Research in Autism Spectrum Disorders 23 (2016) 50–62

Contents lists available at ScienceDirect

Research in Autism Spectrum Disorders

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

Do children with autism spectrum disorders have motor

learning difficulties?
Jin Boa,* , Chi-Mei Leea , Alison Colberta , Bo Shenb
a
Department of Psychology, Eastern Michigan University, 341 MJ Science Building, Ypsilanti, MI 48197, United States
b
Division of Kinesiology, Health and Sport Studies, Wayne State University, 441 Education Building, Detroit, MI 48202, United States

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

Article history: Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by social
Received 23 April 2015 and communication impairments as well as a wide range of behavioral symptoms. For years,
Received in revised form 17 November 2015 motor disturbance reported in ASD has not been treated as a core deficit because of the
Accepted 3 December 2015
overwhelming problems in sociability and communication. Recent studies, however, reveal
Available online 18 December 2015
that motor deficits are also fundamental to ASD presentation and contribute to the core
symptoms of ASD. Untreated motor problems can persist well into adolescence and
Keywords:
adulthood, resulting in long-term physical, psychological, and behavioral issues in individuals
Autism spectrum disorders
Motor adaptation
with ASD. Thus, the ability to understand and address the overall picture of a child with ASD,
Motor sequence learning including motor dysfunction, has become a critical need. This review focuses on sensorimotor
Implicit and explicit learning adaptation and motor sequence learning in children with ASD and presents related evidence
that compromised motor learning may play a critical role in motor dysfunctions of ASD. It
addresses possible factors that explain controversial findings in the literature and discusses
potential strategies for facilitating motor learning. Future intervention studies should address
the importance of motor learning beyond social and language domains in ASD.
ã 2015 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
2. Motor dysfunctions—another core feature of ASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
3. Motor dysfunctions and core symptoms of ASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4. Motor learning in children with ASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.1. Sensorimotor adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.2. Motor sequence learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
5. Implicit learning hypothesis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.1. Address the importance of explicit learning process in ASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.2. Modify the sensory and environmental inputs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.3. Apply the tasks that are appropriate to individual’s ability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.4. Address the individual differences and severity of ASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

* Corresponding author. Fax: +1 734 487 1155.

E-mail address: jbo@emich.edu (J. Bo).

http://dx.doi.org/10.1016/j.rasd.2015.12.001
1750-9467/ã 2015 Elsevier Ltd. All rights reserved.
 J. Bo et al. / Research in Autism Spectrum Disorders 23 (2016) 50–62 51

1. Introduction

Children with autism spectrum disorders (ASD) are characterized as having limitations in social interactions and
communication, as well as restricted interests and stereotyped or repetitive behavior patterns (APA, 2013). Although
clumsiness and delays of fundamental motor skills are commonly observed among individuals with ASD, motor disturbance
is not traditionally considered to be one of the core deficits of ASD (Downey & Rapport, 2012). Recently, however, motor
impairment has been identified as a fundamental deficit that contributes to the core symptoms of ASD (Bhat, Landa, &
Galloway, 2011; Cossu et al., 2012), and insufficient ability to acquire fundamental motor skills has been proposed as the core
for the motor dysfunctions in ASD (Gidley Larson, Bastian, Donchin, Shadmehr, & Mostofsky, 2008). It is estimated that the
prevalence of Autistic Disorder [based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text
Revision (DSM-IV-TR; American Psychiatric Association, 2000) diagnostic criteria] is around 0.1–0.2%, and Pervasive
Developmental Disorder (PDD, based on DSM-IV-TR dianostic criteria) is around 0.51–0.76% (Chakrabarti & Fombonne,
2001; Chakrabarti, Haubus, Dugmore, Orgill, & Devine, 2005). It is estimated that 21–100% of children with ASD display a
number of different motor deficits (Green et al., 2009; Pan, 2009), suggesting that motor impairment is a significant but
under-estimated deficit among individuals with ASD.
Based on the most current version of Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; APA, 2013),
there are two core areas of impairment in ASD: “social interactions/communications” and “restrictive, repetitive patterns of
behaviors, interests, and activities.” Although this new diagnostic system may provide a better overall description of the
disorder, one main concern raised by both clinicians and researchers is that it does not highlight the importance of motor
difficulties among the ASD population. Studies suggest that individuals with ASD not only experience motor coordination
difficulties, they also show delays in various aspects of motor development at an early age (e.g., David, Baranek, Wiesen,
Miao, & Thorpe, 2012). While DSM-IV-TR (American Psychiatric Association, 2000) suggested that Asperger’s disorder, but
not Autism, is associated with motor clumsiness, current evidence reveals that both clinical groups are uncoordinated and
exhibit motor deficits (e.g., Jansiewicz et al., 2006). A recent study even suggests that motor difficulties should be considered
a “cardinal feature” of ASD (Fournier, Hass, Naik, Lodha, & Cauraugh, 2010). In DSM-5 and earlier DSM-IV-TR criteria,
however, minimal description of motor impairment has been addressed. The absence of motor impairment criteria and the
lack of awareness on motor deficits may prohibit appropriate diagnosis and intervention.
Thus, in this review, we focus on the “motor” aspect of ASD, especially the ability to acquire motor skills (i.e., motor
learning). The purpose of this review is to present a synopsis of the current literature on the motor deficits in ASD and their
relationships with social communication and behavioral issues, address a possible hypothesis implicating the role of implicit
motor learning, and suggest directions for future research and intervention strategies.

2. Motor dysfunctions—another core feature of ASD

Since Kanner (1943) and Asperger (1991) proposed the descriptions of ASD, motor dysfunction of individuals with ASD
has focused on stereotyped and repetitive movements, such as hand flapping or body rocking (American Psychiatric
Association, 2000). Although stereotyped and repetitive motor behavior is the diagnostic criterion for ASD, parents and
mental health providers have often described a wide range of motor problems, such as delays of motor milestones in early
development and appearance of atypical motor patterns of both fine and gross motor skills (Lloyd, MacDonald, & Lord, 2013).
It has been reported that infants with ASD often display delays in supine, prone, and sitting skills in the first year of life (Lane,
Harpster, & Heathcock, 2012). Significantly less static and dynamic symmetry supine position (Esposito & Paşca, 2013) and
identifiable sensorimotor symptoms can be clearly demonstrated between 9 and 12 months of age (Baranek, David, Poe,
Stone, & Watson, 2006). Toddlers with ASD often display difficulties in reaching, clapping, and pointing (Gernsbacher, Sauer,
Geye, Schweigert, & Goldsmith, 2008), as well as crawling, walking, and other motor milestones (Lloyd et al., 2013). Children
with ASD also show significant developmental delays in accurately moving hands, wrists, fingers, toes, lips, and tongue (Bhat
et al., 2011; Ming, Brimacombe, & Wagner, 2007). Difficulties on these fundamental motor skills often persist well into
childhood, affecting motor coordination on a wide range of tasks, such as drawing, typing, writing, speaking, and playing
(Jansiewicz et al., 2006).
Clumsiness and atypical motor patterns (such as akinesia/dyskinesia) have been commonly used to describe individuals
with ASD. Loh et al. (2007) reported that non-functional arm wave and awkward “hand-to-ear” posture occurred more often
among children with ASD compared to their matched peers. Individuals with ASD also display poor postural control (e.g., less
static and dynamic symmetry standing position), abnormal gait (e.g., swing leg, waddling gait, etc.), and atypical motor
planning and sequencing (e.g., slow preparation in simple goal-directed motor tasks) (Bhat et al., 2011; Downey & Rapport,
2012; Dziuk et al., 2007). School-aged children with ASD demonstrate poor limb coordination and postural instability
compared to the age-appropriate norms. Specifically, individuals with ASD show poor upper-limb coordination on
visuomotor tasks (Ghaziuddin & Butler, 1998).
With the commonality of motor symptoms (also see extensive reviews in Downey & Rapport, 2012; Fournier et al., 2010)
reported in ASD, there is reason to think that general motor difficulties, beyond stereotyped and repetitive behavior, should
be considered as one of the core features of ASD. Provost, Lopez, and Heimerl (2007) reported that more than 60% of
individuals with ASD demonstrated clear motor symptoms that qualified for early intervention. Thus, evaluation of motor
activity may play a significant role in early identification of and intervention for ASD. Furthermore, studies reveal that delays
52 J. Bo et al. / Research in Autism Spectrum Disorders 23 (2016) 50–62

in motor milestones are present before communicative or social deficits, implying that impaired motor behavior may be an
open window for us to understand the underlying mechanisms of core characteristics of ASD (e.g., Leary & Hill, 1996).

3. Motor dysfunctions and core symptoms of ASD

Significant motor difficulties reported in ASD are closely related to a range of abnormal functions that critically contribute
to core symptoms of ASD, including social communication and restricted interests, activities and behaviors (Dziuk et al.,
2007). For example, akinesia/dyskinesia affect a person’s ability to initiate, switch, efficiently perform, or continue any
action, including those involved in communicating, interacting socially, or performing functional activities (Bhat et al., 2011;
Whittingham, Fahey, Rawicki, & Boyd, 2010). Difficulties with initiation of speech, slowness in responding to another person,
or stopping or freezing during activities are examples of how movement disturbance influences social interactions of
individuals with ASD. Stereotypic movements that seem to be unrelated to interactions (e.g., hand-flapping) can lead to
misunderstanding that individuals with ASD are not interested in the interaction, but prefer to engage in repetitive
behaviors. Disturbances of catatonic-like phenomena (e.g., odd postures, echolalia, and interruption and freezing of
movements) have a profound effect on language communication and the rate and intensity of social activities. Difficulties
with motor planning and sequencing can affect a person’s ability to regulate movement in order to communicate, relate, and
participate effectively with others (Jansiewicz et al., 2006; Ming et al., 2007). Problems with motor control and execution
could relate to pragmatics in social language contexts (Winstein, 1999). In general, motor symptoms of ASD inevitability
impact their development of social interaction and communication.
In addition, findings from neurophysiological and brain imaging studies support the links between motor and
communicative skills (Iacoboni & Wilson, 2006; Pina-Camacho et al., 2012). Areas of the brain implicated in language
functions (e.g., Broca’s area) are found to be involved in motor tasks (e.g., the execution, imagination, imitation, and
observation of finger movements; Heiser et al., 2003). Similarly, activation of brain areas related to motor functioning is
observed during language tasks (Iacoboni & Wilson, 2006). These patterns of activation may be partially attributed to
common neural mechanisms supporting language production and motor sequencing (Ojemann, 1984). In light of the
evidence for links between motor functioning and language communication, the impact of motor deficits on the core
symptoms of ASD warrants further exploration (Leary & Hill, 1996).

4. Motor learning in children with ASD

With the increased awareness and the importance of motor dysfunction in ASD, it is crucial to address possible factors
that contribute to these problems. It has been proposed that the impaired performance of certain movements is due to a
fundamental problem with motor learning, defined as relatively permanent behavioral changes associated with practice or
experience (Schmidt, Sherwood, & Walter, 1988). In clinical practice, children with ASD often show delayed learning of novel
motor skills such as peddling a tricycle or pumping their legs on a swing (e.g., Larson & Mostofsky, 2008). Clinical
assessments reveal that children with ASD demonstrate significant delays on all domains of learning, including motor, social,
and language (e.g., Landa & Garrett-Mayer, 2006). In addition, children with ASD have been found to show Parkinson-like
motor patterns (Hollander, Wang, Braun, & Marsh, 2009; Vernazza-Martin et al., 2005) as well as ataxic movements that are
similar to patients with cerebellar lesions (Esposito & Venuti, 2008; Rinehart et al., 2006a). Due to the relative frequency of
abnormalities in ASD [e.g., deformed caudate, putamen, and globus pallidus (Qiu, Adler, Crocetti, Miller, & Mostofsky, 2010);
reduced Purkinje cells and volumes in the cerebellar vermis (Allen, 2006)], the basal ganglia and cerebellum have been
highlighted as key regions of interest, although the underlying physiological mechanism of ASD is not clear. It is also known
that the basal ganglia and cerebellum play significant roles in motor learning, particularly in regard to motor adaptation and
sequence learning (see review Bo, Langan et al., 2008). Thus, in the current review, we will focus on two broad experimental
categories of motor learning: sensorimotor adaptation and sequence learning (Doyon & Benali, 2005; Willingham, 1998; for
extensive review on different ways of motor learning classification, see Wolpert, Diedrichsen, & Flanagan, 2011). In
sensorimotor adaptation, participants modify movements to adjust to changes in either sensory input or motor output
characteristics. For sequence learning, individuals learn to combine isolated movements into one smooth, coherent action
(Bo, Langan et al., 2008). We believe that the ability to acquire motor skills (i.e., motor learning) may be compromised in
individuals with ASD, which in turn, relates to motor symptoms in this population.

4.1. Sensorimotor adaptation

Sensorimotor adaptation tasks are used to gain insight into how humans adjust their movements to fit a changed
environment (Bo, Block et al., 2008). A useful approach to understanding adaptation is to investigate how motor
performance changes through repetition or practice when the relationship between hand movements and the sensory
feedback of those movements is altered. A real-world example of sensorimotor adaptation is riding a new bike that is in a
different model and size than an old one. The magnitude of the bike movement in response to the control of pedals, wheels,
and turns is changed. Thus, children need to learn the new relationship between his or her actions and the resulting bike
movements.
 J. Bo et al. / Research in Autism Spectrum Disorders 23 (2016) 50–62 53

Experimentally, a typical adaptation task consists of three phases: (1) baseline phase with normal sensory feedback of the
hand movements; (2) adaptation/learning phase (i.e., distorted trials) where the sensory feedback of the hand movement is
changed, and participants have to adaptively adjust their movement to compensate for the changed environment; and (3)
post-adaptation/learning phase where the sensory feedback of the hand movement is returned to normal. Successful
learning can be measured by the presence of an after effect wherein participants make errors in the opposite direction of the
distorted trials during the third phase (Fig. 1).
In the literature, there are two broad types of sensorimotor adaptation. One is kinematic adaptation, where the visual/
auditory feedback of movements is distorted through the use of computer programs (e.g., Cunningham, 1989; Pine, Krakauer,
Gordon, & Ghez, 1996) or the use of laterally displacing prisms (e.g., Held & Bossom, 1961; von Helmholtz, 2005). The other is
dynamic (or kinetic) adaptation, where the anticipated proprioception is altered by having participants move their limb
through an opposing force field (e.g., Izawa, Criscimagna-Hemminger, & Shadmehr, 2012; Shadmehr, 1997). The fundamental
difference between the two types of adaptation is how the sensory feedback is provided: kinematic adaptation mainly relies
on visual or auditory feedback whereas dynamic adaption mainly relies on proprioception (muscular force).
Although such experimental paradigms have been commonly used to assess motor learning in children with motor
disabilities, relevant studies on children with ASD are surprisingly rare. In one of those studies, Larson and Mostofsky (2008)
recruited 13 children with ASD to participate in a force field adaptation task in which force perturbation on the hand was
changed based on hand velocity during the adaptation phase. It was predicted that children with ASD would show a slower
adaptation rate and smaller after-effects compared to age-matched controls. The results, however, showed that children
with ASD demonstrated significant after-effects (i.e., a measure on positive adaptation) at a similar level to the control
children, indicating that children with ASD can adjust their motor output to the applied proprioceptive perturbations (Larson
& Mostofsky, 2008).
Similar findings were found in a ball-dropping adaptation task where weights of the balls were different (Mostofsky,
Bunoski, Morton, Goldberg, & Bastian, 2004). Children with high-functioning autism (HFA) and age-matched controls were
required to catch one of two identical balls of different weights (one light and one heavy) while attempting to maintain their
hand position. The light ball was used during baseline and after-effect phase, and the heavy ball was used in the adaptation
phase to see how participants adapted to the change. The results, again, suggested that children with ASD could adapt as
quickly as the matched controls with a similar level of after-effect. The authors concluded that children with ASD appeared to
have a normal ability to learn from a mismatch between the predicted and observed proprioceptive consequences and
rapidly update the internal model of the consequences of the ball’s impact on their arm.
Recent studies start to explore whether adaption relied upon proprioceptive and visual signals could be different in
children with ASD. Haswell, Izawa, Dowell, Mostofsky, and Shadmehr (2009) reported a study in which children with and
without ASD held a robotic arm to capture animals that were displayed on a computer screen. The robot perturbed the
children’s arm movements by producing a force field, and the children learned to control the robot while the force field
pushed their hand perpendicular to their direction of motion. Results revealed that both groups demonstrated improvement
in regard to the training target and transferred the learning to the targets with identical joint rotation (i.e., same in
proprioceptive signals, intrinsic coordinates). However, when asked to move to the targets with similar locations but not the
same joint rotation (i.e., same in visual signal, extrinsic coordinates), children with ASD did not show any learning whereas

A: Baseline B: Adaptation C: Post Adaptation: Aftereffects

Fig. 1. A typical adaptation task: Participants are asked to move a cursor from home (center of a screen) to target positions (e.g., one of four corner displayed
on a computer screen). Three phases include (A) baseline phase with normal visual feedback of the hand movements. In this phase, participants can move
straight lines (illustrated in solid grey lines) from the home to one of the targets (arrows represent the moving direction); (B) adaptation/learning phase
where the visual feedback of the hand movement is rotated for certain degrees (e.g., about 45 counter-clockwise in this illustration). During this phase, in
order to produce a straight movement to the upright target, participant needs to make a straight left-to-right (horizontal) movement. The dotted lines
represent the straight paths between the home and the targets. The solid grey lines represent the distorted moving trajectories at the early phase of the
adaptation. The dash lines represent the slightly distorted trajectories at the late phase of the adaptation after participants learn the clockwise movements;
and (c) post-adaptation/learning phase where the visual feedback of the hand movement is returned to normal. Now, participants normally demonstrate
errors in the opposite direction (i.e., aftereffect) because they have learned clockwise movements in the adaptation phase. Here, the solid grey lines
represent to the distorted trajectories in the opposite direction.
54 J. Bo et al. / Research in Autism Spectrum Disorders 23 (2016) 50–62

controls did. The authors concluded that children with ASD rely more on the proprioceptive sense rather than visual inputs
during adaptation process (Haswell et al., 2009).
Marko et al. (2015) reported a similar study where children with and without ASD made reaching movements while
holding a robotic manipulandum. During the adaptation trials, the perturbations were introduced in two parts: a
proprioceptive part generated by a force field that displaced the hand, and a visual part generated by a displacement to the
cursor. Participants had to learn how to control the robotic manipulandum under the perturbations from both
proprioceptive and visual feedbacks. Results showed that children with ASD outperformed controls when learning from
errors that were sensed through proprioception, but underperformed controls when errors were sensed through vision.
These findings are consistent to the previous studies reporting that children with ASD have intact or even enhanced
proprioceptive sense (Blakemore et al., 2006), and they greatly rely on proprioception rather than using visual feedback to
guide their movement (Glazebrook, Gonzalez, Hansen, & Elliott, 2009). Thus, it seems reasonable that children with ASD
could successfully adapt when they could employ proprioceptive information in dynamic adaptation tasks. Such results may
also explain that individuals with ASD often show difficulties learning motor skills mostly based on visual inputs (e.g.,
imitation; Vanvuchelen, Roeyers, & De Weerdt, 2007; Wild, Poliakoff, Jerrison, & Gowen, 2012), and failure to integrate visual
input (kinematics) into an action could lead to difficulties with learning in general (Gowen, 2012).
Previous work reveals that adaptation process depends on the integrity of the cerebellum. Numerous studies suggest that
adaptation to distorting prisms (e.g., Küper et al., 2014), visual transformations (e.g., Taig, Küper, Theysohn, Timmann, &
Donchin, 2012), and force fields (e.g., Izawa et al., 2012) is impaired in individuals with cerebellar damage (for review, see Ito,
2002). It is known that the development of cerebellum is abnormal in ASD (e.g., Jeong, Tiwari, Behen, Chugani, & Chugani,
2014; Shevelkin, Ihenatu, & Pletnikov, 2014), and children with ASD often show cerebellar-ataxic symptoms (e.g., Esposito &
Venuti, 2008; Rinehart et al., 2006a). It is a little surprising that impaired learning has not been found in most of classic
adaption tasks. To examine the possible connections between cerebellum and adaptation, Marko et al. (2015) recently
acquired T1-weighted 3D magnetization-prepared rapid gradient-echo (MP-RAGE) images and children with ASD
performed an adaptation task with proprioceptive and visual perturbations outside of the scanner. They found that the
anterior cerebellum, extending into lobule VI, and parts of lobule VIII were smaller than normal in children with ASD
although the whole cerebellar volume was normal. In addition, the volume of the anterior cerebellum related to the pattern
of learning from visual and proprioceptive errors. The authors argued that an increased sensitivity to proprioceptive error
and a decreased sensitivity to visual error during adaptation might be specifically associated with abnormalities in the
sensorimotor cerebellum.
If the abnormalities of sensorimotor cerebellum relate to decreased visual sensitivity, as argued by Marko et al. (2015), it
can be expected that children with ASD will not demonstrate adaptation in tasks with visual perturbations. Until now, few
studies have been reported on kinematic adaptation in this population. In one experiment, children with ASD performed a
visuomotor adaptation task, where the visual feedback of participants’ hand movements was rotated clockwise for 19
during the adaptation phase (Larson & Mostofsky, 2008). In another experiment using a prism, the visual map of the
environment was shifted to left for about 17 (i.e., 30 diopter). The results of both tasks were very similar to the ones in the
dynamic adaptation tasks, that is, children with ASD showed the same adaptation rate and positive aftereffect as typically
developing children. It appears that there is a lack evidence to support impaired adaptation in the current literature.
Recently, several researchers have argued that adaptation includes both implicit and explicit components especially
when participants were aware of the rotation or instruction has been given (Hegele & Heuer, 2010; Heuer & Hegele, 2011).
The measure of aftereffect theoretically reflects the implicit component of adaptation. The explicit component of adaptation
is measured as strategic corrections based on conscious awareness of the rotation. Previous studies revealed that children
with ASD have excessive reliance on explicit learning when acquiring predictive knowledge (Klinger & Dawson, 2001). It is
unclear, at this point, how the explicit learning plays in a role in visuomotor adaptation for ASD. Additionally, besides
cerebellar dysfunction, as suggested by Marko et al. (2015), dysfunctions within other brain regions associated with motor
learning (such as motor and sensorimotor cortexes located in frontal and parietal areas, and basal ganglia) or abnormalities
in connections between these regions may also involved in ASD (e.g., Gidley Larson et al., 2008). With limited number of
adaptation studies available in the literature, future studies are needed to elucidate the process of sensorimotor adaptation
in the ASD and its related neural correlates.

4.2. Motor sequence learning

Sequence learning refers to an ability to combine isolated movements into one smooth, coherent action. It can be implicit,
where the acquisition of information is not accompanied by conscious awareness of what was learned or the fact that
learning occurred (Reber & Robinson, 1993), or explicit, in which subjects develop clear awareness of the learned structure. A
widely used experimental paradigm to investigate sequence learning is the serial reaction time (SRT) task, where
participants are required to respond to a series of stimuli appearing successively at different locations by pressing a
corresponding key (Nissen & Bullemer, 1987). Unknown to the participants, there are probabilities governing the transitions
between stimuli. Typically, implicit sequence learning occurs when participants demonstrate improvements in the speed
and/or accuracy of their responses, but are unable to explicitly describe what they have learned. On the other hand, explicit
sequence learning is concluded if participants show any signs of sequence awareness.
 J. Bo et al. / Research in Autism Spectrum Disorders 23 (2016) 50–62 55

Findings in the ASD literature have been inconsistent. Some studies claim to find impairments in implicit motor sequence
learning in ASD. For example, Mostofsky, Goldberg, Landa, and Denckla (2000) recruited children with and without ASD to
perform a classic SRT task with a 10-element learning sequence. Results revealed that controls demonstrated a significant
reduction in the response time over the learning blocks whereas the children with ASD did not. In addition, the rebounded
time from the random stimuli and the learned elements was significantly greater in the control group compared to the ASD
group, suggestive of the impairment in implicit motor sequence learning.
Similar findings were reported in another study using multiple-sessions of SRT in which children with and without ASD
participated in six training and test sessions of an 8-element SRT task and a 4-element SRT task (Gordon & Stark, 2007).
Slower learning rates were found over multiple learning sessions in children with ASD. In addition, significant individual
differences were found: while positive learning existed at the individual level in the 4-element task, it was not found in the 8-
element task, suggesting that most of children with ASD had difficulty acquiring motor sequences. In addition, they
demonstrated more learning difficulties when the complexity of the tasks increased (i.e., length of the learning sequence in
this case).
It can be argued that the observed learning deficits in SRT tasks could be due to the poor motor execution because
children with ASD often showed long movement time. To address this issue, Mostofsky et al. (2000) employed a rotary
pursuit visuomotor task, in which the differences in motor execution were controlled. Groups of children with ASD,
attention-deficit/hyperactivity disorder (ADHD), and matched controls were asked to keep a handheld stylus over a target as
it moved in a clockwise pattern at a continuous speed. Results revealed that children with ASD had significantly less on-
target time and showed less change across trials than both the ADHD and the control groups after the individual differences
in motor execution were minimized. These findings not only suggest that the impaired sequence learning was not due to the
poor movement execution, but also reveal that such impairment was more specific to ASD.
While some evidence suggests impairment in implicit sequence learning in ASD, there are several studies suggesting
intact sequence learning in this population. For example, Brown et al. (2010) compared children with and without ASD in a
classic serial reaction time task and reported intact implicit learning in ASD. Nemeth et al. (2010) employed an alternative
serial reaction time (ASRT) task in which every other element in a sequence included an interposed random element (to
avoid explicit awareness of the sequence). Results revealed that controls and children with ASD showed similar sequence-
specific and general skill learning. Barnes et al. (2008) also used the ASRT task and reported that the overall magnitude of
learning was even larger in ASD than control groups after controlling for the baseline differences on movement response
speed. The authors argued intact implicit sequence learning in children with ASD, but, at the same time, acknowledged the
fact that they could not rule out the influence of cognitive strategies in their experiments. To address the potential explicit
learning that might take place during sequence learning, Travers, Klinger, Mussey, and Klinger (2010) designed their study
using 0 msec response-stimulus interval, a longer sequence (i.e., 12 elements), and a sequence that controlled for second-
order conditional relationship. Results, again, revealed that individuals with ASD were able to implicitly learn a 12-element
sequence as well as and at the same rate as age- and IQ-matched typically developing participants (Travers et al., 2010). All
these findings suggest that the implicit motor sequence learning may be intact in persons with ASD.
What is interesting is that individuals with ASD appear to have different neural activation patterns even when they show
similar behavioral performance as their matched controls. For example, Müller, Cauich, Rubio, Mizuno, and Courchesn
(2004) reported that participants with ASD showed less overall activation and more activation in the right pericentral and
premotor cortex during the later stages of learning compared to controls despite the fact there were no behavioral
differences when participants learned an 8-element sequence. Sharer et al., (2015) also did not find behavioral differences in
an 8-element SRT task but reported that individuals with ASD had decreased activity in the superior temporal sulcus and
posterior cingulate cortex. In another recent study (Travers, Kana, Klinger, Klein, & Klinger, 2015) using a 12-element
sequence, decreased activation was found in the right superior parietal lobule (SPL) and right precuneus in individuals with
ASD. In this particular study, significant less learning was found in children with ASD. It appears that children with ASD may
rely on different neural processes during motor sequence learning. Further studies are desperately needed to examine how
different brain areas play their roles during the learning processes.
Overall, it is a little surprising that relatively few published studies have been reported to address the “motor learning”
aspect of ASD. Based on the limited number of the studies in the literature, findings were quite inconsistent and
controversial. Some studies claim to find impairments in motor learning in ASD whereas other studies report intact motor
learning in this population. Such discrepancies may due to many possibilities, such as different sample size across studies,
the tested samples (i.e., most studies only test children with high-functioning ASD), and the variations of the experimental
tasks. More studies are needed to clarify how different factors can affect the motor learning in this population. In addition,
studies in other domains of ASD symptomology (e.g., social and language learning) may help us to understand the
controversial findings in motor learning of ASD.

5. Implicit learning hypothesis?

Implicit learning is described as the acquisition of knowledge without intention or awareness (for reviews see: Reber,
1993; Shanks & Berry, 2012). It is thought to be one important mechanism for acquiring social, communicative, and motor
skills (e.g., Kaufman, DeYoung, Gray, Brown, & Mackintosh, 2009; Meltzoff, Kuhl, Movellan, & Sejnowski, 2009; Perruchet &
Desaulty, 2008), raising the possibility that social, communicative, and motor impairments in ASD may arise, in part, from a
56 J. Bo et al. / Research in Autism Spectrum Disorders 23 (2016) 50–62

general deficit in implicit learning. Here, it is important to note that neither the basal ganglia nor cerebellum is a simply
motor structure, though they play critical roles in motor learning. These two structures reciprocally connect to frontal and
other associative and affective areas (Middleton & Strick, 2000; Middleton & Strick, 2001), and interrelated “motor” and
“cognitive” networks have been found in multiple connectivity studies (Bernard et al., 2012; Bo et al., 2014). For example, the
caudal putamen relates more to primary and supplementary motor cortices, and the rostral putamen relates more to frontal
cognitive regions (Bo et al., 2014). Lobules of the anterior cerebellum were more strongly correlated with motor regions, and
those of the posterior cerebellum were correlated with non-motor cortices (Bernard et al., 2012). Thus, it is not surprising
that children with basal ganglia and cerebellar insults show a range of non-motor autistic symptoms (Tavano et al., 2007)
whereas children with ASD often demonstrate Parkinson-like (Hollander et al., 2009; Vernazza-Martin et al., 2005) and
ataxic motor patterns (Esposito & Venuti, 2008; Rinehart et al., 2006a). A recent imaging study revealed that abnormalities
within paralleled (yet overlapping) frontal–subcortical circuits were differentially associated with impaired acquisition of
motor, social and communicative skills in ASD (Qiu et al., 2010). Such findings suggest possible interactions among motor,
social and communicative learning. Impaired motor learning can profoundly impact not only the motor function, but also
social and communicative skills.
A number of studies have reported that children with ASD have difficulty learning in situations that require perceiving
relationships among different parts and multiple experiences in a wide range of tasks (Hudson, Nijboer, & Jellema, 2012;
Naigles, 2013; Reitzel et al., 2013; Schneider, Slaughter, Bayliss, & Dux, 2013). Therefore, it has been proposed that a
fundamental difficulty with general implicit learning is one key contributor to ASD symptomatology (Klinger, Klinger, &
Pohlig, 2007). To test this hypothesis, Klinger et al. (2007) conducted a series of studies to examine whether individuals with
ASD are indeed impaired in their implicit learning. In addition, they investigated whether the impaired implicit learning
could be compensated for by using explicit processes. It was first tested using a prototype category learning task, in which
participants were shown members of a category (e.g., a pretend species of animal) that vary on features (e.g., length of legs,
size of tail, etc; Klinger & Dawson, 2001). After learning, participants should be able to discriminate between the category
prototype (i.e., an animal that is composed of the average of all the previously seen features) and the novel category
members. In their study, children with and without ASD performed one set of category learning tasks that could be solved
using a rule-based approach and a second set of tasks in which there was no rule that defined category membership
(prototype task). Results showed that both groups of children were successful at using a rule to learn new categories whereas
only the typically developing children were able to learn in the prototype tasks. The authors argued that the lack of learning
in the prototype tasks was due to the impaired implicit learning in ASD whereas the explicit learning was intact. However, it
is important to note that participants in this study were relatively young (Mean = 6.5 years of age), and most of the
participants with ASD were relatively low-functioning. It was unclear whether such implicit learning deficits would be
apparent in individuals with ASD who were older and/or higher functioning.
Thus, the same group of researchers recruited a group of older (Mean = 11.5 years of age) and high-functioning (defined
based on Intelligence Quotient, IQ: 92-128) children with ASD for a follow-up study. They used a different measure of implicit
learning with an artificial grammar learning task (Reber, 1989). Participants were first shown examples of sequences of
shapes generated from an artificial grammar but were not told that the sequences were generated by a set of rules. Then, they
were asked to discriminate the sequences that follow the grammar rules in comparison to those that contain a rule violation.
Successfully discriminating these two types of sequences is suggestive of implicit learning. Results showed that both
children with and without ASD chose the grammatical sequences at a higher rate than chance, suggesting that this group of
high-functioning children may not differ from typically developing children in implicit learning. Then, the authors further
examined whether the positive learning found in the learning task was affected by explicit learning ability for each group.
They found that the explicit learning ability (measured by Kaufman Brief Intelligence Test, Kaufman & Kaufman, 1990) was
related to artificial grammar learning for the group with ASD but not for the control group. Those children with ASD who had
low explicit learning ability did not show artificial grammar learning whereas those with high explicit learning did. It
appears that children with ASD who are high functioning may be able to show equivalent learning performance if they can
employ explicit learning processes to compensate for impaired implicit learning.
Similar findings were reported in examining the implicit Theory of Mind (ToM) deficits in ASD. Twenty-four individuals
with high functioning ASD and age-matched controls were instructed to watch ToM movies and detect a hand-wave from an
actor towards the hand puppet (an implicit false-tracking task, for detailed description of the movies see Schneider et al.,
2013). Eye movements were measured between two experimental conditions: false-belief and true-belief scenarios. In the
false-belief scenarios, the puppet hid the ball in one of two boxes and then moved it into the other box. At this stage, an actor
was present and watched these actions. Then, the actor left the room and the puppet moved the ball back to the initial box
(i.e., actor’s belief mismatched with the ball’s actual location). The true-belief scenario was the same as the false-belief trials
except that the actor did not see the ball being moved to the other box and back to the initial box (i.e., actor’s belief was
consistent with the ball’s actual location). Results revealed that while controls implicitly and continuously tracked the false-
beliefs of an actor for a one-hour testing session, individuals with ASD did not show any evidence of implicit false-belief
tracking. However, similar performance between ASD and control groups was found in the explicit ToM measures (i.e., the
Stranger Stories task, where participants read narratives and answered questions about the mental view point of a character:
e.g., a girl is being polite and appreciative about a gift that she really did not want). The authors argued that individuals with
ASD who could not employ the explicit process to perform the task showed persistent impairment in the implicit task over a
prolonged period of testing. It appears that the cognitive awareness of the task can significantly influence the learning
 J. Bo et al. / Research in Autism Spectrum Disorders 23 (2016) 50–62 57

outcome. Although compromised performance existed in the implicit tasks, the impaired behavioral performance could be
hidden when explicit processes are involved.
Beyond the influence of cognitive awareness, several recent studies have tackled implicit learning by examining the effect
of cues in the environment. Clinically, we often notice that children with ASD are unlikely to dynamically adjust their
behavior according to the environment unless explicitly advised to do so. Individuals with ASD also typically report being
unaware of or confused by the contextual cues in their environment that would necessitate a change in their behavior.
Nevertheless, in contrast to self-report and clinical observations that indicate impairments in implicitly learned
environmental information, several experimental studies reported that children with ASD did not have difficulties in context
cueing tasks (Barnes et al., 2008; Kourkoulou, Leekam, & Findlay, 2012). Thus, it becomes interesting to ask why the findings
from experimental tasks do not necessarily reflect the behavior deficits identified by clinical observation? One explanation
may be that most context cueing studies have used highly similar tasks, which make it difficult to know whether the
characteristics of cues may play any role in the learning process.
Recently, Travers et al. (2013) manipulated the stimulus-identity and spatial-configuration characteristics of cueing to
examine implicit learning in ASD. In their first experiment, sixteen individuals with ASD and matched controls completed a
task when the identifying feature of the stimuli was changed but not the location of the distractors (i.e., stimulus-identity
cues). In their second experiment, a different group of individuals with ASD and controls completed a revised version of the
contextual cueing task with both stimulus-identity cues (same as their first experiment) and global spatial-configuration
cues, where the location of the individual distractor was changed. Results showed that when only stimulus-identity cues
were provided, individuals with ASD had significant difficulty with implicit contextual cueing. However, when both
stimulus-identity and spatial-configuration cues were provided, individuals with ASD demonstrated successful learning.
One may argue that the spatial-configuration cues in Travers et al. (2013) might elicit explicit learning because changing
location provided information that may be more salient and explicit compared to stimulus-identity cues. Findings from their
post-hoc awareness tests showed that neither group demonstrated greater than chance explicit knowledge of the stimuli. It
can be concluded that both groups appeared to be using implicit learning to successfully learn the contextual consistencies.
The authors then proposed that, because these two types of cues are thought to rely on distinct neural networks (i.e., the
dorsal or “where” pathway for location–spatial-configuration cueing; the ventral or “what” pathway for object recognition–
stimulus-identity cueing; Huang & Grossberg, 2010), individuals with ASD may have implicit learning deficits when object
recognition is the source of predictable information (Huang & Grossberg, 2010). Alternatively, they may excel when spatial
configurations (in addition to identity relations) are involved in learning. Further brain imaging studies will be helpful to test
this hypothesis and verify whether individuals with ASD are differentially relying on one pathway over the other during
implicit learning.
In general, implicit learning is thought to mediate language learning and the acquisition of motor and social skills
(Cleeremans & Dienes, 2008). With the limited amount of studies from the motor learning perspective, studies from the
social and language literature could shed some lights on understanding the motor dysfunction in ASD. It appears that,
although controversial findings exist in social and language learning, the implicit learning hypothesis is generally supported
(e.g., Klinger et al., 2007). However, more studies are needed to explore whether the social, communicative, and motor
impairments in ASD are due to a general or domain-specific deficit in implicit learning. In addition, researchers should be
cautious of influential factors, such as cognitive awareness and environmental cues, when examining implicit learning.

6. Discussion

Converging evidence suggests that motor impairment should be considered as a fundamental deficit that closely relates
to core symptoms of ASD (e.g., Larson & Mostofsky, 2008). Impaired ability to acquire fundamental motor skills may be the
core reason for motor dysfunctions in ASD (e.g., Larson, Bastian, Donchin, Shadmehr, & Mostofsky, 2008). Although the
research findings on motor learning are quite controversial, studies from the social and language perspectives suggest
several important points when we examine motor learning. Here, we want to highlight several aspects for future studies and
correspondent intervention strategies that may clinically applicable in this population.

6.1. Address the importance of explicit learning process in ASD

Numerous studies from different domains of ASD (e.g., social, language, and motor learning) suggest that explicit
awareness of the learning tasks can facilitate overall performance. For tasks that appear to be effortless and intuitive for
children who are typically developing, individuals with ASD tend to use more effortful, explicit problem-solving approach.
Studies showed that children with ASD rely more on the explicit rule-based learning strategies (e.g., Bowler, Matthews, &
Gardiner, 1997; Happé, 1995). For example, researchers could successfully teach children with ASD to pass a set of ToM tasks
with verbal instructions on specific rules (Hadwin, Baron Cohen, Howlin, & Hill, 1996; Ozonoff & Miller, 1995). Additionally,
children with ASD tend to be more socially responsive and show a higher level of social ability when placed in a highly
predictable social situation (Dawson, Hill, Spencer, Galpert, & Watson, 1990). Furthermore, it has even been hypothesized
that the repetitive behaviors and restricted interests that characterize persons with ASD may be an attempt to make their
tasks more predictable and explicitly understood (Klinger et al., 2007).
58 J. Bo et al. / Research in Autism Spectrum Disorders 23 (2016) 50–62

Thus, if children with ASD have the ability to use explicit learning processes to compensate for their impaired
performance, future interventions will need to either find a method to teach individuals with ASD how to understand
implicit information (i.e., make the subtle information more obvious or present stronger and clearer error feedback
information), or provide clear instructions of explicit rules to solve the motor problems (i.e., teach problem-solving
strategies in an explicit manner). Although instruction-enriched interventions have been used in social and linguistic
domains (Rogers, 2001; Stahmer, 2007), applying such techniques to motor skill learning is rare. Future studies addressing
the importance of cognitive involvements in motor learning are desperately needed, particularly as it is difficult to
differentiate the influence of one factor on the other and how they might influence one another.

6.2. Modify the sensory and environmental inputs

Effective motor learning relies on accurate sensory input/feedback, especially proprioception and vision. Deficits in
sensory processing among individuals with ASD could be another possible factor that influences the learning process.
Several studies indicated that children with ASD demonstrate intact or even enhanced tactile and proprioceptive senses
(Blakemore et al., 2006; Fuentes, Mostofsky, & Bastian, 2009; Glazebrook et al., 2009), but they have difficulties in vision or
sensory integration when controlling movements (Fuentes, Mostofsky, & Bastian, 2011; Pellicano & Gibson, 2008; Pellicano,
Gibson, Maybery, Durkin, & Badcock, 2005). Thus, it is not surprising that children with ASD showed positive learning in
dynamic adaptation tasks (e.g., Larson & Mostofsky, 2008) possibly because they could rely more on their proprioception
rather than visual feedback to guide their movements. Future interventions or teaching methods that enhance the
proprioceptive information, and/or minimize the demands for visual processes, may be more helpful in facilitating motor
learning.
Findings from Travers et al. (2013) in which the characteristics of contextual cueing (i.e., stimulus-identity versus spatial-
configuration) were manipulated may give additional insight into how to facilitate motor learning in tasks that are vision-
dominant. Children with ASD may have difficulties identifying the related sensory information when there is only one
characteristic of stimulus (i.e., stimulus-identity, “what” pathway) changed in the environment. However, if the identity of
the stimulus is coupled with the overall spatial settings (i.e., spatial-configuration, “where” pathway), children with ASD are
able to learn the related cues and make the correct response. Thus, another possible intervention approach to help children
with ASD with motor learning is to provide visual cues in a more predictable setting. Connecting the acquiring skills with the
environment may help them to identify the right cues for learning the appropriate movements. Future studies on sensory
integration in daily living environments will be one of the key domains for effective treatment.

6.3. Apply the tasks that are appropriate to individual’s ability

Children with ASD often show motor patterns that are similar to patients with cerebellar lesions (Esposito & Venuti, 2008;
Rinehart et al., 2006a) and Parkinson disease (Hollander et al., 2009; Vernazza-Martin et al., 2005). Numerous neuroimaging
studies reveal that the cerebellum plays a significant role in adaptation, and the basal ganglia is critical for sequence learning
in addition to a range of other brain areas (review see Bo, Block et al., 2008). Given the fact that cerebellar abnormality is
often reported in individuals with ASD (Rogers et al., 2011), it is a little surprising that evidence of impaired learning in classic
adaption tasks is lacking. It is possible that children with ASD do have compromised adaptation, but the null results were due
to the influential factors in the previous designs, such as provision of sensory feedback (i.e., most studies employed the
proprioceptive feedback), severity of the symptoms (i.e., all reported studies recruited “high-functioning” ASD), and
cognitive awareness.
Alternatively, it can be argued that children with ASD may have a relatively intact adaptation, and the learning deficits in
ASD may be more task-specific. Those brain areas found to be abnormal in individuals with ASD may not be fully implicated
in adaptation processes. If this is the case, it will be useful to introduce a learning task that is built upon the child’s existing
motor ability. For example, if learning deficits in ASD are task-specific and the impaired region mainly relates to graphomotor
skills, learning to type on a keyboard rather than practice handwriting on paper should be more practical. Intervention
programs should select tasks that are feasible and manageable for children with ASD. Future research examining the neural
correlates of motor learning in individuals with ASD is definitely needed to better understand the differential performance
among learning tasks and to examine the possibility of a relatively preserved functionality of brain areas involved in the
learning processes for individuals with ASD.

6.4. Address the individual differences and severity of ASD

Based on the diagnostic criteria in DSM-IV, a number of studies revealed that motor impairment is one of the areas that
shows significant differences between ASD subtypes (Ghaziuddin & Greden, 1998; Papadopoulos et al., 2012). For example,
Ghaziuddin and Butler (1998) reported less impaired hand coordination in groups of children with Asperger’s disorder
compared with children with Autistic disorder and PDD-NOS. Individuals with Autistic and Asperger’s disorders
demonstrated different profiles in their motor preparation/initiation (Rinehart et al., 2006a), ocular motor behaviors (e.g.,
voluntary saccades, Stanley-Cary, Rinehart, Tonge, White, & Fielding, 2011), gait functions (Rinehart et al., 2006b), and ball
skills and balance (Papadopoulos et al., 2012). However, ASD should represent a continuum from mild to severe, rather than
 J. Bo et al. / Research in Autism Spectrum Disorders 23 (2016) 50–62 59

being distinct disorders (i.e., distinguishable subtypes; Wilson et al., 2013) as is now reflected in DSM-5 criteria. Recent
studies reveal that the motor impairment profile predicts the severity levels of core ASD symptoms. Leonard, Bedford,
Pickles, and Hill (2015) found that the scores on motor development in infancy related to the rate of language and
communicative impairments in at-risk sibling who were later diagnosed with ASD. Hellendoorn et al. (2015) reported that
the fine motor skills in early childhood predicted language, visuospatial cognition and object exploration. Freitag et al. (2007)
found that the severity of motor deficits correlates with the degree of social withdrawal and the severity of symptoms. Thus,
counting the number of diverse symptoms, including motor symptoms, may better fit the conceptualization of continuum in
DSM-5. Further studies are needed to evaluate how the new diagnostic criteria in DSM-5 relate to our understanding of
motor dysfunctions in ASD, and how motor dysfunction relates to other core symptom domains (i.e., social communication,
restricted and repetitive behaviors). ”
Besides addressing symptom severity, most ASD studies in the motor learning literature recruit participants who are
“high-functioning.” A series of studies reported by Klinger et al. (2007) revealed that impaired implicit learning could be
clearly illustrated in the children who are “low-functioning” whereas it could be concealed when the participants are more
“high-functioning” (Klinger & Dawson, 2001; Klinger et al., 2007). It seems that children who are “high-functioning” tend to
utilize certain compensational strategies during learning. It is known that learning difficulties are more prominent in lower
functioning individuals with ASD (Vivanti, Barbaro, Hudry, Dissanayake, & Prior, 2013). Therefore, it is somewhat paradoxical
that the majority of research only reported individuals with ASDs whose IQ scores are within or even above the normal range.
Challenges of examining “low-functioning” versus “high-functioning” individuals may include teasing apart cognitive
dysfunctions, differentiating learning difficulties from intellectual impairment, compliance with research protocols, etc.
Future research should address these challenges and involve participants encompassing the spectrum of severity of ASD,
including lower functioning participants, to examine how levels of symptom severity (i.e., individual differences) may affect
motor learning. Intervention should be appropriate to children’s severity level and employ instructions that are
understandable to the patient’s communicative and cognitive abilities.
Recently, use of computer-aided diagnosis has attached strong attention, as it is a tool to provide objective, quantitative
measures of this disorder. Crippa et al. (2015) reported a study to examine whether “low-functioning” children with ASD as
young as 2 years-old could be identified based upon the kinematic analyses on a simple upper-limb movement (i.e., reach-to-
drop). Their results showed that the kinematic features of movements could correctly discriminate preschool children with
ASD at a maximum classification accuracy of 96.7%. Such exciting findings offer insight on a possible motor signature of ASD
and may be valuable to support the clinical practice of diagnosing ASD.

7. Conclusion

Although social and communication impairments and repetitive behavioral deficits are the key features of ASD (Downey &
Rapport, 2012), more recent studies suggest that motor deficits should also be considered to be among the core symptoms of ASD
(Bhat et al., 2011; Cossu et al., 2012). Compromised motor skill acquisition may play a critical role in poor motor performance in
this population (Larson & Mostofsky, 2008). However, findings from the motor learning literature are quite inconsistent and
controversial. Possible factors that may explain the discrepancies from different studies include (1) the ability to employ
additional cognitive functions, such as explicit learning processes; (2) individual differences and spectrum of severity that
characterize the tested participants; (3) the ability to identify related cues in the environment; and (4) intact brain networks for
certain learning tasks. Future research addressing the importance of these factors is definitely necessary. We believe that the
ability to understand and address the overall picture and symptom presentation of a child with ASD, including motor
dysfunctions, has become a critical need for timely diagnosis and development of effective intervention programs.

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