Dyspraxia - Movement Difficulties
in Children with Autism Spectrum Disorders
What is Motor Control and Why Does It Matter?
Throughout the day, each of us performs numerous sequences of movements with little effort or thought, such as showering, brushing our teeth, dressing, driving, typing, etc. The list of these actions is vast, considering that most behavior involves muscle movement, including looking, talking, swallowing and even breathing.
Some of the most complex motor movements take years of practice, such as the twists and turns of an Olympic figure skater, the performance of a concert violinist or the jumping and throwing of a professional basketball player. From the rote and seemingly simple movements of daily life to the dazzling accomplishments of skilled athletes, moving the body in any way, for any purpose, depends upon a complex motor network controlled by the nervous system and maintained through an intricate physiological balance.
This network is based in the brain and connected to the spinal cord through specific pathways. The brain and spinal cord work together to coordinate the planning and execution of motor movements, from learning to tie shoelaces to becoming an Olympic gymnast.
Dyspraxia is a general term used to cover a range of difficulties affecting the initiation, organization and performance of movements. It appears to involve problems with the brain’s ability to process information, which results in messages not being fully transmitted to the body. Dyspraxia can be present from birth or as a result of brain damage suffered from a stroke or other trauma. It may include difficulty with planning sequences of coordinated movements as well as difficulty with executing motor plans, even when they are known.
In the United Kingdom, the term dyspraxia is often used to describe clumsiness in otherwise typically developing children. In this article, dyspraxia refers to the more significant problems of movement described in the preceding paragraph and not to clumsiness in typical children.
Dyspraxia and Autism Spectrum Disorders
While many children with autism spectrum disorders show well-developed motor coordination and dexterity, there are numerous others with significant difficulties in movement and motor planning. Among this group, there are differences in the form that dyspraxia takes. In our experience, the various forms of dyspraxia can exist together or separately.
Some children have marked difficulties with gross (large) motor movements and they may show obvious problems with balance, walking, running, getting up or down, starting or stopping, imitating actions, getting “stuck” in a repetitive movement, etc. Due to low muscle tone (hypotonia), they may have difficulty sitting without support.
Others are more affected at the level of fine motor skills. They may have trouble with pointing, grasping, or with holding on to or letting go of objects. Still other children with autism have such difficulty controlling the muscles surrounding the eyes, that they cannot direct their gaze to a desired person or object.
Finally, there are children who have what is referred to as “speech dyspraxia.” While most of us do not think of speaking as a movement, speech is among the finest controlled combination of muscle movements that the human body can perform. When a child cannot control these movements, the acquisition of speech is affected: oral motor imitation is difficult, words are very difficult to learn and the same sound might be repeated over and over.
Motor Ability and Motor Planning
Your child’s motor ability is not the same as her ability to motor plan. There are many physical actions that your child can do, thus she is demonstrating motor ability. But if she has trouble doing what she wants to do when she wants to do it, she has difficulty with motor planning.
Perhaps she cannot always move her body in the way that she wants. She may have trouble intentionally performing certain actions. It may take her time and a lot of effort to succeed at performing an action. She might have some motor movements that are patterned and she may have difficulty stopping or changing these patterns, leaving her “stuck” in repetitive movements. When she is not trying, she may be quickly successful at various motor actions, while being unable to do the same actions when she is requested to do so.
If a child sees something that he wants at the top of the stairs, he might climb up the stairs and grab the desired item. But, if he is asked to focus on going up the stair, he might have difficulty doing it. There are two different kinds of intention involved. In one case, the boy is acting impulsively. In the other case, he is being asked to focus on the movement. Sometimes with dyspraxia, the child can act according to impulse, but has difficulty being successful when focusing on more planned and sequenced movements.
Another characteristic of dyspraxia is that your child might have certain movements that are habitual and routine. The strength of the routine can be much more powerful than his ability to motor plan. All of us have had the experience of going into automatic pilot and driving to the place that we habitually go, rather than to the place that we intended to go. We say, “Silly me,” and turn the car around. Luckily this doesn’t happen so much that it impairs our day to day functioning. But this dynamic could be severe enough for your child that it might impair his functioning. He might have a number of movements that he does, not because he particularly wants to, but because his automatic pilot is stronger than his intention.
Some of the children who are most involved in repetitious movements as self-stimulating rituals are dyspraxic. If a child is in good rapport, appears to be trying and is having difficulty responding to a clear request, she may be dyspraxic.
Other Signs of Dyspraxia
- Actions take a long time to learn. Then the child often responds with that learned action even when it is not appropriate.
- Delays in responding to requests – he does it, but after time has gone by.
- Your child is extremely inconsistent, sometimes performing an action smoothly and sometimes having great difficulty responding.
- Often he can do matching exercises, or other activities that require the same repeated motor plan.
- She has difficulty imitating.
- Your child takes your hand to perform an action (as if your hand will work better than hers).
- Your child has difficulty learning series of movements.
- Often the child appears unusual in certain movements. She can appear stiff, clumsy, or delayed in these motor skills. This can occur even though many other motor skills appear to be normal.
- Often, when writing or typing, the same scribble or key combinations appear over and over again.
- Your child might leave the table repeatedly because he is stuck in a motor pattern for getting up and going. Or he might bring things to his mouth repeatedly because he has this motor pattern. Often these children will welcome your breaking of the pattern, rather than appearing angry if you obstruct them. Some dyspraxic children even welcome a belt that holds them in a chair or in a bed.
- Often there is a strong sense that the child understands much more than she is demonstrating. Sometimes this comes from seeing differences in the quality of attentiveness when she is spoken to in more sophisticated ways. At other times, the child sporadically responds to sophisticated requests that were thought to be beyond her comprehension.
- Often there is poor bilateral coordination. Often there is no clearly dominant hand.
- There may be poorer performance of tasks that involve alternating contraction and extension of opposing muscle sets. For example, if a child is asked to put an object in a bucket, he might pick it up, hold it over the bucket and not let go. Grasping and then letting go involve opposing muscle sets.
- Sometimes, when a child with dyspraxia does respond, the movement is quick and impulsive. Slow, controlled movements may be rarely seen.
- Surprisingly, with some dyspraxic children who can write, their writing is as good or slightly better when they are blindfolded.
Some Signs of Speech Dyspraxia
- Your child has difficulty making speech sounds.
- She has difficulty sequencing sounds.
- He has difficulty controlling breathing and phonation.
- Your child has had difficulty with feeding
Don’t Be Fooled
Under certain circumstances, children with autism spectrum disorders are likely to “fool” even a well-trained observer into concluding that they do not have dyspraxia, particularly if the observation time is brief.
Here is an example: Robbie has been diagnosed with autism. He loves blowing bubbles with bubble soap. This referred to as his “stim” because he can make and manipulate bubbles for several hours every day. Because he does this every day, he is extremely adept at all of the very fine motor movements that are involved in making bubbles. When observed for ten minutes by a physical therapist during his bubble activities, he was assessed as having excellent motor skills. A more thorough observation would have revealed that Robbie was unable to step over an obstacle, drink from a cup, hold a pencil, jump up and down, imitate simple movements on request, etc.
When evaluating dyspraxia, it can be helpful to consider actions that are practiced extensively every day in a class by themselves. Extremely well practiced movements will be an indicator of how skillful your child can be with practice but they should not be used to evaluate for dyspraxia.
Dyspraxia and Intelligence
Because of their difficulties responding to requests, children with autism and dyspraxia are often considered to be either cognitively impaired or willfully uncooperative. These are both erroneous assumptions.
Dyspraxia does not affect intelligence but it does create problems with learning. Often the intelligence of children with dyspraxia is under-estimated. This creates a problematic cycle. Because they cannot show their intellectual capability, they are considered to have low intelligence and are seldom taught at a level that is commensurate with their intellectual ability. Over time, they are given fewer opportunities to learn, less intellectually challenging material and fewer chances to practice new skills than their peers. As time passes, they are likely to fall further and further behind, seeming to confirm prior assumptions about low cognitive ability.
Even in autism treatment programs, the special motor planning issues of children with dyspraxia are seldom addressed. Treatment tends to focus on the social and communication issues shared by all people with autism. When educational methods are not well designed for their specific needs, children with dyspraxia do not make the desired progress with social and communication issues. This often results in being labeled as more severely or profoundly autistic than children who do not have movement issues. Similar to the situation of children who have autism with executive function difficulties, the problem is not a more severe form of autism, but autism combined with dyspraxia. Until the nature of their problem is understood correctly and addressed with appropriate strategies, these children typically fail to make much progress.
Minimizing Motor Issues
There are a number of ways to help minimize motor challenges. One is to be aware of ergonomics. For teaching or therapy sessions, many children with dyspraxia do better in a chair with a hard back. This extra support gives them one less motor demand. Stuffed chairs that fully support a child can interfere with the development of needed support muscles.
It is important that the chair be a good fit for the child. When he sits in the chair with his feet flat, his upper legs should be parallel to the floor with his knees at a 90 degree angle. When he sits straight with his arms at a 90 degree angle (upper arm hanging straight down), the table should be just below his elbows.
In teaching sessions, be aware of where you hold the materials that you present to her. Present materials at a height where your child’s arms are relaxed and can be moved easily on the table. Also present the materials close enough to her body so that her arms don’t have to be extended, but not so close that she is jammed up. If you present the items while asking her to point, it will be difficult for her if the items are presented at her arm’s length. She would have to extend and support her own arm, as well as getting to the correct target.
When you present materials, also consider your child’s midline. Her midline goes from her nose to her navel. The midline is actually not a line, but a geometric plane that bisects your child, separating the right and left half of her body. If you present two choices, and she tends to indicate with her right hand, you might want to put both choices more to the right so that her right arm doesn’t have dramatically cross her midline to get to one of the choices.
Experiment and be more acutely aware of posture and positioning. Notice when she appears to have greater or less success.
Helping your child overcome motor difficulties
Here are several things that you can do to help your child overcome his or her motor difficulties.
Children with dyspraxia must work very hard to develop abilities that the rest of us take for granted, such as controlling their movements, practicing motor tasks, building strength and improving coordination. Encourage your child to develop attitudes that will help him enjoy making an effort with his body. Teach him to persist and keep trying. Encourage him to never get frustrated. Let him know that you know that he is smart, even though sometimes it is hard for him to show it.
Create a home environment where you enjoy challenges and where improvement and effort are highly valued. If he has success, that is great and it is celebrated – but success in a task is not the only source of good feeling. Good feeling can also be derived from determination, persistence and great effort each day. Some tasks will not be cognitively challenging for him, but they will help him develop coordination and control. Let him know that those tasks are not about how smart he is, but about how controlled he can be in his movements.
More Cognitively Challenging, More Motorically Easy
Children with motor control difficulties are mentally faster than their bodies. For them, most communication and play take place at a speed that they cannot physically keep up with and so they give up on it. The things that they can do well with their bodies are simpler and less sophisticated than what their minds are capable of doing. This can result in children lounging around and not doing much or engaging in some repetitious activities that don’t really engage their minds.
You can design tasks to be cognitively challenging and motorically easy. Multiple choice questions with an array of two or three possible answers is an example. Play a tape of a sound (a train). Give him a choice of two or three items and ask him to give you the one that makes the sound. Place three written names in front of him and ask him to point to his name. Also to point to the names Mama, Papa, etc. These tasks are motorically simple, but more cognitively challenging.
Find a Response Form
In order to design more cognitively challenging tasks, it is important to help your child find a “response form” that he can manage well. This allows him to show what he understands and it can also become the basis to teach new material and skills.
For example, we worked with a boy who was extremely dyspraxic and did not show control of his own hands. If asked to take one item from an array of three items placed on a table, he would turn toward one of the items and look at it. But his hands did not move. If he moved his hands, the movement was uncontrolled and he often knocked the items off the table.
It became clear that his most accessible motor response was moving his head and eyes. We outfitted a headband that had a pointer with a rubber tip extending out in front. Using this equipment, he rapidly gained the ability to touch the pointer to the desired item. Now, he had a “response form”, a way of responding that involved muscle groups that were under his control. By pointing in this way, he was able to show us that he knew names of people, animals, objects, etc. We were also able to use this response form to teach him new material using the method of Discrete Trial Teaching.
Often, the best response form for a child with dyspraxia is a motor response that changes very little. Let’s say that your child can put an item in a bowl. He has trouble pointing and he doesn’t respond when he is asked to touch something. But he can easily put an item in a bowl. You might put three bowls on a table, with a different item in each. Place an item that matches one of the items in the bowls in his hand. Ask him to “Match.” If you see that he is able to put the item in the correct bowl, you can begin to make relatively small variations in his established motor plan, such as putting the bowl with the correct item the middle, slightly to the left or slightly do the right. This single response form can become the basis for assessing and teaching a variety of skills.
A challenge for parents or teachers is to find ways to test or “probe” his understanding and find activities that might be cognitively stimulating. When you do this, it is important to design the tasks so that he can respond motorically. For example, we worked with a boy who was dyspraxic. He seemed to like toy dinosaurs and often picked them up or looked at them. First we established that the boy was able to choose between two items. Then we put two dinosaurs in front of him and asked him to pick up the Tyrannosaurus. His parents were shocked when he consistently picked up the correct dinosaur, based on its scientific name.
We didn’t know in advance whether the boy had the receptive language ability or knew the names. We flatly asked him to do the task and found out that he had the skill. This is not teaching. This is called probing.
The more your child does simple motor tasks, like matching identical items and identifying items by touching them, the more you can probe his understanding of letters, numbers, words, awareness of gender, general knowledge, seasons, food groups, etc.
Use an Effective Teaching Method
Discrete Trial Teaching (DTT) can be very useful for children with dyspraxia. If you put some life and warmth into it, this teaching method has the potential to help your child tremendously, as it allows her to learn and demonstrate a great number of intellectual skills with a manageable set of motor skills.
A single teaching “trial” consists of a clear request, a pause, a prompt if necessary and reinforcement for a successful response. For instance, ask her to point to an item in a book. If she doesn’t, after 4 seconds, form her hand into a point and help her point to the picture. Then praise her for the correct response. As you continue with the activity, fade the prompt as she learns the task and responds more independently.
This method helps with dyspraxia because the task and the timing are clear. If the child gets confused, she knows that the answer will be coming in the prompt. Because you fully prompt your child by taking her body through the action, she can physically experience what it is like to do the task. If you use this routine frequently, your child will learn the routine and become skilled at the motor plans involved. She won’t have to figure out the ever-changing rhythm and order of the tasks she is given and she will be able to put more energy into motor planning.
If you are simply more aware that helping your child increase physical control is a goal, then you will find ways to help him achieve it. The more he responds to your requests, the more he will overcome motor problems. If he wants to grab something and he does, that might not involve a certain kind of motor planning. If you ask him to grab something and he does, he is using himself differently because it was your idea. The more frequently he motor plans, the more intensely he motor plans, over a length of time, the better he will get at motor planning. Frequency, intensity and duration are key.
Warn your Child
Warn your child – tell him a minute or more in advance what you will be asking of him next. This could enable him to prepare and help with motor delays.
If your child is having some difficulty, prompt her by moving her through the task. This is a physical prompt. You might tell her that you are going to “show her.” Then, take her hand or whatever body part is being used for the task and help her through the task. If she resists your prompt, stop the prompt. Consider telling her that she wasn’t quite ready. Tell her that you will give her a few seconds and then you will try again. Wait a few seconds and then try again.
When using physical prompts to guide your child through the action, be sure to slowly reduce the amount of support you are providing as soon as possible. Continue to “fade” the support until you child is performing the action independently.
Slow and Control Impulsive Movements
Sometimes your child may do an action very quickly, as if she is throwing herself at the task. When asked to point to a picture, she might tap her finger on the photo several times in rapid succession. This is not a well-controlled movement. If she does rapid and repetitious movement, help her go more slowly and in control. Demonstrate exaggerated pointing once, in a slow, controlled manner. Then help her, by prompting her if necessary.
When your child starts to master a task, he may pick up speed. Now is the time to work toward fluency with that skill. Fluency involves accurate and controlled speed. Many children with motor control difficulties want to go fast. If he is smooth and relatively fast in his movement (not blurting and impulsive) and if he can control his movement and change it to fit the task, then he is fluent.
When you notice that your child is getting good at responding to certain requests, and is starting to go faster, alternate the requests and ask him to go a little faster. This can add interest, fun and challenge to simple activities.
For example, a girl liked to put things in a basket. We made a slotted color box to put blocks in, sorted by color. When she had learned to correctly identify the colors and put the blocks in the right slot, she wanted to pick up speed. She maintained her accuracy and was not repetitious in her movements, even when she went fast. She appeared to be practicing fluency. She may have been motivated to experience herself as competent. She may have been making the task more stimulating and cognitively challenging by speeding it up. She may have been showing off. My bet is that she was doing them all. Practicing fluency can make a task more cognitively challenging and more fun and give your child a greater source of pride in accomplishment.
Create Motor Challenges
Make a game in which you set up motor challenges by creating obstacles and unusual situations. Then cheer your child’s efforts. Examples might include giving him a food that he has to cut, using toys that require new motor actions like handling controls or creating tasks that require tools that are new to your child, etc.
One resource for ideas is Developmental Dyspraxia, Identification and Intervention by Madeleine Portwood. You may notice that your child’s dyspraxia is different than the dyspraxia described in the book, but the principles are good and some of the ideas are appropriate.
Many people have noticed that a number of children with dyspraxia do better when they are in physical contact with another person. Along with making sure that your child’s body is well-supported if she is doing a fine motor task, you might notice whether she appears to do better when she is in physical contact with another person.
In teaching sessions, experiment with forms of physical contact while she is doing tasks. Try putting an arm around her, sitting shoulder to shoulder, putting your hand on her back or leg or positioning the chair and table in the corner of the room and sitting close to her. These may be especially helpful when she is doing more challenging tasks. If she does better with physical contact, treat this like a prompt and fade the contact as she becomes more competent.
Practice Brings Improvement
Children with dyspraxia require much more effort to create motor patterns. They require more time to practice using motor patterns when appropriate and not using patterns when not appropriate. Over time, and with practice, children can become more and more adept at controlling their bodies. When they do, they begin to show the cognitive ability that they always had, but could not demonstrate. When this happens, they command more respect, and gain the belief of others in their abilities. With more control comes better expressive communication.
If you have the determination and the opportunity to help a child with dyspraxia to gain motor control, you help her to benefit more and more from the world around her, even as you receive the benefit of her growing ability to give to you.
Copyright © 2012 Steven R. Wertz