Assessment of Motor/Orthopedic Conditions

Describe major motor impairments, because by definition they are likely to affect the total behavioral constellation of an individual. Describe even minor motor impairment if it is related to the referral concerns. Here are some ways in which we have seen motor impairments affect development in other domains:

Parental Difficulties with Setting Expectations

When a child is born with obvious motor impairments such as cerebral palsy (below), parents are confronted with questions of how much to expect in the way of their child’s independence and desire for independence. Chances are (and remember – ultimate effects are the result of temperament and other factors as well), that setting expectations too low can lead to unnecessary helplessness and dependence, while setting them too high can lead to frustration and discouragement.

Difficulty in setting expectation is inherent with any developmental difference. When you think about it, setting expectations is a difficult enough task with any Guide. Guides of neurotypical children can differ quite a bit in their expectations of normal function – and the results of overestimation and underestimation can be the same (although usually not to the pervasive degree seen in disabling conditions).

Disabling conditions of any kind confuse the developmental picture even further. Go to the bookstore and you will see rows of books on raising children and “What to Expect…” A developmental disorder on the other hand is unique to every individual – every person with a disability has a different profile. Even when books refer to specific diagnoses such as Autism, ADD, Cerebral Palsy etc., they are describing very heterogeneous within-diagnosis populations.

Learned Helplessness

Perhaps the most significant factor to analyze when motor impairments are present is how they affect the IP’s desire for independence (and sometimes thGuides’ desire for their IP’s independence).

Difficulties with movement are likely to have started before birth,[27] making it difficult for the Student to accomplish the simplest movements and coordination between the senses and movement. This affects the IP’s expectations of him or herself – even before interactions begin with the external world.  Parental underestimation can further compound the emotional affects of a motor impairment – leading them to do for the IP what might be healthier for the IP to do for him or herself.

Over time, patterns of dependence can take on secondary functions for individuals in the relationship.  A person can grow afraid of frustration to the point where they grossly underestimate their own abilities and refuse to do things for themselves. Guides can reinforce this when they offer care too quickly, or when their anxious emotional signals lead to similar, resonant reactions in the IP. By offering care too quickly (whether by necessity of time, basic belief about the level of true impact of the disability, or to avoid their own anxieties related to these things) – they deprive the IP of the chance to develop a tolerance for frustration and to experience new levels of function.

Guides can also become wedded to the caregiving role far beyond the level of care that is necessary. Caregiving can take on an overly defining role in the Guide’s self-concept, and the Gide can become unhealthily invested in the IP’s disability. Such a Guide can view steps towards independence as threatening, and tend to [consciously or unconsciously] sabotage the IP’s initiative. This is a very important thing to notice when it is present.

Understimulation/Hypotonia

The more obvious signs of motor coordination delays are very often accompanied with muscle weakness, low muscle tone, and “under-registration” of tactile, proprioceptive, and/or vestibular input.

These symptoms are also highly correlated with problems regulating arousal. IP’s that under-register sensory input (in general, but especially with motor/proprio-/vestibular channels) can be hypoaroused (under-alert, spacey, distractible, sleepy, etc.), or hyperaroused (sensory seeking: hyperactive, impulsive, or, rigid, anxious, etc.).

Lack of Exploration and/or Persistence

The pattern of behavior most often associated observed in motor-impaired children has to do with a lack of interest in the environment and a tendency to terminate exploration almost as soon as frustration occurs.

Neurotypical children without motor impairments should be aggressive explorers of their environment. They are driven in a way to act upon objects and with people in order to learn from them. Throughout these interactions with objects and people, there are enough successes to encourage the child through a lifetime of exploration. Constant experimentation leads to further interest, which leads to further exploration, etc.  Feelings of competence lead a person to prefer variety and novelty, rather than sameness.

Motor impairments affect an IP’s feelings of competence adversely, often leading to a lack of exploration. A history of frustration can lead to a “learned disinterest,” or even an aversion to interacting with objects.

Over time, this results in delays in cognitive skills that might not otherwise happen. More specifically, the IP whose motor coordination difficulties are an ever-present obstacle lacks practice and development of means of exploration that would lead to further learning. Furthermore, a history of frustration teaches a person that persistence is pointless or even disastrous, which in turn leads to less than necessary levels of persistence and problem solving efforts.

Fleeting Attention

In the brain, perception and action are intertwined. Thoughts and the focusing and refocusing of attention are internalized motor actions (see below: Thinking, Memory, and Anticipation as internalized motor action). Attention also involves [physical] ocular-motor and pupillary actions).

The coordination of the head, eyes, and neck is one of the first things an infant learns. This begins the person’s life-long journey of exploration. In other words, the coordination of the head, eyes, and neck is among the first means of exploration to develop. At this stage, children learn to shift and set their focus on interesting things, and to maintain their attention for increasingly longer periods of time. Over time, as available mental real-estate (synapses) grows and increased capacity for memory results, the child learns to improvise, remember and anticipate sequences and problem-solving steps (“sequential thinking,” “sequential memory”).

As the IP accumulates experience, he or she acquires greater capacity to improvise, remember, and anticipate longer sequences. However, if development proceeds with a significant lack of experience with objects or people, then there is typically a correlated lack of ability to maintain focus on objects or people.

Finally, knowledge primes attention. That is, we are more likely to become and stay interested in things in which we have some knowledge or familiarity. A Student might find it difficult to become interested in things in which he has no experience.

Proprioception and Toilet Training

The sense of bladder or bowel fullness is conveyed to the brain by proprioceptors in the bladder or bowel wall. These proprioceptors convey a sense of fullness when they are distended (stretched).

As in all perception, proprioception occurs in the brain. Delays in proprioception are evident in a variety of neurodevelopmental and neurodegenerative (e.g., Alzheimer’s, Parkinson’s, etc.) disorders. A Student’s under-registration of proprioceptive input can be an obstacle to continence and toilet learning. Therefore, signs and reports of diminished proprioception, hypotonia (low [muscle] tone resulting from inadequate muscle innervation), arousal dysregulation, and other motor-muscular-perception-arousal axis symptoms can be identified as setting conditions related to problems in toilet learning.

Trunk Control

Toilet learning problems are also found in children who have had a history of severe movement-coordination and muscle tone developmental delays.

Note that young NT children (18 months to 3 years on average – who are aware of the somatic signals of bowel or bladder fullness, and who have sphincter control), will often find a private place to have a bowel movement.

When they do this, note that they often have their bowel movements in a standing position (they might lean on something – but they remain upright). Toilet teaching requires a Student to be able to have a bowel movement in a folded position, which can be difficult or impossible for a severely hypotonic Student.

Thinking, Memory, and Anticipation as Internalized Motor Actions

Advances in the mammalian, primate, and then human brains – the neocortex, enabled higher animals to “store” motor actions at least temporarily before executing them. Behavior then evolved from reflexive or stereotyped (“fixed”) action patterns into increased ability to select from “behavioral options.” Anything that can be considered a neurobehavioral option is an entity that is somehow stored in the brain and not yet executed.

Any observable movement is the result of a sequence of neural firings to the muscles involved (a motor program, motor routine, or motor plan – depending upon who is describing it). Even the simpler steps of complex movements consist of an encapsulation of a serious of “bursts” to individual muscle groups. The seeming smooth extension of the arm to reach for something can consist of thousands of these bursts, executed in fine sequence. Such simple behaviors such as taking a step or reaching or extending one’s tongue are loaded into a buffer prior to being executed one by one in sequence.

For the reptile, all behaviors are stereotyped. That is, in reaction to a stimulus, a behavioral sequence – one largely inherited and not subject to environmental shaping or learning, is loaded into the buffer a split second before it is executed. There is no other structure in the reptile’s brain that can stop it once it is activated. The buffer only holds the sequence so the individual bursts can be sequentially executed.

Mammals have the ability to inhibit their behavioral responses. They can have the intent to do something (the behavior is planned and loaded), but for some reason, the animal can choose not to execute the behavior. The animal can stop or reverse behavioral course.

Developmentally mature humans have additional abilities. Not only do they have the ability to select from behavioral options, they can “imagine” behaviors by running the sequences internally. This is experienced as “seeing it in one’s mind.” This can be done in the auditory mode when it comes to remembering something one has heard, such as a conversation or melody.

Implicit v. Explicit Memory

Very briefly, implicit memory is for “knowing how,” whereas explicit memory is for “knowing what.” Explicit memory is available to consciousness: one can think about facts and experiences; whereas implicit memory is not available to consciousness.

For instance, walking (for those who have mastered walking to the point where it is no longer “thought about”) is a procedure that was learned at one time through repetition, and cannot be adequately described in terms of conscious, explicit thinking. In other words, you cannot explain how to walk completely. You might be able to describe the movements, and you can get into great detail regard the kinesiology involved, but you can not describe how it feels to walk and what to do in terms of the millions of calculations involved as the body continuously rebalances itself and moves forward.

Why do we need to know this? For our purposes, it is very important to understand the process of learning and how learned content becomes memory, and how sensorimotor acquisition becomes working memory, short-term memory, and long term memory. One of the core deficits of autism is difficulty acquiring perceptions and coordinating actions in a coherent, synchronized way, which causes people with autism to think about their perceptions and actions on a conscious level. This in turn, deprives them of available working memory that could be used to focus on the external world.

Sensorimotor Learning

Sensory memory is memory that forms from the moment a stimulus is perceived. This form of memory enables the mind to hold on to sensory perceptions for brief moments in order to guide motor action and thinking. Individual sensory memory systems act as buffers for information received through their respective channels, and attention filters out the interesting and/or relevant stimuli and routes it to short-term memory.[28]

Motor Action

Sensory perception provides feedback for the actions the body takes. There is a continuous loop: perception guides the next movement, the movement is experienced through the open sensory channels, which in turn guides the adjustment or next motor movement.

Sensorimotor learning therefore, is a form of learning where the information coming through the senses occupies the majority of working memory. It is necessary in order to master physical actions (including speaking), but it is not a good condition for social learning.

We never graduate completely form sensorimotor learning. For a lot of things, especially with those skills that require physical interaction with an object, our first attempts at learning require most of our conscious attention:

Example

Think about learning how to drive a stick-shifted car. In your first attempts at learning, all you can really think about are the sensory perceptions and physical (motor) actions you are doing. You’re concentrating on the feeling of the clutch under your left foot and how hard you have to press down on the shifter to shift gears with your right hand. You are consciously searching your memory to remember the gear patterns.

The total of these activities occupy you almost completely. If someone were to turn on the radio or try to have a conversation with you about another topic, you would probably find that quite disconcerting.

The above is a good description of the sensory/motor learning style and experience. The sensory and motor experiences/perceptions occupy the vast majority of available working memory. That is why the learning or cognitive processing involved, the memories involved, are termed “explicit memory.” The thinking is explicit, out in the open and available for self-examination.

As you might expect with the stick-shift example above, repeated practice results in what we often called “second-nature” in the vernacular. We no longer have to think about the actions very much, and they seem to go on at some other level of consciousness.

This is because they are going on at a different level of thinking and memory. Sensory and motor experiences that go through the process of overlearning become “decorticated,” that is, they become under the control of older, subconscious parts of the brain near the brain stem and spinal cord. Decortication is the process of moving thinking from the newer and higher-thinking parts of the cerebral cortex to brainstem and spinal mechanisms that can run them as subconscious routines. Here are some subconscious routines we all have by maturity:

Sitting up
Walking
Talking
Tying shoes
Writing your name
Using a fork

These are pretty obvious examples. I put “using a fork” last, because if most of us Westerners think about using chopsticks, we’re still somewhat sensorimotor with them – in other words – they require conscious thinking and use up working memory. This of course would not be true for someone who uses chopsticks enough to not have to think about it.

There was a time when you did have to think about these things – but you don’t remember it. Watching infants closely, one can see what a challenge learning to sit up, balance, walk, etc. these very basic skills are when they’re developing. One can also see how mastery of these skills requires less and less of their conscious attention. This process allows for instance, the child who has mastered sitting up to take in the world a new way: to see further, to reach and grab with arms that are now free. Instead of focusing on sitting up, the child focuses on her surroundings and explores from her new position and vantage point. This process occurs for every newly acquired motor skill throughout life, given sufficient repetition.

Working Memory

Working memory is a temporary form of memory that guides action. Working memory has been called the “mental sketchpad” or on-line” memory. It keeps information only long enough until we need to use it. It is continuously updated and available to conscious memory.

The contents of long term declarative memories (things we can consciously remember) can also be loaded into the working memory “buffer,” to guide actions as well. Here are some applications of WM that might be relevant:

Remembering what someone said in order to follow a direction
Remembering rules
Remembering what others have said or done while thinking of what to do next in a fluid social situation.

Short-Term Memory

Working memory is defined as the structures and processes used for temporarily storing and manipulating information, while short-term memory generally refers only to the storage structures involved. Thus, short-term memory can be considered a subset of working memory

Perception and Action

It is also important to realize that there is no action without perception, and there is no perception without action. The two are not only intertwined; at the neural level, they are merely flip sides of the same coin. Perception and action are different aspects of the same thing. For instance, in the act of walking, the brain is constantly monitoring the body’s shifting weight from top to bottom, side to side, forwards and back. Hundreds of thousands of signals are sent to the brain, and actions are coordinated in response without thinking.

Sensorimotor learning and resulting decortification, transfer actions that have been learned/remembered into a form of memory called ‘implicit memory.’

Forms of Memory Defined

Implicit Memory

This is a form of long-term memory that has to do with anything remembered at the unconscious level (where the memory is not available to consciousness – even with efforts to recall them). This form of memory is not available to consciousness and cannot be consciously recalled.

One form of implicit memory is called “procedural memory,” which occurs when learning is transferred to brain stem (basal ganglia) and cerebellar mechanisms that run motor sequences in a somewhat automatic way. Procedural memory is almost exclusively talked about in terms of motor actions, but if thought is really internalized motor actions, than it is possible that recurrent thoughts can also be governed by procedural mechanisms.

Another form of implicit memory has to do with remembering the emotions of an event, but not being able to remember the event. This might seem odd, but it is what occurs in young children, especially before they learn language. They have very poor or absent memories of what happened, but an unconscious association between stimulus and emotional memory occurs. This can lead individuals of any age to feel a certain way in the presence of certain stimuli – without knowing why they feel that way.

Explicit or Declarative Memory

This is a form of long-term memory that is available to consciousness, and requires conscious recall to be activated – hence the term ‘explicit.’ There are two forms of declarative memory: Semantic Memory and Episodic Memory. These two forms of memory use vastly different neural mechanisms, and more importantly: episodic memory is significantly impaired in autism; whereas semantic memory is often not significantly impaired.

Semantic memory

Semantic memory has to do with remembering static facts that are independent of context. People with PDDs can have relatively well-developed semantic memory, because the content of this form of memory is most static. For instance, people’s names and birthdates don’t change, Sacramento is the capital of California, Abraham Lincoln will always be the 16th President, and so on.

Episodic Memory

This has to do with the encoding of personal experience – the perceptions, sensations, the personal meaning of episodes.

People with PDDs tend to view the world through a key-hole. That is, they tend to favor in a lopsided way certain sensory channels over others. They often close off some sensory channels completely in order to concentrate on a single one (either looking or listening, but not both at the same time). As a result, personal experiences are encoded in a fragmented or one-dimensional way.

Furthermore, experiences and perceptions tend to be encoded in a static manner. Keep in mind that a personal experience is a dynamic one. It is a movie, not a photograph. It is a conversation, not a tape. The perceptions of a personal episode are constantly changing, and working memory has to be constantly updated in order to track the changes. There are usually problems with working memory capacity in all developmental disorders, usually associated with transfer of memory from one memory type to another.

This form of memory is autobiographical – the memory of personal experiences, which is the foundation for sharing experiences with others, perspective-taking, and empathy.

It is very important look at intervention programs in terms of their emphasis on either semantic (static) or episodic memory. It can be quite impressive when an IP who previously showed little in the way of organized learning to be able to label objects and people, play with toys “correctly,” learn their colors, shapes, numbers; to learn reading decoding, and even to be able to learn so-called “pragmatic” social language skills (e.g. greetings, social scripts, manners, turn-taking, etc.) and to label feelings.[29] However, intervention that focuses exclusively on these skills (that are much easier to teach to children with PDDs because of their relative strengths in semantic memory) and ignores an equal or greater emphasis on episodic memory does nothing to remediate the core deficits of their disability. The result is typically a more knowledgeable, but no less autistic individual.

Forethought

Internal seeing and hearing are the only senses that we can conjure up at will – that is – we can conjure up a fairly rich representation of the perception in consciousness without the stimulus having to be present.[30] This allows us to rehearse and modify behavior in our minds the way no other animal can.

I say that developmentally mature humans can do this, because very young children cannot. Because the frontal and orbitofrontal lobes of the brain are not mature before 18-24 months or so, infants and toddlers have little in the way of short-term memory, and are somewhat dependent upon the continued presence of stimuli in order to create internal mental “pictures” or sounds. For this reason, they are distracted easily.

Because of the short-term memory capacity problem, children have trouble remembering rules and ideas especially when there is a competing – “in the present” stimulus.

Little Nicholas (18 months), is adamant that he wants to play with the clock on the dresser. He reaches for it; Mom says, “Don’t touch,” and Nicholas protests. He keeps trying, and Mom repeats herself several times. Finally, Mom takes Nicholas to the play room and gives him the bubble lawn mower. He immediately started to play with it, apparently having forgotten the clock.

Mom took advantage of the fact Nicholas doesn’t have a real extensive working memory. For the most part, changing the scenery took care of the problem, because at this stage, his frontal lobes have only begun to mature to the point where information can be retained in consciousness.[31] There isn’t much room, and the only thing that can occupy Nicholas’s consciousness at his age is one idea – almost always – the thing that is present.

Austin
20-month-old Austin has discovered the entertainment system in the living room. The buttons of the TV were right at eye-level for him – and were practically irresistible. He pushed the button and the TV turned on. He pushed it again and it went off. He did it over and over with great fascination. Mom said, “Don’t touch,” and Austin stopped.

Austin usually tries to please his Teacher. After Austin complied, Mom went on with what she was doing. So did Austin. Even though Mom and Austin were in the same room together and Mom could see him constantly, Austin went right back to the button as soon as he turned around and saw it again. Mom repeated, “Austin, “No, No.” Austin complied – he stopped for a few seconds and went on to do something else.

It happened again within 5 minutes. Austin saw the button, and started pushing the button again. This time, Mommy was getting a little ticked, and said more sharply, “Austin NO!” Austin recoiled this time.

2 minutes pass, Austin toddles past the TV, and it happened AGAIN.

Austin also has trouble keeping more than one idea in his mind at once. For him, it was either the admonition not to touch, or the button – but not both. He has real trouble seeing the button, and experiencing all of the positive and motivating motions that come with that, AND remembering what his Teacher told him.

After about a dozen times, Austin is beginning to operate from working memory. He makes several more passes by the button, looks at his Mom, and actually inhibits himself. Viola!

The same thing happened again the next day. Mom was talking to Dad for a moment and Austin did it again! “Austin, NO!” Austin reels backward and cries. He was genuinely surprised by Mom’s reaction. Exasperated, Mom says to Dad, “He knows better.”

Well, sort of. When Mom makes eye-contact with him and both of their attention joins on the TV, Austin recalls Mom’s rule.[32] With periodic reminders, he can stay away from the button, and with consistent repetition, he can stay away from that TV.

Inhibition

Inhibiting a potential motor action (e.g., reaching for the button), is a first step towards working memory, but more importantly: development of the ability to think about (or plan) an action and not do it.

As the brain grows and reorganizes (especially the frontal cortices), there is more mental real estate (synapses) available to hold memory – at least temporarily. When this happens, something developmental psychologists call “forethought” is possible. You can see it in the way a Student solves a problem. They begin to go from random actions on objects and with people to more purposeful actions. They are able to think about what they’re going to do – before they do it – suggesting the ability to hold an idea in mind while they are performing steps.