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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 ñ 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.
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Locomotion
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, modelling 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.
Basic skills
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.
Balance
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.
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Manual Dexterity
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 ñ 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)
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Handwriting
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.
Rapid movements
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.
Lax joints
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 school work
requires the use of a pencil or pen.
Rhythm
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. 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.
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Recognized Disorders of Movement
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Tourette Syndrome
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 hear,
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.
Cerebellar dysfunction
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 fulfil
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.
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This article was excerpted from, with the author's
permission, his most recent book, Asperger's Syndrome ñ a Guide for
Parents and Professionals, Jessica Kingsley Publishers, 1997
Brief Summary of Strategies for Motor Clumsiness
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Walking and Running
Improve upper and lower limb coordination
Ball Skills
Improve catching and throwing skills to enable the child to be
included in ball games
Balance
Use adventure playground and gymnasium equipment
Manual Dexterity
Try "hands on hands" teaching
Handwriting
Remedial exercises
Learn to use a keyboard
Rapid movements
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
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