Spectrum: Autism Research News
Specify motor impairment in autism criteria to open paths to treatment
With a diagnosis of autism comes the expectation that it will open the door to therapy — opportunities to help the autistic person, and those within their support network, to navigate the challenges encountered in daily life. Unfortunately, for many that door leads only to a one-way street where the goals of therapy are mainly targeted toward improving “core deficits.” Too often, diagnosticians and therapists overlook functional domains sitting outside the traditional conceptualization of the condition.
Clinicians have detailed movement challenges in the earliest observations of autism and identified those challenges as a prominent early sign of autism, with delays in motor milestones serving as a key marker. They have continually reported motor difficulties as a highly prevalent functional impairment in autistic people across the lifespan. Yet motor problems continue to sit on the outskirts of recognition.
Motor impairment currently appears in the DSM-5 autism entry as an “associated feature.” Motor impairment is not specific or universal to autism, but neither are intellectual or language impairments, which feature more prominently within the diagnostic guidelines as domain-specific impairments referred to as “specifiers,” in which emphasis is placed on identifying whether a person has challenges within that functional domain, rather than attempting to situate those challenges as separate co-occurring diagnoses. This makes it possible to identify domain-specific impairments early, at the point of autism diagnosis, and to target therapy toward a broader range of needs.
At present, motor impairments in the context of autism can only be specified if a child is diagnosed with a neurodevelopmental condition referred to as developmental coordination disorder (DCD). This condition can occur on its own but more frequently co-occurs with other neurodevelopmental conditions. It is diagnosed when a person experiences persistent difficulty acquiring and performing motor skills, resulting in a significantly reduced ability to perform common, everyday activities.
Specifying DCD alongside an autism diagnosis presents several challenges for clinicians, autistic people and their families. First, it does not enable an early recognition of motor impairment, because a diagnosis of DCD is not recommended until age 5 or later, which could be years after an autism diagnosis has been made and initial motor delays and difficulties have been identified. Second, it results in a person receiving multiple diagnostic labels. Whilst diagnostic labels help to define challenges and can allow for greater understanding, having more than one makes it more difficult for people to communicate those challenges. Third, awareness of DCD is lacking.
The diagnostic label DCD is often used synonymously with the term motor dyspraxia (meaning “partial” impairment of movement), which has created considerable confusion for families and supporting professionals. Knowledge of DCD among medical and allied health professionals is poor, and the condition is less likely to be identified, diagnosed and supported as a result. Finally, the process of making any additional diagnosis places further financial and time burdens on everyone involved.
There is little debate over whether motor difficulties are common among people with autism. Studies investigating motor impairment in autistic children and adults have been accumulating rapidly, with DCD screening measures, broader measures of adaptive functioning, and gold-standard motor proficiency assessments all demonstrating a high prevalence (35 to 87 percent) in cohorts of autistic people.
Our research has shown that 79 percent of autistic children have below-average motor skills, one in three falling within a clinical range. This statistic is comparable to that of intellectual and language impairments: One in three autistic children has intellectual impairment and 81 percent have language difficulties. Our research has also demonstrated that motor impairment is rarely identified at the time of autism diagnosis, with only 1 percent of autistic children having their motor impairment clinically recognized at diagnosis. This is a concerning statistic.
Given the substantial evidence, motor impairment should be recognized at the same level as intellectual and language impairments: as a domain-specific specifier.
Some may argue that there are other potential explanations for motor impairment in autism, such as lack of interest, lack of motivation or intellectual disability. But one could also argue that delays in early motor development, whatever their origin, limit a child’s ability to interact with their environment, affecting other developmental domains, and therefore need to be acknowledged and addressed.
Without proficient motor skills, a person cannot interact in the complex ways required to function in their everyday environment. Poor motor proficiency can also influence a person’s ability to interact with others. Including appropriate measures to assess motor proficiency during autism evaluation and enabling motor impairment to be “specified” will increase awareness of movement challenges that commonly present in autism. Clear recognition will open the door to insurers to fund opportunities that will better support the development of motor skills required for daily living, academic and employment productivity, prevocational and vocational activities, leisure and play. Clear recognition will ensure the door to therapy does not lead to a one-way street but instead provides a choice of paths that meet the needs and goals of each person at different points of their life.
It is time to stop arguing. It is time to recognize that regardless of causality, many autistic people have movement challenges. It is time to ensure that these challenges are identified early and supported.