When my grandson was born he was a finicky baby.  He used to cry a lot and holding him in your arms offered no solace.   He seemed to be awake for most of the night.  We also seemed to never be able to capture his attention.  Still all of this was easily overlooked and attributed by the pediatrician to either infantile colic or overzealous parents. However, what really caught my attention was his lack of fine and gross motor skills.  It was difficult for him to hold a baby bottle and feeding by himself was out of the question.  Even when engaging in stereotyped behaviors, e.g., constantly slapping on a wheel to make if spin, his movements were awkward and seemingly lacked fluidity.  Motor skills have played such an important component in his life that I decided to do some research on the same.  However, before explaining some of our findings and potential explanations, I would like to describe the problem.  As an aside, I am using the word «clumsiness» in the title as fine and gross motor abnormalities would not be necessarily understood by all of the audience.  Also, other synonyms for clumsiness, like awkwardness, carried negative connotations which I wanted to avoid.  Some practical suggestions are offered in the last paragraph of this blog.

WHAT DO WE KNOW? Ever since Kanner’s publication in 1943, abnormalities in motor skills have been regarded as part of the symptomatology characterizing autism as a unique syndrome. Kanner’s report was brief describing his patients as clumsy in gait and gross motor performance but otherwise failing to elaborate on the subject.  One year later, Asperger expanded on the motor difficulties of his patients which he described as clumsy. More specifically, Asperger described his incept case, Fritz, as having a slouched posture and as having no mastery over his body (Asperger, 1944).  More recently, Wing, based on her experience and the original cases reported by Asperger, proposed that ill-coordinated movements and odd posture is a central feature of the syndrome (Wing, 1981; Burgoine & Wing, 1983). In effect, parental accounts indicate that affected children have difficulties in imitating someone, skipping, throwing or catching a ball, handwriting, tying shoelaces, and riding a bike.  The magnitude of the deficit appears similar to those with intellectual disabilities who are themselves motor impaired (DeMyer, 1976). It is therefore unsurprising that motor difficulties have made their way into our modern classification system: «Motor clumsiness and awkwardness may be present but usually are relatively mild, although motor difficulties may contribute to peer rejection and social isolation, e.g., inability to participate in group sport» (DSM-IV-TR, p. 81).

It can be surmised that children with autism and Asperger syndrome are as clumsy and awkward in their motor behavior as they are socially. Motor abnormalities in autism bear the characteristics of precedence and universality that characterize a core symptom.  According to Ornitz et al. (1977) by 6 months of age autistic children have noticeable delays in attaining their motor milestones. The magnitude of the delay increases during the 2^nd half of their 1^st year of life. The presence of delayed motor skills at 2 years of age is the clearest distinguishing factor for children who continue meeting diagnostic criteria for autism spectrum disorders (ASD) at 4 years of age (Sutera, et al. 2007). These motor abnormalities are not readily identified in a routine neurological examination and prevalence rates depend on the number and types of symptoms examined.  In a recent study of 154 children with ASD, hypotonia was the most common symptom (51%), followed by apraxia (41%), toe walking (25%), gross motor delay (12%) and reduced ankle mobility (2%) (Ming et al., 2007). These motor deficits are observed early in infancy in the majority of examined patients and appear to improve over time (Ming et al., 2007).

Another recent study using the Test of Gross Motor Development in ASD revealed that all patients had below average to very poor locomotor skills and most were similarly impaired in object control skills (Berkeley et al., 2001).Underlying the motor skill deficits in autism and Asperger syndrome is a dyspraxia or an inability to plan, organize, and execute movement in the absence of any known physical and/or neurological condition.  It has been estimated that 80% of autistic individuals display «motor dyspraxia”, or clumsiness (Weimer et al., 2001). The prevalence of dyspraxia is higher in boys than girls and it is often associated with sleeping disorders and Sensory Integration Dysfunction. Dyspraxia has also been linked to difficulties with sequencing and language, as well as in maintaining attention. It is therefore unsurprising that a recent study of dyspraxia in autism concluded that “ …praxis in children with autism is strongly correlated with the social, communicative, and behavioral impairments that define the disorder, suggesting that dyspraxia may be a core feature of autism or a marker of the neurological abnormalities underlying the disorder” (Dziuk et al., 2007, page 734).

This deficit is specific to autism when compared to other neurodevelopmental disabilities, i.e., ADHD (MacNeil & Mostofsky, 2012). The neurological basis of dyspraxia is unknown. People with ASD do worse than controls on a modified Romberg test, tandem gait and in repetitive finger-thumb apposition (Weimer et al., 2001). The pattern of symptoms eliminate a vestibular abnormality in these patients. In general, when attempting localization, the genesis of proprioceptive deficits is usually attributed to a polyneuropathy, dorsal column lesion, or cerebral cortical abnormality. In the case of ASD individuals the deficit may be in the cortex and its connections.

The above discussion may be of practical importance.  I remember watching  Mel Kaplan interview a patient for visuomotor exercises.  That particular morning the patient was quite finicky and uncooperative.  Mel claimed that the patient had lost his sense of body position (proprioception) and placed a small bean bag over his head.  Almost immediately the patient started behaving better and being more cooperative. For the same reason I am an ardent proponent of providing swimming lessons to autistic individuals as part of teaching curriculums.  The pressure from the surrounding water is reassuring for many of them. This may be the same reason why tight vests or the squeeze machine machine seemingly have a calming effect on patients. An abnormality in sensing our own body plan is extremely incapacitating but not unique to autism.  For those interested you may find suitable reading material in:

1) Jill Bolte Taylor, «My Stroke of Insight»

2) Elyn Saks, «The Center Cannot Hold»

References Cited:

Asperger H; tr. and annot. Frith U. Autistic psychopathy’ in childhood.in Frith U. Autism and Asperger syndrome. Cambridge University Press. pp. 37–92, 1991 [1944].

Berkeley SL., Zittel LL., Pitney LV,  Nichols SE. Locomotor and object control skills of children diagnosed with autism. Adapted Physical Activity Quarterly, 18(4): 405-416, 2001.

Burgoine E, Wing L. Identical triplets with Asperger’s syndrome. British Journal of Psychiatry 143:261-265, 1983.

DeMyers MK. Motor, perceptual-motor, intellectual disabilities of autistic children.In L. Wing (Ed.) Early Childhood Autism. New York, NY: Pergamon Press, 1976.

Dziuk MA, Gidley Larson JC, Apostu A, Mahone EM, Denckla MB, Mostofsky SH. Dyspraxia in autism: association with motor, social, and communicative deficits. Developmental Medicine and Child Neurology 49:734-739, 2007.

Jahanshani M, Hallet M. Bereitschaftspotentail: movement-related cortical potentails. New York:Kluwer Academic/Plenum Publishers, 2003.

Kanner L. Autistic disturbances of affective contact. Nervous Child, 2:217-250,1943.

Kawamura M, Mochizuki S. Primary progressive apraxia. Neuropathology, 19(3): 249-58, 1999.

MacNeil LK, Mostofsky SH. Specificity of dyspraxia in children with autism. Neuropsychology 26(2):165-171, 2012.

Ming X, Brimacombe M, Wagner GC. Prevalence of motor impairment in autism spectrum disorders. Brain Development 29: 565-570, 2007.

Ornitz EM., Guthrie D, Farley A J.  The early development of autistic children. Journal of Autism and Childhood Schizophrenia, 7, 207-229, 1977

Platz T, Kim IH, Pintschovious H, Winter T, Kieselbach A, Villringer K, Kurth R, Maurits KH. Multimodal EEG analysis in man suggests imnpairment-specific changes in movement-related electric activity after stroke. Brain 123:2475-90, 2000.

Ramachandran VS, Oberman LM. Broken Mirrors, Scientific American. p. 63- 69, 2006.

Rowland LP, Pedley TA. Meritt’s Neurology. Lippincot Williams and Wilkins: Philadelphia, 12th edition, 2010.

Sokhadze GE, Sears L, El-Baz A, Sokhadze EM, Casanova MF. AN event-related potential study of visual attention deficits in autism. J Neurotherapy,  16, 2012 (accepted)

Smith IM, Bryson SE.  Imitation and action in autism: a critical review. Psychological Bulletin 116: 259-273, 1994.

Sutera S, Pandey J, Esser EL, et al. Predictors of optimal outcome in toddlers diagnosed with autism spectrum disorder. J Autism Dev Disorders 37: 98-107, 2007.

Weimer AK, Schatz A, Lincoln A, Ballantyne A, Doris T. Motor impairment in Asperger syndrome: evidence for a deficit in proprioception.  Journal of Developmental and Behavioral Pediatrics. 22: 92-101, 2001.

Wing L. Asperger’s syndrome: A clinical account. Psychol Med, 11:115-129, 1981