Left Arm Rotates in Baby 4 or 5 Months Old

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

Psychology

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

Philip Teitelbaum

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

Osnat Teitelbaum

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

Jennifer Nye

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

Joshua Fryman

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

Ralph G. Maurer

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

Abstruse

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 age of 4–6 months, and sometimes fifty-fifty at birth. We used the Eshkol–Wachman Movement Analysis System in combination with all the same-frame videodisc analysis to study videos obtained from parents of children who had been diagnosed every bit autistic by conventional methods, commonly around three years old. 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 rima oris and in some or all of the milestones of development, including, lying, righting, sitting, crawling, and walking. Our findings support the view that move disturbances play an intrinsic part in the phenomenon of autism, that they are present at birth, and that they can exist used to diagnose the presence of autism in the first few months of life. They indicate the need for the development of methods of therapy to be applied from the first few months of life in autism.

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

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

On the other hand, Damasio and Maurer (2) and Vilensky et al. (3) showed that autistic children betwixt 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 [but run into Piven (5)]. This too supports the view that motion disorders might play a role in autism (half dozen, 7).

We believe that the findings presented here help to resolve this controversy. We used Eshkol–Wachman Motion Analysis in combination with flicker-costless laser-disc still-frame analysis to study videos taken in infancy of 17 children who after turned out to be autistic, as diagnosed at the age of 3 years or older by conventional methods of diagnosis. Every one of these children displayed movement disorders, some subtle, some obvious.

Furthermore, because these movement disorders always could be detected with our methods as early every bit 4–6 months of age and sometimes as early as the first few days after birth, we suggest that the written report of movement disorders in infancy may serve as an before indicator than before long available methods for diagnosing autism in children.

As a framework for the study of infant movement, nosotros decided to clarify the movements involved in the major motor milestones in the development of the baby from nascency through the time that he or she starts to walk: i.e., 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 not included in the present word). Therefore, these motor milestones can serve equally a common denominator by which to evaluate and compare normal and disintegrated motility in infants.

METHODS

We advertised in the monthly periodical published by the National Commission on Autism and in the e-mail list run by the Autism Society of America. We asked parents of autistic children (diagnosed past conventional methods usually at three years or older) to send us videos of their children taken when they were infants. We 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 usa in the nurseries of Kibbutz Merhavia in Israel when each design was just beginning to develop. Selected portions of these behaviors were transferred to videodisc (Panasonic Rewritable Optical Disc Recorder LQ-4000, Secaucus, NJ) for still-frame assay by using Eshkol–Wachman Movement Note (viii). Eshkol–Wachman Motion Annotation is a general assay system in which spherical coordinates are practical independently to each segment of the body. By distinguishing betwixt which segments are actively moving versus those that are beingness carried passively forth, a deeper agreement of aberrant movement is possible.

RESULTS

Motor Milestones in Development

Lying.

Lying is an active posture, even in the showtime few days of life. As has been pointed out by Casaer (nine), a newborn baby maintains specific active 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 present report showed a persistent asymmetry^§ at the historic period of 4 months when lying on his stomach. His right arm ever was defenseless under his chest, and even when engaged in reaching for an object with the other arm, he notwithstanding did not use his right arm. Throughout his first year, this asymmetry persisted, causing the kid to fall to his right side when lying on his tummy, or when sitting, and even when he started to walk.

Righting from Supine to Prone.

Rolling over from back to stomach unremarkably begins around 3 months of age. It involves a rotation around the longitudinal centrality of the body (come across Fig. ​ 11), in a corkscrew fashion, i body segment later on the next. Typically, in the primeval class of such righting, the pelvis turns first, then the trunk, and finally the shoulders and caput. Past vi months of age, cephalic dominance is evident (10, xi), and this order is reversed. The head turns offset, and the shoulders, trunk, and pelvis follow (Fig. ​ one).

A normal baby, ≈half-dozen months old, shows cephalic potency in the initiation of righting to prone when lying supine on the basis. The head turns first, and the shoulders, torso, and pelvis follow sequentially until the child reaches the prone position.

A definition of the iii types of movement that can exist performed past the body. (Plane motion) The limb segment moves in a aeroplane that is at xc degrees to the axis of its movement. (Rotatory movement) The limb moves at an bending of cipher degrees to its own centrality: i.east., it does not move in space, but simply twists around the centrality through its length. (Conical motility) The limb moves at an angle <90 degrees and >0 degrees to its axis of movement.

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

An autistic baby, ≈five months old, cannot correct past rotation. Instead, he arches the head and pelvis sideways up, moves the acme leg frontwards, and topples over en bloc, without the sequential segmental rotation in the righting movement characteristic of normal children.

It must be noted that, even though we have videos of 17 autistic children so far, only a few of these habitation videos actually filmed righting on the basis in such children. Thus, we have only a very limited sample (due north = iii) of the righting behavior of autistic infants. However, the sideways–upwards pattern of righting seen in all iii of these autistic children is quite different from what normal children ever bear witness when righting on the ground. The abnormal pattern of righting that we have just described was seen by us when the autistic children ranged in historic period from 6 to 9 months old. One of these children, at the age of 3 months, when lying supine, flexed his head and neck strongly forward in the midline (run across Fig. ​ 3 a and b). Such midline frontwards flexion tin be seen in the normal newborn at the age of five days (9), merely it is atypical for it to appear at 3 months of historic period. In other words, the forward-flexion pattern shown by the autistic child may exist a more infantile blueprint.

An autistic child, ≈3 months old, lacking the ability to rotate around the torso midline during righting (a), attempts to sit down upward past ventroflexing his trunk in the midline plane (b).

Sitting.

Commonly, at ≈6 months of age, a normal babe can sit upright. He maintains his equilibrium past distributing his torso weight equally on his sitting bones, fifty-fifty when, past reaching for a toy, his upper torso will exist out of the vertical. Turning his caput, rocking in place, or busying his hands with objects, he maintains his stability.

Some autistic children were not able to maintain sitting stability at this age. In the extreme, he or she simply fell over like a log, without using whatever allied reflexes to protect himself (come across Fig. ​ iv). In other cases, where at that place was less severe movement disturbance, the baby managed to sit for a few minutes at a fourth dimension, but, because his weight ofttimes was not distributed equally on both sides, his posture was asymmetrical, leaning to one side, and he fell over when reaching for objects or moving his arms and upper torso.

An autistic girl, eight.5 months old, shows no allied protective reflexes when falling (e.g., extending the arms and easily out to protect herself from hitting her head when falling toward the footing).

Itch on Hands and Knees.

Most babies beginning to clamber at near the same fourth dimension they begin to sit. At that place are several forms of creeping and crawling and there is much fence about the interlimb patterning involved (see ref. 12 for a detailed give-and-take of this topic). We will consider here simply itch on hands and knees. The following will be used every bit a reference starting position: arms vertical at shoulder width, palms on the floor fingers pointing forwards; thighs vertical and hip-width autonomously, knees on the ground with lower legs and anxiety resting on the floor pointing backwards; and weight every bit distributed on all four limbs (see Fig. ​ five). Note that this is an "ideal" position: a infant who is playing and moving effectually rarely will terminate in this position, but it can serve as a reference relative to which other movement patterns—normal and abnormal—can be studied. When crawling frontward on hands and knees, the arms and thighs move parallel to the midline axis of the body. That ways that the arms stay shoulder-width autonomously, and and then practice the thighs.

A normal infant, ≈6 months erstwhile, shows good support in the arms and legs while itch forrad.

Autistic Children May Show Deviations from the Normal Pattern of Crawling.

Asymmetrical lack of adequate support in the arms. Equally shown in Fig. ​ half-dozen, this infant did not have adequate support in his arms, then that he supported himself on his forearms rather than his hands. Note that ane arm is crossed in front of the other so that his base of operations of support on his artillery is very narrow. Although back up was deficient in both arms, the right arm was weaker than the left, and then that reaching was washed with the left arm while the right arm often was caught nether the body. He appeared to intend to crawl forward to achieve the small-scale roller on the floor in forepart of him. Because he could not movement his thighs toward his stomach, and thus was not able to "step" frontwards 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 past bringing his knees to the ground and pushing himself, but again and again, instead of moving forward, his knees came off the floor, extending his legs and bringing his bottom up.

An autistic baby, ≈5 months onetime, is unable to back up himself on his hands and is unable to bring his knees toward his chest to crawl forward, so he lifts his rump up while trying to crawl but cannot movement frontward from the spot.

Asymmetry in the legs.

(i) In the adjacent video taken of the kid described above, at the historic period of six months, the arms had developed support, and the legs now could be used in crawling. Nonetheless, a rest right-sided deficiency remained in the use of his legs in crawling: from the starting position described above, the left leg moved the usual manner (thigh moves forward nether the belly, lower leg and human 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 move of the hip carried the thigh medially every bit well every bit forward, so that, with each crawling step, the base of operations of the body progressively was narrowed, resulting in eventual falling over to the right.

(ii) Another autistic kid is shown in Fig. ​ 7. When this baby crawled, the left leg moved the usual way (the left thigh moved forward under the abdomen with the lower leg and foot sliding on the floor, and the left knee joint 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 only the foot contacting the basis at the end of each stride).

An autistic baby shows asymmetry in his crawling: the left leg crawls properly, only the right foot steps rather than crawls.

Standing.

A normal infant, ≈8–x months old, may pull himself up and stand for a few minutes, sometimes leaning against a piece of heavy furniture. Later on a brusque period of fourth dimension, though, he typically volition subside to the flooring to go along his activities. One autistic daughter of that age seen in Fig. ​ 8 stood in one place leaning her back against a heavy furniture for periods every bit long as 15 minutes at a time. Such relative akinesia may signal abnormality.

Moebius Syndrome shape of the rima oris in an 8.5-calendar month-old autistic daughter. The lower lip is flat, only the upper lip is arched in a characteristic shape.

Walking.

When a babe starts to walk, his gait develops through stock-still stages that contain a proximal–distal gradient that governs the control of the unlike segments of the legs. The thigh, the segment of the leg most proximal to the trunk, is the only segment that actively moves at kickoff. The lower leg and the foot merely are carried passively along by the movement of the thigh. They do not move actively. Later, they add their action successively. This image of normal walking enables united states of america to analyze deviations from information technology.

When a baby starts to walk, 3 stages can be differentiated. (i) Waddling: From a starting position of stability (see Fig. ​ nine), in which the baby stands notwithstanding, both legs parallel and weight equally distributed, the body weight is shifted laterally to 1 leg. This enables the other leg to elevator and step forward. Because only the thigh moves actively (as in crawling, the lower leg and foot are being carried passively along), the step is very short. The foot is planted every bit a whole, neither toes nor heel touching the floor start. The baby then shifts his weight sideways to the leg that has but stepped, releases the other leg and brings information technology in a "grab-up" pace to a position parallel to the leg that merely had stepped. The issue is a "waddling walk" in which, although the infant progresses forward, he does it past waddling from side to side, with long intervals of standing withal between each pair of steps. (This can be noticed most conspicuously past watching the head.) The easily are raised shoulder high, forearms vertical (See Fig. ​ nine).

A normal baby, ≈10 months old, holds his arms upward at shoulder level as he is just outset to acquire to walk.

(ii) Intermediate stage: Kickoff the step-gesture, so the shift of weight; the grab-up step is transformed into a full step frontwards and the step cycle develops as follows. The body weight shifts, allowing the infant to release the rear foot from the ground by rolling it from heel to toe, which, in plough, 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 dorsum to the ground, the foot landing flat alee of the other foot. Only after the leading foot has been placed on the flooring is the body weight shifted frontward (rather than from side-to-side as in stage i). The arms are lowered so that the upper arms hang downward along the sides of the body, and the lower arms are held waist-high, parallel to the ground, pointing forwards. Information technology should be noted that, in adults with Parkinson'due south disease, at that place is a stage of deterioration of the footstep cycle that parallels the form of stepping shown in this intermediate stage of the normal development of walking. Only after the leading human foot is on the ground does the body weight shift frontwards (13).

(3) Final stage: The trunk weight is superimposed on the pace gesture; although in stages i and ii, the shift in body weight was delayed until both feet were on the ground, in this phase, weight shift occurs simultaneously with the stepping movement of the leading leg (while the leading leg is in the air). The leading foot then touches the floor heel get-go, and, as the rest of the foot rolls onto the floor, information technology acts to wheel the trunk weight smoothly forward. The rear heel lifts from the footing before the front foot touches the basis, enabling i to see that the weight is being shifted. The whole bicycle is permitted by and permits the continuous shift of weight forward. The rolling of the foot determines the flexing of the lower leg, which and so swings forward and extends to bring the heel of the flexed human foot in touch with the floor. The artillery are down along the sides of the torso, not coordinated yet with the step bicycle.

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

In the gait of autistic children, the deviations from the normal can be categorized every bit follows. (i) Asymmetry: In normal walking, the movements involving the arms and legs are symmetrical. In every autistic kid we accept seen and so far, some degree of asymmetry has been found. For example, when walking, a 10-year-old girl held the right arm in a more infantile position (lower arm held at waist height, as described above) while the left arm was held downward every bit it swung alongside the torso. When walking, a 3-year-old boy exhibited an infantile blueprint in the right leg, where merely the thigh was moving, carrying the lower leg and the foot with it. The other leg showed a more mature pattern; that is, all parts of the leg moved relative to ane some other, the heel of the pes beingness placed on the basis first.

(ii) Delayed evolution: At the age of two or fifty-fifty later, the gait may be more infantile than normal. Thus, one autistic kid at the age of 2 exhibited agile movement of each thigh only, with the lower leg and foot being carried passively. As well, 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, non superimposition: At the age of v, equally shown in Fig. ​ ten, this autistic child exhibited all of the components of a "mature" stride; that is, the thigh and lower leg and foot moved actively frontwards, but this was done without the shift of weight that usually goes with it. Only later on the leg was extended fully in the air did the shift of weight occur, and then that the child barbarous forward on to information technology in a "goose step" grade of walking. The shift of body weight occurred after, non forth with, the movement of the leg.

(a) A five-year-old autistic male child has a fully developed footstep gesture. All 3 segments of the leg move actively (see text), but his body weight does not shift at the same time, resulting in a form of goose-step. (b) The torso weight but then is shifted so that the boy falls on to the outstretched leg at each step. This is a form of sequencing rather than superimposition of i movement on the other.

(4) The arms: In our experience, as a general rule, papers written almost walking deal simply with the activity of the legs, omitting any discussion of the role of the arms in walking. This is unfortunate, considering the activity of the arms is extremely important in facilitating the gait via allied reflexes. In earlier work (13), information technology was shown that patients with Parkinson's illness tin profoundly augment the size and speed of their steps by increasing the amplitude of their arm swing. Furthermore, as described above, at that place are specific positions of the arms that back-trail the stages of development of walking. These arm positions can serve as milestones along the grade of normal development. If, in the course of evolution, there is abort in an early stage (every bit signaled by the position of the arms), this can signal abnormality. For example, in the study carried out by Vilensky, Damasio, and Maurer (three), several autistic children (ages 3–10) exhibited more infantile positions of the arms while walking: the forearm often was held parallel to the ground, pointing forward. In several cases, the artillery were not held in a symmetrical position: one arm was in a more mature position (the arm fully extended downwards aslope the torso) while the other was in a more than infantile position (forearm held horizontal, pointing forrard).

(v) Arm-and-hand flapping: Arm-and-manus flapping often can be seen in autistic children. Information technology also can appear in normal children, usually for a few months, before it disappears. For this reason, information technology is difficult to use as a sign diagnostic of autism. However, if it persists to an age at which the mature class of walking should be well adult (2 years old or more), then other confirming signs should exist looked for as well.

In some of the children studied here, we observed a characteristic oral fissure shape (come across Fig. ​ 8) chosen "Moebius Syndrome" (14). This mouth shape can be seen in the commencement few days after nativity and may persist throughout infancy and on into adulthood. It does not occur in all infants who plough out to exist autistic, just, when information technology does occur, it signals the demand to notice closely the movements displayed by the infant. If some of the other symptoms of motion disorder that nosotros have described here besides occur, it strengthens the possibility that autism is involved.

Discussion

Autism mostly is diagnosed at ≈3 years of historic period, when a child begins to participate in organized social settings (in a nursery school, for instance). Because social skills required are aberrant in such a kid, it is relatively easy to spot autistic beliefs there. Such a child may non participate in social play with other children, stays past himself, and does non want to be touched by anyone. He refrains from eye 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 outset birthday party. The trouble is that, in infancy (4–six months), the social symptoms are non so readily apparent. The infant in his crib relates largely to himself, and merely his movements reflect the action of his nervous system. The kid's mother is usually aware very early that something is wrong, but, because she is unable to specify something diagnostic, the pediatrician she consults frequently tends to reassure her that this is a small problem that the child will grow out of. Hashimoto et al. (16), using developmental delay, poor facial expression, and failure to make eye contact as indicators, were able to screen for autism at 6 months. Because it has been shown that virtually all autistic children at afterwards ages have movement abnormalities (2, three), we reasoned that such abnormalities might be evident in the get-go few months of life. As shown in the present paper, this is indeed so.

Information technology is of import that the abnormalities in movement that nosotros take described here can be seen very early in infancy, long before the behaviors in social settings that currently form the ground for the diagnosis of autism. Diagnosis in infancy can bespeak the demand 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 volition exist. Therefore, the fact that abnormalities in movement tin can be very early indicators of potential autism is important to know.

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

The present findings are also of import for pediatricians. Time and time again, in our correspondence with the mothers of autistic children, nosotros take heard that the mother suspected that something was wrong with her baby but that the pediatrician told her that everything was all right and that she need not worry. The pediatrician should be the earliest, not the last, to know that the child might be autistic. An awareness that simple movements such as those described in the nowadays newspaper 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 exist effective in the treatment of potentially autistic children. Because diagnosis was not more often than not possible so early, no systematic methods are currently bachelor for the treatment of infants at risk for autism. Our findings should provide the impetus for systematic search for such treatment methods.

How exercise we reconcile our findings of deficits in the evolution of movement in autistic infants with the reports from parents cited past Rimland (1) indicating that many autistic children brandish hyperagility and hyperdexterity? Two possibilities exist. Beginning, it is possible that, in our limited sample of autistics, we accept not accomplished an adequate sample and that at that place exists a subgroup of autistics that display such hyperagility and dexterity even in infancy. Because we obtained our videos without request for whatever special characteristics other than a diagnosis of autism, we have no reason to presume 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 later age show hyperagility and dexterity, akin to that reported by Rimland (1). This claim further investigation.

Finally, in infancy, the movement disorders present in autism are clearest, not yet masked past other mechanisms that take developed to recoup for them. It is possible that they may vary according to the areas of the encephalon in which developmental delay or damage has occurred. For instance, Kemper and Bauman (6) have pointed out from anatomical assay of the brains of autistic individuals that the limbic system as well every bit the cerebellum may show modest shrunken cells. Courchesne (4) has prove from MRI assay that the cerebellum may evidence hypoplasia or even hyperplasia in certain regions of the cerebellum. By combining movement analysis in infancy with MRI assay, information technology may be possible somewhen to diagnose differential areas of brain involvement in different subtypes of autism.

Annotation. Unfortunately, we did not have electronic versions of the figures used in this paper. Nosotros attempted to increment the clarity of the figures (which were taken directly from home videos) with numerous methods, but, because of the nature of the original images, we had petty success.

Acknowledgments

Nosotros are grateful to the families who sent u.s.a. the videotape material that we have analyzed in this newspaper. Their goodwill and cooperation made this work possible.

Footnotes

^§Asymmetry can be seen briefly in many normal babies. Still, 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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