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Fine and gross motor performance of the MABC-2 by children with autism spectrum disorder and typically developing children
Research in Autism Spectrum Disorders 7 (2013) 1244–1249
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Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Fine and gross motor performance of the MABC-2 by children with autism spectrum disorder and typically developing children Ting Liu a,*, Casey M. Breslin b a b
Texas State University-San Marcos, United States Temple University, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 31 May 2013 Received in revised form 28 June 2013 Accepted 1 July 2013
The purpose of this study was to investigate the fine and gross motor performance of children with autism spectrum disorder (ASD) and age-matched typically developing children as measured by the Movement Assessment Battery for Children-2 (MABC-2). Thirty children with ASD (ages 3–16 years, male = 25, female = 5) and 30 age-matched typically developing children (male = 16, female = 14) performed the MABC-2. Group differences on MABC-2 percentile scores were analyzed using descriptive data and oneway ANOVAs. Effect sizes were also calculated for practical significance. Descriptive data showed that all typically developing children were classified in the green zone on MABC-2. However, the majority of children (80%) with ASD were categorized in the red and amber zones suggesting they experienced motor difficulty or were at risk for motor delay. In addition, children with ASD showed significantly lower MABC-2 percentile scores than the typically developing children on manual dexterity, ball skills, and static and dynamic balance, F(1, 59) = 109.043, p < .001, and the effect sizes were large (>.80). In conclusion, children with ASD were delayed in both fine and gross motor skill performance on MABC-2 when compared to their age-matched typically developing children. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Autism Typical Youth Fine motor skills Gross motor skills
1. Introduction Although motor performance is not part of the diagnostic criteria for children with autism spectrum disorder (ASD), the severity of motor impairment is so widespread that some autism researchers have discussed including motor impairments as part of the diagnostic criteria (Liu, 2012; Ozonoff et al., 2008; Papadopoulos et al., 2012; Vasileva, 2012; Whyatt & Craig, 2012). Other researchers study the motor skills of infants in the hopes of identifying a potential avenue for earlier diagnosis of ASD (Lane, Harpster, & Heathcock, 2012; Liu, 2012; Mulligan & Prudhomme White, 2012; Teitelbaum et al., 2004). Furthermore, early educational intervention has been found to be the only effective treatment for symptoms of ASD (Corsello, 2005; National Research Council, 2001). Thus, it is of critical importance to understand the motor abilities of children with ASD as a pathway to early intervention. Fundamental fine and gross motor skill development forms the building blocks of future physical activity (Clark & Metcalfe, 2002). Early motor skill development has been found to predict later cognitive development (Hill, 2010) and is
* Corresponding author at: Department of Health and Human Performance, Texas State University-San Marcos, San Marcos, TX 78666, United States. Tel.: +1 512 245 8259; fax: +1 512 245 8678. E-mail address: [email protected] (T. Liu). 1750-9467/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rasd.2013.07.002
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related to engagement in physical activity (Stodden et al., 2008) and perceived competence (Robinson, 2011). Motor development may mediate the relationship between cognitive and social skills, as research has suggested that opportunities affording the practice and refinement of fine and gross motor skills are also an authentic setting to practice social and communication skills (Lloyd, MacDonald, & Lord, 2013; Schmidt, Fitzpatrick, Caron, & Mergechea, 2011). Numerous interventions have targeted the issue that children with ASD often have difficulty with communication (reviewed by Rhea, 2008) and social interactions (reviewed by Kasari & Patterson, 2012; American Psychiatric Association, 2000). For children with ASD, fine motor delays may adversely impact handwriting and/or keyboarding ability, thus, leading to challenges in communication. Gross motor delay may negatively impact balance, social appearance, and motivation to engage in social activities involving gross motor behaviors (e.g., playing ball games at recess). Both types of motor delays may influence the frequency of challenging behavior, especially avoidant behavior such as tantrums. These behaviors are commonly reported for children with ASD in physical education classes and during writing tasks (Fittipaldi-Wert & Mowling, 2009). This suggests a specific need for intervention in this population so that they can improve their fine and gross motor skills early enough to fully participate in different types of sport and physical activity. However, few interventions to target motor skill development have been developed for children with ASD. This may be due to the questions pertaining to the validity of measurement of motor development by children with ASD (Berkeley, Zittel, Pitney, & Nichols, 2001; Breslin & Rudisill, 2011; Brown & Lalor, 2009; Green et al., 2009; Liu & Breslin, 2013; Staples & Reid, 2010). The literature reports that children with ASD are delayed in terms of their motor skill development as compared to their typically developing peers, regardless of whether researchers measure fine or gross motor skills (Baranek, Parham, & Bodfish, 2005; Berkeley et al., 2001; Breslin & Rudisill, 2011; Dziuk et al., 2007; Green et al., 2002, 2009; Jansiewicz et al., 2006; Liu, 2012; Liu & Breslin, 2013; Lloyd et al., 2013; Pan, Tsai, & Chu, 2009; Provost, Lopez, & Heimerl, 2007; Staples & Reid, 2010; Whyatt & Craig, 2012). However, the methodologies used to obtain these results varied. Several of these studies compared a group of children with ASD to typically developing peers (Dziuk et al., 2007; Pan et al., 2009), while others compared performance to that of standardized normative data (Berkeley et al., 2001; Breslin & Rudisill, 2011; Liu & Breslin, 2013; Staples & Reid, 2010). Furthermore, the assessment tools utilized varied. Three of these studies used the Test of Gross Motor Development-Second Edition (TGMD-2) to assess fundamental gross motor skill development (Berkeley et al., 2001; Breslin & Rudisill, 2011; Staples & Reid, 2010), and two used the Movement Assessment Battery for Children-Second Edition (MABC2) to assess gross and fine motor skills (Liu & Breslin, 2013; Whyatt & Craig, 2012). Although both of these are valid standardized assessments measuring motor skills (Henderson, Sugden, & Barnett, 2007; Ulrich, 2000), they measure different aspects of motor skill development (Logan, Robinson, & Getchell, 2011). The MABC-2 is a valid and reliable assessment of fine and gross motor skills that has been used with children with ASD (Brown & Lalor, 2009; Henderson et al., 2007; Green et al., 2002, 2009; Liu & Breslin, 2013; Whyatt & Craig, 2012). The strengths of the MABC-2 include its ability to assess children using a different combination of fine and gross motor skill items appropriate for the three different age groups within the range of 3–16 years (Brown & Lalor, 2009). Specifically, the MABC-2 examines the constructs of manual dexterity, ball skills, and static and dynamic balance. In one study, the impact of using visual supports to provide instructions to children with ASD during the MABC-2 was measured. 76% of participants were found to be delayed (or at risk for delay) in terms of their motor skill development regardless of how instructions were provided (Liu & Breslin, 2013). In another study, performance on the MABC-2 by children aged 7–10 years with ASD was compared to that of receptive vocabulary and IQ matched peers (Whyatt & Craig, 2012). These children with ASD were found to be delayed in terms in both fine and gross motor skills. However, the delays were found to be caused by delays in terms of manual dexterity and ball skills only. In Green et al. (2002) study, children with Asperger’s aged 6–10 years were compared to a group of age-matched children with motor delays. The children with Asperger’s syndrome were best identified through aiming and catching tasks, and found to have a slight delay on the manual dexterity and ball skills tasks compared to the children diagnosed with motor delays (but not Asperger’s syndrome). In a final study evaluating the motor skill development of children with ASD, participants aged 10–14 years were assessed using the MABC and using a retrospective parent questionnaire examining gross and fine motor skills called the Developmental Coordination Disorder Questionnaire (Green et al., 2009). The motor development of a majority of participants was found to be delayed using the MABC and the Developmental Coordination Disorder Questionnaire. Nonetheless, none of these studies sought to compare the fine and gross motor skills of children with ASD across the entire age range eligible for evaluation using the MABC-2 to that of their typically developing peers. To fill the gap in the literature comparing the motor development of children with ASD to their typically developing peers, the purpose of this study was to compare the fine and gross motor skills of children with and without ASD aged 3–16 years using the MABC-2. It was hypothesized that children with ASD aged 3–16 would be delayed in their motor skill development compared to their age-matched typically developing children. A secondary hypothesis was that across the three constructs of the MABC-2, children with ASD would be delayed compared to their age-matched typically developing peers. 2. Methods 2.1. Participants A total of 30 children with ASD (3–16 years, 25 males, 5 females) and 30 age-matched typically developing children (16 males, 14 females) participated in this study. It was difficult to match typically developing children with children with ASD in
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Table 1 Demographic information for the participants’ age and gender. Mean age (year)
Children with ASD Typically developing children
7.96 7.44
N
30 30
Gender
Age band (n)
Male
Female
3–6 year
7–10 year
11–16 year
25 16
5 14
10 10
12 13
8 7
gender because the gender ratio in children with ASD has roughly 5 males to every female (CDC, 2013). Children with ASD were originally diagnosed by a psychiatrist or a licensed psychologist according to the criteria outlined in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000). Ten children were diagnosed with Asperger syndrome, 10 children had a diagnosis of autistic disorder, and 10 children were diagnosed with PDD-NOS. Participants were recruited through advertisements and personal contacts from local school districts. The special education teachers working with the participants reported that the children with ASD had IQ scores ranged between 70 and 100, and all were free of any concomitant profound psychiatric and developmental disorder. Typically developing children were recruited from the same schools as the children with ASD attended. Although IQ was not assessed for the typically developing children, the teachers reported that they were of average intelligence and had no known cognitive, communication, and learning problems. Descriptive data for the participants are presented in Table 1. Parents were informed of their rights and the nature of the study, and were asked to sign a consent form prior to their child’s participation. The study was approved by the local University Institutional Review Board. The inclusion criteria for the participants were (1) the children were capable of understanding and communicating with the investigators, (2) they were able to follow the given instructions, and (3) the children were willing to engage in the requested motor skill performance. Parents provided medical histories for their child with ASD and that information was used to ensure each child could participate in the fine and gross physical activities. Children with orders from a physician to limit physical activity were excluded from the study. All children in this study met the inclusion criteria. 2.2. Instrument 2.2.1. Movement Assessment Battery for Children-2 (MABC-2) The MABC-2 (Henderson et al., 2007) is an evaluative assessment tool that can be used to identify children who are significantly behind their age-matched peers in motor skill performance. The MABC-2 measures both fine and gross motor skill performance for children in three age bands (3–6 years, 7–10 years, and 11–16 years). It contains eight tasks for each of the three age bands in three different constructs: manual dexterity, ball skills, and static and dynamic balance. Each task’s raw score can be converted to a standard score, and a total test score can be calculated by summing the eight task standard scores. Using the total test score, a percentile score can be found from the norm tables published in the MABC-2 MANUAL to determine a child’s motor delays. The test percentile scores are described as a traffic light scoring system including a red zone, amber zone, and green zone. A percentile score 5th is classified in the red zone indicating a significant movement difficulty, a percentile score between the 5th and 15th is classified in the amber zone indicating at risk of movement difficulty, and a percentile score >15th is classified in the green zone indicating no movement difficulty detected. 2.3. Procedure Parent consent was obtained before each child’s performance. The primary investigator and research assistants administered the MABC-2 at a local elementary school gym. For safety purposes, unnecessary furnishings were removed in the assessment area of the gym. An enclosed area of the gym was chosen to minimize any distractions during assessment. Participants were asked to wear exercise appropriate attire and shoes to complete the MABC-2 (for each child’s applicable age band). The primary investigator and research assistants followed the MABC-2 MANUAL when administering all tasks. Participants received detailed verbal descriptions and demonstrations prior to their motor skill performance. They were also provided additional instructions and demonstrations if they did not seem to understand or made mistakes during their practice trials. A research assistant, blind to the diagnosis and the purpose of the study, was trained to administer and then evaluate the children’s performance for each test item. Both the principal investigator and a research assistant evaluated the children’s MABC-2 motor performance in all three constructs. The assistant was considered trained once 90% agreement with the scores of the principal investigator was achieved (Breslin & Rudisill, 2011; Liu & Breslin, 2013). An inter-rater reliability test was performed between scores of the principal investigator and the assistant. Percentage of inter-rater agreement between the principal investigator and the assistant was high (99%). 2.4. Data analysis Fine (i.e., manual dexterity) and gross (i.e., ball skills, static and dynamic balance) motor skill raw scores were converted to percentile scores for each child using the MABC-2 conversion tables. That is, the percentile scores were generated for each
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Fig. 1. Children with ASD scored significantly lower than their age-matched typically developing children across all tasks. * indicates significant differences between the two groups.
area (i.e., manual dexterity, ball skills, static and dynamic balance) and their overall percentile scores (combination of all eight tasks). Descriptive data were used for percentile scores on children with ASD and typically developing children. Oneway ANOVAs were conducted on MABC-2 percentile scores to compare motor performance of children with ASD and their age-matched typically developing children. Results were considered significant if p values were less than .05 and effect sizes (ES) were determined for practical significance using Cohen’s d (Cohen, 1988). 3. Results Descriptive data showed that all percentile scores for typically developing children were in the green zone indicating that they had no movement difficulties and motor delays. In contrast, the majority of children with ASD (80%) were classified in the red and amber zones on MABC-2 assessment. Specially, 77% of children with ASD were in the red zone demonstrating that those children with ASD experienced significant motor delays, 3% were in the amber zone suggesting that they were at risk for motor delays, and 20% of children with ASD were in the green zone, indicating no motor delays or difficulties. One-way ANOVAs on overall percentile scores (combination of eight tasks) revealed a significant performance difference between children with ASD and age-matched typically developing children, F(1, 59) = 109.043, p < .001. In addition, follow up ANOVAs showed significant differences between the two groups on manual dexterity, F(1, 59) = 88.259, p < .001; ball skills, F(1, 59) = 78.582, p < .001; and static and dynamic balance, F(1, 59) = 34.734, p < .001. The findings suggest that children with ASD elicited significantly lower percentile scores than that of typically developing children across on all tasks (i.e., manual dexterity, ball skills, static and dynamic balance, and overall percentile score). MABC-2 task item percentile scores on group differences are illustrated in Fig. 1. The effect sizes (ES) describing motor delays of the study participants between the two groups were large on manual dexterity (ES = 2.43), ball skills (ES = 2.30), static and dynamic balance (ES = 1.66), and overall percentile score (ES = 2.70). The large ES (>.80) results were in agreement with the statistically significant findings indicating that the true effect of the performance differences in two populations might be large. 4. Discussion The purpose of this study was to examine the fine and gross motor skill performance of children with ASD and their agematched typically developing children using the MABC-2. The results of this study supported our main hypothesis that children with ASD would be delayed in fine and gross motor skill development compared to their age-matched typically developing peers. These results were determined using the MABC-2, an assessment examining motor skill development of children aged 3–16 years old on three different constructs: manual dexterity, ball skills, and static and dynamic balance. By comparing performance to a control group of age-matched, typically developing children, this extends the findings of Liu and Breslin (2013) which found that even when instructions were modified to include visual supports during the MABC-2 assessments, children with ASD aged 3–16 years were classified as delayed in terms of their fine and gross motor skill development. The secondary hypothesis that children with ASD would be delayed on all three constructs, manual dexterity, ball skills, and static and dynamic balance, was also supported. The statistical analyses examining differences between children with and without ASD on each of the three constructs comprising the MABC-2 were found to be significantly different. This finding replicates findings examining the motor skill development of children with ASD aged 6–10 years and 10–14 years using the MABC-2 (Green et al., 2002, 2009). This finding partially contradicts the findings of Whyatt and Craig (2012), which found children with ASD were significantly delayed in ball skills and manual dexterity only. In that study, each item on the MABC-2 was analyzed to ascertain why the children were not delayed in terms of the balance skills. Those children with ASD did not
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have as much difficulty with dynamic balance tasks than with the static, timed balanced task. As the children with ASD in present study showed delays in all three constructs, analyzing each construct on the MABC-2 was unnecessary. That is, during the balance construct, children with ASD had difficulties in both static and dynamic balance tasks. The different findings on balance tasks probably due to a larger age range (i.e., 3–16 years, assessed all three age-band tasks) of children with ASD were included in this study than the Whyatt & Craig’s study (i.e., 7–10 years, only age-band 2 tasks were tested). Perhaps a cohort effect could explain the Whyatt and Craig (2012) finding of less difficulty on the balance tasks. Prior to this study, no known attempt had been made to measure and compare motor skill development by children with ASD to their typically developing peers using the MABC-2 across all three age bands. In previous studies using the MABC-2 to examine differences in motor skill development by children with ASD and their typically developing peers, the children participating in each study were of limited age ranges (Green et al., 2002, 2009; Whyatt & Craig, 2012). In each of those studies, age differences between the youngest and oldest participants were <5 years. One strength of the present study is that participants ranged in age from 3 years to 16 years. Thus, this study provides evidence that across childhood, children with ASD are delayed in their fine and gross motor skill development. Reports in the literature have noted the persistence of this gap throughout childhood and adolescence, but using other measurement methodologies (Baranek et al., 2005; Berkeley et al., 2001; Breslin & Rudisill, 2011; Jansiewicz et al., 2006; Staples & Reid, 2010). All of these studies used a cross-sectional research design (like the one presented here), so it would be interesting for researchers to longitudinally study groups of typically developing children and children with ASD to follow the trajectory of these reported delays in motor performance. Another strength of this study is that data regarding the IQ of children with ASD were obtained. The nature of the relationship between IQ and motor performance in children with ASD seems inconclusive. Previously in the literature, a relationship between IQ and motor problems was suggested in children with ASD (Green et al., 2009), however, SmitsEngelsman and Hill (2012) reported that motor impairment was found at all IQ levels suggesting that IQ scores could not explain all aspects of motor performance in children. This relationship merits further exploration, especially when one considers that IQ is related to autism severity (Charman et al., 2011). Perhaps the complex relationship between IQ, motor performance, merits further explanation. Although these findings suggest that the delay in motor skill development is robust and lasting throughout childhood, care should be taken before using these results as evidence to suggest that motor skill development as measured by the MABC-2 can serve as a potential indicator for ASD screening. Autism can be reliably diagnosed among children younger than 3 years (Corsello, Akshoomoff, & Stahmer, 2013), but the MABC-2 is not valid for use with children younger than 3 years. Thus, a different motor skill assessment would need to be used for evaluating motor skill performance as a screening tool for ASD. 4.1. Limitations and future directions This study was not without limitations. There are far more girls enrolled in this study in the control group of typically developing children than girls with ASD. Although this is consistent with diagnostic trends by gender (CDC, 2013; Newschaffer et al., 2007), it may affect studies examining motor skill development more meaningfully as girls have less developed motor skills than boys (Robinson, 2011). While no gender differences are identified in MABC-2 assessment (Henderson et al., 2007), it is recommended that future research include more girls when assessing motor skill development in ASD population. 4.2. Implications It is critical that researchers, educators, and therapists recognize that children with ASD are delayed in terms of their fine and gross motor development. This finding supports that the inclusion of fine and gross motor performance in ASD screening process is important since motor development typically precedes language development, thus enhancing the potential for earlier diagnosis. Early diagnosis leads to earlier intervention and better prognostic outcomes. In addition, motor delays may have a negative effect on subsequent language, social, and cognitive development. This inclusion of motor performance in the ASD screening process can improve the chance of targeting and addressing these delays in treatment programs. Failure to assess and treat motor delays might make it more difficult to address other common developmental challenges in children with ASD. Furthermore, interventions to improve fine and gross motor skill development should be developed, especially in light of the emerging relationship between motor skill development, physical activity habits, and obesity (Stodden et al., 2008). Participation in physical activity is impacted by motor skill development. Children with ASD may need additional practice of their fine and gross motor skills to be able to participate in complex recreational programming (Liu, 2012; Lloyd et al., 2013) to compensate for their delayed motor skill development. Recreational programs targeting motor skill development may be especially beneficial to children with ASD, so long as these programs providing a variety of challenge in their activities in order to meet their skill levels. Beyond providing strategies to develop the motor skills serving as the building block for future complex movements, these interventions could also provide authentic settings for communication and social interaction (Lloyd et al., 2013). In conclusion, the present study indicates that children with ASD are delayed in terms of their fine and gross motor skill development compared to their age-matched typically developing children as measured by the MABC-2. Moreover, findings suggest that this delay is true across all three constructs, manual dexterity, ball skill, and static and dynamic balance.
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Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Fine and gross motor performance of the MABC-2 by children with autism spectrum disorder and typically developing children Ting Liu a,*, Casey M. Breslin b a b
Texas State University-San Marcos, United States Temple University, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 31 May 2013 Received in revised form 28 June 2013 Accepted 1 July 2013
The purpose of this study was to investigate the fine and gross motor performance of children with autism spectrum disorder (ASD) and age-matched typically developing children as measured by the Movement Assessment Battery for Children-2 (MABC-2). Thirty children with ASD (ages 3–16 years, male = 25, female = 5) and 30 age-matched typically developing children (male = 16, female = 14) performed the MABC-2. Group differences on MABC-2 percentile scores were analyzed using descriptive data and oneway ANOVAs. Effect sizes were also calculated for practical significance. Descriptive data showed that all typically developing children were classified in the green zone on MABC-2. However, the majority of children (80%) with ASD were categorized in the red and amber zones suggesting they experienced motor difficulty or were at risk for motor delay. In addition, children with ASD showed significantly lower MABC-2 percentile scores than the typically developing children on manual dexterity, ball skills, and static and dynamic balance, F(1, 59) = 109.043, p < .001, and the effect sizes were large (>.80). In conclusion, children with ASD were delayed in both fine and gross motor skill performance on MABC-2 when compared to their age-matched typically developing children. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Autism Typical Youth Fine motor skills Gross motor skills
1. Introduction Although motor performance is not part of the diagnostic criteria for children with autism spectrum disorder (ASD), the severity of motor impairment is so widespread that some autism researchers have discussed including motor impairments as part of the diagnostic criteria (Liu, 2012; Ozonoff et al., 2008; Papadopoulos et al., 2012; Vasileva, 2012; Whyatt & Craig, 2012). Other researchers study the motor skills of infants in the hopes of identifying a potential avenue for earlier diagnosis of ASD (Lane, Harpster, & Heathcock, 2012; Liu, 2012; Mulligan & Prudhomme White, 2012; Teitelbaum et al., 2004). Furthermore, early educational intervention has been found to be the only effective treatment for symptoms of ASD (Corsello, 2005; National Research Council, 2001). Thus, it is of critical importance to understand the motor abilities of children with ASD as a pathway to early intervention. Fundamental fine and gross motor skill development forms the building blocks of future physical activity (Clark & Metcalfe, 2002). Early motor skill development has been found to predict later cognitive development (Hill, 2010) and is
* Corresponding author at: Department of Health and Human Performance, Texas State University-San Marcos, San Marcos, TX 78666, United States. Tel.: +1 512 245 8259; fax: +1 512 245 8678. E-mail address: [email protected] (T. Liu). 1750-9467/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rasd.2013.07.002
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related to engagement in physical activity (Stodden et al., 2008) and perceived competence (Robinson, 2011). Motor development may mediate the relationship between cognitive and social skills, as research has suggested that opportunities affording the practice and refinement of fine and gross motor skills are also an authentic setting to practice social and communication skills (Lloyd, MacDonald, & Lord, 2013; Schmidt, Fitzpatrick, Caron, & Mergechea, 2011). Numerous interventions have targeted the issue that children with ASD often have difficulty with communication (reviewed by Rhea, 2008) and social interactions (reviewed by Kasari & Patterson, 2012; American Psychiatric Association, 2000). For children with ASD, fine motor delays may adversely impact handwriting and/or keyboarding ability, thus, leading to challenges in communication. Gross motor delay may negatively impact balance, social appearance, and motivation to engage in social activities involving gross motor behaviors (e.g., playing ball games at recess). Both types of motor delays may influence the frequency of challenging behavior, especially avoidant behavior such as tantrums. These behaviors are commonly reported for children with ASD in physical education classes and during writing tasks (Fittipaldi-Wert & Mowling, 2009). This suggests a specific need for intervention in this population so that they can improve their fine and gross motor skills early enough to fully participate in different types of sport and physical activity. However, few interventions to target motor skill development have been developed for children with ASD. This may be due to the questions pertaining to the validity of measurement of motor development by children with ASD (Berkeley, Zittel, Pitney, & Nichols, 2001; Breslin & Rudisill, 2011; Brown & Lalor, 2009; Green et al., 2009; Liu & Breslin, 2013; Staples & Reid, 2010). The literature reports that children with ASD are delayed in terms of their motor skill development as compared to their typically developing peers, regardless of whether researchers measure fine or gross motor skills (Baranek, Parham, & Bodfish, 2005; Berkeley et al., 2001; Breslin & Rudisill, 2011; Dziuk et al., 2007; Green et al., 2002, 2009; Jansiewicz et al., 2006; Liu, 2012; Liu & Breslin, 2013; Lloyd et al., 2013; Pan, Tsai, & Chu, 2009; Provost, Lopez, & Heimerl, 2007; Staples & Reid, 2010; Whyatt & Craig, 2012). However, the methodologies used to obtain these results varied. Several of these studies compared a group of children with ASD to typically developing peers (Dziuk et al., 2007; Pan et al., 2009), while others compared performance to that of standardized normative data (Berkeley et al., 2001; Breslin & Rudisill, 2011; Liu & Breslin, 2013; Staples & Reid, 2010). Furthermore, the assessment tools utilized varied. Three of these studies used the Test of Gross Motor Development-Second Edition (TGMD-2) to assess fundamental gross motor skill development (Berkeley et al., 2001; Breslin & Rudisill, 2011; Staples & Reid, 2010), and two used the Movement Assessment Battery for Children-Second Edition (MABC2) to assess gross and fine motor skills (Liu & Breslin, 2013; Whyatt & Craig, 2012). Although both of these are valid standardized assessments measuring motor skills (Henderson, Sugden, & Barnett, 2007; Ulrich, 2000), they measure different aspects of motor skill development (Logan, Robinson, & Getchell, 2011). The MABC-2 is a valid and reliable assessment of fine and gross motor skills that has been used with children with ASD (Brown & Lalor, 2009; Henderson et al., 2007; Green et al., 2002, 2009; Liu & Breslin, 2013; Whyatt & Craig, 2012). The strengths of the MABC-2 include its ability to assess children using a different combination of fine and gross motor skill items appropriate for the three different age groups within the range of 3–16 years (Brown & Lalor, 2009). Specifically, the MABC-2 examines the constructs of manual dexterity, ball skills, and static and dynamic balance. In one study, the impact of using visual supports to provide instructions to children with ASD during the MABC-2 was measured. 76% of participants were found to be delayed (or at risk for delay) in terms of their motor skill development regardless of how instructions were provided (Liu & Breslin, 2013). In another study, performance on the MABC-2 by children aged 7–10 years with ASD was compared to that of receptive vocabulary and IQ matched peers (Whyatt & Craig, 2012). These children with ASD were found to be delayed in terms in both fine and gross motor skills. However, the delays were found to be caused by delays in terms of manual dexterity and ball skills only. In Green et al. (2002) study, children with Asperger’s aged 6–10 years were compared to a group of age-matched children with motor delays. The children with Asperger’s syndrome were best identified through aiming and catching tasks, and found to have a slight delay on the manual dexterity and ball skills tasks compared to the children diagnosed with motor delays (but not Asperger’s syndrome). In a final study evaluating the motor skill development of children with ASD, participants aged 10–14 years were assessed using the MABC and using a retrospective parent questionnaire examining gross and fine motor skills called the Developmental Coordination Disorder Questionnaire (Green et al., 2009). The motor development of a majority of participants was found to be delayed using the MABC and the Developmental Coordination Disorder Questionnaire. Nonetheless, none of these studies sought to compare the fine and gross motor skills of children with ASD across the entire age range eligible for evaluation using the MABC-2 to that of their typically developing peers. To fill the gap in the literature comparing the motor development of children with ASD to their typically developing peers, the purpose of this study was to compare the fine and gross motor skills of children with and without ASD aged 3–16 years using the MABC-2. It was hypothesized that children with ASD aged 3–16 would be delayed in their motor skill development compared to their age-matched typically developing children. A secondary hypothesis was that across the three constructs of the MABC-2, children with ASD would be delayed compared to their age-matched typically developing peers. 2. Methods 2.1. Participants A total of 30 children with ASD (3–16 years, 25 males, 5 females) and 30 age-matched typically developing children (16 males, 14 females) participated in this study. It was difficult to match typically developing children with children with ASD in
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Table 1 Demographic information for the participants’ age and gender. Mean age (year)
Children with ASD Typically developing children
7.96 7.44
N
30 30
Gender
Age band (n)
Male
Female
3–6 year
7–10 year
11–16 year
25 16
5 14
10 10
12 13
8 7
gender because the gender ratio in children with ASD has roughly 5 males to every female (CDC, 2013). Children with ASD were originally diagnosed by a psychiatrist or a licensed psychologist according to the criteria outlined in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000). Ten children were diagnosed with Asperger syndrome, 10 children had a diagnosis of autistic disorder, and 10 children were diagnosed with PDD-NOS. Participants were recruited through advertisements and personal contacts from local school districts. The special education teachers working with the participants reported that the children with ASD had IQ scores ranged between 70 and 100, and all were free of any concomitant profound psychiatric and developmental disorder. Typically developing children were recruited from the same schools as the children with ASD attended. Although IQ was not assessed for the typically developing children, the teachers reported that they were of average intelligence and had no known cognitive, communication, and learning problems. Descriptive data for the participants are presented in Table 1. Parents were informed of their rights and the nature of the study, and were asked to sign a consent form prior to their child’s participation. The study was approved by the local University Institutional Review Board. The inclusion criteria for the participants were (1) the children were capable of understanding and communicating with the investigators, (2) they were able to follow the given instructions, and (3) the children were willing to engage in the requested motor skill performance. Parents provided medical histories for their child with ASD and that information was used to ensure each child could participate in the fine and gross physical activities. Children with orders from a physician to limit physical activity were excluded from the study. All children in this study met the inclusion criteria. 2.2. Instrument 2.2.1. Movement Assessment Battery for Children-2 (MABC-2) The MABC-2 (Henderson et al., 2007) is an evaluative assessment tool that can be used to identify children who are significantly behind their age-matched peers in motor skill performance. The MABC-2 measures both fine and gross motor skill performance for children in three age bands (3–6 years, 7–10 years, and 11–16 years). It contains eight tasks for each of the three age bands in three different constructs: manual dexterity, ball skills, and static and dynamic balance. Each task’s raw score can be converted to a standard score, and a total test score can be calculated by summing the eight task standard scores. Using the total test score, a percentile score can be found from the norm tables published in the MABC-2 MANUAL to determine a child’s motor delays. The test percentile scores are described as a traffic light scoring system including a red zone, amber zone, and green zone. A percentile score 5th is classified in the red zone indicating a significant movement difficulty, a percentile score between the 5th and 15th is classified in the amber zone indicating at risk of movement difficulty, and a percentile score >15th is classified in the green zone indicating no movement difficulty detected. 2.3. Procedure Parent consent was obtained before each child’s performance. The primary investigator and research assistants administered the MABC-2 at a local elementary school gym. For safety purposes, unnecessary furnishings were removed in the assessment area of the gym. An enclosed area of the gym was chosen to minimize any distractions during assessment. Participants were asked to wear exercise appropriate attire and shoes to complete the MABC-2 (for each child’s applicable age band). The primary investigator and research assistants followed the MABC-2 MANUAL when administering all tasks. Participants received detailed verbal descriptions and demonstrations prior to their motor skill performance. They were also provided additional instructions and demonstrations if they did not seem to understand or made mistakes during their practice trials. A research assistant, blind to the diagnosis and the purpose of the study, was trained to administer and then evaluate the children’s performance for each test item. Both the principal investigator and a research assistant evaluated the children’s MABC-2 motor performance in all three constructs. The assistant was considered trained once 90% agreement with the scores of the principal investigator was achieved (Breslin & Rudisill, 2011; Liu & Breslin, 2013). An inter-rater reliability test was performed between scores of the principal investigator and the assistant. Percentage of inter-rater agreement between the principal investigator and the assistant was high (99%). 2.4. Data analysis Fine (i.e., manual dexterity) and gross (i.e., ball skills, static and dynamic balance) motor skill raw scores were converted to percentile scores for each child using the MABC-2 conversion tables. That is, the percentile scores were generated for each
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Fig. 1. Children with ASD scored significantly lower than their age-matched typically developing children across all tasks. * indicates significant differences between the two groups.
area (i.e., manual dexterity, ball skills, static and dynamic balance) and their overall percentile scores (combination of all eight tasks). Descriptive data were used for percentile scores on children with ASD and typically developing children. Oneway ANOVAs were conducted on MABC-2 percentile scores to compare motor performance of children with ASD and their age-matched typically developing children. Results were considered significant if p values were less than .05 and effect sizes (ES) were determined for practical significance using Cohen’s d (Cohen, 1988). 3. Results Descriptive data showed that all percentile scores for typically developing children were in the green zone indicating that they had no movement difficulties and motor delays. In contrast, the majority of children with ASD (80%) were classified in the red and amber zones on MABC-2 assessment. Specially, 77% of children with ASD were in the red zone demonstrating that those children with ASD experienced significant motor delays, 3% were in the amber zone suggesting that they were at risk for motor delays, and 20% of children with ASD were in the green zone, indicating no motor delays or difficulties. One-way ANOVAs on overall percentile scores (combination of eight tasks) revealed a significant performance difference between children with ASD and age-matched typically developing children, F(1, 59) = 109.043, p < .001. In addition, follow up ANOVAs showed significant differences between the two groups on manual dexterity, F(1, 59) = 88.259, p < .001; ball skills, F(1, 59) = 78.582, p < .001; and static and dynamic balance, F(1, 59) = 34.734, p < .001. The findings suggest that children with ASD elicited significantly lower percentile scores than that of typically developing children across on all tasks (i.e., manual dexterity, ball skills, static and dynamic balance, and overall percentile score). MABC-2 task item percentile scores on group differences are illustrated in Fig. 1. The effect sizes (ES) describing motor delays of the study participants between the two groups were large on manual dexterity (ES = 2.43), ball skills (ES = 2.30), static and dynamic balance (ES = 1.66), and overall percentile score (ES = 2.70). The large ES (>.80) results were in agreement with the statistically significant findings indicating that the true effect of the performance differences in two populations might be large. 4. Discussion The purpose of this study was to examine the fine and gross motor skill performance of children with ASD and their agematched typically developing children using the MABC-2. The results of this study supported our main hypothesis that children with ASD would be delayed in fine and gross motor skill development compared to their age-matched typically developing peers. These results were determined using the MABC-2, an assessment examining motor skill development of children aged 3–16 years old on three different constructs: manual dexterity, ball skills, and static and dynamic balance. By comparing performance to a control group of age-matched, typically developing children, this extends the findings of Liu and Breslin (2013) which found that even when instructions were modified to include visual supports during the MABC-2 assessments, children with ASD aged 3–16 years were classified as delayed in terms of their fine and gross motor skill development. The secondary hypothesis that children with ASD would be delayed on all three constructs, manual dexterity, ball skills, and static and dynamic balance, was also supported. The statistical analyses examining differences between children with and without ASD on each of the three constructs comprising the MABC-2 were found to be significantly different. This finding replicates findings examining the motor skill development of children with ASD aged 6–10 years and 10–14 years using the MABC-2 (Green et al., 2002, 2009). This finding partially contradicts the findings of Whyatt and Craig (2012), which found children with ASD were significantly delayed in ball skills and manual dexterity only. In that study, each item on the MABC-2 was analyzed to ascertain why the children were not delayed in terms of the balance skills. Those children with ASD did not
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have as much difficulty with dynamic balance tasks than with the static, timed balanced task. As the children with ASD in present study showed delays in all three constructs, analyzing each construct on the MABC-2 was unnecessary. That is, during the balance construct, children with ASD had difficulties in both static and dynamic balance tasks. The different findings on balance tasks probably due to a larger age range (i.e., 3–16 years, assessed all three age-band tasks) of children with ASD were included in this study than the Whyatt & Craig’s study (i.e., 7–10 years, only age-band 2 tasks were tested). Perhaps a cohort effect could explain the Whyatt and Craig (2012) finding of less difficulty on the balance tasks. Prior to this study, no known attempt had been made to measure and compare motor skill development by children with ASD to their typically developing peers using the MABC-2 across all three age bands. In previous studies using the MABC-2 to examine differences in motor skill development by children with ASD and their typically developing peers, the children participating in each study were of limited age ranges (Green et al., 2002, 2009; Whyatt & Craig, 2012). In each of those studies, age differences between the youngest and oldest participants were <5 years. One strength of the present study is that participants ranged in age from 3 years to 16 years. Thus, this study provides evidence that across childhood, children with ASD are delayed in their fine and gross motor skill development. Reports in the literature have noted the persistence of this gap throughout childhood and adolescence, but using other measurement methodologies (Baranek et al., 2005; Berkeley et al., 2001; Breslin & Rudisill, 2011; Jansiewicz et al., 2006; Staples & Reid, 2010). All of these studies used a cross-sectional research design (like the one presented here), so it would be interesting for researchers to longitudinally study groups of typically developing children and children with ASD to follow the trajectory of these reported delays in motor performance. Another strength of this study is that data regarding the IQ of children with ASD were obtained. The nature of the relationship between IQ and motor performance in children with ASD seems inconclusive. Previously in the literature, a relationship between IQ and motor problems was suggested in children with ASD (Green et al., 2009), however, SmitsEngelsman and Hill (2012) reported that motor impairment was found at all IQ levels suggesting that IQ scores could not explain all aspects of motor performance in children. This relationship merits further exploration, especially when one considers that IQ is related to autism severity (Charman et al., 2011). Perhaps the complex relationship between IQ, motor performance, merits further explanation. Although these findings suggest that the delay in motor skill development is robust and lasting throughout childhood, care should be taken before using these results as evidence to suggest that motor skill development as measured by the MABC-2 can serve as a potential indicator for ASD screening. Autism can be reliably diagnosed among children younger than 3 years (Corsello, Akshoomoff, & Stahmer, 2013), but the MABC-2 is not valid for use with children younger than 3 years. Thus, a different motor skill assessment would need to be used for evaluating motor skill performance as a screening tool for ASD. 4.1. Limitations and future directions This study was not without limitations. There are far more girls enrolled in this study in the control group of typically developing children than girls with ASD. Although this is consistent with diagnostic trends by gender (CDC, 2013; Newschaffer et al., 2007), it may affect studies examining motor skill development more meaningfully as girls have less developed motor skills than boys (Robinson, 2011). While no gender differences are identified in MABC-2 assessment (Henderson et al., 2007), it is recommended that future research include more girls when assessing motor skill development in ASD population. 4.2. Implications It is critical that researchers, educators, and therapists recognize that children with ASD are delayed in terms of their fine and gross motor development. This finding supports that the inclusion of fine and gross motor performance in ASD screening process is important since motor development typically precedes language development, thus enhancing the potential for earlier diagnosis. Early diagnosis leads to earlier intervention and better prognostic outcomes. In addition, motor delays may have a negative effect on subsequent language, social, and cognitive development. This inclusion of motor performance in the ASD screening process can improve the chance of targeting and addressing these delays in treatment programs. Failure to assess and treat motor delays might make it more difficult to address other common developmental challenges in children with ASD. Furthermore, interventions to improve fine and gross motor skill development should be developed, especially in light of the emerging relationship between motor skill development, physical activity habits, and obesity (Stodden et al., 2008). Participation in physical activity is impacted by motor skill development. Children with ASD may need additional practice of their fine and gross motor skills to be able to participate in complex recreational programming (Liu, 2012; Lloyd et al., 2013) to compensate for their delayed motor skill development. Recreational programs targeting motor skill development may be especially beneficial to children with ASD, so long as these programs providing a variety of challenge in their activities in order to meet their skill levels. Beyond providing strategies to develop the motor skills serving as the building block for future complex movements, these interventions could also provide authentic settings for communication and social interaction (Lloyd et al., 2013). In conclusion, the present study indicates that children with ASD are delayed in terms of their fine and gross motor skill development compared to their age-matched typically developing children as measured by the MABC-2. Moreover, findings suggest that this delay is true across all three constructs, manual dexterity, ball skill, and static and dynamic balance.
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