“How should I apply this information?”
This retrospective chart analysis of young children who have been referred to an autism-evaluation clinic reveals that a delay in motor performance (gross and fine) may be regarded as an early childhood sign in this specific group of children. However, delay in motor performance does not distinguish young children with an autism spectrum disorder (ASD) from children who otherwise develop atypically. The clinical symptoms observed in these children include social emotional, receptive language, and expressive language deficits. When we find deficits in adaptive behavior and social interaction in combination with low motor outcomes in early development, we should be aware of the possibility of an ASD. This provides professionals the opportunity to diagnosis ASD early, even before early school age and consequently the opportunity to start with early intervention programs.
“What should I be mindful about in applying this information?”
The authors of this study conclude that children who are referred to an ASD clinic demonstrate a delay in gross and fine motor skills at 6 and 8 months, respectively. However, according to the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) manual, developmental ages should only be presented when the scaled scores fall outside the normal ranges, that is, less than −2 SD. From the scaled scores (Table 1), one can conclude that the mean gross and fine motor development of these children is still within normal ranges, that is, between the 0 and −1 and −1 and −2 SD. It is therefore not appropriate to express motor delay in developmental ages for these children. Not only from a methodological point of view but also from a clinical standpoint, motor performance may best be expressed in scaled scores. Otherwise children will be, when only based on the developmental age, unjustifiably diagnosed as having delayed motor development while they are functioning within the normal variance.
Table 1 shows that within the patient population diagnosed with an ASD, considerable variation is measured in gross and fine motor performance, thus implying that a number of children indeed have significant motor delay and should be looked upon in a more individualized manner. At least we should evaluate all children whether or not there is a delay in motor development, based on scaled scores or on developmental age, according to the BSID-III manual. We should look at both the quality and quantity of the motor performance and children's and parents' needs, before starting pediatric physical therapy intervention.
The study describes a retrospective and cross-sectional analysis of medical charts; we therefore should interpret the findings with great care. It is not clear, for example, whether children who were diagnosed with an ASD had previous motor scores that were better or possibly worse than the scores at the time of diagnosis.1 This information is of great importance for clinicians to be able to draw the right conclusions from just 1 developmental assessment. Future studies should therefore use a longitudinal design with consecutive developmental assessments.
In this article, a group of children younger than 3.5 years was evaluated. The study found a trend for gross motor skills to be moderately associated with functional difficulties (eg, adaptive and social emotional limitations) in children diagnosed with ASD. From these analyses, it is not clear in what direction this association points. The (fine) motor tasks in the BSID-III are complex tasks, and it is therefore more likely that the functional difficulties in this study will have a larger effect on motor skills than the opposite, that is, that motor impairment will limit adaptive and social emotional limitations, at least in early childhood. At a later age, that is, children at school age, it is more plausible that limited participation in physical activities due to motor problems may affect the functional skills (eg, adaptive and social emotional limitations).
Table 1 shows that the main problems of these children seem to be in the social emotional, receptive language, and expressive language domains. Should we not focus on these functional limitations in the intervention of these children, which may influence indirectly development of motor performance? Further research is needed to answer that question.
Janjaap van der Net, PT, PhD, PCS
University Children's Hospital/UMC Utrecht, Utrecht, The Netherlands
Maaike C. A. Sprong, PT, MSc, PCS
University Children's Hospital/UMC Utrecht, Utrecht, The NetherlandsThe authors declare no conflict of interest.