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Dyspraxia in Autism Spectrum Disorders:

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S PECI A L I N T ER E ST SE C TI ON QUART ERLY
Sensory Integration
Dyspraxia in Autism Spectrum
Disorders: Evidence and
Implications
Judith Abelenda, MS, OTR; Zoe Mailloux, OTD, OTR/L,
FAOTA; and Susanne Smith Roley, OTD, OTR/L, FAOTA
Dyspraxia is “a developmental condition in which the ability to plan
unfamiliar motor tasks is impaired” (Bundy, Lane, & Murray, 2002,
p. 477–478). The purpose of this article is to review current views
of dyspraxia and its relationship to occupational therapy services
for clients with an autism spectrum disorder (ASD). An emerging
body of evidence demonstrates the impact of dyspraxia on partici-
pation in individuals with an ASD (Dziuk et al., 2007; Roley et al.,
2015). First, this article reviews seminal work on praxis and ASDs,
followed by consideration of recent findings on the evidence for a
neural basis of dyspraxia in ASDs. Next, we will highlight the risks
and implications for occupational performance. Finally, we will
discuss how this body of evidence informs occupational therapy
practice, especially in applying Ayres Sensory Integration® (ASI)
for people with an ASD.
Historical View: Dyspraxia and Autism
Ayres (1972) was among the first to describe sensory differences in
individuals with ASDs. In her theory of sensory integration (ASI),
she hypothesized that difficulties in registering, modulating, and
integrating sensations were likely to interfere with the ability to
create internal maps of the body for relating to the environment.
Her theory also posited that these sensory differences further inter-
fered with the ability to figure out how to use the body in mean-
ingful interactions with people, space, and objects, and to explore
new and novel ways of interaction. Thus, she highlighted the con-
nection between sensory integration and praxis and linked diffi-
culties in these areas with the participation challenges commonly
observed among individuals with an ASD (Ayres & Cermak, 2011).
Ayres (2005) hypothesized that deficits in the central nervous
system, specifically the limbic system, interfered with motivational
functioning in people with an ASD, which she termed a problem of
“I want to do it” (p. 132). Her innovative view led to a deeper under-
standing of the neural basis for behaviors such as the lack of initia-
tive, now commonly recognized as part of an ASD. Dr. Bauman, a
pediatric neurologist and leading researcher in the field of ASDs,
stated in reference to the chapter on autism in the anniversary edi-
tion of Sensory Integration and the Child (Ayres, 2005):
It is clear from reading Dr. Ayres’ description of the autistic child
and her interpretation of the potential underlying neurobiology
associated with some of the clinical characteristics that she was
ahead of her time. This chapter was written in 1979, 5 years before
the publication of the first report of definable neuro-anatomic
abnormalities in the autistic brain (Bauman, 2005, p. 180).
Published by The American Occupational Therapy Association, Inc.
Sponsored in part by WPS
September 2015, Volume 38, Number 3
Given the poverty of research on dyspraxia in ASDs prior to
the 1980s, it is reasonable to assume that Ayres’ understanding of
the sensory and praxis issues evolved from her own research and
practice (Ayres, 1972; Ayres & Henderson, 1974), rather than from
contemporary views of autism. Ayres not only theorized about the
role of sensation and praxis in ASDs, she further posited that the
application of a specific intervention using natural activities, in
the context of play, could facilitate the remediation of these areas,
thereby changing nervous system functions. Imbued by a profound
understanding of the difficulties experienced by the children she
treated, she wrote, “How does it feel to be a dyspraxic child?” (Ayres
& Cermak, 2011). In this work, she strived to understand the world
of a child with dyspraxia from within, and suggested that we care-
fully monitor our interventions in order to foster growth, while
avoiding resistance and negativism. Always presuming the innate
drive toward competence, she instructed therapists to “back off” at
times in order for the child’s motivation to self-actualize and for
problem solving to flourish.
Ayres designed several pediatric measures of praxis, meant
to be used in concert with the other sensory tests of the Sensory
Integration and Praxis Tests (Ayres, 1989). These included the Imi-
tation of Postures Test (later renamed the Postural Praxis), Oral
Praxis, Sequencing Praxis, Constructional Praxis, and Praxis on
Verbal Command. Patterns of dyspraxia emerged from a variety
of factor analyses that included visual praxis, somatopraxis, and
praxis based on verbal command (Ayres, 1989). Additionally, she
considered ideation as an essential element of praxis that is often
limited in ASDs. The multifaceted view of praxis that emerged from
her study of adult literature and from her work in pediatrics pro-
vides a broad perspective of praxis that highlights the essential role
of sensation in praxis, particularly, of the somatosensory system
(Ayres & Cermak, 2011).
Current Views: Dyspraxia and Autism
Sensory concerns and dyspraxia are ubiquitous in autism. Through
retrospective analysis, Roley et al. (2015) found that, in addition
to atypical sensory reactivity, children with an ASD display com-
mon patterns of somatodyspraxia with vestibular processing defi-
cits, along with strengths in the visual perceptual and visual praxis
areas. This classic pattern of somatodyspraxia significantly corre-
lated with the Social Participation scores on the Sensory Processing
Measure (Parham, Ecker, Kuhaneck, Henry, & Glennon, 2007), even
more than the sensory reactivity scores.
Jones and Prior (1985) found a correlation between imitation
difficulties and neurological soft signs in a small sample of chil-
dren with ASDs and posited central nervous system involvement
in the disorder. Dawson and Adams (1984) contributed to the
understanding of imitation in autism, primarily with a cognitive
and behavioral focus. Imitation deficits in ASDs reflect dyspraxia
and are often measured by observation of gestures (McDuffie
et al., 2007; Rogers, Bennetto, McEvoy, & Pennington, 1996; Smith
1
& Bryson, 2007). Dziuk et al. (2007) indicated that dyspraxia was
consistently reported in autism without a clear understanding of
the relationship between issues in motor skills and sensory per-
ception. Their study showed deficits in command gestures, imita-
tion, and tool use among those with an ASD. Dowell, Mahone, and
Mostofsky (2009) described developmental dyspraxia as “a devel-
opmental impairment in the performance of learned skilled move-
ments that does not stem from a basic motor or perceptual deficit”
(p. 564). They stated that praxis performance requires basic motor
skill, knowledge or representation of the movement, and subse-
quent transcoding of the representations into movement plans.
They found that dyspraxia among those with an ASD is associated
with difficulties forming spatial representations of movement, rec-
ognizing and understanding the movements of others, as well as
with transcoding one’s own representations into motor plans and
executing them. They inferred that these difficulties are related
to abnormal connectivity between parietal, premotor, and motor
cortices. They found a strong correlation between praxis deficits
and the core social and communication deficits of those with an
ASD. These results suggest a need for further studies on the efficacy
of occupational and physical therapy aimed at improving motor
functioning, and thereby improving core deficits.
Mostofsky and Ewen (2011) explored whether a core fea-
ture of those with an ASD, a pervasive impairment in the ability
to engage in reciprocal interactions with peers, could be related
to the same underlying neural basis as dyspraxia. They found
that decreased long-range neural connectivity (between inferior
parietal and pre-motor cortices) is conducive to decreased forma-
tion of action models, which in turn results in deficits in skilled
social gestures. They highlighted that discrete action plans and the
sensory feedback, stored as internal action models, form a fun-
damental mechanism for developing cognition. Moreover, citing
Klin, Jones, Schultz, and Volkmar (2003) they sustained that the
same faulty action models, when used in feed-forward fashion,
are responsible for the theory of mind deficits seen in those with
an ASD, or the difficulty reading others’ intentions. The difficulty
of performing skilled social gestures, coupled with difficulty read-
ing others, greatly impairs reciprocal interactions. Thus, under-
connectivity would be responsible both for decreased abilities to
engage in social skills and to interpret others’ actions. Mostofsky
and Ewen (2011) related imitation difficulties seen in children
with an ASD with their praxis difficulties, since both rely on the
same sensory motor circuits necessary for action model forma-
tion. They also explained why children with an ASD typically
have good development of the early motor milestones that rely
on reflexes but show delays with the acquisition of skilled ges-
tures such as pumping a swing, getting dressed, and riding a bike,
and with social gestures such as waving goodbye. This study lends
support to the statement that autism “reflects a developmental
dyspraxia of social/communicative skills” (Mostofsky & Ewen,
2011, p. 439).
Currently, it is broadly accepted that an ASD is characterized
by neurologically based sensory and motor differences (MacNeil &
Mostofsky, 2012; Siaperas et al., 2012). Some authors (De Jaegher,
2013; Donnellan, Hill, & Leary, 2013; Kapp, 2013) have cautioned
that, in spite of the knowledge that communication, participation,
Sensory Integration Special Interest Section Quarterly
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Published quarterly by The American Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, MD 20814-3449; subscriptions@aota.org (email). Periodicals postage paid at
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2
and relationships require organisms to organize sensory informa-
tion into synchronized movement plans, most of the available
interventions for autism continue to rely on behavioral or cog-
nitive strategies. These strategies are appropriate to teach how to
solve explicit social dilemmas in a laboratory setting, but they may
not necessarily be enough to enable the use of these skills sponta-
neously in naturalistic settings where demands are implicit. This
questions their generalizability (Klin et al., 2003). This has signifi-
cant implications for occupational therapy practice, as occupa-
tional therapists work with other professionals in understanding
and modifying interventions to address sensory and motor issues
limiting the ability to generalize skills.
Roley et al. (2015) emphasized that it is important to include
assessment of somatosensory, vestibular, and praxis functions
for individuals with an ASD in the evaluation process; otherwise,
these important developmental areas may be missed and remain
untreated. If the sensory and motor difficulties experienced by per-
sons with an ASD are overlooked, the sensory-related behaviors
may be misunderstood and seen as willful, meaningless, or due
to lack of interest in relating (Ayres, 2005; Donnellan et al., 2013).
Understanding the sensory nature of behavior allows therapists
and caregivers to adjust the sensory environment, consider the
sensory challenges within activities, and provide sensory enriched
activities in the daily routine. Highlighting that interaction and
communication deficits are a reflection of a different neurobiology
impacting sensory and movement challenges, Kapp (2013) calls for
the need to empathize with those hidden challenges, just as Ayres
(1972) did decades earlier. Occupational therapists in their role of
advocates in the home and school settings can share information
about monitoring and adjusting sensory challenges and opportu-
nities that improve engagement and participation.
Donnellan et al. (2013) maintained that understanding motor
and sensory differences in ASDs is necessary for individually devel-
oped support systems, which will require knowledge of the person’s
unique differences and strengths, an investment of time spent with
the person, and a presumption of competence. These researchers
called for collaboration rather than control, and they reminded the
reader that the essential factor of any successful intervention is the
quality of the therapeutic relationship.
We attach meaning to experiences and make sense of the
world within the context of our own actions and our interactions
with others (De Jaegher, 2013). However, inefficient sensory and
motor functions that are common in ASDs can impact this ability
(Klin et al., 2003). Following this premise, De Jaegher (2013), Klin
et al. (2003), and others suggest that children with an ASD may be
best able to develop social skills in settings rich in sensory motor
experiences where the experiences can be perceived with greater
salience. Interventions that target the difficulties with social, affect,
cognitive, and sensorimotor capacities in real time require thera-
pists who are ready to actively and effectively engage children in
coordinated interactions that address individual neurological dif-
ferences (De Jaegher, 2013). Occupational therapists using ASI to
address social participation challenges for a child whose family-
centered goal is to increase play with peers, needs to consider the
underlying dyspraxia in an environment affording opportunities
for self-directed participation in meaningful activities rich in novel
 sensory experiences within the context of a collaborative thera-
peutic relationship (Parham et al., 2011).
Recent research including a feasibility study (Schaaf, ­Benavides,
Kelly, & Mailloux-Maggio, 2012), two pilot studies (Iwanaga et al.,
2014; Pfeiffer, Koenig, Kinnealey, Sheppard, & Henderson, 2011),
one randomized controlled trial (Schaaf et al., 2013), and detailed
information on ASI application in a case report (Schaaf, Hunt, &
­Benavides, 2012) seem to confirm that praxis deficits in ASDs and
their correlated social and communication impairments can be suc-
cessfully ameliorated through participation in self-directed, sensory
rich activities that promote adaptive responses.
Conclusion
This article briefly reviewed the current literature on dyspraxia
in ASDs and some of the literature that explores how sensory and
motor differences in ASDs impact one’s ability to make sense of the
world. ASI addresses the sensory and praxis deficits of ASDs in a
manner that is mindful of the person’s experience and acknowl-
edges the impact of sensory integration and praxis on participation.
It is important to embed the understanding of sensory perceptual
deficits contributing to praxis and dyspraxia in ASDs as a routine
part of occupational therapy assessment and intervention. Occu-
pational therapists working with people with ASDs are encouraged
to include observations and measures of proprioceptive, tactile,
and vestibular functions that support praxis, as well as observa-
tions and measures of praxis including those that assess ideation,
imitation, construction, and sequencing. In this way, occupational
therapy practitioners working with individuals with an ASD better
understand the contributions to planning, organization, and social
skills, and can design interventions that effectively address the bar-
riers to performance. Further research is needed to understand the
way in which sensory integration and praxis affects participation
in individuals with and without an ASD. ●
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Judith Abelenda, MS, OTR, is the owner of Uutchi Desarrollo Infantil in
­Vitoria-Gasteiz, Spain; judith@uutchi.com.
Zoe Mailloux, OTR/L, OTD, FAOTA, is the Adjunct Associate Professor for the
Department of Occupational Therapy at Jefferson School of Health Pro-
fessions, Thomas Jefferson University, Philadelphia, PA 19107.
Susanne Smith Roley, OTD, OTR/L, FAOTA, is the owner of Susanne M. Smith,
Inc. in Irvine, CA. 
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