ASSIGNMENT 24

Article

Exploring the Interaction of Motor and Social Skills With Autism Severity Using the SFARI Dataset

Andrew M. Colombo-Dougovito 1

and Ronald E. Reeve

1

Abstract

Social communicative deficits and stereotyped or repetitive interests or behaviors

are the defining features of autism spectrum disorder (ASD). A growing body of

research suggests that gross motor deficits are also present in most children with

ASD. This study sought to understand how pediatric ASD severity is related to

motor skills and social skills. A multivariate analysis of variance analysis of 483 chil-

dren with autism (N¼444) and ASD (N¼39) revealed a nonsignificant difference

between groups. Results suggest little difference between severity groups on gross

motor and social skills within the limited age range of the participants (about 5.6

years of age).

Keywords

autism severity, gross motor skills, social skills, children, diagnosis

Introduction

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) defines autism

Perceptual and Motor Skills

2017, Vol. 124(2) 413–424

! The Author(s) 2017

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DOI: 10.1177/0031512516689198

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1 University of Virginia, Charlottesville, VA, USA

Corresponding Author:

Andrew M. Colombo-Dougovito, University of Virginia, 210 Emmet Street South, Charlottesville,

VA 22903-1738, USA.

Email: [email protected]

spectrum disorder (ASD) as a condition in which a person has ‘‘persistent def- icits in social communication and social interaction across multiple contexts’’ and ‘‘restricted, repetitive patterns of behavior, interests, or activities. (p. 50)’’ Social skill deficits and repetitive behaviors are defining features assessed dur- ing diagnostic assessments on tools, such as the Autism Diagnostic Observation Schedule, 2nd Edition (ADOS-2; Lord, Rutter, Di Lavore, & Risi, 2002; Lord et al., 1989) that evaluate level of impairment within these two characteristics.

Recent research (Liu & Breslin, 2013; Lloyd, MacDonald, & Lord, 2013; Staples & Reid, 2010) has demonstrated concurrent gross motor deficits present in many children with ASD. Liu, Hamilton, Davis, and ElGarhy (2014) compared motor performances of children with ASD and typically developing children and demonstrated significant delays in gross motor performance among those with ASD. Furthermore, in a review of 101 children with ASD, Green et al. (2009) found that 79% had definite movement impairments and another 10% were bor- derline for these problems. Thus, nearly 8 in 10 children with ASD demonstrate some movement impairment, leading some researchers to stress the importance of including motor skills intervention in early intervention programs for this clinical population (Lloyd et al., 2013). Others suggest adding an assessment of possible motor deficits to diagnostic screening, particularly since motor deficits are often present prior to social communicative delays (Liu, 2012).

Further evidence suggests that deficits in gross motor skills are related to social communication deficits; children with more significant motor skill deficits have more significant deficits in social communication skills (MacDonald, Lord, & Ulrich, 2013). The DSM-5 defines severity of ASD by areas of needed support (APA, 2013) such that more severe ASD is associated with more serious deficits and greater support needs in social communication and repetitive behaviors. More recently, early gross motor skill problems have been shown to predict later language problems in children who are ultimately diagnosed with ASD (Bedford, Pickles, & Lord, 2016). While underlying brain development mechan- isms for gross motor skills share development mechanisms for social skills, vari- ations in deficits between these domains and variations in severity as assessed by the ADOS remain unexplained, since gross motor and social skill deficits are usually compared separately with skill levels in typically developing, nonaffected peers or developmentally matched peers.

Purpose of the Present Study

This study sought to answer the following questions: (a) What effect does ADOS-determined level of severity among children with ASD have on level of motor and social skills difficulties? and (b) How might motor and social skills differ across groups with different ASD severity?

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Methods

Dataset

The SFARI Base is a central database of clinical and genetic information about families affected by autism and other neurodevelopmental disorders, provided as part of the Simons Foundation Autism Research Initiative (SFARI). The data included in this analysis were taken from the Simons Simplex Collection. These data are the result of collaboration between the SFARI and 13 university- affiliated research sites across North America. Active enrollment for data col- lection was ended in 2011.

Participants

This dataset consists of a rigorously characterized sample of 2,644 simplex families, that is, each family has only one child with a diagnosis of ASD. Each of the affected participants and unaffected parents and siblings were given a wide variety of clinical assessments, in addition to contributing bio- specimen samples. Inclusion criteria limited affected participants to those aged 4–17, meeting standard cutoff scores on the Autism Diagnostic Interview – Revised (ADI-R) and Autism Diagnostic Observation Schedule, 2nd Edition (ADOS-2), and with verbal ability of at least 24 months. In addition to these inclusion criteria, the SFARI had equally rigorous exclusion criteria including, but not limited to, no presence of other disorders (e.g., Fragile X or Down syndrome) or sensory or motor difficulties that would preclude valid use of the diagnostic instruments. Participants included in the present subsample also had available data used within this study as dependent variable data and a diagnosis of either autism or ASD (terms in use prior to the DSM-5) as reported by the ADOS or ADOS-2. A total subsample of 483 affected participants com- prised this study, divided into two further subgroups based on ADOS- or ADOS-2-determined severity as defined by: (a) those diagnosed with autism (i.e., more severe, N¼444) and (b) those diagnosed with autism spectrum (less severe, N¼39). Participant’s ages ranged from 48–150 months with an average of 66.3 months or about 5.6 years of age; mean age for participants diagnosed with autism was 66.5 months, and mean age for participants diagnosed with autism spectrum was 63.9 months (groups were not significantly different in age, t(481)¼1.152, p¼ .250).

Measures

Two dependent measures were used in this analysis; a gross motor skills score and a social skills score. The raw composite score of each dependent measure was used in data analysis.

Colombo-Dougovito and Reeve 415

Gross motor score. The gross motor score was from a subtest of the Vineland Adaptive Behavior Scales, 2nd Edition (VABS-II). The VABS-II assesses func- tioning in four adaptive skill domains: Communication, Daily Living skills, Socialization, and Motor skill, and an optional fifth Maladaptive domain (Sparrow, Cicchetti, & Balla, 2005). The VABS-II has been used clinically to assess individuals with cognitive delays, and for children with various neurode- velopmental problems, including Autism, Attention-Deficit/Hyperactivity Disorder, emotional/behavioral disturbance, learning disability, and visual and hearing impairments (Community-University Partnership for the Study of Children, Youth, and Families [CUP], 2011). The motor skill subtest is designed for ages birth through six years and for older persons with motor handicaps (Frick, Barry, & Kamphaus, 2009). Item scores are obtained by reports from parents or teachers, through item ratings of never, sometimes, usually performed, don’t know, or no opportunity; parent report was utilized in this analysis. Although the VABS is observational in nature, the gross and fine motor subtests have been correlated to the Mullen Scales of Early Learning (MSEL) and the Peabody Developmental Motor Scales (Staples, Macdonald, & Zimmer, 2012). The VABS-II has demonstrated high content and criterion-related validity, including principal component analyses, and reliability through split-half, inter- nal consistency through, test–retest, and interrater measures (Sparrow et al., 2005).

Social skills score. The Social Responsiveness Scale (SRS) was utilized as the meas- ure of social skills; this measure yields a composite score from assessments of receptive, cognitive, expressive, and motivation aspects of social behavior, as well as autistic preoccupation (Constantino & Gruber, 2005). The SRS is an effective tool in capturing subtle aspects of social deficit associated with ASD and has high correlations with other ASD assessment measures, such as the Social Communication Questionnaire (SCQ) and the Children’s Communication Checklist (CCC; Constantino et al., 2003). The SRS contains 65 items and utilizes reports from a parent or teacher; this analysis utilized parent report. Each item on the scale is rated from ‘‘0’’ (never true) to ‘‘3’’ (almost always true).

Data Analysis

A two-group multivariate analysis of variance (MANOVA) was used in these data analyses to address differences in the multivariate means of social skills and gross motor skills (i.e., dependent variables) between the two severity groups (i.e., independent variable). Significant results were to have been followed by post hoc analysis using Roy-Bargmann step-down analyses on the prioritized dependent variable, though no significant results were found.

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Results

Prior to analyses, data were screened for univariate and multivariate outliers and were examined for multivariate normality as well as for homogeneity of between group variance/covariance matrices. All variables were examined separately for the two grouping variables of autism and autism spectrum. No outliers or vio- lations of normality were found within the univariate (standardized values greater than 3.29) or multivariate outcomes (utilizing a Mahalanobis Distance greater than 13.8). Box’s test supported the equality of covariance matrices between groups, multivariate F(3, 52050.029)¼0.49, p¼ .69.

Wilk’s criterion indicated that the combined dependent variables were not significantly related to severity of the autism diagnosis, F(2, 480)¼1.64, p¼ .19. Thus, the combined multivariate means of the two severity groups were not significantly different in either social skills or gross motor abilities. Results fur- ther revealed a very weak association between the severity of these groups and their gross motor and social skill scores, partial �2¼0.007, and, due to the nonsignificant results, no step-down analysis was conducted.

Analysis of the between-subject effects on univariate tests further revealed a nonsignificant difference between groups on gross motor scores, F(1, 201.883)¼1.303, p¼ .25 (See Table 2). Participants in the less severe group (autism spectrum) scored arithmetically higher (M¼83.31) than those in the more severe (autism) group (M¼80.93) (see Figure 1), but this arithmetic dif- ference was not statistically significant. This nonsignificant difference was also seen in the social skill univariate evaluation, F(1, 4535.99)¼2.24, p¼ .13, though the less severe group (M¼70.62) again scored arithmetically higher in social skills than the more severe group (M¼59.37), as would be expected (see Figure 1). Effect sizes further demonstrate a very weak association between gross motor and social skills and group severity, partial �2¼0.003 and partial �2¼0.005, respectively. Similarly, a post hoc analysis of the correlation between dependent variables revealed a very weak, nonsignificant association between the dependent variables, r¼ .08, p¼ .06.

Discussion

The purpose of this study was to enhance an understanding of differences in gross motor and social skills among different groups of children diagnosed with autism or autism spectrum prior to the introduction of the DSM-5 that no longer differentiates these groups. A nonsignificant MANOVA result from data analysis of a relatively large data base suggested no clear relationship between ASD severity level and motor and social skills in this sample of children with ASD. The absence of any control group of peers without ASD make it difficult to ascertain whether a performance deficit is present in either gross motor or social skills. Yet, when comparing the gross motor data of the present

Colombo-Dougovito and Reeve 417

sample to normative data from the VABS-II (Sparrow et al., 2005) and a supple- mental normative group with autism (Carter et al., 1998), it is evident that the present sample may not accurately represent typical motor deficits among chil- dren with ASD (see Figure 2). Using the VABS-II normative data (M¼100, SD¼15; Sparrow et al., 2005), the present sample’s score is one standard devi- ation below the mean of the normative sample, which shows delay, but not neces- sarily a deficit. Conversely, when using supplementary norms for children with ASD (Carter et al., 1998), a score of 43/44 or 50, depending on whether or not the child was nonverbal or verbal, respectively, would place the child at the 50th percentile. A score of 72 or higher would place them at the 99th percentile, regard- less of communicative ability. The present sample’s mean (81), regardless of autism severity, would place them at the 99th percentile, demonstrating that the present sample may represent the highest end of motor performers among those with ASD. This high-functioning subset may have resulted from a participant selection process that excluded children with motor skill assessed with the ADOS.

Furthermore, the difficulty in finding group defects may be due to a reli- ance on the ADOS or ADOS-2. While often considered the gold standard for autism diagnosis, this measure may not be sensitive enough, on its own, to detect differences in subsets of ASD; hence, the executive decision to consolidate sub- labels of autism under one ASD umbrella term in the DSM-5 (APA, 2013).

Figure 1. Sample means by group.

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This study provides evidence to suggest that—for diagnostic purposes—practi- tioners should utilize a battery of assessments, as the ADOS scores (used in this analysis) were unable to detect known differences in social ability. In regards to motor skills, while it has been suggested that severity has an impact on gross motor ability (MacDonald, Lord, & Ulrich, 2014) and motor skill deficits may be hallmark to ASD (Flanagan, Landa, Bhat, & Bauman, 2012), differences in motor skills in more ‘‘severe’’ cases of ASD may be related to other mitigating factors, such as IQ, verbal communication, or motivation.

Within this SFARI data base, these groups demonstrate similar performance on both the assessments. These findings are in contrast to previous research that found a link between level of autism severity and motor skills (MacDonald et al., 2014). Previous research demonstrating associations between gross motor scores and social skills (MacDonald et al., 2013), as well as relationships of gross motor scores and autism severity (MacDonald et al., 2014) utilized different gross motor assessments than what were used in this analysis and accounted for the

Figure 2. Sample, normative, and supplemental motor means.

Colombo-Dougovito and Reeve 419

breadth of scores from the ADOS, instead of the dichotomous groups based on the composite scores from the assessment. MacDonald et al. (2014), in assessing the relationship of motor and social skills in children with ASD, utilized the Test of Gross Motor Development (TGMD-2). Using a sample of 35 participants (mean age 9.2 (�2.5) years) with ASD, MacDonald et al. demonstrated that object- control skills successfully predicted social communicative skills as indi- cated by calibrated autism severity scores (2013). In this analysis, overall gross motor scores did not demonstrate a significant interaction (MacDonald et al., 2013). The results from this analysis demonstrated that there is an interaction between social skills and motor skills; however, it is uncertain that motor skills are causing the interaction. In the current analysis, the gross motor measure was an overall measure and, perhaps, was not sensitive enough to detect the specific differences captured by the TGMD-2. Furthermore, in an analysis of motor skills and calibrated autism severity, MacDonald et al. (2014) utilized the gross motor quotient from the MSEL to analyze the differences within severity groups. In an analysis of 159 participants between the ages of 14 and 33 months, results showed children with lower fine and gross motor skills had higher cali- brated autism severity scores (MacDonald et al., 2014). This result was one the first studies to demonstrate a direct relationship between motor skills and cali- brated autism severity in young children with ASD (MacDonald et al., 2014). Perhaps the assessments utilized in the above studies are more sensitive, stand- alone assessments of gross motor ability than the gross motor subtest of the VABS-II. The nonsignificant result demonstrated in the present study may be attributed to the difference from assessment tools used in prior research.

Additionally, the average age of children used in the SFARI database was approximately 5.6 years of age. Differences in populations may not have been great enough at this relatively young age. It has been suggested that, without intervention, delays and deficits in gross motor ability may increase with age (Lloyd et al., 2013; Staples & Reid, 2010). Perhaps, over time, in several years the gap in gross motor ability between the more and less severe group may grow. While research on the longitudinal differences of motor development is lacking, Staples et al. (2012) suggest that when research on motor ability in ASD is looked at collectively, the gap between typically developing peers and individ- uals with ASD continually increases. Deficits within severity levels may continue to increase as well, although further research is needed to understand this issue. MacDonald et al. (2014) found a significant delay and difference in severity level among toddlers (aged 12–33 months); however, their analysis focused on sever- ity as a continuum, whereas the present analysis focused on differences between severity groups in aggregate. The severity of ASD at very young ages may pro- vide important insight into differences between the levels of severity; however, there may be other confounding factors that impact the production of motor tasks at such young ages. Further, gross motor assessments of toddlers focus on underlying movement concepts, such as balance and coordination, whereas

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motor assessment of older children focuses on the production of skills. Perhaps severity of ASD has an impact on the balance and coordination of an individual, which ultimately will impact the production of skills. Within this present ana- lysis, no differences were seen between the two severity groups; while both groups demonstrated delays, neither group was significantly different from one another on the production of motor tasks. This suggests that, perhaps, gross motor ability is impacted equally regardless of severity diagnosis and should not be a differentiating factor between levels of ASD severity, but treated equally within all children with ASD.

While there was no statistical difference between groups on gross motor and social skills, when looking at the means for each group on the dependent variables (Figure 1), the less severe group scored higher in each area. The differences in social skills resemble what would be expected when assessing each group for social communicative ability. Since diagnosis for ASD is heav- ily weighted on social communicative ability, the presence of lower social skills within the more severe group is in line with diagnosis. When looking at the means of the gross motor skills, the less severe groups performed slightly higher than the more severe group, which echoes research findings (MacDonald et al., 2014); however, in the present sample, differences were not significant. While this study provides further insight into how motor skills and social skills are affected by the severity of autism and ASD, there are several limitations to this analysis that are acting as potential hindrances toward a significant finding:

Uneven Groups in Sample

In this analysis, there were many more participants in the more severe group (Autism), when compared with the less severe group (autism spectrum). While potentially hindering the MANOVA, this is likely to be a fair representation of the disproportionate number of children with the more severe diagnosis in the overall sample. Parents with children with more severe forms of ASD may be more willing to volunteer their child for research and be more willing to accept their child’s diagnosis. Parents of children with less severe forms of ASD may not have had their child diagnosed because they are ‘‘keeping up with peers’’ and it is not yet an issue, or they are in denial of the disability itself and have not yet come to terms with their child’s diagnosis. Future research should look to include individuals with all levels of diagnostic severities, even targeting those that are on the cusp of diagnostic eligibility.

Gross Motor Variable Not Sensitive Enough

Table 1 shows that the standard deviation among gross motor scores among children in this study is small, compared with the variance seen in their social

Colombo-Dougovito and Reeve 421

skills. This could be because the gross motor assessment on the VBAS-II was limited to a small number of items within only one subtest, whereas social skills data were from a more extensive assessment and were represented by a compos- ite score of several subtests. Furthermore, the results from the VABS-2 are from parent report, which is less reliable than a direct measure. Of course, more extensive assessments are difficult to obtain with large datasets of this kind, as they require more time, money, and effort in data collection. Another concern lies in the exclusion/inclusion criteria for recruitment, limiting participants to those that can perform motor tasks. Future research could benefit greatly by including these direct motor skills assessments within an overall assessment protocol and by gaining a understanding of how gross motor ability is related to other measures within larger populations.

Conclusion

This study provides insight into problems associated with evaluations of gross motor and social skills severity for children with ASD. Our finding of no stat- istical difference between severity groups defined by the ADOS suggests that for young children (about 5 years of age) capable of taking the ADOS, there is little difference between ADOS-defined severity groups of ‘‘autism’’ and ‘‘ASD.’’ Further research is needed, utilizing varying assessment tools (and especially

Table 1. Descriptive Statistics by Severity Group.

Autism (N¼444) Autism Spectrum (N¼49)

Gross motor Social Gross motor Social

M (SD) 80.93 (12.43) 59.37 (44.81) 82.90 (12.72) 65.38 (46.87)

Range [51, 121] [1, 166] [56, 124] [1, 155]

Kurtosis �0.236 �1.260 1.624 �1.408

Skewness 0.220 0.342 0.611 �0.124

Note. Gross motor¼dependent variable as a result from Vineland Adaptive Behavior Scales subtest;

Social¼dependent variable as a result from Social Responsiveness Scale; Range¼minimum to maximum.

Table 2. Between-Group Univariate Output.

Variable Value F df p Partial �2

Gross motor skills 201.88 1.399 1, 483 0.254 0.003

Social skills 4535.97 2.242 1, 483 0.135 0.005

422 Perceptual and Motor Skills 124(2)

direct assessments of motor skills) with a broader range of diagnostic severity and over both a larger age range and over time to better determine how these variables may interact and change over time.

Acknowledgments

We are grateful to all of the families at the participating Simons Simplex Collection (SSC) sites, as well as the principal investigators (A. Beaudet, R. Bernier, J. Constantino,

E. Cook, E. Fombonne, D. Geschwind, R. Goin-Kochel, E. Hanson, D. Grice, A. Klin, D. Ledbetter, C. Lord, C. Martin, D. Martin, R. Maxim, J. Miles, O. Ousley, K. Pelphrey, B. Peterson, J. Piggot, C. Saulnier, M. State, W. Stone, J. Sutcliffe, C. Walsh, Z. Warren,

and E. Wijsman). Approved researchers can obtain the SSC population dataset described in this study (http://sfari.org/resources/simons-simplex-collection) by applying at https://base. sfari.org.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publica- tion of this article.

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Author Biographies

Andrew M. Colombo-Dougovito is a currently a PhD candidate at the University of Virginia in

Adapted Physical Education. Andrew’s research interests focus on the motor development of chil-

dren with ASD. He will defend his dissertation, ‘‘A mixed-methods analysis of a fundamental motor

skill intervention for children with ASD’’, this spring, 2017.

Ronald E. Reeve is a psychologist and professor in the Curry School of Education at the University of

Virginia.

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