Review

Association between Social Skills and Motor Skills in

Individuals with Autism Spectrum Disorder:
A Systematic Review
Reiko Ohara 1,2 , Yuji Kanejima 2,3,4 , Masahiro Kitamura 2,4,5 and Kazuhiro P. Izawa 2,4, *
1 Department of Health Science, Faculty of Medicine, Kobe University, Kobe 654-0142,
Japan; 1473905m@stu.kobe-u.ac.jp
2 Cardiovascular stroke Renal Project (CRP), Kobe 654-0142, Japan; 183k323k@stu.kobe-u.ac.jp (Y.K.);
136k902k@stu.kobe-u.ac.jp (M.K.)
3 Department of Rehabilitation, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan
4 Department of Public Health, Graduate School of Health Sciences, Kobe University, Kobe 654-0142, Japan
5 Department of Physical Therapy, Kokura Rehabilitation College, Kitakyushu 800-0206, Japan
* Correspondence: izawapk@harbor.kobe-u.ac.jp; Tel.: +81-78-796-4566




Received: 13 November 2019; Accepted: 9 December 2019; Published: 12 December 2019


Abstract: Social communication and motor skill deficits are prevalent characteristics of individuals
with autism spectrum disorder (ASD). This systematic research review investigates whether and
how broad social skills and motor skills may be related among individuals with ASD. We performed
a PubMed search of articles written in English, using these study inclusion criteria: (a) an association
between social and motor and skills among individuals previously diagnosed with autism; (b) one
or more social skills measures were used; and (c) one or more measures of gross or fine motor
skills were used. We classified data into two categories, and we based the association of these
variables on correlation coefficients, p-values, coefficients of determination, and authors’ description
of “may be associated” and “may not be associated.” Despite heterogeneity among these relevant
studies, a highly likely association between social and motor skills emerged. Of a total of 16 studies
reviewed, 12 reported associations between these skill sets. Three studies reported that fine motor
skills had a stronger relationship with social skills than did gross motor skills. Among the gross
motor skills associated with social skills, object control skills seemed most closely linked to social
skills. Among fine motor skills, manual dexterity seemed to most closely related to social skills.

Keywords: autism spectrum disorder; restricted and repetitive behaviors; social skill; motor skill

1. Introduction
Autism spectrum disorder [ASD] is a neurodevelopmental disorder characterized by impairments
in social communication and interaction and atypical patterns of restricted and repetitive behaviors
[RRBs] [1]. Prevalence statistics suggest that about one in 59 children have ASD [2]. Various studies and
experiment-based analyses have attempted to provide the probable causes of autism, including genetic
variations, impairments in white matter connectivity and gray matter diffusivity, over-connectivity
between neural assemblies, under-connectivity of functional brain regions, and environmental
factors [3]. However, the exact causes are still unclear, and no commonly implemented diagnostic test
or treatment is available for this disorder [4]. The diagnosis of autism at a very early age is challenging,
due to the phenotypic and etiological heterogeneity of individuals with ASD [3]. Diagnosis is possible
at 24 months, but it typically does not occur until 40 months of age [5]. Although both pharmacological
and non-pharmacological interventions are available [6], the care is to support rather than fully treat

Eur. J. Investig. Health Psychol. Educ. 2020, 10, 276–296; doi:10.3390/ejihpe10010022 www.mdpi.com/journal/ejihpe
Eur. J. Investig. Health Psychol. Educ. 2020, 10 277

this disorder. This means that there remains a continued search for more effective diagnostic and
treatment methods.
Although not being included in diagnostic criteria, motor skill deficits are prevalent in individuals
with ASD. Early descriptions of autism by Kanner [7] included characteristic limitations of the
individual’s spontaneous activity and/or failures of the person’s body adjustment. More recently,
a growing number of experts in ASD have reported the presence of diverse motor impairments,
including clumsiness, motor coordination abnormalities, postural instability, and impaired gross and
fine motor movements, relative to typically developing people [8]. Dewey et al. [9] and Green et al. [10]
previously reported poor motor skill prevalence rates among children with ASD to be 59% and 79%,
respectively. One of the reasons motor deficiency in individuals with ASD has received increasing
attention is a growing awareness that this characteristic can potentially be used as a diagnostic criterion
of this disorder [11].
In recent years, there has also been an increase in studies exploring the association between
motor skills and social communication skills in the ASD population. Various studies have shown
that motor skill deficits among individuals with ASD relate to their social communication functions.
For instance, West [12] reported, in her meta-analysis, that infant motor skills and communication
skills were related in ASD. MacDonald et al. [13] reported a relationship between motor skills and
both adaptive social skills and adaptive communication skills. Similarly, Bhat et al. [14] reported
that in infants at risk for ASD, early motor delays were predictive of the children’s future social
communication delays. The authors recommended the surveillance of motor development from a
very early stage of development, as motor delays become apparent at earlier ages than do social skill
deficits. Any association between motor skills and social communication skills gains importance
through the implication that early motor skill interventions might enhance later social development.
Healy et al. [15] reported in their meta-analysis that early physical activity interventions seemed to
have a moderately positive effect on later social functioning. Sam et al. [16] also reported that exercise
mastery and social competence had a medium to large effect. Furthermore, Al Sagheer et al. [4] reported,
within a well-acknowledged animal model of ASD, the valproic acid model, that motor dysfunction
correlated with reduced social behavior. This finding suggested that early motor dysfunction might
contribute to later social and communication deficits in a possible causal connection between these
two skill sets. Although language development plays a key role in social development and may affect
how ASD symptoms manifest, language impairments or social communication skill problems alone
are not core ASD symptoms [17]. Gerbsbacher et al. [18] reported that delayed language development
is a common but not a universal characteristic of autism since some studies that measured language
ability did not show that language development among individuals with ASD differed from typical
language development.
Finding more specific relationships between motor and social skills may help in designing
effective motor skill interventions for improved social functioning among individuals with ASD.
Accordingly, this study seeks to systematically review available research to determine whether social
skills and motor skills are associated in ASD and, if so, what specific motor skills may be especially
related to social skills.

2. Materials and Methods

2.1. Data Sources and Search Strategies

We searched for English articles published from May 1994 to August 2018 in the PubMed database,
using combinations of search keywords that included “relat* OR associat*, motor, social, autism,” “link,
balance OR postur* severity autism”, and “relat* OR associat* gait social autism.” We also conducted
an MeSH search with the terms of “motor skill disorder” and “social skills”. As we were searching for
studies of individuals diagnosed with ASD, we used a time period for our search that would yield
Eur. J. Investig. Health Psychol. Educ. 2020, 10 278

articles published after the May 1994 publication of the American Psychiatric Association’s (APA)
fourth edition of the Diagnostic and Statistical Manual IV [DSM-4].

2.2. Study Procedures

Eur. J. Investig. Health Psychol. Educ. 2019, 1, x FOR PEER REVIEW 3 of 22
Figure 1 shows the flow of study selection in this review. First, we read the titles and abstracts to
select2.2. Study Procedures
relevant studies examining associations between motor skills and social skills in persons with ASD.
Second, we Figure
read1inshows
morethe flowthose
detail of study selection
studies in this
elicited by review. First, we read
initial screening the titles
of these titlesand
andabstracts
abstracts to
assesstotheir
select relevant We
contents. studies
thenexamining associations
selected articles for thisbetween
reviewmotor
if theyskills
met theandfollowing
social skills in persons
inclusion criteria:
with ASD. Second, we read in more detail those studies elicited by initial
(a) the association between these variables of interest was examined within individuals previouslyscreening of these titles and
abstracts to assess their contents. We then selected articles for this review if they met the following
diagnosed with autism including Asperger’s syndrome or “pervasive developmental disorders—not
inclusion criteria: (a) the association between these variables of interest was examined within
otherwise specified” as named under the DSM-4 diagnostic scheme so as to cover in this review
individuals previously diagnosed with autism including Asperger’s syndrome or “pervasive
individuals previously diagnosed as having ASD by more specific diagnostic criteria; (b) the study
developmental disorders—not otherwise specified” as named under the DSM-4 diagnostic scheme
used sooneasortomore
coversocial
in thisskill measures:
review socialpreviously
individuals skills included socialasinteraction
diagnosed having ASD skills, socialspecific
by more behavioral
skills,diagnostic
verbal/nonverbal communication skills, and social comprehension skills, and the
criteria; (b) the study used one or more social skill measures: social skills included social study used one
or more social skills
interaction skills,measures; (c) studies
social behavioral that verbal/nonverbal
skills, included one or more measures skills,
communication of eitherandgross
socialmotor
skillscomprehension skills, (gross
or fine motor skills and themotor
study skills
used one
useorlarge
moremuscle
social skills
groupsmeasures; (c) studies body
for coordinated that included
movements
such one or more measures
as walking, running,ofjumping,
either gross
andmotor skills or fine motor
the maintenance skills (gross
of balance motor skills
[19], whereas fineuse largeskills
motor
muscle groups for coordinated body movements such as walking,
include grip strength, manual dexterity, and upper-limb coordination [20]); and (d) the studies running, jumping, and thewere
maintenance of balance [19], whereas fine motor skills include grip strength, manual dexterity, and
available in English. We excluded the literature if (a) the association between motor and social skills
upper-limb coordination [20]); and (d) the studies were available in English. We excluded the
was examined among individuals with and without ASD (without separating them) and individuals
literature if (a) the association between motor and social skills was examined among individuals with
who were at high risk for autism and/or typically developing [TD] individuals; (b) the studies used
and without ASD (without separating them) and individuals who were at high risk for autism and/or
only typically
languagedeveloping
development [TD] measures;
individuals;and(b) (c)
thethe studies
studies usedassessed types development
only language of motor functionsmeasures; such as
motorand coordination.
(c) the studies assessed types of motor functions such as motor coordination.

Figure1.1.Study
Figure flowdiagram.
Study flow diagram.

2.3. Data Reduction

2.3. Data andand
reduction Analyses
analyses
We classified
We classified thethe
data into
data intotwo twocategories
categories based
based onon the
thecorrelation
correlation coefficients,
coefficients, p-values,
p-values,
coefficients of determination,
coefficients of determination, ororthe
theauthors’ descriptions
authors’ descriptions that
that motor
motor skillsskills and social
and social skillsorwere
skills were
were
or were notnot associated. The
associated. The “may
“may be associated”
associated” category
category includes studies
includes studiesin which
in whichthe the
correlation
correlation
coefficient (r) is higher than 0.2, and the p-value is lower than 0.05, η2 is higher than 0.1, or R2R2
coefficient (r) is higher than 0.2, and the p-value is lower than 0.05, η2 is higher than 0.1, or is is
higher
higher than 0.2. Studies were also included in the “may be associated” category if such
than 0.2. Studies were also included in the “may be associated” category if such analysis data were not analysis data
were not provided but the author claimed that there was an association. The “may not be associated”
provided but the author claimed that there was an association. The “may not be associated” category
category includes those studies in which the correlation coefficient (r) is lower than 0.2, and the p-
value is higher than 0.05, η2 is lower than 0.1, or R2 is lower than 0.2. Studies were also included in
Eur. J. Investig. Health Psychol. Educ. 2020, 10 279

includes those studies in which the correlation coefficient (r) is lower than 0.2, and the p-value is higher
than 0.05, η2 is lower than 0.1, or R2 is lower than 0.2. Studies were also included in the “may not be
associated” category if such analysis data were not provided but the author claimed that there was
little association.

3. Results

3.1. Result of First and Second Screenings

Our search initially found 723 potentially relevant papers, of which 632 were excluded based
on review of their titles and abstracts. The excluded articles included studies with a rat model or
developmental disorders other than ASD. Of the 41 studies for which we read the full text, 25 were
excluded based on the study’s inclusion/exclusion selection criteria, leaving 16 studies for this review
(Figure 1).

3.2. Study Characteristics

Table 1 summarizes each study, including its methods and results [13,21–35]. The following
characteristics findings comprise the integrated data. We examined data from 16 studies that included
3355 individual participants with ASD. The studies’ participants’ ranged in age from 1 year to 39 years,
with a mean age of 6.7 years. We included a wide age range so that we can generalize the associations
in individuals with ASD. The ratio of male to female participants was 13%–87%. Only one study [21]
was a longitudinal research design; all of the other studies were cross-sectional designs.

3.3. Motor Skill Measurements

Among the 16 studies reviewed, 8 measured both gross and fine motor skills, six measured only
gross motor skills, and two measured only fine motor skills. Table 2 shows the methods used to
measure motor skills, including the Movement Assessment Battery for Children-2 [MABC 2] [36],
the Mullen Scales of Early Learning [MSEL] [37], the Vineland Adaptive Behavior Scale-Second
Edition [VABS-2] [38], the Test of Gross Motor Development-2 [TGMD-2] [39], the Peabody
Developmental Motor Scales Second Edition [PDMS2] [40], the Miller Function and Participation
Scales [M-FUN] [41], the Learning Accomplishment Profile-Diagnostic [LAP-D] [42], and the Chinese
Children Developmental Inventory [CCDI] [43]. Among these motor skill tests, the VABS-2 is a parent
report test without direct observation, whereas the other tests assess performance through direct
observation. The three studies using the VABS-2 may be potentially less accurate in motor skill
measurement, as the accuracy of the VABS-2 is highly dependent on the honesty and objectivity of the
parent respondents [22].

3.4. Social Skill Measurements

Table 3 shows the methods used in these studies to measure social skills. The comprehensive
measurement methods of social skills in these studies included the Social Skills Improvement
System Rating Scales [SSIS] [44], Social Responsiveness Scale [SRS] [45], VABS-2, Autism Diagnostic
Observation Schedule [ADOS] [46]/Autism Diagnostic Observation Schedule-2 [ADOS-2] [47],
calibrated severity scores [mapped based on ADOS] [48], Autism Diagnostic Interview-Revised
[ADI-R] [49], the Social Communication Questionnaire [SCQ] [50], the Learning Accomplishment
Profile-Diagnostic [LAP-D] [43], the Devereux Early Childhood Assessment [DECA] [51], CCDI [43],
and the Child Behavior Checklist/4–18 [CBCL] [52]. The ADOS/ADOS-2 [46,47], and the calibrated
severity scores [48] assess social skills through observation, whereas the other tests are parent/caregiver
questionnaires or interviews. The studies using parent/caregiver questionnaires or interviews may
be less objective and/or accurate. Also of note, the SSIS [44], SRS [45], ADOS [46], calibrated severity
scores [48], and ADI-R [49] contain assessment items pertaining to restricted and repetitive behavior.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 280

Table 1. Summaries of the present study.

Author (Year) Title ASD Participants Motor Tests Social Tests Other Tests Results
Associated
•Fine motor skills and
calibrated autism severity were
The relationship of ASD194 children (157
significant predictors of
motor skills and M, 37 F) aged 14-49 •Mullen scales of early
The Vineland adapted behavior composite,
MacDonald M. et al. adaptive behavior monthsnon-ASD learning
Adaptive Behavior daily living skills, adaptive
(2013) [13] skills in young (DD)39 children (M 27 •gross motor skills
Scales, 2nd Ed. social skills, and adaptive
children with autism F 12) in the same age •fine motor skills
communicative skills.
spectrum disorders range
•Gross motor skills as
predictors of daily living skills.
•Learning Accomplishment
Relations among •Learning
Profile-Diagnostic •Devereux Early
motor, social, and Accomplishment •Neither gross motor nor fine
ASD •gross motor Childhood
cognitive skills in Profile-Diagnostic motor skills significantly
Kim H. et al. (2016) •373 children, ages •body movement Assessment
pre-kindergarten •cognitive predicted improvements in
[21] between 3.55 and 5.70 •object movement •initiative
children with •language their cognitive skills or social
years old •fine motor •self-control
developmental •naming skills.
•manipulation •responses
disabilities •comprehension
•writing
ASD •Low socialization scores in
Gross Motor Profile
•40 children aged the children with ASD who
and Its Association •Vineland Adaptive
between 18 months •Vineland-II; had poor gross motor skills.
Pusponegoro H.D. et with Socialization Behavior Scales, 2nd
and 6 years Socialization •Did not find an independent
al (2016) [22] Skills in Children Edition; Gross motor
TD subdomain association between gross
with Autism subdomain
•40 children aged 18 motor impairments and
Spectrum Disorders.
months-6 years socialization skills.
•The Movement •British Picture
Assessment Battery for Vocabulary •Sensory Profile
Children—2 Scale-Third Edition •sensory responsivity
•manual dexterity •receptive language •modulation
ASD
Sensorimotor •ball skills •The Social •behavioral emotional •The MABC2 significantly
18 children (13 M, 5 F)
Difficulties Are •static and dynamic balance Communication response correlated with the ADOS-2
Hannant P. et al. aged 7–16 years
Associated with the •The Beery-Buktenica Questionnaire •Wechsler Abbreviated with medium to large effect.
(2016) [23] TD
Severity of Autism Developmental Test of (Lifetime form) Scale of •The MABC2 did not correlate
18 children (7 M, 11 F)
Spectrum Conditions Visual-Motor Integration, •Autism Diagnostic Intelligence-2nd with the ADI-R or SCQ.
aged 6–12 years
Sixth Edition Observation Edition
•visual motor integration Schedule-2nd Edition •verbal and non-verbal
•visual perception •Autism Diagnostic intelligence
•fine motor coordination Interview-Revised
Eur. J. Investig. Health Psychol. Educ. 2020, 10 281

Table 1. Cont.

Author (Year) Title ASD Participants Motor Tests Social Tests Other Tests Results
•In the ASD+ID group, a
Motor competency ASD + ID •Movement Assessment significant negative correlation
and social 46 children between Battery for Children-second •Leiter International between MABC-2 aiming and
•Social
Craig F. et al. (2018) communication skills 3-6 years edition (MABC-2) Performances Scale catching scores with SCQ
Communication
[24] in preschool children ID •manual dexterity Revised (Leiter-R) scores.
Questionnaire
with autism spectrum 42 children aged 3–6 •aiming and catching —IQ level •MABC-2 total test scores
disorder. years •balance correlated negatively with SCQ
scores.
•The manual dexterity
standard score was
•Movement Assessment
Relationship between significantly correlated
ASD Battery for Children-second
motor skill and social negatively with the SRS T-score.
Hirata S. et al. (2014) 26 children aged 7–16 edition (MABC-2) •Social
impairment in •The correlation between the
[25] years with the IQ •manual dexterity Responsiveness Scale
children with autism MABC-2 total standard score
between 73-124 •aiming and catching
spectrum disorders and SRS total score was
•balance
moderately high, but it did not
reach the significance level.
•Both GM and FM skills were
found to be significantly
•Mullen Scales of
associated with social
Early Learning
Communication •Vineland Adaptive interaction skills.
ASD -expressive/receptive
Deficits and the Behavior Scale-Second •There was a significant
1781 children aged languages
Motor System: Edition(VABS); Gross motor negative association between
Mody M. et al. (2017) 2–15.5 years, with all •VABS; Interpersonal
Exploring Patterns of subdomains QSOV scores and fine motor
[26] IQ levels subdominant
Associations in •Mullen Scales raw scores but not gross motor
(gender composition •Autism Diagnostic
Autism Spectrum of Early Learning; Fine raw scores.
not specified) Observation Schedule
Disorder motor scales •There was no significant
-quality of social
association of QSOV scores
overtures
with
gross motor skills.
•Pearson’s correlation
coefficient showing that all
Chinese Children achieved
Developmental statistical significance.
The relationship of ASD Inventory •Using a stepwise linear
Chinese Children
social function with 32 children (27 M, 5 F) •expressive language regression test, the results
Hsu H.C. et al. (2004) Developmental Inventory
motor and speech (mean age, 44.5 •concept showed
[27] •Gross Motor
functions in children months) (mean age, comprehension the PS function was highly
•Fine Motor
with autism 44.9 months) •social correlated with SC.
comprehension •The remaining variables of
•personal social GM, FM, EL, and CC did not
significantly increase the
association.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 282

Table 1. Cont.

Author (Year) Title ASD Participants Motor Tests Social Tests Other Tests Results
•Total raw motor skill scores
were not a significant predictor
of calibrated ASD severity
holding all other variables in
Motor Skills and this
ASD •Social Skills
Social •Test of Gross Motor model constant.
23 high-functioning Improvement System
MacDonald M. et al. Communicative Skills Development-2 •Object-control motor skills
and 12 PDD-NOS, Rating Scales
(2013) [28] in School-Aged •locomotor skills significantly predicted
aged 6–15 years old •Calibrated ASD
Children With Autism •object control skills calibrated
with the IQ above 64 severity score
Spectrum Disorder ASD severity.
•Neither the locomotor or
object-control subscale
predicted
standardized social skills.
•Moderately high correlations
were found between the
overall PDMS2 motor quotient
and the overall SSIS score.
•Moderately high correlations
•Peabody Developmental
were also found between the
Motor Scales Second
M-FUN motor score and the
Edition (PDMS2)
overall SSIS score.
-gross motor skills
•There were moderate,
•stationary
positive correlations between
Relationships •locomotion
ASD •The Social Skills the overall motor score and the
Between Gross Motor •object manipulation
21 boys aged 48–71 Improvement System communication, assertion,
Holloway J.M. et al. Skills and Social •Miller Function and
months, previously Rating Scales(SSIS) empathy, and engagement
(2018) [29] Function in Young Participation Scales
diagnosed as having •social skills subtests.
Boys With Autism (M-FUN)
ASD •problem behaviors •No significant relationships
Spectrum Disorder -gross motor skills
were found between overall
•motor accuracy
motor and SSIS problem
•motor planning
behaviors.
•stability
•All subtests of the PDMS-2
•balance and equilibrium
had positive, moderate
•weight shifting
correlations with the overall
social score. Motor accuracy
and stability had moderate,
negative correlations with
overall social scores.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 283

Table 1. Cont.

Author (Year) Title ASD Participants Motor Tests Social Tests Other Tests Results
•Weaker grip strength was
Brainstem White
ASD significantly correlated with
Matter Predicts
67 males aged 5–39 Fine motor more
Individual IQ - Differential
Travers B.G. et al. years •grip strength •Social severe autism symptoms in the
Differences in Manual Abilities Scales,
(2015) [30] TD •finger tapping Responsiveness Scale ASD group, and slower
Motor Difficulties and WISC-III, WAIS-III
42 males aged 5–39 speed finger tapping was marginally
Symptom Severity in
years correlated with more severe
Autism.
autistic traits in the ASD group.
Social cognition
•Vineland Adaptive (Theory of Mind)
Fine motor skills Behavior Scales •Sally-Anne
•Greater social cognition, but
Correlates of Social •speed - finger •Socialization domain experiment
ASD not motor function, was
Functioning in tapping for the •Child Behavior •first-order false-belief
Bishop-Fitzpatrick L. 108 individuals aged significantly associated with
Autism Spectrum dominant hand Checklist/4–18 task
(2017) [31] 9–27.5 years old with better social functioning when
Disorder: The Role of •manipulative - •Social Problems •John-Mary
normal IQ controlling for sex, age, and
Social Cognition grooved pegboard test for •does not get along experiment
intelligence quotient.
the dominant hand with other kids •Peter-Jane experiment
•gets teased a lot •second-order
false-belief task
•Early social
communication scale
(ESCS)
•initiating joint
•A significant correlation was
attention (IJA)
The Relationship obtained between TGMD-2
•responding to joint
between Motor, object control subtest with IJA,
•Test of Gross Motor attention (RJA)
Imitation, and Early ASD RJA, and IBR, but not with
Dadgar H. et al. Development-2 •initiating behavioral
Social 20 children aged 3–5 •Motor Imitation Scale RBR, ISI, and RSI.
(2017) [32] •locomotor skills requests (IBR)
Communication Skills years old •The correlation between
•object control skills •responding to
in Children with TGMD-2 locomotor subtests
behavioral requests
Autism. with ESCS subscales was not
(RBR)
significant.
•initiating social
interaction (ISI)
•responding to social
interaction (RSI)
Eur. J. Investig. Health Psychol. Educ. 2020, 10 284

Table 1. Cont.

Author (Year) Title ASD Participants Motor Tests Social Tests Other Tests Results
•The SRS demonstrated a
ASD
small-sized, non-significant
•26 adolescents
correlation with postural
and adults (24 M, 2 F)
asymmetry with eyes opened,
aged between 16 •Nintendo®Wii balance
but a medium-sized,
Motor difficulties in years 8 months to 28 board
•Social marginally significant
Autism Spectrum years 10 months •Postural Stability
Travers B.G. et al. Responsiveness Scale •Wechsler Abbreviated correlation with postural
Disorder: Linking TD •Visual input condition
(2013) [33] •Repetitive Behavior Scale of Intelligence-IQ asymmetry during eyes closed.
Symptom Severity •26 participants (eyes open or eyes closed),
Scale-Revised •There was a trend for more
and Postural Stability (24 M, 2 F) aged and the number of legs used
asymmetrical standing to be
between 18 years 2 (one or two).
associated with greater social
months to 30 years 10
symptom severity, but this
months with an IQ of
relation did not reach
80 and over
significance.
•Effect sizes further
demonstrate a very weak
Exploring the 444 children with association between gross
•Vineland Adaptive
interaction of motor autism (more severe) motor and social skills and
Colombo-Dougovito Behavior Scales, 2nd •Social
and social skills with and 39 with ASD (less group severity.
A.M. et al. (2017) [34] Edition; Gross motor Responsiveness Scale
autism severity using severe) aged between •The association between
subdomains
the SFARI Dataset 48–150 months. social skills and gross motor
abilities revealed as very weak
and nonsignificant.
•Gross motor skills were
ASD related to calibrated autism
Motor skills and
136 children aged 14 •Mullen scales of early severity.
calibrated autism
MacDonald M. et al. (12)–33 months learning •Calibrated Autism •Fine motor skills were related
severity in young
(2014) [35] non-ASD (DD) •gross motor skills severity scores to calibrated autism severity.
children with autism
23 children in the •fine motor skills •Effect sizes were small for
spectrum disorder.
same age range both fine and gross motor
skills.
ASD, autism spectrum disorder; TD, typically developing; ID, intellectual disabilities.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 285

Table 2. Measurements of the motor skill tests.

Author (Year) Test Name Age Coverage Test Description Procedure

•Gross motor (57 items)
Learning Accomplishment - body movement, object movement The subject is asked to perform simple
Kim H. et al. (2016) [21] 36 to 72 months
Profile-Diagnostic (LAP-D) •Fine motor (59 items) actions.
- manipulation, writing
•Gross motor
Hannant P. et al. (2016) [23] - ball skills (2 items), e.g., catching,
throwing
The Movement Assessment - balance (3 items) e.g., static and •Quantitive assessment of the
Craig F. et al. (2018) [24] Battery for Children—2 (MABC 3 years to 16 years 11 months dynamic balance performance
2) •Fine motor e.g., time taken, the number of
- manual dexterity (3 items), e.g., successful executions.
Hirata S. et al. (2014) [25] a unimanual or bimanual task, an
untimed drawing task
•Gross motor (35 items)
- central motor control
MacDonald M. et al. (2013) [13] •Majority of items are scored as either
- mobility in supine, prone, sitting, and
•Gross Motor: birth to 33 upright positions 1 (present) or 0
Mullen scales of early learning
MacDonald M. et al. (2014) [35] months •Fine motor (30 items) (not present/completed).
(MSEL)
•Fine Motor: birth to 68 months - motor planning and control •Standarized scores do not provide
Mody M. et al. (2017) [26] - unilateral and bilateral manipulation subscores below 20.
- writing readiness
•Gross motor
Mody M. et al. (2017) [26] - sitting, beginning mobility, beginning •Item scores were obtained by reports
Vineland Adaptive Behavior Birth to 90 years with to stand and walk, throwing a ball, from parents or teachers, through
Colombo-Dougovito A.M. et al. Scale-Second Edition (VABS-2) disabilities climbing, running, using stairs, item ratings of “never”, “sometimes”,
(2017) [34] jumping, hopping, skipping, walking “usually performed”, "don’t know",
Pusponegoro H.D. et al. (2016) places, catching a ball, riding a tricycle or “no opportunity”.
[22] or bicycle, lifting and carrying, stamina
Eur. J. Investig. Health Psychol. Educ. 2020, 10 286

Table 2. Cont.

Author (Year) Test Name Age Coverage Test Description Procedure

Chinese Children
•Gross motor
Hsu H.C. et al. (2004) [27] Developmental Inventory 6 to 78 months
•Fine motor
(CCDI)
•Require the subject to perform
threetrials of each skill.
•Each skill is evaluated based on 3 to
•Gross motor 5 performance criteria.
MacDonald M. et al. (2013) [28] -locomotor skills, e.g., run, gallop, leap, •If two out of three trials are
Test of Gross Motor horizontal jump, hop, and slide - object performed correctly, score 1, and if not,
3 to 10 years control skills, e.g., striking a stationary ball,
Development-2 (TGMD-2) score 0.
stationary dribble, kick, catch, overhand •Scores for locomotor and object
Dadger H. et al. (2017) [32] throw, and underhand throw control skills are obtained by
summing
the scores for related skills.
•Total scores range from 0 to 48.
•Gross motor skills
-stationary, e.g., standing on a foot or
The Peabody Developmental reaching on tiptoes
•Participants are requested to perform
Holloway J.M. et al. (2018) [29] Motor Scales Second Edition Birth to 5 years -locomotion, e.g., walking, running, and
as instructed.
(PDMS2) jumping.
- object manipulation, e.g., throwing,
catching, and kicking a ball
•The test consists of 2 parts:
•Gross motor skills performance scales and participation
- motor accuracy, e.g., kick or jump checklists for home and school.
correctly •Each activity is given a total score
-motor planning e.g., planning and based on performance on several
performing tasks in a smooth, items/tasks.
The Miller Function and
coordinated manner •Individual items/tasks are scored on
Holloway J.M. et al. (2018) [29] Participation Scales 2 to 7 years
-stability e.g., maintaining upright a 0-3 scale.
(M-FUN)
posture while performing tasks •The overall score was reported as a
-balance and equilibrium e.g., maintain scaled score.
a position while standing on 1 foot •The subtests scores are reported as
-weight shifting e.g., shifting weight to the number of items in the scale in
the stance leg while kicking a ball which the child demonstrated poor
performance and received a“0” or a “1.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 287

Table 3. Measurements of the social skill tests.

Author (Year) Test Name Age Coverage Test Description Procedure

- Social skills
•communication, cooperation, assertion,
responsibility,
empathy, engagement, self-control
Holloway J.M. et al. (2018) [29] - Problem behaviors
The Social Skills Improvement •internalizing behaviors, externalizing behaviors, Parent/caregiver questionnaire
3 to 18 years
System Rating Scales (SSIS) hyperactivity, bullying, autism signs such as with Likert scales
stereotypical
MacDonald M. et al. (2013) [28] movements or difficulty transitioning during daily
routines.
-Academic competence (not used in Holloway’s
study)
•Mapped based on ADOS but independent of
MacDonald M. et al. (2014) [35] Calibrated severity scores Observation of ADOS sessions
verbal IQ
Colombo-Dougovito A.M. et al.
•receptive, cognitive, expressive, motivation
(2017) [34]
Social Responsiveness Scale aspects of social Parent-completed screening
Hirata S. et al. (2014) [25] 4 to 18 years
(SRS) behavior questionnaire
Travers B.G. et al. (2015) [30]
•autistic preoccupation
Travers B.G. et al. (2013) [33]
•Child Behavior Checklist/4–18
Bishop-Fitzpatrick L. et al. 4 to 18 years •emotional, behavioral, social problems Parent report with Likert scales
(CBCL)
(2017) [31]
- Socialization domain
The Vineland Adaptive
Pusponegoro H.D. et al. (2016) •interpersonal relationships (only Mody uses this),
Behavior Scales, 2nd Ed. Birth to 90 years Parent/caregiver questionnaire
[22] leisure,
(VABS-2)
MacDonald M. et al. (2013) [13] coping skills
Mody M. et al. (2017) [26]
Autism Diagnostic Observation •communication
Mody M. et al. (2017) [26] Assessment through
Schedule (ADOS) 2 to 17 years
•social interaction (Mody used only) observation of ADOS sessions
Autism Diagnostic Observation •play/imagination,
Schedule -2nd Edition (ADOS-2) •restricted and/or repetitive behaviors
•social and communication Detailed semi-structured
Hannant P. et al. (2016) [23]
•repetitive stereotyped behaviors interview to gather evidence
Autism Diagnostic
18 months and above •sensory and motor skills from an informant (parent,
Interview-Revised (ADI-R)
•talents sibling or partner of an
•challenging behaviors individual)
Current and lifetime forms available
The Social Communication Over 4 years, with a mental age •communication Parent/caregiver questionnaire
Craig F. et al. (2018) [24]
Questionnaire (SCQ) over 2 years •reciprocal social interactions with 40 yes-or-no items
•restricted and repetitive behaviors and interests
Eur. J. Investig. Health Psychol. Educ. 2020, 10 288

Table 3. Cont.

Author (Year) Test Name Age Coverage Test Description Procedure

Nonverbal communication skills
•initiating joint attention
•responding to joint attention Semi-structured assessment
Early Social Communication
Dadger H. et al. (2017) [32] 8 to 30 months •initiating behavioral requests through observation of a
Scale (ESCS)
•responding to behavioral requests videotaped session
•initiating social interaction
•responding to social interaction
After an observation period of
•initiative
Devereux Early Childhood at least 4 weeks, the DECA is
Kim H. et al. (2016) [21] 2 to 5 years •self-control
Assessment (DECA) completed by both a parent and
•responses
a teacher
•expressive language
Chinese Children
•concept comprehension
Hsu H.C. et al. (2004) [27] Developmental Inventory 6 to 78 months
•social comprehension
(CCDI)
•personal social
IQ, intelligence quotient.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 289

3.5. Association between Motor Skills and Social Skills

Twelve studies reported an association between motor skills and social skills in either overall test
scores or subdomain test scores. More specifically, nine studies reported an association between overall
motor skill scores and social skills. Three studies reported on both gross and fine motor skills (using the
MABC-2), and associations with social skills in these studies varied with the social skill measurement
methods used. Hannant et al. [23] found that the MABC-2 total motor skill scores were correlated with
scores on the ADOS-2. The ADOS-2 is an in-person measure of ASD symptoms relying on a skilled
examiner‘s observation, and the Hannant et al [23] study found a medium to large negative motor skill
and social skill association effect (r = –0.647, p = 0.002). This study did not correlate motor skills with
the adolescent version of the ADOS-2, the ADI-R, or the SCQ, both of which are parent-report/interview
measures. Craig et al. [24] reported that MABC-2 total test scores correlated negatively with SCQ scores
(r = –0.46, p < 0.001) in children with both ASD and a low intelligence score on an intelligence measure.
Hirata et al. [25] used a different measurement method and found a moderate negative correlation
between the MABC-2 total standard score and the SRS total score (r = –0.51).
Three other studies assessed both gross motor and fine motor skills and two of these reported that
both gross and fine motor skills showed associations with social skills. In these studies, fine motor
skills tended to have stronger correlations with social skills than did gross motor skills. Mody et al. [26]
reported both gross motor and fine motor skills to be significantly associated with social interaction
skills and also found that the scores for quality of social overtures were significantly associated with
raw fine motor skill scores but not with raw gross motor skill scores. Hsu et al. [27] also reported
that both gross and fine motor skills correlated with social skills, and their study reported a stronger
correlation between social skills and fine motor skills than between social skills and gross motor skills
(r = 0.767, p < 0.01 and r = 0.593, p < 0.01, respectively). MacDonald et al. [28] reported that fine motor
skills and autism severity were significantly associated with adaptive social skills (β = 0.196, p < 0.05)
as were fine motor skills and adaptive communicative skills (β = 0.358, p < 0.001) while there were no
significant correlations in this study between social skills and gross motor skills.
Regarding studies of gross motor skills alone, Holloway et al. [29] assessed gross motor skills with
two measurement tools (PDMS2 and M-FUN) and reported moderately high correlations between the
overall (gross) motor quotient and the overall social skill score (PDMS2: r = 0.644, p < 0.01; M-FUN:
r = 0.637, p < 0.01). Regarding studies of fine motor skills alone, Travers et al. [30] assessed fine motor
skills, including handgrip strength and finger tapping speed, and found that both correlated with
social skills, though grip strength correlated with social skills more strongly than did finger tapping
speed (r = –.26, p = 0.045 and r = –.23, p = 0.07, respectively). Bishop-Fitzpatrick et al. [31] also assessed
fine motor skills with finger tapping speed and manual dexterity, and these researchers found that
only manual dexterity had a marginal correlation with social adaptive behavior (r = 0.20, p < 0.05).
Six studies reported an association between subdomains of gross motor functioning and social
skills. Four of these included object control/aiming and catching skills. Holloway et al. [29] reported
that stationary balance, locomotion, object manipulation, motor accuracy, and stability were moderately
correlated with the overall social score. Motor planning and balance tended to be associated with
the overall social score, but these findings were not statistically significant. Craig et al. [24] reported,
in children with ASD and low intelligence, that MABC-2 aiming and catching scores correlated
significantly with SCQ scores (r = –0.57, p < 0.001), while manual dexterity and balance were not
correlated with SCQ scores. Third, Hirata et al. [25] reported that only the manual dexterity score
correlated significantly with the SRS T-score (r = –0.70), whereas aiming, catching, and balance scores
did not correlate with SCQ scores. Dadgar et al. [32] studied social skill subdomains and reported
a significant correlation between the TGMD-2 object control subtest and the social skill of initiating joint
attention (r = 0.838, p <.001), responding to joint attention (r = 0.831, p < 0.001), and initiating behavioral
requests (r = 0.643, p = 0.002). MacDonald et al. [28] also reported that TGMD-2 object-control motor
skills were significantly correlated with calibrated ASD severity, even while the total TGMD-2 score was
not correlated with ASD severity. Neither object control nor locomotor skills correlated with SSIS scores.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 290

Travers et al. [33] reported that postural asymmetry during eyes closed and drift during two-legged
standing with eyes closed were marginally correlated with the SRS score (r = 0.39, p = 0.07 and r = 0.35,
p = 0.11, respectively). Postural waver during two-legged standing with eyes open was significantly
correlated (r = 0.54, p = 0.01) with the SRS score. Among fine motor skills, manual dexterity tended to
relate most to social skills.

3.6. Relationship between Motor Skills, Cognitive Skills, and Social Skills
Four reviewed studies found little association between these variables of interest.
Colombo-Dougovito et al. [34] reported a very weak, non-significant association between social
skills and gross motor abilities. Pusponegoro et al. [22] reported that, although low socialization scores
were found in the children with ASD who had poor gross motor skills, there was no independent
association between gross motor impairments and socialization skills. Kim et al. [21] conducted the
only longitudinal study among the studies reviewed. They reported that neither gross motor nor
fine motor skills significantly predicted improvements in social skills over time. They also examined
the relationship between motor skills and cognitive skills and reported that motor skills predicted
cognitive skills better than later social skills. MacDonald et al. [35] claimed an association between
both gross and fine motor skills and calibrated autism severity scores, but the effect sizes in this study
were considered too small for this review to accept, according to our a priori criteria (both effect sizes
were represented by η2 = 0.02).

4. Discussion
This study examined possible relationships between motor skills and social skills in individuals
with ASD over sixteen studies that met inclusion/exclusion criteria for inclusion in a systematic review.
As twelve of these sixteen studies reported an association between motor skills and social skills, there is
sufficient replication of this association to accept it as highly likely.
Among studies of gross motor skills, object control/aiming and catching skills, which include ball
throwing, catching, and kicking, were found to be most likely to be related to social skills, based on
repeated findings of these links in past research. Past studies have reported that lower-level object
control/aiming and catching skills are prominent characteristics of individuals with ASD. Pusponegoro
et al. [22] reported that impaired object control skills have been more often found among individuals
with ASD than among typically developing individuals. Even when comparing children with ASD to
those with intellectual disabilities (ID; i.e., an IQ score below 70), Craig et al. [24] reported that aiming
and catching scores were lower in the ASD group than the ID group. They inferred that deficits on tasks
involving the ability to integrate social and motor cues appeared to be specific to ASD. Our finding
that object control/aiming and catching skills are associated with social skills in ASD populations of
past research studies mirrors the Craig et al. [24] report that children with ASD have lower social skills
than either groups of typically developing children or children with ID.
Among fine motor subdomains, our review found manual dexterity to be most likely to be related
to social skills. McPhillips et al. [53] reported that children with ASD had a significantly lower score
than children with specific language impairment for a threading task on the MABC-2, whereas other
subtest scores of children with ASD were similar to these children with a language impairment.
A threading task involves the coordination of both hands and a high level of visual-motor integration.
Children with specific language impairment do not necessarily have social communication problems,
but correlations between language impairments and motor impairments raise the possibility that the
coordination of both hands relates to social skill deficits of individuals with ASD.
Our review of past research also suggests that the association between social skills and motor
skills among individuals with ASD may be more significant for fine motor skills than for gross motor
skills. This observation is consistent with West’s [12] findings of that fine motor skills were more
strongly correlated than gross motor skills with communication/language skills. Not only in individuals
with ASD but also in typically developing individuals, fine motor skills have been found to be more
Eur. J. Investig. Health Psychol. Educ. 2020, 10 291

closely related to social skills more than gross motor skills. Kim et al. [21] reported that in typically
developing children, fine motor skills were more strongly related to some cognitive and social skills
than gross motor skills, and Davis et al. [54] suggested that an association between cognitive and motor
subdomain skills was largely due to fine motor control and visual processing as opposed to gross
motor functioning.
Although most of the studies we reviewed reported correlations between variables of primary
interest in this review, four studies found little association, perhaps for several reasons. Firstly, none of
these four studies examined motor subdomains. Some studies that found associations between
motor skill subdomain scores and social skill scores but no association between overall motor skill
scores and social scores. Thus, overall motor skill scores may not be sensitive enough to detect
an association between these skills. Secondly, the two studies by Colombo-Dougovito et al. [34] and
Pusponegoro et al. [22] used the VABS-2. The VABS-2 is a parent report test without direct observation
for assessing social skills, and the absence of direct observation may lead to less accurate measurements
of social deficits. Thirdly, there was only one longitudinal study [21] in our review, perhaps limiting
the detection of correlations or even a possible directional relationship between these variables.

4.1. Underlying Mechanisms to Explain Motor and Social Skill Associations

While explanations for the apparent correlation between motor skills and social skills among
individuals with ASD remain unclear, a possible mechanism includes shared neuroanatomical
functioning between these skill sets. Among individuals with ASD, postmortem and brain imaging
studies have consistently identified the cerebellum as one of the most abnormal brain regions
associated with ASD, specifically including loss of cerebellar Purkinje cells in this population [55,56].
The cerebellum is considered critical for motor coordination and movement control, and but it is
also implicated in higher functions such as cognition, speech, and emotion, all of which relate to
social interaction [4]. The cerebellum controls motor balance and timing and has an important
contribution in facilitating language and executive functions, all behaviors associated with social skills
in individuals with ASD [57]. The cerebellum is also crucial for sensory-motor integration, with deficits
in motor coordination and visual feedback control linked to impaired cerebellar functioning [58,59].
Because perception and action form an integrated loop [60], atypical visual processing may also
contribute to the motor disturbances in ASD [8], perhaps influencing social interaction in turn [61].
We found that object control skills and manual dexterity are most closely related to social skills
among studies of individuals with ASD. As both object control skills and manual dexterity require
visual–motor integration, a link between visual–motor integration and social skills in individuals with
ASD may evolve through maturation.
In addition, Rourke [62] elucidated the difference between language attainment and social skill
development in ASD. He reported that the acquisition of language may be prevented by substantial
destruction or permanent disruption of white matter within the left cerebral hemisphere. He suggested
that, in ASD, there may be a general condition of white-matter deterioration rather than the one
confined to the left hemisphere; this is why it is important to examine the associations between motor
skills and broad social skills other than language development.

4.2. Developmental Perspectives

The development of motor skills and social skills are reciprocally intertwined. Social skill
development involves learning complex motor sequences [63], including nonverbal communications
that require relevant eye contact, gestures, and other social synchronization. Core impairments in
interpreting others’ social cues may, in turn, play a role in limiting motor learning among individuals
with ASD [64], since many motor skills are learned by watching others [30]. Moreover, movement is
a fundamental aspect of children’s play, and early motor delays and clumsiness may limit the
social opportunities of young children, reducing opportunities to practice both social cognition and
motor skills.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 292

4.3. Clinical Importance

As correlations between motor skills and social skills were observed in most of the studies we
reviewed, motor skill deficits may predict social impairments in individuals with ASD (and the reverse
prediction may also apply.) To use motor skills as diagnostic clues, further research using longitudinal
designs will be needed to determine if there is a causal relationship between these skill sets. If motor
skill deficits were found to precede social skill deficits, early motor delays might assist the early
diagnosis of ASD, and interventions for motor skill impairments might be beneficial in improving later
social skills problems of individuals with ASD. Interventions for object control skills and dexterity
might be of particular help in improve social skills. Further research might address the types of
activities/exercises that may be most effective for improving social skills in this population.

4.4. Study Strengths and Limitations

This is the first systematic review, to our knowledge, of the association between social skills,
including but not limited to language skills and motor skills. This is also the first review to investigate the
association between motor subdomain scores and social skill scores in greater detail. However, we could
couldno’t make sufficient effort (such as inclusion and exclusion criteria, methods of statistical analysis)
to normalize/standardize measurements of motor skills and social skills before drawing results
and conclusions. Even among those studies we were able to review, measurement methods for
motor skills and social skills varied. The subdomains and evaluation methods were different in
each standardized test, challenging the ability to summarize results across studies. For example,
the ADOS may not be sensitive enough to measure all of the social skills in individuals with ASD [34].
Maddox et al. [65] reported that social communication difficulties measured by the ADOS-2 are not
specific to ASD, particularly in clinically complex settings. In addition, some social skill tests contained
a repetitive and restricted behaviors subdomain that may have contributed to motor skills correlations,
partially confounding the presumed independence of these social and motor skill measurements.
We permitted standardized social skill tests that included restricted and repeated behavior
(RRB) domains because RRB domains in the standardized social skill tests were not separable
from other domains measured by the tests. Of note, however, RRBs do not necessarily refer
to social skills, as they include (i) stereotyped or repetitive motor movements, use of objects,
or speech, (ii) insistence on sameness, inflexible adherence to routines, or ritualized patterns and/or
verbal/nonverbal communication, and (iii) highly restricted, fixated interests that are abnormal in
intensity or focus by definition (American Psychiatric Association, 2013) [1]. The data analysis
methods also varied across these studies, and we could not conduct a meta-analysis because there was
insufficient raw data available. Additionally, there were differences in the ages of the individuals with
ASD in these studies. As the development stage differs among ages, it may not have been accurate
enough to include all ages. In addition, assessing social skills of very young children with ASD
can be especially challenging as their social communication skills are even more limited than those
of adults with ASD [66]. Finally, only one of the studies we reviewed used a longitudinal (versus
a cross-sectional) research design, limiting any inferences about a causal relationship between these
variables, as discussed above.

5. Conclusions
In the context of this small sample of studies to review and the important differences between
them in their measurement methods and research designs, our conclusions should be considered
preliminary and tentative until further research has provided further clarification regarding the
relationship between motor skills and social skills in individuals with ASD.

Author Contributions: R.O., K.P.I., M.K., and Y.K. prepared the manuscript and researched the literature. R.O.,
K.P.I., M.K., and Y.K. conceived and designed the study. R.O. and M.K. collected the data. R.O. and Y.K. analyzed
the data. R.O., K.P.I., M.K., and Y.K. drafted or critically revised the manuscript for important intellectual content.
Eur. J. Investig. Health Psychol. Educ. 2020, 10 293

Funding: This research received no external funding.

Acknowledgments: We thank the staff members of Kobe University who collaborated in this study. This
study was also benefitted by the support and encouragement of Tamami Kitano, Chieko Kaneda of the Faculty
of Health Sciences, Kobe University, and Hiroto Ogi, Ikko Kubo, Takayuki Shimogai, Asami Ogura, Kodai
Ishihara, Masashi Kanai, Masato Ogawa, and Shinichi Shimada, all of the Graduate School of Health Sciences,
Kobe University. We also thank Minato Nakazawa, Department of Public Health, Graduate School of Health
Sciences, Kobe University, for statistical support of the present study.
Conflicts of Interest: The authors declare no conflict of interest.

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