Let's talk about autistic motor disability

Motor disability in autism is hugely underrecognized, often unsupported, and can be an underlying factor behind many autistic traits commonly considered to be “social deficits,” including difficulty with oral speech, differences in posture, body language, and facial expression, and challenges with activities of daily living. So, I was excited to read the recent publication by Miller et al, “Motor problems in autism: Co-occurrence or feature?”. This paper will generate important and sorely needed conversations within the community of professionals supporting autistic people.

Some critical points articulated in this paper that I’d like to highlight include:

• Despite research indicating that 85-97% of autistic people experience motor disability, clinicians  currently  document  motor  problems  in  only  ~  1%  of  autistic  individuals.

• All autistic patients should be screened/assessed for motor developmental disability, in order to help match patients with the supports and accommodations they need.

• When we as clinicians choose not to recognize motor disability in our autistic patients, we choose to perpetuate ableist assumptions that those autistic communication challenges rooted in motor challenges are due to a lack of competence or lack of motivation.

These points are so important for the healthcare community to understand in order to start better recognizing, understanding, and supporting many autistic communication differences, in both speaking and non-speaking autistic people.

Miller et al. propose that motor impairments be added as a specifier to the DSM diagnostic criteria for autism. In my opinion, this could potentially be a temporary small step in the right direction, but in the long term would miss the mark. 

I agree that adding a “motor impairments specifier” would help clinicians better recognize and refer for support (such as physical therapy) for motor disability. However, if the rest of the DSM criteria remain the same, motor disability resulting in communication challenges and/or social exclusion due to cultural stigma around movement differences will still be seen by clinicians as “autistic behavior” or “lack of social skills” and result in inappropriate referrals for supports.

When an autistic child asserts their autonomy and declines to participate in school activities that are inaccessible to them due to their motor challenges, I don’t want them referred to a professional who will use incentives and consequences to “address their refusal behavior”. I want to see that child’s teachers get access to guidance from physical and occupational therapy as to how to make their educational activities accessible for the student.

When an autistic adult is denied opportunities in the workplace due to their tone of voice or body language making them a “poor cultural fit within the organization”, I want us to be able to put words to that situation as discrimination due to motor disability.

When an autistic adolescent is repeatedly rejected by their peers because of motor differences that result in facial expressions or rhythms of speech that are “too much”, “not enough”, or “too awkward” during social interactions, I don’t want this teen referred for social skills groups by their school counselor. I want this adolescent’s peers educated in accepting the diverse range of human expressiveness.

We need to do more than add a “motor impairments specifier” to the diagnostic criteria for autism to help clinicians understand autism through an accurate and non-pathologizing lens, so that autistic patients can get the supports and accommodations they need.