3 Month Old Baby Constantly Moving Arms and Legs

Proc Natl Acad Sci U S A. 1998 Nov x; 95(23): 13982–13987.

Psychology

Movement analysis in infancy may be useful for early diagnosis of autism

Philip Teitelbaum

Departments of ^*Psychology and ^‡Kid Psychiatry, University of Florida, Gainesville, FL 32611

Osnat Teitelbaum

Departments of ^*Psychology and ^‡Kid Psychiatry, Academy of Florida, Gainesville, FL 32611

Jennifer Nye

Departments of ^*Psychology and ^‡Child Psychiatry, University of Florida, Gainesville, FL 32611

Joshua Fryman

Departments of ^*Psychology and ^‡Kid Psychiatry, University of Florida, Gainesville, FL 32611

Ralph G. Maurer

Departments of ^*Psychology and ^‡Kid Psychiatry, University of Florida, Gainesville, FL 32611

Abstract

All of the 17 autistic children studied in the nowadays paper showed disturbances of movement that with our methods could be detected clearly at the historic period of 4–half dozen months, and sometimes even at birth. We used the Eshkol–Wachman Motility Analysis System in combination with yet-frame videodisc analysis to written report videos obtained from parents of children who had been diagnosed every bit autistic past conventional methods, usually around 3 years former. The videos showed their behaviors when they were infants, long before they had been diagnosed as autistic. The movement disorders varied from kid to child. Disturbances were revealed in the shape of the mouth and in some or all of the milestones of development, including, lying, righting, sitting, crawling, and walking. Our findings support the view that motion disturbances play an intrinsic part in the phenomenon of autism, that they are present at birth, and that they tin be used to diagnose the presence of autism in the kickoff few months of life. They betoken the need for the evolution of methods of therapy to exist applied from the starting time few months of life in autism.

There is controversy over whether motility disorders play a central office in the miracle of autism and fifty-fifty whether such movement disorders exist in autism at all. For instance, Rimland (1) has stated:

It has been widely recognized for many decades that the vast majority of autistic persons are quite unimpaired with regard to their finger dexterity and gross motor capabilities. They have in fact often been described as especially dexterous and coordinated. The literature abounds with stories of young autistic children who tin can take autonomously and reassemble small mechanical devices, build towers of blocks and dominos college than a normal developed can, gather jigsaw puzzles and climb to dangerously high places without falling… The idea that autism is, or typically involves, a "motility disorder" is just ludicrous … .

On the other manus, Damasio and Maurer (2) and Vilensky et al. (3) showed that autistic children between the ages of 3 and 10 walk somewhat like Parkinsonian adults in that they walk more slowly than normal, with shorter steps. Correspondingly, Courchesne et al. (4), using MRI, accept shown that certain areas of the cerebellar vermis are incompletely developed in autistic children [merely see Piven (five)]. This also supports the view that movement disorders might play a role in autism (6, 7).

Nosotros believe that the findings presented here help to resolve this controversy. Nosotros used Eshkol–Wachman Movement Analysis in combination with flicker-free laser-disc nevertheless-frame analysis to study videos taken in infancy of 17 children who later turned out to be autistic, every bit diagnosed at the age of 3 years or older past conventional methods of diagnosis. Every ane of these children displayed movement disorders, some subtle, some obvious.

Furthermore, because these movement disorders always could be detected with our methods as early as 4–6 months of age and sometimes every bit early as the beginning few days after birth, nosotros propose that the study of motion disorders in infancy may serve as an earlier indicator than shortly bachelor methods for diagnosing autism in children.

As a framework for the study of infant move, we decided to clarify the movements involved in the major motor milestones in the development of the infant from birth through the time that he or she starts to walk: i.east., lying, righting, sitting, crawling, continuing, and walking. Every child goes through these stages (infants with severe neurological defects who are unable to progress through these stages of evolution are non included in the present word). Therefore, these motor milestones can serve every bit a common denominator by which to evaluate and compare normal and disintegrated move in infants.

METHODS

We advertised in the monthly periodical published by the National Commission on Autism and in the electronic mail listing run by the Autism Society of America. We asked parents of autistic children (diagnosed past conventional methods commonly at three years or older) to ship us videos of their children taken when they were infants. Nosotros received and copied videos of 17 such infants and compared their patterns of lying (decumbent and supine), righting from their back to their tummy, sitting, crawling, standing, and walking with that of 15 normal infants. The normal infants were filmed by us in the nurseries of Kibbutz Merhavia in State of israel when each pattern was only commencement to develop. Selected portions of these behaviors were transferred to videodisc (Panasonic Rewritable Optical Disc Recorder LQ-4000, Secaucus, NJ) for even so-frame analysis by using Eshkol–Wachman Motion Notation (8). Eshkol–Wachman Movement Notation is a general analysis organization in which spherical coordinates are applied independently to each segment of the body. By distinguishing between which segments are actively moving versus those that are being carried passively forth, a deeper agreement of abnormal movement is possible.

RESULTS

Motor Milestones in Development

Lying.

Lying is an active posture, fifty-fifty in the first few days of life. As has been pointed out by Casaer (9), a newborn baby maintains specific agile postures while lying. Persistent deviations from the normal patterns of lying can indicate abnormalities associated with autism. For instance, one of the children in the nowadays written report showed a persistent asymmetry^§ at the age of 4 months when lying on his tummy. His right arm ever was caught under his chest, and fifty-fifty when engaged in reaching for an object with the other arm, he all the same did not use his right arm. Throughout his start year, this asymmetry persisted, causing the child to fall to his right side when lying on his tummy, or when sitting, and fifty-fifty when he started to walk.

Righting from Supine to Decumbent.

Rolling over from back to tummy usually begins effectually 3 months of age. It involves a rotation around the longitudinal axis of the torso (run across Fig. ​ 11), in a corkscrew manner, i body segment after the next. Typically, in the earliest course of such righting, the pelvis turns showtime, so the body, and finally the shoulders and head. Past six months of age, cephalic dominance is evident (10, 11), and this order is reversed. The head turns first, and the shoulders, trunk, and pelvis follow (Fig. ​ i).

A normal infant, ≈vi months former, shows cephalic dominance in the initiation of righting to prone when lying supine on the ground. The head turns start, and the shoulders, torso, and pelvis follow sequentially until the kid reaches the prone position.

A definition of the 3 types of movement that can be performed by the body. (Plane motion) The limb segment moves in a airplane that is at ninety degrees to the centrality of its motion. (Rotatory motion) The limb moves at an angle of zero degrees to its own axis: i.e., it does not move in space, but merely twists effectually the axis through its length. (Conical movement) The limb moves at an bending <90 degrees and >0 degrees to its centrality of movement.

In our feel, impairments in righting exist in autistic infants. Some cannot turn over at all. Others, although managing to plow over, and thus "getting the job done," practice it in the following manner: starting from lying on their side (rather than on their dorsum as normal children would exercise), they arch themselves sideways by raising the caput and pelvis upward (Fig. ​ 2). This narrows the base of operations of the body so that past moving the upper leg frontward that leg tin serve equally a weight to topple the trunk over. All of the segments of the body motility en bloc, not in a corkscrew fashion. This results in the child falling over, without any active rotation.

An autistic baby, ≈5 months erstwhile, cannot right by rotation. Instead, he arches the head and pelvis sideways upward, moves the summit leg forward, and topples over en bloc, without the sequential segmental rotation in the righting movement characteristic of normal children.

Information technology must exist noted that, fifty-fifty though we have videos of 17 autistic children so far, but a few of these home videos actually filmed righting on the ground in such children. Thus, we take only a very express sample (n = 3) of the righting behavior of autistic infants. Nevertheless, the sideways–upwardly pattern of righting seen in all three of these autistic children is quite unlike from what normal children ever evidence when righting on the basis. The aberrant pattern of righting that we have just described was seen by us when the autistic children ranged in age from 6 to 9 months old. I of these children, at the age of 3 months, when lying supine, flexed his caput and neck strongly forward in the midline (see Fig. ​ 3 a and b). Such midline forward flexion can be seen in the normal newborn at the historic period of five days (ix), simply it is atypical for information technology to appear at 3 months of age. In other words, the forward-flexion pattern shown past the autistic child may be a more infantile pattern.

An autistic child, ≈three months old, defective the ability to rotate around the body midline during righting (a), attempts to sit upwardly past ventroflexing his torso in the midline aeroplane (b).

Sitting.

Usually, at ≈6 months of historic period, a normal babe can sit upright. He maintains his equilibrium by distributing his torso weight every bit on his sitting bones, fifty-fifty when, past reaching for a toy, his upper torso will be out of the vertical. Turning his head, rocking in identify, or busying his hands with objects, he maintains his stability.

Some autistic children were non able to maintain sitting stability at this age. In the extreme, he or she simply vicious over like a log, without using any allied reflexes to protect himself (see Fig. ​ four). In other cases, where there was less severe movement disturbance, the baby managed to sit for a few minutes at a time, but, because his weight often was non distributed equally on both sides, his posture was asymmetrical, leaning to ane side, and he savage over when reaching for objects or moving his arms and upper body.

An autistic daughter, viii.5 months old, shows no allied protective reflexes when falling (e.thousand., extending the arms and hands out to protect herself from hit her head when falling toward the ground).

Crawling on Hands and Knees.

Most babies kickoff to crawl at about the same time they begin to sit. In that location are several forms of creeping and crawling and there is much argue well-nigh the interlimb patterning involved (see ref. 12 for a detailed discussion of this topic). Nosotros will consider here only crawling on hands and knees. The following volition be used as a reference starting position: arms vertical at shoulder width, palms on the flooring fingers pointing forrard; thighs vertical and hip-width autonomously, knees on the ground with lower legs and feet resting on the floor pointing backwards; and weight equally distributed on all four limbs (meet Fig. ​ five). Note that this is an "ideal" position: a baby who is playing and moving effectually rarely will stop in this position, but it can serve as a reference relative to which other motility patterns—normal and abnormal—can be studied. When itch frontwards on easily and knees, the artillery and thighs motility parallel to the midline centrality of the body. That means that the artillery stay shoulder-width apart, and and so do the thighs.

A normal baby, ≈6 months old, shows skillful back up in the artillery and legs while crawling forward.

Autistic Children May Bear witness Deviations from the Normal Blueprint of Crawling.

Asymmetrical lack of adequate support in the artillery. Equally shown in Fig. ​ 6, this infant did not take adequate support in his arms, so that he supported himself on his forearms rather than his easily. Note that one arm is crossed in front of the other so that his base of support on his arms is very narrow. Although support was deficient in both artillery, the right arm was weaker than the left, so that reaching was done with the left arm while the right arm often was caught under the body. He appeared to intend to clamber forward to attain the pocket-size roller on the floor in front end of him. Because he could non move his thighs toward his stomach, and thus was not able to "step" forward on his knees and shift his weight, he was stuck in place. The result was that he raised his pelvis into the air while leaning on his upper arms, his body in an upside down V shape. He tried a few times to move forward by bringing his knees to the footing and pushing himself, but again and over again, instead of moving forward, his knees came off the floor, extending his legs and bringing his bottom up.

An autistic infant, ≈5 months erstwhile, is unable to support himself on his easily and is unable to bring his knees toward his breast to crawl forward, and then he lifts his rump upward while trying to crawl but cannot movement forrad from the spot.

Asymmetry in the legs.

(i) In the next video taken of the child described above, at the age of 6 months, the arms had adult support, and the legs now could be used in crawling. Nonetheless, a residue right-sided deficiency remained in the apply of his legs in crawling: from the starting position described higher up, the left leg moved the usual way (thigh moves forward under the belly, lower leg and foot sliding on the floor) whereas the right thigh did not move actively. It was carried passively past a sideways flexion of the right hip (so that the hip came closer to the rib cage). This motility of the hip carried the thigh medially besides as forrad, so that, with each itch step, the base of the trunk progressively was narrowed, resulting in eventual falling over to the right.

(ii) Some other autistic child is shown in Fig. ​ vii. When this baby crawled, the left leg moved the usual mode (the left thigh moved forward under the belly with the lower leg and foot sliding on the floor, and the left knee contacted the ground at the end of each step) whereas the right leg stepped forward by using the foot (the lower leg is vertical with simply the foot contacting the ground at the terminate of each step).

An autistic babe shows disproportion in his crawling: the left leg crawls properly, merely the correct foot steps rather than crawls.

Standing.

A normal baby, ≈8–10 months erstwhile, may pull himself upwardly and stand for a few minutes, sometimes leaning against a piece of heavy piece of furniture. After a short period of time, though, he typically will subside to the floor to go along his activities. One autistic girl of that historic period seen in Fig. ​ 8 stood in one place leaning her back against a heavy piece of furniture for periods equally long as fifteen minutes at a time. Such relative akinesia may signal aberration.

Moebius Syndrome shape of the mouth in an viii.5-month-former autistic girl. The lower lip is apartment, but the upper lip is biconvex in a characteristic shape.

Walking.

When a baby starts to walk, his gait develops through fixed stages that incorporate a proximal–distal gradient that governs the command of the different segments of the legs. The thigh, the segment of the leg well-nigh proximal to the torso, is the only segment that actively moves at first. The lower leg and the foot but are carried passively along by the movement of the thigh. They do not move actively. Later, they add their action successively. This paradigm of normal walking enables the states to analyze deviations from it.

When a infant starts to walk, iii stages tin can be differentiated. (i) Waddling: From a starting position of stability (see Fig. ​ 9), in which the baby stands still, both legs parallel and weight every bit distributed, the trunk weight is shifted laterally to 1 leg. This enables the other leg to lift and pace forward. Because merely the thigh moves actively (as in crawling, the lower leg and foot are beingness carried passively along), the pace is very short. The foot is planted every bit a whole, neither toes nor heel touching the floor start. The infant and then shifts his weight sideways to the leg that has just stepped, releases the other leg and brings information technology in a "catch-up" step to a position parallel to the leg that just had stepped. The consequence is a "waddling walk" in which, although the baby progresses forward, he does it by waddling from side to side, with long intervals of standing withal betwixt each pair of steps. (This tin can exist noticed near clearly past watching the head.) The hands are raised shoulder high, forearms vertical (Meet Fig. ​ 9).

A normal baby, ≈10 months old, holds his arms upwards at shoulder level as he is only first to learn to walk.

(ii) Intermediate stage: Kickoff the pace-gesture, then the shift of weight; the catch-up step is transformed into a full step forrad and the step cycle develops as follows. The body weight shifts, allowing the baby to release the rear pes from the ground by rolling it from heel to toe, which, in turn, flexes the lower leg relative to the thigh. When, from this position, the lower leg swings forward, carried by the movement of the thigh, the whole leg is lowered back to the basis, the foot landing flat ahead of the other foot. Only subsequently the leading foot has been placed on the floor is the body weight shifted forward (rather than from side-to-side as in stage i). The arms are lowered then that the upper artillery hang downwards forth the sides of the body, and the lower artillery are held waist-high, parallel to the ground, pointing forward. It should be noted that, in adults with Parkinson's disease, there is a phase of deterioration of the stride wheel that parallels the form of stepping shown in this intermediate stage of the normal development of walking. Only later on the leading foot is on the ground does the body weight shift forrard (13).

(iii) Final stage: The body weight is superimposed on the stride gesture; although in stages i and ii, the shift in body weight was delayed until both anxiety were on the footing, in this stage, weight shift occurs simultaneously with the stepping movement of the leading leg (while the leading leg is in the air). The leading foot so touches the flooring heel first, and, as the rest of the foot rolls onto the flooring, it acts to cycle the trunk weight smoothly forward. The rear heel lifts from the ground before the front foot touches the basis, enabling ane to encounter that the weight is being shifted. The whole cycle is permitted by and permits the continuous shift of weight forward. The rolling of the foot determines the flexing of the lower leg, which then swings frontwards and extends to bring the heel of the flexed foot in bear upon with the floor. The arms are down along the sides of the trunk, not coordinated yet with the step bicycle.

These three stages in the development of the step can exist observed in every baby that starts to walk. However, the duration of each stage may vary greatly, lasting anywhere from a few days to several weeks. Also, the control of the arms may develop at different rates from that of the legs. For example, the arms may be in an advanced stage (down alongside the body), and the legs may be in stage i or ii, and vice versa.

In the gait of autistic children, the deviations from the normal can be categorized as follows. (i) Asymmetry: In normal walking, the movements involving the arms and legs are symmetrical. In every autistic child we have seen and then far, some caste of asymmetry has been found. For example, when walking, a ten-twelvemonth-old daughter held the right arm in a more infantile position (lower arm held at waist height, as described above) while the left arm was held down as it swung aslope the body. When walking, a three-year-old boy exhibited an infantile pattern in the right leg, where just the thigh was moving, conveying the lower leg and the human foot with it. The other leg showed a more mature design; that is, all parts of the leg moved relative to 1 another, the heel of the foot being placed on the ground kickoff.

(ii) Delayed evolution: At the age of 2 or even later, the gait may exist more infantile than normal. Thus, one autistic child at the historic period of two exhibited agile movement of each thigh merely, with the lower leg and foot being carried passively. Likewise, the foot was planted on the floor as a whole, and there was no release of the hind heel and thus no smooth transfer of weight.

(iii) Sequencing, not superimposition: At the age of 5, as shown in Fig. ​ x, this autistic child exhibited all of the components of a "mature" step; that is, the thigh and lower leg and foot moved actively frontward, but this was done without the shift of weight that usually goes with it. Only afterwards the leg was extended fully in the air did the shift of weight occur, so that the child roughshod forward on to it in a "goose step" course of walking. The shift of trunk weight occurred after, not along with, the motility of the leg.

(a) A 5-twelvemonth-old autistic boy has a fully developed footstep gesture. All three segments of the leg motility actively (encounter text), but his body weight does not shift at the aforementioned time, resulting in a form of goose-step. (b) The torso weight only then is shifted and so that the male child falls on to the outstretched leg at each step. This is a course of sequencing rather than superimposition of 1 movement on the other.

(iv) The arms: In our feel, every bit a general dominion, papers written about walking bargain only with the action of the legs, omitting any discussion of the office of the arms in walking. This is unfortunate, because the action of the arms is extremely important in facilitating the gait via centrolineal reflexes. In earlier work (13), it was shown that patients with Parkinson's disease can profoundly augment the size and speed of their steps by increasing the amplitude of their arm swing. Furthermore, equally described to a higher place, at that place are specific positions of the arms that accompany the stages of development of walking. These arm positions can serve as milestones along the course of normal development. If, in the class of development, there is arrest in an early stage (as signaled by the position of the arms), this can indicate aberration. For example, in the study carried out by Vilensky, Damasio, and Maurer (3), several autistic children (ages 3–10) exhibited more infantile positions of the arms while walking: the forearm often was held parallel to the footing, pointing forrad. In several cases, the arms were not held in a symmetrical position: one arm was in a more mature position (the arm fully extended downwards alongside the torso) while the other was in a more than infantile position (forearm held horizontal, pointing forward).

(5) Arm-and-hand flapping: Arm-and-hand flapping oftentimes tin be seen in autistic children. It likewise can announced in normal children, ordinarily for a few months, before information technology disappears. For this reason, it is difficult to use as a sign diagnostic of autism. Even so, if it persists to an age at which the mature class of walking should be well developed (2 years old or more), then other confirming signs should be looked for also.

In some of the children studied here, we observed a characteristic mouth shape (encounter Fig. ​ 8) chosen "Moebius Syndrome" (14). This oral fissure shape can exist seen in the first few days afterward birth and may persist throughout infancy and on into adulthood. It does not occur in all infants who turn out to exist autistic, but, when it does occur, information technology signals the need to observe closely the movements displayed past the infant. If some of the other symptoms of movement disorder that we accept described hither as well occur, it strengthens the possibility that autism is involved.

DISCUSSION

Autism generally is diagnosed at ≈3 years of historic period, when a child begins to participate in organized social settings (in a plant nursery school, for instance). Because social skills required are aberrant in such a child, it is relatively piece of cake to spot autistic behavior at that place. Such a child may not participate in social play with other children, stays by himself, and does not want to be touched past anyone. He refrains from middle contact, has difficulty expressing himself verbally, and sometimes does non talk at all. Indeed, Osterling and Dawson (fifteen) were able to depict the deviant behaviors of autistic children by analyzing their social behavior from videos taken at their showtime birthday party. The problem is that, in infancy (4–half dozen months), the social symptoms are not so readily credible. The infant in his crib relates largely to himself, and only his movements reverberate the action of his nervous system. The child's mother is usually enlightened very early that something is wrong, but, because she is unable to specify something diagnostic, the pediatrician she consults often tends to reassure her that this is a minor problem that the child will grow out of. Hashimoto et al. (sixteen), using developmental delay, poor facial expression, and failure to make center contact as indicators, were able to screen for autism at half dozen months. Considering it has been shown that nearly all autistic children at later ages accept motion abnormalities (2, 3), we reasoned that such abnormalities might exist evident in the first few months of life. Every bit shown in the nowadays paper, this is indeed so.

Information technology is of import that the abnormalities in motion that we accept described here tin be seen very early in infancy, long before the behaviors in social settings that currently form the basis for the diagnosis of autism. Diagnosis in infancy can betoken the need for therapeutic behavioral interventions that might provide greater degrees of recovery from autism. Temple Grandin (17) is a famous instance of the remarkable caste of spontaneous recovery that is possible in autism. It is axiomatic that the before the therapy, the more effective it will exist. Therefore, the fact that abnormalities in movement tin can be very early indicators of potential autism is important to know.

It as well should exist noted that the movement disturbances that we have found in autistic children typically occurred on the right side of the torso. This is in contrast to the movement disturbances reported in schizophrenic children in infancy, where they occur typically on the left side of the body (18). A more than detailed comparison of the motion disorders found in autistic infants with those found in schizophrenic infants would be very valuable.

The nowadays findings are too important for pediatricians. Time and time over again, in our correspondence with the mothers of autistic children, we take heard that the mother suspected that something was wrong with her baby just that the pediatrician told her that everything was all right and that she need not worry. The pediatrician should be the primeval, non the last, to know that the child might be autistic. An awareness that simple movements such every bit those described in the present paper might assist in the diagnosis of potential autism would be valuable for pediatricians.

The fact that such early on diagnosis is possible now highlights the need for the development of earlier therapies that will be effective in the treatment of potentially autistic children. Considering diagnosis was not mostly possible so early, no systematic methods are currently available for the handling of infants at adventure for autism. Our findings should provide the impetus for systematic search for such treatment methods.

How do nosotros reconcile our findings of deficits in the development of movement in autistic infants with the reports from parents cited by Rimland (1) indicating that many autistic children display hyperagility and hyperdexterity? Two possibilities exist. First, information technology is possible that, in our limited sample of autistics, nosotros have not accomplished an adequate sample and that there exists a subgroup of autistics that display such hyperagility and dexterity fifty-fifty in infancy. Considering we obtained our videos without asking for whatsoever special characteristics other than a diagnosis of autism, we have no reason to assume that there was a systematic bias in our sample. Alternatively, it is possible that a transformation occurs in development in autistic children, so that many of the children whose videos showed movement abnormalities in infancy might at a afterwards age evidence hyperagility and dexterity, alike to that reported by Rimland (one). This claim further investigation.

Finally, in infancy, the movement disorders present in autism are clearest, not yet masked by other mechanisms that have developed to compensate for them. It is possible that they may vary according to the areas of the brain in which developmental filibuster or harm has occurred. For example, Kemper and Bauman (6) take pointed out from anatomical analysis of the brains of autistic individuals that the limbic system likewise as the cerebellum may show modest shrunken cells. Courchesne (four) has evidence from MRI analysis that the cerebellum may prove hypoplasia or even hyperplasia in certain regions of the cerebellum. By combining move analysis in infancy with MRI assay, information technology may be possible somewhen to diagnose differential areas of encephalon involvement in different subtypes of autism.

Annotation. Unfortunately, nosotros did non have electronic versions of the figures used in this paper. We attempted to increase the clarity of the figures (which were taken directly from home videos) with numerous methods, only, considering of the nature of the original images, we had little success.

Acknowledgments

We are grateful to the families who sent us the videotape fabric that we accept analyzed in this paper. Their goodwill and cooperation made this work possible.

Footnotes

^§Asymmetry tin can be seen briefly in many normal babies. However, if such asymmetry is persistent, a closer examination would be worthwhile.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC25000/

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