Sensory and Motor Behaviors of Infant Siblings of Children With and Without Autism

Sensory and Motor Behaviors of Infant Siblingsof Children With and Without Autism

Shelley Mulligan, Barbara Prudhomme White

KEY WORDS

� autistic disorder

� early diagnosis

� motor activity

� sensation

� siblings

Shelley Mulligan, PhD, OTR/L, is Associate Professor

and Chair, Department of Occupational Therapy, Hewitt

Hall, University of New Hampshire, Durham, NH 03824;

[email protected]

Barbara Prudhomme White, PhD, OTR/L, is

Associate Professor, Department of Occupational Therapy,

University of New Hampshire, Durham.

We compared the sensory and motor behaviors of typically developing infants with those of infant siblings of

children with autism spectrum disorders (ASD), who are considered high risk for the disorder, to explore

potential sensory and motor markers for use in early diagnosis of ASD. We compared frequencies of sensory

and motor behaviors during 10-min, videotaped, infant–mother play sessions and during 5 min of spoon-

feeding between groups of 12-mo-old infants. Data from standardized measures of development, sensory

processing, and behaviors commonly associated with ASD were also analyzed descriptively for the

high-risk group. The results indicated that high-risk infants demonstrated fewer movement transitions

(t [23] 5 22.4, p 5 .03) and less object manipulation (t [23] 5 22.4, p 5 .03) than low-risk infants.

The sensory and motor differences found between typical and high-risk infants suggest that early screen-

ings for ASD should include the examination of sensory and motor behaviors.

Mulligan, S., & White, B. P. (2012). Sensory and motor behaviors of infant siblings of children with and without autism.

American Journal of Occupational Therapy, 66, 556–566. http://dx.doi.org/10.5014/ajot.2012.004077

Autism spectrum disorders (ASD) are developmental disorders characterized by

pervasive deficits in social interaction and communication and a tendency

toward restricted and repetitive behaviors (American Psychiatric Association,

2000). ASD diagnoses have been steadily on the rise, and estimates from the

Centers for Disease Control and Prevention (2012) indicate a prevalence of 1 in

88. Kogan and colleagues (2009) estimated a U.S. ASD prevalence among

3–17-yr-olds of as high as 1.1%. Although the cause remains unknown for most

people with ASD, twin and family studies indicate a strong genetic link.

For children with ASD, early detection is essential for facilitating access

to interventions that can shape neural connections during sensitive periods

of development (Robins, Fein, Barton, & Green, 2001). Early intervention

has been associated with improved developmental and functional outcomes

such as language development, cognitive development, and success at school

(McEachin, Smith, & Lovaas, 1993; Ospina et al., 2008). More specifically for

young children with autism, a combination of play-based and behavioral in-

terventions may be vital in promoting development and adaptive functioning

and minimizing clinical features of the disorder (Dawson, 2008; Johnson &

Myers, 2007).

Unfortunately, children with ASD are often not diagnosed until age 2–4 yr

(Filipek et al., 1999; Ospina et al., 2008; Zwaigenbaum et al., 2007), although

much progress in early detection has been made over the past 5–10 yr. The

American Academy of Pediatrics Council on Children with Disabilities (2006)

recommended that pediatricians incorporate autism screening as part of routine

practice. However, Al-Qabandi, Gorter, and Rosenbaum (2011) reported that

routine screening of all infants may be premature at this time because of a lack

of effective screening tools and evidence-based, efficacious practices and because

of the need for a cost–benefit analysis of conducting universal early screenings.

556 September/October 2012, Volume 66, Number 5

Nonetheless, early identification allows families access to

supports and resources and has the potential to enhance

our understanding of ASD by promoting the study of en-

vironmental, behavioral, and developmental factors that

may influence the course of the disorder.

Retrospective parent interviews (Young, Brewer, &

Pattison, 2003) and studies of home movies of infants

later diagnosed with autism (Baranek, 1999; Osterling &

Dawson, 1994; Werner, Dawson, Osterling, & Dinno,

2000) suggest that abnormalities in development are evi-

dent in the first 2 yr of life. However, the higher incidence

of ASD in infant siblings of children with autism provides

a unique opportunity to look prospectively at the devel-

opment of ASD from infancy and inform us of potential

early signs that may be of diagnostic importance.

Siblings of children with autism have an estimated risk

that is at least 50 times greater than that of the general

population (Liu et al., 2001). Studies using infant siblings

have reported a recurrence risk of 14% (Zwaigenbaum

et al., 2005) to more than 20% (Ozonoff, Young, et al.,

2008; Sullivan et al., 2007; Yirmiya & Charman, 2010).

Several prospective, longitudinal studies of siblings have

been completed or are under way to identify indicators of

ASD in infants and toddlers through ongoing standardized

developmental evaluations and structured observations of

this at-risk population (Bryson et al., 2007; Iverson &

Wozniak, 2007; Ozonoff, Macari, et al., 2008; Yirmiya &

Charman, 2010; Yirmiya et al., 2006; Zwaigenbaum et al.,

2005). Veness et al. (2012), for example, found social

and communication differences between 12-mo-olds with

and without ASD, including the early use of gestures.

Prospective designs enable researchers to examine early

neurodevelopmental signs, behaviors, and developmental

patterns over time under standardized conditions, allowing

greater comparability both within and between individuals

over time. Ultimately, the information can be used in the

development of screening and evaluation tools aimed at

early detection.

Motor disturbances have commonly been noted in

children with autism (Baranek, 2002; Minshew, Sung,

Jones, & Furman, 2004; Molloy, Dietrich, & Bhattacharya,

2003; Provost, Lopez, & Heimerl, 2007; Rinehart,

Bradshaw, Brereton, & Tonge, 2001). Although researchers

have begun to study early motor signs (Loh et al., 2007;

Ozonoff, Young, et al., 2008; Teitelbaum, Teitelbaum,

Nye, Fryman, & Maurer, 1998), few studies have ex-

amined scores from standardized motor assessments in

conjunction with more functional fine and gross motor

behaviors during typical infant activity such as feeding

and play. Studies completed to date have produced in-

consistent results. For example, Teitelbaum et al. (1998)

reported that a sample of infants later diagnosed with

autism showed many abnormal movement patterns,

whereas more recent studies demonstrated no or few

significant motor differences in infants later diagnosed

with autism (Ozonoff, Young, et al., 2008; Provost et al.,

2007). Loh et al. (2007) provided some evidence that

arm waving in the context of standardized test adminis-

tration was more often seen in children who were later

diagnosed with ASD. Motor stereotypies and repetitive

use of objects were found in a sample of high-risk infants

at age 12 mo (Ozonoff, Young, et al., 2008). In a study of

older boys with ASD (6–17 yr), Jansiewicz et al. (2006)

found that children with ASD performed more poorly on

many measures of motor control, including balance and

coordination.

In examining potential early markers for identifying

ASD in infants, Zwaigenbaum and colleagues (2005)

noted that sensory orienting behaviors such as visual at-

tention, orienting to name, visual fixation on certain ob-

jects, and visual tracking may be useful in distinguishing

children with the disorder from typical children. Loh et al.

(2007) found that high-risk infants who were later di-

agnosed with ASD used their hands to cover their ears

(aversive response to sound) in the context of standard-

ized test administration more often than children who

did not have the disorder. Rogers, Hepburn, and Wehner

(2003) found that parents reported sensory differences

in their toddlers who were later diagnosed with ASD.

Baron-Cohen, Ashwin, Ashwin, Tavassoli, and Chakrabarti

(2009) conducted an interesting study examining the

talents of children with autism, concluding that the ex-

cellent attention to detail and pattern recognition abil-

ities of children with the disorder were often rooted in

underlying sensory processing differences such as sensory

hypersensitivities.

In a meta-analysis of 14 studies, Ben-Sasson et al.

(2009) found evidence of significant differences in sen-

sory modulation behaviors between typically developing

children and children with ASD. In an examination of

the sensory modulation patterns of sensory overresponsivity,

sensory underresponsivity, sensory seeking, and total per-

formance, differences were most pronounced from 6–9 yr

of age, with a tendency toward sensory underresponsivity.

More relevant to this study was the finding that children

with ASD birth to age 3 yr were less often categorized

as being sensory seeking than their typically developing

counterparts. In summary, the research indicates that our

understanding of the nature of early infant sensory pro-

cessing and motor development is emerging with this

population and suggests that these are promising areas for

consideration in early screening of ASD.

The American Journal of Occupational Therapy 557

Screening tools such as the Modified Checklist for

Autism in Toddlers (Robins & Dumont-Mathieu, 2006)

emphasize the examination of behaviors associated with

emerging language, social interaction, and play that, if

disrupted, are hallmark features of ASD. Because many of

these types of behavior do not emerge developmentally

until around 12–24 mo of age, however, relying on tools

emphasizing social, language, and play behaviors is lim-

iting at this young age (Baron-Cohen, Allen, & Gillberg,

1992). In contrast, sensory and motor behaviors are easily

captured from birth, and if differences do exist in such

behaviors, they may be able to be detected earlier than

social, play, and language behaviors. Although sensory

and motor behaviors are not core features of ASD, dif-

ferences or abnormalities in sensory processing and motor

skill development have commonly been found, as noted

in the literature described earlier.

Feldman et al. (2012) emphasized the value of ex-

amining child behaviors in the natural context, leading

them to develop the Parent Observation of Early Markers

Scale (POEMS). POEMS includes a large range of pos-

sible early markers or signs of ASD that parents can

observe within the context of their daily routines and

interactions with their child. Feldman et al. found that

differences between typically developing children and

children diagnosed with ASD were more pronounced

at 18–24 mo of age, although subtle differences were

noted as early as 9 mo. The authors concluded that

tools for ongoing surveillance of children by their parents

in natural contexts are helpful additions to performance-

based developmental measures for early detection of

ASD.

The study described in this article examined both

sensory processing and motor behaviors that we thought,

on the basis of prior research, would be useful for the early

detection of autism in 12-mo-old infants at high risk for

developing the disorder. Data collection for this study

included observations and coding of sensory and motor

behaviors within the context of the typical daily routines

of play and feeding via videotape for both typically de-

veloping children and high-risk siblings. Standardized de-

velopmental measures and caregiver questionnaires were

also administered for the high-risk ASD siblings. Details

of these measures are provided in the Methods sec-

tion. The specific aims of this study were to describe the

sensory and motor development and behaviors of infant

siblings of children with ASD at 12 mo of age and to

compare sensory and motor behaviors of high-risk infants

with those of low-risk, typically developing infants at 12mo

during both a semistructured infant–mother play session

and spoon-feeding.

Method

Research Design

In this study we implemented a two-group exploratory

design to describe and compare data regarding the sensory

and motor behaviors of 13 infant siblings at high risk for

ASD and 12 typically developing infants. The University

of New Hampshire institutional review board for the

protection of human subjects approved the study, and we

obtained informed consent from the parents before data

collection.

Participants

All infants in the study were between age 11 and 13 mo.

Exclusion criteria included known genetic, neuromotor,

or developmental problems or disorders as well as pre-

maturity. High-risk infants were recruited through local

service providers and clinics specializing in young children

and through local organizations for children with special

needs and their families. The high-risk group included 13

infants with a sibling who had a confirmed diagnosis of

ASD determined by a qualified team of professionals that

included a developmental neurologist or pediatrician. All

older siblings were assessed using the Autism Diagnostic

Observation Schedule (Lord, Rutter, DiLavore, & Risi,

2002) either before diagnosis or for confirmation as part

of this study.

We recruited the 12 typically developing infants in the

low-risk group through personal contacts and local day

care and preschool centers. All typically developing infants

had siblings without any developmental concerns. Al-

though the typically developing infants were not formally

tested as part of this study, they were screened by the first

author (Mulligan) and a pediatrician, and only infants for

whom the parents and pediatrician identified no de-

velopmental concerns were recruited to be in the low-risk

group. We made a follow-up phone call to the parents

when the low-risk children reached age 30 mo to verify

that the parents continued to have no concerns regarding

their child’s development.

Procedures

All infants participated with their caregivers in a 10-min

play session and a 5-min feeding session. Each session was

videotaped and subsequently coded for sensory and motor

behaviors. The format of the play and feeding sessions

and the defining and coding of sensory and motor be-

haviors were developed and refined by the primary author

(Mulligan). Sensory and motor behaviors were selected on

the basis of previous research examining potential early


markers and on a review of ASD screening tools. Each

sensory and motor behavior was operationally defined and

tested for interrater reliability. In total, we analyzed 16

behaviors for play and 14 behaviors for the feeding session

(see the Appendix for a list of behaviors and definitions).

We used time sampling, recording the presence or absence

of each behavior in 30-s time intervals. To examine in-

terrater reliability, we analyzed data coded from three

trained raters using nine play and feeding sessions. Total

occurrences for each of the 30 variables were tallied and

analyzed using the intraclass correlation coefficient (ICC).

The results yielded an ICC of .97 using average measures,

demonstrating strong consistency across raters.

Infants in the high-risk group were administered

developmental assessments at 11–13 mo of age by the first

author (Mulligan), who was aware that the older sibling

was diagnosed with ASD. Standardized performance-based

measures included the Mullen Scales of Early Learning

(Mullen, 1995) and the Autism Observation Scale for Infants

(AOSI; Bryson, Zwaigenbaum, McDermott, Rombough,

& Brian, 2008; Zwaigenbaum et al., 2005). The stan-

dardized interview format for the Vineland Adaptive

Behavior Scale (VABS; Sparrow, Balla, & Cicchetti, 1984)

was also administered. Test administration followed stan-

dardized protocols and occurred at a university setting with

clinic space and testing rooms for children. In all cases, the

mother was present throughout the testing. A parent

(typically the mother) completed the Infant–Toddler Sen-

sory Profile (Dunn, 2002) before the clinic visit.

The first author and a trained research assistant con-

ducted the play and feeding videotaped sessions in par-

ticipants’ home for both the high-risk and the low-risk

groups. Play sessions occurred in the living room or play

room where the child most often played and included

10 min of the infant playing with the mother on the

floor using a standardized set of common, enticing toys.

The toys included large soft blocks, a mirror, a play

phone, rattles, balls of various sizes and textures, a doll

with a spoon, a bottle and blanket, and a toy hammer–

play structure. The toy hammer–play structure had balls

that, when hammered into holes on the structure, moved

through a maze and out another hole. The mother was

directed to play with her infant and the toys in any way

she liked and in ways that would reflect how the dyad

would typically interact and play with toys. They were

not required to use all the play materials or toys. Feeding

occurred in the family’s kitchen using the child’s high

chair. The mother was asked to support the child in any

way she typically would, and the mother provided a food

item that the child was accustomed to eating (cereal,

applesauce, and yogurt were most common).

Instruments

The VABS assesses adaptive functioning for individuals from

birth to age 90 across four domains—Communication,

Daily Living Skills, Socialization, and Motor Skills—

and provides an overall Adaptive Behavior Composite

score. The VABS was standardized on a national sam-

ple of 3,000 children matched to U.S. census data.

Internal consistency examined by split-half reliability

coefficients is acceptable, ranging from .84 to .88, and

test–retest reliability reported in the manual is also

acceptable, with r values ranging from .78 to .92 for

all areas for the birth to 3 yr age range (Sparrow et al.,

1984).

The Infant–Toddler Sensory Profile (Dunn, 2002) is

a caregiver questionnaire measuring the ability to process

and modulate sensory information, developed with a nor-

mative sample of 589 children from birth to age 36 mo.

The caregiver rates on a scale ranging from 1 to 5 the

frequency with which his or her child exhibits certain

behaviors indicative of sensory processing. Internal con-

sistency estimates across sensory processing sections and

quadrants (representing Low Registration, Sensory Seek-

ing, Sensory Sensitivity, and Sensory Avoiding) varied

with the children aged 7–36 mo and ranged from .42 to

.85, with the strongest values representing the sensory

processing patterns. Test–retest reliability values are ac-

ceptable on the basis of a study of a normative subsample

(n 5 32), with coefficients of .86 for sensory processing

section scores and .74 for quadrant scores. Evidence re-

garding content, construct, and discriminant validity is

also provided in the manual (Dunn, 2002).

TheMullen Scales of Early Learning is a standardized,

norm-referenced, developmental measure for children

from birth to age 68 mo. It was normed on 1,849 children

based on U.S. census data and generates standard

scores for five subscales—Gross Motor, Fine Motor, Vi-

sual Reception, Receptive Language, and Expressive

Language—as well as an Early Learning Composite score.

Split-half internal consistency coefficients are acceptable,

with median values (from the normative data) ranging

from .75 to .91. Test–retest reliability was obtained with

97 children over a 2-wk period and ranged from .71 to

.96 (Mullen, 1995).

The AOSI was developed to assess behaviors specific

to ASD in infants. The clinician administers several play-

based activities to elicit possible behavioral markers for

ASD, such as poor eye contact, lack of orienting to name,

lack of social smiling, deficit in interest in others, and

reactivity to sensory stimuli. The AOSI has demonstrated

strong interrater reliability (.94 with children at 18 mo),


fair test–retest reliability (.61 using the total score for

infants 12 mo of age). Predictive validity when admin-

istered at 12 mo has also been found to be strong (Bryson

et al., 2008).

Data Collection and Analysis

Videotaped data from the play and feeding sessions were

transferred to a DVD, and the sessions were viewed to

record the targeted sensory and motor behaviors as being

either present or absent every 30 s. Coding was conducted

by the first author and three research assistants whom

she trained in the use of the measure. Three demonstra-

tion tapes were used for training purposes, and research

assistants achieved 90% agreement with Mulligan across

all cells before coding independently. Training involved

approximately 6 hr of review of the definitions, practice

coding, and discussion with Mulligan to resolve dis-

agreements. The research assistants were blind to group

assignment and coded 70% of the digital recordings;

Mulligan coded the remaining recordings.

The first author or a trained research assistant scored all

standardized tests (i.e., AOSI, Mullen Scales) and parent

questionnaires. Descriptive statistics were used to analyze

data from the standardized developmental measures ad-

ministered to the high-risk infants. One-sample t testswere used to compare the mean developmental scores of

each of the 13 children in this group with each test’s

normative data to determine whether the group differed

significantly from the normative sample. To examine

sensory and motor differences between the high-risk and

low-risk groups, we coded mean frequencies for each

behavior from the play and feeding sessions and then

compared the groups using independent t tests, with the

a level for determining statistical significance set at .05.

All data were analyzed using PASW Statistics 18, Release

Version 18.0 (SPSS, Inc., Chicago).

Results

The study sample included 8 girls and 5 boys in the high-

risk group (mean age 12.6 mo) and 7 girls and 5 boys in

the low-risk group (mean age 12.1 mo). Most participants

were White, and all were from New England. The groups

did not significantly differ with respect to race, gender, and

age. Follow-up at age 30 mo indicated that four of the

high-risk infants met criteria for ASD, and another two

children had received early intervention services for mild

developmental concerns. None of the children received

early intervention services before 12 mo of age, and none

of the infants placed in the low-risk group exhibited

developmental concerns.

The developmental profile of the high-risk group fell

largely within the low end of the average range, although

some relative strengths and weaknesses are noteworthy. A

summary of these results is presented in Table 1. Fine

motor performance and visual reception skills fell in the

average to above-average range, whereas gross motor skills

were within the low-average range. Test scores measuring

social and communication skills were mixed, although

most fell within the low-average to below-average range.

The number of markers noted using the AOSI indicated

that 31% of the children were at high risk for developing

ASD. Sensory processing differences were also found;

scores from the high-risk group reflected less sensory-

seeking behavior than scores of children from the nor-

mative sample and a tendency for more difficulties in the

area of auditory processing.

The results of the one-sample t tests revealed some

significant differences between the scores of this group

and the normative data for each of the tests. On the

Mullen Scales of Early Learning, scores from the high-

risk group were higher on Visual Reception (t [12]5 2.1,

p 5 .059), approaching significance, and significantly

higher on the Fine Motor Scale (t [12] 5 3.2, p 5 .009).

Performance of the high-risk group was, however, sig-

nificantly poorer on the Expressive Language (t [12] 523.6, p 5 .004) and Receptive Language (t [12] 523.7, p 5 .004) scales. On the VABS, the Motor Scale

showed significantly lower scores for the high-risk

group than the normative sample (t [12] 5 22.4, p 5.03); there were no other significant differences.

Videotaped coding of sensory and motor behaviors

during play and feeding revealed that compared with

infants from the low-risk group, the high-risk group

demonstrated significantly fewer movement transitions

(t [23]5 22.4, p 5 .03) and less object manipulation

(t [23] 5 22.4, p 5 .03; see Table 2). Thus, children in

the high-risk group tended to move around less during

the play session, and they manipulated objects in their

hands less frequently (see definitions in the Appendix).

No significant differences were found between groups on

the other sensory and motor behaviors coded during the

play sessions, and no differences between groups were

noted on the behaviors coded from the feeding sessions.

Discussion

The results suggest that contextual, play-based observa-

tions in conjunction with standardized developmental

measures may have a vital role in the early detection of

ASD. In this study, how the infants used their hands to

manipulate toys in play and how much they moved


around during play appeared to be important consid-

erations. Although many of the high-risk infants scored

within the normal range on the standardized motor

measures, during more unstructured play, they used less

sophisticated functional fine and gross motor movements

than would be expected.

An examination of the variability and frequency of the

sensory andmotor behaviors that were observed and coded

Table 2. Mean Frequencies of Sensory and Motor Behaviors Coded From Play Sessions

Coded Behavior High-Risk Group, Mean (SD ) Low-Risk Group, Mean (SD ) p

Motor stereotypy 0.2 (0.6) 0.2 (0.6) .95

Object stereotypy 0.85 (1.1) 1.9 (0.5) .19

Mouthing objects 5.7 (5.3) 3.7 (2.9) .27

Movement transition 7.5 (5.5) 12.3 (4.7) .03*

Orients toward visual stimulus 19.8 (1.3) 17.7 (4.1) .09

Orients toward auditory stimulus 15.5 (3.9) 14.9 (4.7) .75

Orients toward tactile stimulus 9.7 (6.5) 6.3 (4.1) .13

Aversive response to visual stimulus 0.23 (0.6) 0 (0) .20

Aversive response to auditory stimulus 0.46 (1.1) 0.2 (0.9) .61

Aversive response to tactile stimulus 0.61 (1.3) 0.2 (0.4) .25

Object manipulation 9.7 (4.4) 13.4 (3.3) .03*

Motor imitation 3.3 (2.7) 2.5 (2.3) .43

Construction play 0.15 (0.5) 0.3 (0.6) .46

Sensorimotor play 13.4 (6.6) 12.1 (6.7) .62

Functional play 10.8 (5.2) 11.2 (3.7) .83

Associative play 9.0 (6.3) 10.3 (3.6) .55

Note. SD 5 standard deviation.*p < .05.

Table 1. Developmental Standard Scores of the High-Risk Group (n 5 13)

Test Variable Mean (SD )% Scoring in the

Dysfunctional Range

Autism Observation Scale for Infants 31% received 7 or more markers, whichhas been reported to be predictive of ASD.Total score 8.4 (4)

Number of ASD markers 5.2 (2.3)

Mullen Scales of Early Learning 50 (10)

Gross Motor 46.7 23

Fine Motor 57.1a 15

Visual Reception 55.5a 0

Receptive Language 36.9b 69

Expressive Language 40.8b 46

Early Learning Composite 95.9 15

Vineland Adaptive Behavior Scales 100 (15)

Communication 97.1 23

Daily Living Skills 101.5 0

Socialization 94.8 15

Motor Skills 94.3b 15

Adaptive Behavior Composite 97.8 15

Infant–Toddler Sensory Profile Range within 1 SD

Low Registration 47.4 (46–54) 36

Sensory Seeking 35.0 (19–35)a 72

Sensory Sensitivity 47.6 (41–52) 36

Sensory Avoiding 51.2 (45–56) 45

Low Threshold 98.8 (87–107) 45

Auditory Processing 39.7 (35–43) 54

Visual Processing 24.9 (20–27) 45

Tactile Processing 58.1 (48–61) 45

Vestibular Processing 20.1 (18–23) 36

Oral Sensory Processing 24.8 (21–29) 36

Note. ASD 5 autism spectrum disorder; SD 5 standard deviation.aSignificantly above the norm. bSignificantly below the norm.


during the play sessions provides some insight into which

behaviors may be useful for future consideration related

to screening for ASD. For example, behaviors that were

coded as being absent or not observed in almost all

intervals would not be helpful, such as movement ste-

reotypy; aversive responses to visual, auditory, and tactile

sensory input in both feeding and play sessions; con-

struction play; and motor imitation during feeding. Be-

haviors that were seen a moderate amount of time that

appear more promising as possible early markers in young

infants include object stereotypy; mouthing of objects;

motor imitation during play; and spontaneous sensori-

motor, functional, and associative forms of play.

It was somewhat surprising to find no differences

between groups in the frequency of functional, sensori-

motor, and associative forms of play. It may be that dif-

ferences in types of play and other behaviors may not be

clear until after age 12 mo. Christensen et al. (2010), for

example, in a study of infant siblings of children with

ASD at age 14 mo, found that high-risk infants engaged

less often in functional play than did age-matched, typ-

ically developing counterparts.

During the feeding session, the finding of no significant

differences in sensory or motor behaviors between groups

may be explained in part by the nature of the context. First,

the opportunity for movement was limited in the high

chair to largely oral–motor and upper-extremity move-

ment. Second, the task of feeding is familiar and routine

and lends itself to little variation in how it is performed. It

may be that such a familiar task, with little variation in

how it was carried out among the dyads, resulted in similar

sensory and motor behavioral responses from the infants.

The developmental profile of the high-risk group in

this study was consistent with that found in other studies

of young siblings, which have found relative strengths in

visual–perceptual skills, motor performance falling within

the low end of the average range or borderline, and dif-

ficulties in receptive and expressive language (Landa &

Garrett-Mayer, 2006). We also found sensory processing

differences in the high-risk infant siblings, detected

through the use of the Infant–Toddler Sensory Profile

(Dunn, 2002). In particular, the high-risk infants tended

to be less sensory seeking, a finding consistent with that of

Ben-Sasson et al. (2009). It may be that early on, these in-

fants have less capacity or motivation for exploration within

their natural environments. It may also be an adaptive re-

sponse learned by the infants to avoid exposure to sensory

stimulation that they may experience as distressing.

Prospective study designs have been helpful for sup-

porting research in the design of valid screening and eval-

uation instruments for young children before age 2 yr.

Zwaigenbaum et al. (2007) reported that valid instruments

are becoming increasingly available, and clinicians trained

in their use are showing evidence for reliable and stable

early diagnosis (as early as age 2). Although consensus on

the need for universal screening has not yet been reached,

early identification of ASD provides families with impor-

tant information and resources. With very early entry into

effective intervention services, the possibility for significant

reductions in symptoms associated with ASD, or even the

possibility for prevention, is promising.

Limitations and Future Research

A number of limitations must be considered in the in-

terpretation of this study’s findings. First, the sample size

was small, which increases the risk for Type I error, and

because only predominantly White families from New

England were represented, generalizability is limited. Sec-

ond, the high-risk group, as expected, was quite hetero-

geneous in that 4 children ultimately were diagnosed with

ASD, 2 children received early intervention for speech

and language concerns but were not diagnosed with the

disorder, and 7 were not identified as having any neuro-

developmental disorder or delays in development. In ad-

dition, a few of the children who were diagnosed with an

ASD may have represented a broader ASD phenotype

with subtle characteristics of the disorder, but not to the

extent that a diagnosis was made. Therefore, as more data

are collected, analyses using data from only those children

who eventually have confirmed ASD diagnoses would

provide a clearer picture of early markers.

The inconsistency in scores across the measures of

social and communication skills is also a weakness of the

study and may be attributed in part to the specific

characteristics of the tests used and the differences in the

measures’ sensitivity for detecting differences in children

at age 12 mo. For example, the expectation of word ut-

terances at 12 mo of age is very low for even typically

developing infants. Therefore, this type of test item is not

as discriminating as it would be for children at age 18 mo.

The study design would also have been strengthened if all

data had been coded by researchers blind to group assign-

ment; although we attempted to blind researchers, occa-

sionally they were able to hear siblings on the videos in the

background, and because of limited resources, only about

70% videotapes were coded blindly. Therefore, researcher

bias may have affected the coding, although the operational

definitions of the behaviors and strong interrater reliability

data addressed the risk of researcher bias to some degree.

Ongoing research is needed to further develop and

validate screening and assessment measures for early


diagnosis. Larger studies that systematically collect data

longitudinally from at-risk infants from more diverse

populations at multiple time points, such as at 6, 12, 18,

and 24 mo of age, would provide a more in-depth un-

derstanding of potential markers and increase generaliz-

ability. In addition, an analysis of data from only those

children who eventually develop ASDwould providemore

clarity with respect to potential markers for early screening

and diagnostics.

Implications for OccupationalTherapy Practice

The results of this study have the following implications

for clinical occupational therapy practice:

• Occupational therapists and other team members who

are involved in the initial diagnosis of children with

ASD should be aware of reliable and valid evaluation

and screening tools, receive training in their use, and

apply them in the diagnostic process.

• Occupational therapists are and should continue to be

involved as valuable contributors in the evaluation

process for determining ASD diagnoses, in light of

their expertise in the areas of occupational perfor-

mance, sensory processing, play behaviors, and motor

development of infants and toddlers.

• Contextual observations of mother–infant play should

be considered for inclusion in the diagnostic process.

Not only do they have the potential to elicit sensory and

motor behaviors that may be important for diagnostic

purposes, but they can enhance our understanding of

how such behaviors may influence a young child’s abil-

ity to play, learn, and perform daily activities. s

Acknowledgments

The authors would like to express their gratitude to the

occupational therapy students and Maternal Child and

Health Leadership Program for Working With Children

WithNeurodevelopmental Disabilities and Their Families

(MCH LEND) trainees who were involved as research

assistants in multiple phases of the project and to the

children and families who agreed to participate in the

study. We also would like to thank the University of New

Hampshire, Office of the Provost and Vice President, for

partial funding, and Anne Dillon, Michelle Sullivan, and

Rae Sonnenmeier for all of their work with the Early

Markers Project.

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Appendix.Operational Definitions for Coding Sensory and Motor Behaviors

Behaviors During PlayMotor stereotypy—Repetitive body movement. Child may engage in wiggling, flapping, or flicking of the fingers or hands; alternate flexion and extension ofthe fingers; alternate pronation and supination of the forearm; or head rolling, head banging, body rocking, or body swaying back and forth.Object stereotypy—Repetitive movement with an object. Child makes the same movement with an object more than 10 times in a 30-s interval.Mouthing objects—Child puts a toy or object partially or completely in mouth for any length of time, or an object touches child’s lips.Movement transition—Child transitions from one position to another or physically moves from a location. Examples of movement transitions include movingin or out of sitting or to and from kneeling; side lying, supine, or prone lying positions; crawling; scooting; pivoting in sitting; or walking. Repositioning self insitting—for example, from side sitting to cross-legged or a long sit—does not qualify as a movement transition if child remains in the same spot.Orients toward visual—Child responds positively to visual stimuli, such as mirror, mom’s face, moving objects, or bright colors, by turning head toward,moving body toward, reaching for, or looking toward the stimulus.Orients toward auditory—Child responds positively to auditory stimuli, such as squeaky ball, ringing phone, rattle, banging of the mirror, mom’s voice, orother environmental sounds, by turning head toward, moving body toward, reaching for, or looking toward the stimulus.Orients toward tactile—Child responds positively to tactile stimuli, such as parent’s touch, baby blanket, bumpy ball, or fuzzy blocks, by turning headtoward; moving body toward; repeatedly touching, rubbing, or patting; or mouthing the stimulus.Aversive response to visual—Child reacts negatively to visual stimuli, such as mirror, moving objects, or bright colors, by closing eyes, screaming, crying,or turning head or moving away from the stimulus.Aversive response to auditory—Child reacts negatively to auditory stimuli, such as squeaky ball, ringing phone, rattles, or banging, by covering ears,screaming, pushing toys away, crying, or turning head or moving away from the stimulus.Aversive response to tactile—Child reacts negatively to tactile stimuli, such as baby doll, blanket, or bumpy ball, by withdrawing hands after touchingobject, pushing object away, or moving body away from the object. Child cries or sounds distressed following a tactile stimulus.Object manipulation—Child transfers object from one hand to the other; repositions object in the hand, perhaps using the floor or body part to helpreposition object in the hand; or manipulates object in the hands, which does not include simple picking up, grasping, holding, throwing, and shaking.Motor imitation—Child imitates hand motions (pushing, rubbing, tapping, banging hammer, squeezing, turning, pointing, shaking rattle), facial movements(blowing, kissing, sticking out tongue), or other body movements that he or she has seen the caregiver perform; includes movements performed afterverbal prompting if the movement was also demonstrated. The imitated behavior must occur within the same time segment as the stimulus movement.Types of PlayAll forms of play may be seen in the same segment.Construction play—Child builds or attempts to build with soft blocks.Sensorimotor play—Child examines sensory features of play objects by feeling, looking at, touching, listening to, or exploring the objects but does notneed to display any functional use of the objects.Functional play—Child uses objects functionally for their intended purposes, such as covers baby doll with blanket, puts bottle to baby doll’s mouth,hammers ball into hole, rolls ball, talks or babbles on phone, brings phone to ear, presses phone buttons, or builds with blocks.Associative play—Child demonstrates at least one instance of social play or engagement with the parent during the segment. Examples include turn taking,performing 3-point eye gaze between parent and object (parent–object–parent or object–parent–object), imitating, giving, showing, following a verbaldirection, and responding appropriately to gestural communication.Behaviors During FeedingMotor stereotypy—Repetitive body movement. Child may engage in wiggling, flapping, or flicking of the fingers or hands; alternate flexion and extension ofthe fingers; alternate pronation and supination of the forearm; or head rolling, head banging, body rocking, or body swaying back and forth.Object stereotypy—Repetitive movement with an object. Child makes the same movement with an object, such as banging the spoon or spinning the bowl,more than 10 times.Independently scoops—Child uses spoon to scoop food on his or her own.Spoon to mouth—Child brings food to mouth using spoon and places food in mouth.Hand to mouth without spoon—Child brings hand to mouth in the context of feeding, such as putting food item in mouth, pushing food into mouth,stopping food loss, wiping food, or sucking fingers.Plays with food—Child uses food nonfunctionally (not trying to eat it) by, for example, pushing food around tray, throwing food, or mashing food betweenfingers.Orients toward visual—Child responds positively to visual stimuli, such as mom’s face or moving objects, by moving head or body toward or reaching forstimulus; child visually tracks spoon as it is brought to mouth.Orients toward auditory—Child responds positively to auditory stimuli, such as mom’s voice or other environmental sounds, by turning head toward,moving body toward, reaching for, or looking toward the stimulus.Orients toward tactile—Child responds positively to tactile stimuli, such as parent’s touch or contact with food, by turning head toward, moving bodytoward, or repeatedly touching the stimulus; child plays with food or licks food off lips or hands.Aversive response to visual—Child reacts negatively to visual stimuli, such as caregiver’s face or moving spoon or bowl, by closing eyes, screaming,crying, or turning head or moving away from the stimulus.Aversive response to auditory—Child reacts negatively to auditory stimuli, such as mom’s voice or other environmental sounds, by covering ears,screaming, pushing stimulus away, crying, or turning head or moving away from the stimulus.Aversive response to tactile—Child reacts negatively to tactile stimuli, such as holding spoon or feeling food on hands, by withdrawing hands; shakinghands to remove food; pushing food, bowl, or spoon away; or moving body away from the stimulus.Sits upright—Child sits upright in high chair without slouching or needing repositioning by the parent.Motor imitation—Child imitates hand motions (pushing, rubbing, tapping, pointing, scooping) or facial movements (blowing, kissing, sticking out tongue)that he or she has seen the caregiver perform; includes movements performed after verbal prompting as long as the movement was also demonstrated inthe same segment.


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Sensory and Motor Behaviors of Infant Siblings of Children With and Without Autism