Motor Hand Movements in

Prelinguistic Children with Autism

Spectrum Disorders
Barbara Braddock, PhD, CCC-SLP
Saint Louis University

Jena McDaniel, BSEd

Vanderbilt University

Jess Poyer and Jane Hilton, PhD, CCC-SLP

University of Virginia

American Speech-Language Hearing Association Annual Convention

(November, 2010)
 Course
• Preintentional and Intentional Communication
• Gesture Types
• Gesture Assessment
• Gesture Use in Atypical Development
• Motor Hand Use in Atypical Development
• Object Use in Atypical Development
• Research Phase I: Case Series
• Research Phase II: Gesture Data Tracker
Two Types of Infant Communication

• Preintentional

• Intentional
 Preintentional Communication
• Communication of some learners may be entirely or
predominantly nonsymbolic (Snell, 2002).

• A set of behaviors and/or communication forms and

meanings unique for the child.
 Intentional Communication
Communication act is defined as a sequence of
observable behaviors in that:

1) the sender performs an signal or form,

2) that is directed towards another individual, and
3) in a manner that appears to indicate some
communication function.

(Wetherby & Prizant, 1989)

 Communication Intentionality
• Children learn intentionality through caregiver’s
interpretation of the child’s behaviors.

• Gestures are one of the most consistent early

indicators of intentionality.
 JOINT ATTENTION
Request information
Comment

BEHAVIOR REGULATION SOCIAL INTERACTION

Request action Unknown context
Protest Request Object Known context

Taken from Crais et al., 2009

Protesting for behavior regulation
9-12 months
(Crais et al., 2004)
 Communicative Gesture
• Actions performed with the intent to communicate

• Typically involve the fingers, hands, and arms

• Can include facial features (lip smacking for eating)

• Full body motions (bouncing for ‘horsie’)

(Iverson & Thal, 1998)

 Gesture Progression
• Research consistently documents a continuous
development of communication, from early gestures
progressing to first words.

(Volterra, Caselli, Capirici, & Pizzuto, 2005)

 Gesture Types

• DEICTIC GESTURE: Examples requesting,

reaching, showing, giving and pointing
– Used to indicate or call attention to an object
– Can be used to single out a referent from other
possible ones
– Communication function must be interpreted in
relation to current context
 Child reaches to request an object

(Ritualized requests include reaching with open-close grasping,

placing an adult’s hand on an object, or pulling at an empty hand
to obtain something; Bates et al., 1979; Crais et al., 2009;
Capone & McGregor, 2004)
Movement of another’s hand to
request an object

(Crais et al., 2009; Capone & McGregor, 2004)

 Child shows an object

(Showing, giving and pointing increase in occurrence at 11

months as reaching and other more primitive gestures decline;
Blake & Dolgoy, 1993; Bates et al., 1979; Crais et al., 2009;
Capone & McGregor, 2004)
 Child gives an object
(Crais et al., 2009; Capone & MacGregor, 2004)
Pointing to obtain an object Pointing to object/event
for behavioral regulation for joint attention

(Crais et al., 2009; Capone & McGregor, 2004)

About half of all deictic points between
8 and 11 months are
accompanied by vocalizations
(Carpenter et al., 1983)
 Gesture Types
• CONVENTIONAL GESTURE: Comprehension and
production is culturally-defined (example: waving
bye-bye).
• Typically observed in young children’s
communications a few months after deictic gestures.
• Often tied to the context of familiar games and social
routines.
• As language develops used in a wide range of
different contexts.
For example, a young child may nod head ‘yes,’ wave
‘bye-bye’ and as gesture progresses use other
conventional gestures, such as
‘thumbs up’ or ‘high five.’
 Gesture Types
• REPRESENTATIONAL GESTURE: Similar to
conventional gestures (Example: waving arms to
resemble bird in flight).
• Typically represent some aspect of a referent (such
as size, shape, direction of movement).
• Must be produced empty-handed (without referent
in hand).
 Representational gestures appear
in the first half
of the second year of life
(Representational gestures emerge around the 25-word
milestone and have been also labeled as iconic, symbolic, empty-
handed, referential; Acredolo & Goodwyn, 1988, Capirici et al.,
1996; Nicoladis, Mayberry, & Genesee, 1999).
 Gesture Assessment
• Observation of gesture production
– Parental diaries
– Parental questionnaires
– Naturalistic observation

Data trackers: quantify/classify gesture (may be

used in combination with parental diaries,
questionnaires, and naturalistic observation)
CDI (Fenson et al., 1994)
 Naturalistic Observation
• Videotaping of parent-child interaction.
• Variations can be introduced.
Communication temptation tasks and procedures
Communication and Symbolic Behavior Scales (CSBS;
Wetherby & Prizant, 1993).
 Gesture Use in Atypical Development
Osterling & Dawson, 1994

• Compared typically children with those later

diagnosed with ASD
• Relative to TD children, children later diagnosed with
ASD:
– Failed to orient to name more often
– Showed objects less often (DEICTIC GESTURE)
– Looked at the face of another less often
– Did not point (DEICTIC GESTURE)

(Pointing deficits in ASD; See reviews by Charman, 1998;

Goodhart & Baron-Cohen, 1993).
Motor Hand Use in Atypical Development
Iverson & Wozniak, 2007

• Examination of the vocalizations and rhythmic hand

movements in younger infant of children with ASD.
• As a group, they demonstrated attenuated patterns
of change in rhythmic arm activity around babble
onset time.
• More likely to exhibit delayed onset of reduplicated
babbling (and reductions in language development at
18 months).
 Object Use in Atypical Development
Ozonoff et al., 2008

• 66 12-month old infants (9 were subsequently

diagnosed with ASD).
• Coded repetitive behaviors during play task
(spinning, rotating, unusual visual exploration).
• Relative to two comparisons (children with typical
development and general developmental delay), the
ASD outcome group displayed significantly more
atypical object exploration.
 Object Use in Atypical Development
Rogers et al., 2003

• 24 children (mean age 34 months) with Autism.

• Relative to two comparisons (children with typical
development and general developmental disability),
the children with autism were significantly more
impaired in overall imitation abilities.
• Impaired motor imitation skills were strongly
correlated with joint attention and ASD symptoms.
 Literature Review Summary
• Intentional communication is first observed in
children’s production of gestures.
• Young children’s gestures can be classified by type:
Deictic, conventional, representational.
• Assessment of gesture may proceed using parent
diaries, questionnaires, naturalistic observation, data
trackers.
• Differences in rhythmic hand movement and object
exploration may be related to ASD.
• Research suggests that early reductions in gesture
use is characteristic of a later ASD diagnosis.
 Research Phase I: Project Aim

• To determine how hand movement fits into the

developmental picture given that motor hand acts
relate to object exploration; and the gesture
production is linked to language development.
 Research Phase I: Questions
1. What types of hand movement characterize
children with ASD when examined during social
communication with another?

2. Does the proportional use of hand movement by

category change between pre- and post-treatment
measurements?
 Research Phase I: Case Series
• Participants
– Five males with a medical diagnosis of ASD.
– Aged 2;5 – 3;7.
– English as the primary language.
– No known complicating factors (e.g., traumatic
brain injury, or prior neurological disease or
injury).
– Vision and hearing reported to be normal or near
normal.
 Research Phase I: Methods and
Procedures
• All children with ASD completed pre- and post-
treatment measurement.

• Pre- and post-treatment measurement consisted of a

standardized language assessment (CSBS; Wetherby
& Prizant, 1993).

• Following the CSBS pre-test, all children with ASD

received DIR and ABA intervention 4x week over six
weeks.

• After the completion of the intervention, the CSBS

assessment was re-administered (post-test).
 CSBS
• Motor hand acts and gestures produced in the CSBS
Communication Temptations subtests were coded
from videotape:
1. Wind-up toy
2. Balloon
3. Bubbles
4. Peek-a-boo
5. Walk Mouse, Creep Mouse
6. Blocks in a box
7. Jar
8. Toys in a bag
 Coding
1) Motor hand acts were coded in 1 of 10
categories:
Infantile rhythmic hand movement (IRM)
Idiosyncratic hand movement (IDIO)
Appropriate action on a object (AA)
Inappropriate action on a object (IA)
Rejecting protest motor hand act (REJ)
Protection motor hand act (PRO)
Reaction motor hand act (RE)
Movement of another’s body (MAB)
Give motor act (GIV)
Reach motor act (RCH)
 Coding
2) Gestures were coded in 1 of 3 categories
clearly directed towards the examiner.
(DEICTIC, REPRESENTATIONAL, CONVENTIONAL)

3) Use of trained augmentative and alternative

communication system was coded.
(MANUAL SIGN or PECS)
 Coding
• All vocalizations were coded:

1. With hand movement

2. Without hand movement

 Research Phase I: Results
• What type of hand movement characterizes
children with ASD when examined during social
communication with another (given a standard
communication temptation task and toy set)?

• Motor hand acts accounted for more than 85%

of all hand movements.

• Few hand movements were coded as empty-

handed gestures (less than 15%).
 Hand movements produced by children at
relatively higher proportions at
Time 1 by category
• Appropriate Action on object (AA)
• Infantile Rhythmic movements (IRM)
• Inappropriate Action on object (IA)
• Give (GVR)
• Idiosyncratic movements (IDIO)
• Rejection (REJ)
Proportional use of hand movements by category significantly
changed between pre- and post-test measurements (each
reaching statistical significance p<.008)
60
52
50

40
34
Proportion

Pre
30
Post
20 17
14 13
8 9 8 8
10 5
2 0
0
AA GVR IRM IA IDIO REJ
 Research Phase I: Summary
• Why quantify and categorize motor hand movement
from videotaped assessment?

• Offers diagnostic & prognostic value in both

cognitive and language realms of development
(i.e., motor imitation, play, gesture).
• Allows for a more sensitive measure of progress
over intervention time.
• Provides clinician with more flexible, and
individual assessment and treatment options.
Research Phase II: Gesture Data Tracker
 Research Phase II: Questions
• Will speech-language clinicians and parents report
similar patterns of children’s motor hand
movements?
• Will clinicians find the data tracker highly relevant to
communication assessment, easy to use, and a
potential guide for planning communication
intervention?
 Research Phase II: Methods
• Survey Respondents: parents (N=5) and speech-
language clinicians (N=5).
• Child diagnoses included Autism Spectrum Disorder
(ASD; N=2), Down Syndrome (DS; N=1) and Language
Delay (LD; N=2).
• Expressive language level varied from vocalizations to
multi-words.
• Each respondent observed child’s interactions during
play at an University Clinic, then completed the
Gesture data tracker.
• Speech-language clinicians completed a survey
regarding the use of the Gesture data tracker.
 Research Phase II: Data Tracker
The data tracker is made-up of 31 yes/no questions
examining the presence or absence of motor hand
movements in 5 areas:
• 1) sensorimotor hand movements (i.e., does the
child repetitively bang an object against another
surface?)
• 2) appropriate use of objects (i.e., does the child use
an object in play for its intended use?)
• 3) communicative hand acts (i.e., does the child take
another’s hand as if to lead for communication?
 Research Phase II: Data Tracker
• 4) adult-like gesture production (i.e., does the child
point to an object to single it out to another person?)
• 5) idiosyncratic hand movements (i.e., does the child
provide deep pressure with the hands to the face or
body, as if to pinch or push?)

(Additional items documented the frequency of self-

injurious, repetitive, and/sensory-driven hand
movements; use of AAC system, and presence of
vocalizations/verbalizations; motor notes, space for
comments)
Research Phase 2: Agreement Results
• For questions in which both responded (N=120),
interrater agreement between parents and
clinicians for categorizing hand movements and
gestures was moderately low.

[# of agreements/# of agreements + # of disagreements]

89/89 +31 = .74

Agreement scores at .80 and above are considered acceptable.

Research Phase II: Clinician Survey

How strongly do you agree or disagree with the

following statements?

Strongly agree
Somewhat agree
Neutral
Somewhat disagree
Disagree
 1) I believe hand movement observations should be
included in communication assessment for
prelinguistic children.

Strongly agree=4
Somewhat agree=1
Neutral
Somewhat disagree
Disagree
 2) As I learn more about the value of children’s hand
movements, I would use the data tracker in my
clinical practice with prelinguistic children.

Strongly agree=4
Somewhat agree=1
Neutral
Somewhat disagree
Disagree
 3) I found the listing of behaviors helpful in the
observations of hand movements of prelinguistic
children.

Strongly agree=1
Somewhat agree=4
Neutral
Somewhat disagree
Disagree
4) I found the listing of vowels and consonants helpful
in describing communication.

Strongly agree=1
Somewhat agree=1
Neutral= 3
Somewhat disagree
Disagree
 6) This data tracker helps me visualize a
developmental pattern in hand movements.

Strongly agree=1
Somewhat agree=3
Neutral= 1
Somewhat disagree
Disagree
 5) It is easy to observe hand movements
in real time.

Strongly agree=1
Somewhat agree=2
Neutral
Somewhat disagree=2
Disagree
 7) This data tracker could assist in planning
treatments that may engage children in hand
movements plus vocalizations.

Strongly agree=2
Somewhat agree=3
Neutral
Somewhat disagree
Disagree
 8) This data tracker would be beneficial to
document progress for treatment plans and IEPs
of prelinguistic children.

Strongly agree=2
Somewhat agree=3
Neutral
Somewhat disagree
Disagree
 Research Phase II: Summary
Why use a clinical data tracker in gesture
measurement? More research is needed.
• Has potential to offer parents a reporting tool to
quantify and categorize hand movements and
gestures in their children.

• Has potential to offer speech-language clinicians an

easy to use and accessible tool to examine children’s
complete communication profile.
 Research Phase II: Summary
• Agreement between parents and clinicians was
moderately low.
• Clinicians may not understand the value of
reporting verbalization/vocalizations (and its link
to motor hand and gesture co-productions).
• Clinicians do not endorse that hand movements
are easy to observe in real time.
• Unclear if the data tracker assists clinicians in
examining developmental pattern of motor hand
acts and gesture.
 Research Phase II: Implications
• Data tracker may not be as reliable in practice as
counting frequency of behaviors from videotape.
• Clinicians generally do not have the time and
resources to code hand movements and gestures
from videotape.
• Combination of approaches may work best for
busy clinicians.
• Improved tools for tracking and recording
gestures in real time.
As we move to understand the complete
communication profile in children with
language delays and disorders, in this
small sample, speech-language clinicians
tend to agree that hand movements and
gesture observations are valuable, and
endorse their value in assessment and
intervention.
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