The clumsiness was particularly well demonstrated during PE classes. They were never able to swing with the rhythm of the group. Their movements never unfolded naturally and spontaneously – and therefore pleasingly. Hans Asperger 1944
People with Asperger’s can also have a different way of moving. Walking or running coordination is immature and adults with AS may have a strange, sometimes idiosyncratic gait that lacks fluency and efficiency. There can be a lack of synchrony in the movement of the arms and legs, especially when running. Children are often delayed by a month or two in learning to walk and need considerable guidance in learning manual dexterity to tye shoelaces, dress, and using eating utensils. Fine motor skills like writing and using scissors may be problematic. Activities that require coordination and balance can be affected – learning to ride a bicycle, skate, or use a scooter. They may have difficulty knowing where their body is in space, which may cause them to trip, bump into objects, and spill drinks. The overall appearance is someone who is clumsy.
The movement and coordination problems will be obvious to the PE teacher and in playing games that require ball skills. They are immature in the ability to catch, throw, and kick a ball. When catching a ball with two hands, the arm movements are poorly coordinated and affected by problems with timing – the hands close in the correct position but a fraction of a second too late. The child had taken too long to think about what to do. When throwing a ball, they will often not ook in the direction of the target before throwing, which will affect the accuracy. One consequence is the exclusion of the child from some of the social games in the playground. They may then avoid these activities or bravely attempt but can be deliberately excluded due to being perceived as a liability, not an asset to the team, and then are less likely to improve by practicing.
From an early age, parents need to practice ball skills. Some children with AS have greater coordination and fluency when swimming, develop agility on a trampoline, acquire coordination in solitary sports such as golf, and enjoy riding. These can be to a level in advance than their peers.
Specific movement disturbances occur in almost all children with AS. Gillberg included motor clumsiness as one of the six diagnostic criteria, but the DSM-IV includes it as mild.
PROFILE OF MOVEMENT ABILITIES
This can include manual dexterity, impaired coordination, balance, grasp, tone, and slower speed on manual tasks. Balance is tested by the ability to stand on one leg with eyes closed and tandem walking (the task of walking a straight line as though on a tightrope placing one foot in front of the other. When walking, not using their arms and the upper body remaining stiff, they develop an odd gait, waddling like a duck or a human with bladder problems.
These will affect the ability to use adventure playground equipment or competence in the gymnasium and increase the vulnerability to being teased.
Facial expressions are often sparse and rigid. There can be a lack of variation in facial movements to express thoughts and feelings. A ‘flat’ facial expression that lacks tone and subtle movements can also make the person look sad. Clumsy or gauche body language impairs the synchronized ‘dance’ with the conversational partner.
EARLY DETECTION OF MOVEMENT DISTURBANCE
Primitive reflexes persist too long and reflexes did not appear at the expected age. They may have an unusual mouth shape described as Moebius mouth – a tented upper lip and flat lower lip. There is unusual symmetry when lying on their backs and reaching for and manipulating toys – using only one hand, and a different movement or rotation from supine to prone. Sitting can be delayed by a few months and the crawling movement may not have the basic diagonally opposing limb patterns. With walking and falling, there is a tendency to fall to one side and a failure to use protective reflexes.
The tilting test shows late development of turning the head to maintain a vertical position when the body is rotated. Between 6-8 months, typical infants can be held in the air at the waist and their body slowly tilted about 45 degrees to one side then back to the vertical and then the other side and they will be expected to have a compensatory movement of the head to maintain a vertical head position. In AS, this can be another indication of the delayed reflexes observed.
THE MENTAL PLANNING AND COORDINATION OF MOVEMENT
Apraxia describes problems with the conceptualization and planning of movement, so the action is less proficient and coordinated than one would expect. The problem is in mental preparation and planning of movement with relatively intact motor pathways. This may be a more precise description than simply being clumsy.
The experience is one of having a delay between thought and action. It’s as if they don’t have a body, fall down when they try to turn, have difficulty seeing and focusing, and not being able to make their hands move the way they want them to.
There may be problems with proprioception, the integration of information about the position and movement of the body in space, and the ability to maintain posture and balance. These are skills used in the climbing and adventure games of children. There is a tendency to fall off climbing apparatus and risk of falling and injury when climbing a tree.
They often really enjoy being held upside down for long periods of time. When watching TV, they adopt a position where the feet are at the top of the chair and their head rests just above the floor.
Ataxia, that is, less orderly muscular coordination and abnormal patterns of movement, include movements performed against abnormal force, rhythm and accuracy, and an unsteady gait. Observations of walking and running, climbing stairs, jumping, and touching a target (the finger-to-nose test) indicate signs of ataxia. Occupational therapists, physiotherapists, and medical specialists in developmental movement disorders should consider screening new referrals for the possibility of an additional diagnosis of Asperger’s syndrome.
Associated with movement disorders are lax joints that may be due to a structural abnormality or low muscle tone. Holding a pen properly may be difficult due to double joints. Copying and keeping in time with rhythms may show when clapping in time with the music. When walking next to someone, people with AS appear to walk to the beat of a different drum.
HANDWRITING
Hans Asperger described his patients “in his tense grip the pencil could not run smoothly”, “The pen did not obey him, it stuck and it spluttered.” Letters can be poorly formed and larger than expected (macrographia). They can take too long to form each letter, causing delays in completing written tasks. They try to write legibly and become frustrated or embarrassed about their inability to write neatly and consistently. This is an expression of a movement disorder, not necessarily a lack of commitment to the work.
Lots of practice can improve the fine motor skills needed to write legibly, but this gets boring and is resisted by the child. It may help to use a slightly slanted writing surface or a pen that is easier to grasp. Modern technology has come to the rescue in terms of typing. Even young children with AS should be encouraged to learn to type and use a keyboard, computer, and printer in the classroom. Talking into a word processing device can record and print speech. Exams can be completed by typing answers and is more easily read by examiners.
ACTIVITIES AND STRATEGIES TO IMPROVE MOVEMENT AND COORDINATION
An assessment by an occupational therapist or physiotherapist should be done. Remedial activities at home should be enjoyable with clear progress, encouragement, and success. PE activities should emphasize physical fitness rather than competitive team sports. The teacher needs to discourage other children from laughing and should not have team leaders select team members, which so often results in both the being chosen last and in groans from the other children that they must have such a clumsy child as a member of their team.
The gymnasium is an adverse environment with high noise levels, fast-moving action that is hectic and bewildering, and close physical contact inevitable. Inventive things for team games include being the referee’s assistant, scorekeeping, and responsibility for the school league tables. The teacher should demonstrate what to do from beside, rather than facing the child. Video recordings may be used to allow the child to see their movements and document progress. A daily fitness program can improve movement and coordination and release physical energy that can be emotionally restorative.
INVOLUNTARY MOVEMENTS OR TICS
20 to 30% of children with AS develop tics that can range from momentary ‘twitches’ to complex movements. The vocal muscles can produce an involuntary sound or phrase. The involuntary movement or sound is unexpected and purposeless. Over time the frequency and complexity of the tics gradually increase, with a relative peak between ages 10 and 12 years. In late adolescence, the frequency of tics tends to diminish, with 40% who develop tics being tic-free by age 18.
The child’s vocabulary of tics can change over time and there can be months when the child is relatively tic-free. Tics can disappear when the child is concentrating or become more noticeable with specific activities, such as answering open-ended questions. They can occur when the child is relaxed and the frequency can increase when experiencing stress.
Simple motor tics may be eye blinking, facial grimacing, nose twitching, lip pouting, shoulder shrugging, arm jerking, head nodding, tongue protrusion, throat clearing, sniffing, grunting, whistling, coughing, snorting, barking, or a sucking sound.
Complex tics may be hopping, twirling, touching objects, biting lip, facial gestures, licking, Pinching (self and others), waving both arms, bent at the elbow like a bird’s wings, muttering under the breath, animal noises, repetition of word or phrase just uttered or complex breathing patterns.
People with a tic disorder comment that “irrational thoughts pop up into my brain” and these are called thought and emotion tics. The thought and subsequent action or feeling may not be related to the context. Sometimes the thought can be to do something inappropriate and potentially embarrassing or the emotional tic can be a sudden feeling of intense sadness, anger, or anxiety. These feelings last only a few seconds but can be of concern if they occur frequently throughout the day.
Tics are due to a disorder in the planning loop between the cortex and the movement disorders of the brain and the neurotransmitters dopamine and norepinephrine. Lowering dopamine levels medically can reduce tics. The stimulant drugs used to treat ADHD increase dopamine and can increase the frequency of tics.
As the movement disorder is involuntary, the child does not consciously know when the tic is going to occur and thus has difficulty inhibiting it. Actions such as intermittent sniffling can be infuriating for family members and lead to teasing and ridicule at school. It is best to simply ignore them and for a parent to offer sympathy and emotional support. In the classroom, the child may take longer to complete work due to them and often distract the other children. The teacher can be a role model by encouraging the other children to try to ignore the movements or sounds.
Of concern, three other developmental disorders can develop. Tourette’s syndrome is diagnosed when there is a combination of at least two motor tics and at least one vocal tic and the tics have lasted more than one year. The combination can also have a greater risk of developing ADHD and an anxiety disorder like obsessive-compulsive disorder.
Deterioration in Movement Abilities
This extremely unusual condition is more likely in an adolescent between the ages of 10 and 19 with autism rather than AS and has been termed autistic catatonia. Resembling catatonia and Parkinson’s disease, they have difficulty starting and completing movements, may momentarily ‘freeze’ during an activity, and may develop a resting tremor, a slow shuffling gait, muscle rigidity, and a flat, almost mask-like face. Medication, guidance in initiating a movement, listening to music, and physiotherapy may all help.
EXCELLENCE IN MOVEMENT ABILITIES
Many children and adults with AS may achieve exceptional abilities by winning national and international championships. Swimming, trampoline, golf, horse riding, endurance sports such as marathon running, i.e., activities that can be practiced in solitude, may develop as a special interest. With extensive practice and single-minded determination, a very high standard can be reached. Fencing requires a mask (no problems with eye contact with the opponent) and can be enjoyable. Martial arts can also be appealing as history and culture become an intellectual interest. Pool and snooker require a natural understanding of the geometry of the moving balls.