and children
atypically developing on gross and fine
motor scores. Children with AD did have
significantly lower fine and gross motor
scores than children who were developing
atypically. Motor impairments were
present in all groups. The authors
suggested that motor impairments in
children with AD are apparent at an early
age and they may benefit from early
intervention services.
Noterdaeme Comparison AD (n = 11) Standardized Qualitatively, statistically significant
et al57 Expressive language neurological differences were found on motor
disorder age and IQ examination: fine performance between the children with
matched (n = 11) motor, gross motor, TD and the children with expressive and
Receptive language disorder coordination, receptive language disorders in all areas
age and IQ matched balance, and oral except for coordination. Children with AD
(n = 11) motor for global had significantly poorer scores than
TD age and IQ matched neuromotor children with TD for all sections except for
(n = 11) impairment score, oral motor and coordination tasks.
performance times
Morin and Reid58 Comparison AD (n = 8) 5 test items: dynamic On motor testing, there was an overall trend
Intellectually delayed balance, catching, (not significant) toward poorer motor
(n = 8) standing long jump scores in the group with AD than the
(adapted from the group that was intellectually delayed. The
BOT), throwing, group with AD demonstrated significantly
running higher balance scores than the group that
was intellectually delayed, which the
authors suggested may be due to slowed
movements seen in functional play. The
group that was intellectually delayed
demonstrated superior target throwing
skills. The authors suggested that low
motor scores in children with AD might be
related to level of cognitive impairment,
rather than diagnosis alone.
Pan et al59 Comparison ASD (n = 28) Test of Gross Motor Children with ASD demonstrated
ADHD (n = 29) Development– significantly poorer scores on locomotion,
TD (n = 34) Second Edition, object control, and GMDQ than children
calculation of the with ADHD and children with TD.
Gross Motor Children with ADHD also demonstrated
Development significantly poorer scores on measures
Quotient (GMDQ) than children with TD. When children in
the group with ASD who demonstrated
attention deficits were omitted from
analysis, results still indicated that
children with ASD have poorer scores,
suggesting that motor ability is not related
to attention. The authors suggested that
based on GMDQ, differences might be
secondary to limited social skills.
(continued)

Pediatric Physical Therapy Motor Activity in Autism 19

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 APPENDIX
Brief Summary of Each Article Revieweda (Continued)

Study Design/
Author(s) Methodology Study Groups Examination Toolsb Summary of Findings

Kopp et al60 Comparison ASD (n = 20) EB-test (used for All study participants were female. High
ADHD (n = 34) children older than 6 rates of DCD were found in the group with
TD age and IQ matched years), Cailler-Asuza ASD and ADHD. In school-aged girls, 25%
(n = 57) Scale (children below of those with ASD and 32% of those with
4 years), MABC, ADHD were diagnosed with DCD. In the
motor-neurological- preschool-aged girls, 80% of girls with
perceptual ASD were diagnosed with DCD. On the
assessment EB-test, girls with ASD and ADHD scored
significantly lower than girls with TD, and
girls with ADHD had lower overall scores
than those with ASD. On the basis of
overall clinical picture, the authors
suggested that younger age, low IQ, and
autistic symptoms are predictors for lower
motor scores.
a Articles are listed in the same order in which they appear in the article.
b Tests related to motor and imitation skills were reported in the table. Studies may have used other testing (such as the ADOS), for diagnostic purposes,

and these tests were not included in the descriptions of each study in the table. See specific studies for more details on tests used.

20 Downey and Rapport Pediatric Physical Therapy

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