By: Tony Attwood and MAAP Services, Inc.
One of the first indicators of motor clumsiness is that some children with Asperger's Syndrome learn to walk a few months later than one would expect (Manjiviona and Prior 1995). In early childhood there may be a limited ability with ball games, difficulty in learning to tie shoelaces, and an odd gait when walking or running. When the child attends school, the teacher may be concerned about their poor handwriting and lack of aptitude in school sports. In adolescence a small minority develop facial tics, that is, involuntary spasm of muscles of the face, or rapid blinking and occasional grimaces. All these features indicate clumsiness and specific disturbances of movement.
Clumsiness is not unique to Asperger's Syndrome, and occurs in association with a range of disorders of development. However, research suggests that between 50 per cent and 90 per cent of children and adults with Asperger's Syndrome have problems with motor coordination (Ehlers and Gillberg 1993; Ghaziuddin et al. 1994; Gillberg 1989; Szatmari et al. 1990; Tantam 1991). Thus Corina and Christopher Gillberg have included motor clumsiness as one of their six diagnostic criteria. In contrast, the criteria of Peter Szatmari and colleagues and the American Psychiatric Association make no direct reference to motor coordination. However, the APA has a list of features associated with Asperger's Syndrome that includes the presence of motor clumsiness in the pre-school period and the delay of motor milestones. In addition, the field trials of their criteria have indicated that motor delays and clumsiness are very common in Asperger's Syndrome (Volkmar et al. 1994).
While there continues to be some confusion as to whether motor clumsiness should be a diagnostic criterion, there is no doubt that when it does occur with such children it can have a significant effect on their lives.
What abilities are affected?
There have been several studies that have investigated motor coordination in children with Asperger's Syndrome, using a range of standardized tests. These tests include the Griffiths, Bruninks-Oseretsky and the Test of Motor Impairment - Henderson Revision, The results suggest that poor motor coordination affects a wide range of abilities involving gross and fine motor skills. There have also been research studies of more specific motor skills and there is considerable information from clinical observation of movement. The author recommends that children with this syndrome have a comprehensive assessment by a physiotherapist and occupational therapist to determine the nature and degree of any problems with movement. The following are some of the areas where motor clumsiness is apparent, and some strategies to improve particular skills.
When the person walks or runs, the movements appear ungainly or "puppet" like, and some children walk without the associated arm swing (Gillberg 1989). In technical terms there may be a lack of upper and lower limb coordination (Hallett et al. 1993). This feature can be quite conspicuous and other children may tease the child, leading to a reluctance to participate in running sports and physical education at school. A physiotherapist or occupational therapist can devise a remedial program to ensure the movements are coordinated. This may involve the use of a large wall mirror, video recording, modeling and imitating more "fluid" movements using music and dance. It is interesting that the ability to swim appears least affected, and this activity can be encouraged to enable the child to experience genuine competence and admiration for proficiency with movement.
Catching and throwing accuracy appears to be particularly affected (Tantam 1991). When catching a ball with two hands, the arm movements are often poorly coordinated and affected by problems with timing, that is the hands close in the correct position, but a fraction of a second too late. One study noted the children would often not look in the direction of the target before throwing (Manjiviona and Prior 1995). Clinical observation also suggests the child has poor coordination in their ability to kick a ball. One of the consequences of not being good at ball games is the exclusion of the child from some of the most popular social games in the playground. They may avoid such activities because they know they lack competence, or are deliberately excluded because they are a liability to the team. Thus, they are less able to improve ball skills with practice. From an early age, parents need to provide tuition and practice in ball skills, not to be an exceptional sportsperson, but to ensure the child has basic competence to be included in the games. Some children can be enrolled in a junior soccer or basketball team to improve coordination and to learn how to play specific games. It is also important to have the child's eyesight examined to establish whether wearing glasses improves hand/eye coordination.
There can be a problem with balance, as tested by examining the ability to stand on one leg with eyes closed (Manjiviona and Prior 1995; Tantam 1991). Temple Grandin (1992) also describes how she is unable to balance when placing one foot in front of the other (tandem walking) i.e. the task of walking a straight line as though it were a tightrope. This may affect the child's ability to use some adventure playground equipment, and activities in the gymnasium. The child may need practice and encouragement with activities that require balancing.
This area of movement skills involves the ability to use both hands, for example learning to dress, tie shoelaces or eat with utensils (Gillberg 1989). This may also extend to the coordination of feet and legs as in learning to ride a bicycle. Should the child have problems with manual dexterity, a useful strategy is "hands on hands" teaching - that is, a parent or teacher physically patterns the child's hands or limbs through the required movements, gradually fading out physical support. This characteristic of movement skills can continue to affect the manual dexterity of adults. Temple Grandin (1984) describes how:
I can perform one motor activity very well. When I operate hydraulic equipment such as a backhoe I can work one lever at a time perfectly. What I can not do is coordinate the movement of two or more levers at once. I compensate by operating the levers sequentially in rapid succession. (p. 165)
The teacher may spend considerable time interpreting and correcting the child's indecipherable scrawl. The child is also aware of the poor quality of their handwriting and may be reluctant to engage in activities that involve extensive writing. Unfortunately, for some children, high school teachers and prospective employers consider the neatness of handwriting a measure of intelligence and personality. The person with Asperger's Syndrome then becomes embarrassed or angry at their inability to write neatly and consistently. The child may well require assessment by an occupational therapist and remedial exercises, but modern technology can help minimize this problem. Children with Asperger's Syndrome are often very skilled at using computers and keyboards and the child could have special dispensation to type rather than write homework and examinations. The presentation of their work is then comparable to the other children. A parent or teacher aide could also act as the child's scribe to ensure the legibility of the child's written answers or homework. In tomorrow's world the ability to write longhand will become much less important, to the great relief of thousands of children with Asperger's Syndrome.
A recent study noted that while engaged in activities that require motor coordination, such as cutting out shapes with a pair of scissors, a significant proportion of children with Asperger's Syndrome tended to rush through the task (Manjiviona and Prior 1995). They appeared to be impulsive, unable to take a slow and considered approach. With such haste, mistakes occur. This can be infuriating for the child, teacher and parent. The child may need supervision and encouragement to work at an appropriate pace, having time to correct errors. Sometimes the child can be encouraged to slow down by having to count between actions and using a metronome to indicate an appropriate pace.
One of the features examined during a diagnostic assessment is the presence of lax joints (Tantam, Evered and Hersov 1990). We do not know if this is a structural abnormality or due to low muscle tone, but the autobiography of David Miedzianik (1986) describes how:
At infant school I can seem to remember playing a lot of games and them learning us to write. They used to tell me off a lot for holding my pen wrong at infant and primary school. I still don't hold my pen very good to this day, so my handwriting has never been good. I think a lot of the reason why I hold my pen badly is that the joints of my finger tips are double jointed and I can bend my fingers right back. (p. 4)
Should problems occur from lax joints or immature or unusual grasp, then the child may be referred to an occupational therapist or physiotherapist for assessment and remedial activities. This should be a priority with a young child, as so much schoolwork requires the use of a pencil or pen.
When Hans Asperger (1991) originally defined the features of the syndrome, he described a child who had significant problems copying various rhythms. This characteristic has been described in one of Temple Grandin's (1988) autobiographical essays
Both as a child and as an adult I have difficulty keeping in time with a rhythm. At a concert where people are clapping in time with the music, I have to follow another person sitting beside me. I can keep a rhythm moderately well by myself, but it is extremely difficult to synchronize my rhythmic motions with other people or with musical accompaniment. (p. 165)
This explains a feature that is quite conspicuous when walking next to a person with Asperger's Syndrome. As two people walk side by side they tend to synchronize the movements of their limbs, much as occurs when soldiers are on parade. Their movements have the same rhythm. The person with Asperger's Syndrome appears to walk to the beat of a different drum. This can also affect the person's ability to play an instrument. They may excel with a solo performance but have considerable difficulty when playing with other musicians.
There is imitation of movements. During conversation there is a tendency to imitate the posture, gestures and mannerisms of the other person. This is more likely to occur if there is a high degree of rapport or agreement, and occurs without conscious thought. As previously described, the person with Asperger's Syndrome may have difficulty in synchronizing or mirroring their movements with those of another person. They may try to overcome the problem by looking at body movements and immediately echo them. Clinical experience has identified individuals with Asperger's Syndrome who will meticulously duplicate the body postures of the other person to a degree that is conspicuously artificial. They may be unsure what are the appropriate body postures for the situation, and imitation is one way of attempting cohesion in movement. Where this problem occurs it has proved extremely difficult to identify strategies to learn how to synchronize movements without them appearing contrived or false.
Recognized Disorders of Movement
There is increasing evidence that some children and adults with Autism and Asperger's Syndrome develop signs of Tourette Syndrome (Kerbeshian and Burd 1986, 1996; Marriage and Miles 1993; Sverd 1991; Wing and Attwood 1987). The signs fall into three major categories: motor, vocal and behavioural. Motor signs are characterized by repetitive and involuntary movements. Common motor tics include rapid eye blinking, facial twitches, shoulder shrugging and head, arm or leg jerking. Sometimes complex motor tics develop such as skipping or twitching. All these odd movements can be misinterpreted as "nervous habits." Vocal signs include uttering uncontrollable and unpredictable sounds such as repeated throat clearing, grunting, snorting or animal noises such as barking or the shrieking associated with monkeys. Other vocal disturbances included palilalia (repeating one's own words) and echolalia (repeating anther's words). All these occur in someone who otherwise has fluent speech.
The behavioral signs are obsessive or compulsive behaviors such as continuous making and unmaking of the bed or checking to see if doors are locked. Occasionally the person develops a compulsion to commit a socially obnoxious act, such as touching genitals in public, or outbursts of obscenities that are not relevant to the context or mood. Should any of these characteristics become apparent then it is essential that the person be referred to a psychiatrist or neurologist for diagnosis of this syndrome. Treatment can be quite effective and may involve medication and Cognitive Behavior Therapy from a clinical psychologist. There are also support groups for families and individuals with Tourette Syndrome.
Catatonia and Parkinsonian features
Signs of catatonia have been identified in association with Autism and Asperger's Syndrome (Realmuto and August 1991; Wing and Attwood 1987). With catatonia the person develops odd hand postures and the momentary interruption of ongoing movements. In the middle of a well-practiced activity such as eating breakfast cereal or making one's bed, the person becomes motionless and seems to "freeze" for a few seconds. This is not a petit mal epileptic seizure or daydreaming, but a genuine problem getting limbs and hands moving again.
These movements appear superficially similar to those occurring in Parkinson's disease, a condition that predominantly occurs over the age of 60 (Maurer and Damasio 1982; Szatmari et al. 1990; Vilensky, Damasio and Maurer 1981). The signs are a flat, almost mask-like face, difficulty starting or switching movements, a slow shuffling gait, tremor and muscle rigidity. The author's extensive clinical experience has identified several young adults with Asperger's Syndrome who show a deterioration in movement skills very similar to the pattern in Parkinson's disease. However, it must be stressed that this is extremely rare. Should the person develop signs of catatonia or Parkinsonian features, it is important that they are referred to a neurologist or neuropsychiatrist for a thorough examination of their movement skills.
Medication can significantly reduce the expression of these rare movement disorders, and there are simple techniques to help initiate or restart the movement. For example, another person touching the limb or hand that is required to move can be of considerable help, or working alongside the person with a duplicate set of equipment. Listening to music can maintain movement fluency. It is interesting that certain types of music have proved more beneficial. This is music with a clear and consistent structure and rhythm, as occurs in Baroque and Country and Western music. Physiotherapists have also developed activities for people with Parkinson's disease that could be applied to a younger person.
Recent advances in brain imaging techniques have enabled neuropsychologists and neurologists to examine specific brain structures of people with Autism and Asperger's Syndrome. Eric Courchesne originally identified abnormalities of specific areas of a part of the brain called the cerebellum. His pioneering studies have been substantiated by independent research that has included patients who fulfill the criteria for Asperger's Syndrome (Courchesne 1995; El-Badri and Lewis 1993; Hashimoto et al. 995; McKelvey et al. 1995). The cerebellum has long been recognized as vitally important in regulating muscle tone, limb movements, timing of movement, speech, posture, balance and sensory modulation.
Temple Grandin (1988) has had a Magnetic Resonance Image of her brain, which revealed that she too has a cerebellum that is smaller than normal. Thus we now have physiological evidence that confirms the clinical observation of problems with movement. Parents and teachers must be aware that this is a physiological problem, not laziness, and seek remedial activities from experts in the area of movement, particularly physiotherapists and occupational therapists.
This article was excerpted from, with the author's permission, his most recent book, Asperger's Syndrome - a Guide for Parents and Professionals, Jessica Kingsley Publishers, 1997
Brief Summary of Strategies for Motor Clumsiness
Walking and Running
Improve upper and lower limb coordination
Improve catching and throwing skills to enable the child to be included in ball games
Use adventure playground and gymnasium equipment
Try "hands on hands" teaching
Learn to use a keyboard
Supervision and encouragement to slow the pace of movements
Lax Joints/Immature Grasp
Remedial programs from an occupational therapist
Disorders of Movement
Tics, blinking, involuntary movements (examine for Tourette Syndrome)
Odd postures, "freezing", shuffling gait (examine for catatonia or Parkinsonian features) Refer the person to the relevant medical specialist