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Child Neuropsychol. Author manuscript; available in PMC 2017 January 01.
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Published in final edited form as:

Child Neuropsychol. 2016 ; 22(7): 795–817. doi:10.1080/09297049.2015.1056131.

Beery VMI Performance in Autism Spectrum Disorder

Ryan R. Green1, Erin D. Bigler*,1,2,3, Alyson Froehlich3, Molly B.D. Prigge3, Brittany G.
Travers4, Annahir N. Cariello3, Jeffrey S. Anderson5, Brandon A. Zielinski6, Andrew
Alexander4,7,8, Nicholas Lange9,10, and Janet E. Lainhart4,8
1
Department of Psychology, Brigham Young University, Provo, Utah
2
Neuroscience Center, Brigham Young University, Provo, Utah
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3
Department of Psychiatry, University of Utah, Salt Lake City, Utah
4
Waisman Laboratory for Brain Imaging and Behavior, University of Wisconsin, Madison, WI, USA
5
Department of Radiology, University of Utah, Salt Lake City, Utah
6
Department of Pediatrics and Neurology, School of Medicine, University of Utah, Salt Lake City,
Utah
7
Department of Medical Physics, University of Wisconsin, Madison, Wisconsin
8
Department of Psychiatry, University of Wisconsin, Madison, Wisconsin
9
Departments of Psychiatry and Biostatistics, Harvard University, Boston, Massachusetts
10
Neurostatistics Laboratory, McLean Hospital, Belmont, Massachusetts
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Abstract
Few studies have examined the visual-motor integration (VMI) abilities of individuals with
Autism Spectrum Disorder (ASD). An all-male sample consisting of 56 ASD participants (ages 3–
23) and 36 typically developing participants (TD) (ages 4–26) completed the Beery-Buktenica
Developmental Test of Visual-Motor Integration (Beery VMI) as part of a larger
neuropsychological battery. Participants were also administered standardized measures of
intellectual functioning and the Social Responsiveness Scale (SRS), which assesses autism and
autism-like traits. The ASD group performed significantly lower on the Beery VMI and on all IQ
measures compared to the TD group. VMI performance was significantly correlated with FSIQ,
PIQ, and VIQ in the TD group only. However, when FSIQ was taken into account, no significant
Beery VMI differences between groups were observed. Only one TD participant scored 1.5
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standard deviations below the Beery VMI normative sample mean, whereas 21% of the ASD
sample did. As expected, the ASD group was rated as having significantly higher levels of social
impairment on the SRS compared to the TD group across all major domains. However, level of
functioning on the SRS was not associated with Berry VMI performance. These findings
demonstrate that a substantial number of individuals with ASD experience difficulties compared
to TD in performing VMI-related tasks and that VMI is likely affected by general cognitive
ability.
The fact that lowered Beery VMI performance occurred only within a subset of individuals with

Correspondence should be addressed to: Erin D. Bigler, Ph.D., Department of Psychology & Neuroscience Center, 1001 SWKT,
Brigham Young University, Provo, UT 84602, Phone: (801) 422-4287, Fax: (801) 422-0602, [email protected].
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ASD and did not correlate with SRS would indicate that visuomotor deficits are not a core feature
of ASD, even though they present at a higher rate of impairment than observed in TD participants.
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Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder typified by

impairments in social communication and stereotyped behaviors (DSM-5, American
Psychiatric Association, 2013). Additionally, individuals with ASD often present with an
array of developmental delays which may affect multiple cognitive domains (Duffield et al.,
2013; Geschwind, 2009; Gidley-Larson & Mostofsky, 2008; Gilbert, Meuwese, Towgood,
Frith, & Burgess, 2009; Keary et al., 2009; Minshew, Goldstein, & Siegel, 1997; Polsek,
Jagatic, Cepanec, Hof, & Simic, 2011; Takarae, Luna, Minshew, & Sweeney, 2008;
Southwick et al., 2011). Problems with sensory sensitivity and responsivity in the form of
hypo- or hyper-reactivity for tactile, visual, and/or auditory information is now considered
another core feature of ASD (DSM-5, American Psychiatric Association, 2013; Minshew &
Hobson, 2008; Occelli, Esposito, Venuti, Arduino, & Zampini, 2013; O’Riordan, Passetti,
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2006; Simmons et al., 2009). Deficits with temporal integration of multisensory

information in ASD have been considered as potential explanations for sensory and motor
disturbances in autism (Stevenson et al., 2014).

Children with ASD have increased difficulty with visual-motor integration (VMI; Dowd,
McGinley, Taffe & Rinehart, 2012), including problems with handwriting (Fuentes,
Mostofsky & Bastian, 2010; Johnson et al., 2013; Kushki, Chau Anagnostou, 2011).
Combined with motor skills, visual control over motor function is requisite in tasks such as
copying (Braddick & Atkinson, 2013). The degree to which visuomotor impairments in
ASD are influenced by motor impairments is not known, but various deficits in motor
functioning such as stereotyped/repetitive behaviors, abnormal gait and posture, diminished
fine motor coordination, catching and balance as well as deficits in imitative movements
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such as facial expressions or waving goodbye have been well documented (Ament et al.,
2014; Dawson & Watling, 2000; Duffield et al., 2013; Chukoskie, Townsend, &
Westerfield, 2013; Hardan, Kilpatrick, Keshavan, & Minshew, 2003; Hilton, Zhang,
Whilte, Klohr, & Constantino, 2012; McPhillips, Finlay, Bejerot, & Hanley, 2014;
Mostofsky et al., 2009; Soper, Wolfson, & Canavan, 2007). Indeed, Libertus and collegues
(2014) have shown that fine motor and grasping skills at 6-months in infants at high risk for
autism are below matched infants without a family history of ASD.

Assessment of visuomotor functioning has long been a standard part of neuropsychological

testing (Lezak, Howieson, Bigler & Tranel, 2012). Tasks that assess VMI are assumed to
evaluate the “ability to integrate the visual images of letters or shapes with the appropriate
motor response” (p. 923, Tseng & Cermak, 1993). Wolynski and colleagues (2009) stated
that “Visual information is of crucial importance for the preparation, initiation and guidance
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of motor actions and a key aspect of behavioral neuroscience” (p. 1313). These authors go
onto state that a general agreement has been established that VMI processes are
accomplished by a cortical network involving posterior parietal and premotor areas of the
frontal lobe – the traditional sensory-motor systems of the brain. Integrating a sensory input
with a behavioral output is a more complex neurological process than performing either on
its own and requires intra- as well as inter-hemispheric transfer of information. Additionally,

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recent developments in the understanding of the cerebellum and its relation to coordinating
cognitive tasks and motor function suggest cerebellar involvement in VMI (O’Halloran,
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Kinsella, & Storey, 2012; Rogers et al., 2013). Moreover, producing a written product also
necessitates complex cognitive processes such as planning, goal orientation, and sustaining
attention throughout the task (Jones & Christensen, 1999). VMI thus requires higher-order
assimilation of multidimensional sensory input (visual), behavioral output (motor), and a
variety of cognitive processing demands that coordinate guided eye-hand movements
(Bertone, Mottron, Jelenic, & Faubert, 2005; Takarae, Minshew, Luna, & Sweeney, 2007).

The above evidence suggests that VMI deficits are expected in individuals with ASD given
the multiple, complex neurological processes that must be integrated in order to perform a
VMI task and the fact that deficits have been observed in various neurocognitive processes
in ASD, yet published VMI studies in ASD have resulted in inconsistent findings.

An early study by Fulkerson and Freeman (1980) demonstrated reduced Beery VMI
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performance in a sample of individuals with autism. A more recent study by Reinvall,

Voutilainen, Kujala, and Korkman and colleagues (2013) found deficits in visuomotor
precision and design copying on the Finnish version of a Developmental Neuropsychology
Assessment, Second Edition (NEPSY-II, Korkman, Kirk, & Kemp, 2008) in individuals with
Asperger syndrome. Also using the NEPSY-II, Narzisi, Muratori, Calderoni, Fabbro, and
Urgesi (2013) found deficits in a group which consisted of individuals with Pervasive
Developmental Disorder- Not Otherwise Specified (PDD-NOS) and individuals with ASD
(both of which exhibited FSIQs above 80) compared to controls in design copy and line
orientation. Additionally, Mayes and Calhoun (2007) found significant differences between
autism and control groups on the Developmental Test of Visual Motor Integration (DTVMI).

In contrast, Minshew and colleagues (1997) did not observe VMI deficits in an ASD
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sample that included children and adults (IQ > 80). However, consistent with the previously
mentioned potential for motor deficits in individuals with ASD, these authors did find
significant differences in performances on Grooved Pegboard and Trail Making A but not
in Finger Tapping. A follow-up study of children with ASD (IQ >80) compared to adults
with ASD by Williams, Goldstein, and Minshew (2006) also did not find the visuospatial
domain to significantly exemplify the ASD neuropsychological profile for either children or
adults. They did however demonstrate that deficits in grip strength and the Wechsler
Intelligence Scale for Children-III Coding (Wechsler, 1991), but not Finger Tapping or
Grooved Pegboard (see Lezak et al., 2012), were associated with the neuropsychological
profile of adults and children with ASD.

Visuomotor integration is likely a composite brain function that requires visual attention,
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visual feature detection and identification, anticipatory judgment, motor planning and motor
execution. The small functional imaging literature to date has generally not observed deficits
in visual perception and feature detection in autism. For example, in four separate studies
using an embedded figure task (Ring et al., 1999; Lee et al., 2007; Manjaly et al., 2007;
Malisza et al., 2011), autism participants exhibited normal or increased activation of visual
cortex and lateral occipital regions, and relatively normal activation of visual attentional
regions along the medial intraparietal sulcus. More complex tasks requiring mental rotation

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have shown decreased activation in autism in anterior cingulate cortex, frontal eye fields, and
caudate nuclei (Silk et al., 2006).
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Although both gross and fine motor skills may be impaired in autism (Fournier, Hass, Naik,
Lodha, & Cauraugh, 2010), functional imaging of motor responses has been mixed. A
button pressing task demonstrated increased cerebellar activation for continuous pressing,
but decreased cerebellar activation when buttons were pressed in response to attentional
cues (Allen & Courchesne 2003). In another study examining appositional finger tapping,
autism subjects showed reduced activation of the ipsilateral cerebellum but greater
activation in the supplementary motor area (Mostofsky et al., 2009). Furthermore, Nebel
and colleagues (2014) have shown differences in frontal connectivity involving the
precentral gyrus in individuals with autism.

One of the most commonly used standardized measures of VMI is the Beery-Buktenica
Developmental Test of Visual-Motor Integration (Beery, 1989; Beery, 1996; Beery &
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Beery, 2004), typically referred to as the Beery VMI (Lezak et al., 2012). Although the
Beery VMI has a rich tradition in assessing children and adults with various developmental
disorders and acquired brain injuries (Bloch et al., 2011; Sutton et al., 2011), remarkably
few studies have examined Beery VMI findings in ASD. The current study sought to add to
the VMI literature in ASD by examining Beery VMI performance in a large ASD group
whose ages ranged from childhood through young adulthood.

The specific aims of the study were to provide a descriptive analysis of the relation between
VMI performance, IQ, and ASD in an attempt to clarify previous discrepant findings.
Although cross-sectional, we felt that is was important to assess a broad age-range of ASD
participants and typically developed controls, since it is well established that VMI
performance is, in part age-dependent. Furthermore, since visuomotor abilities positively
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correlate with IQ measures (Bolen, 2003; Baron et al., 2014), the only restriction on IQ was
a lower limit, which ensured some ability to comply with the demands of
neuropsychological testing. To explore ASD severity issues, we examined Beery VMI
findings in relation to scores on the Social Responsiveness Scale (SRS; Constantino, 2002),
where SRS is used to specify severity of ASD symptoms (see Constantino et al., 2003).
Although not using the SRS, MacDonald, Lord and Ulrich (2014) have shown that ASD
children with reduced motor skill had greater social communicative skill deficits. Since
motor activities required to perform VMI tasks are but a subset of overall motor
functioning, we wanted to explore if relations were present between SRS findings and
Beery VMI findings. Furthermore, we hypothesized that individuals with ASD would
perform more poorly on a VMI task compared to individuals in the typical development
(TD) group and that individuals with more severe forms of ASD would perform more
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poorly on both IQ and VMI measures.

There are major participant ascertainment issues for both those assessed with ASD as well
as TD controls (see Howe, Yatchmink, Viscidi, & Morrow, 2014; Tager-Flusberg, (2004);
Idring et al., 2012). For the current study we elected to examine a broad age-range (3–26)
of only male participants recruited to be part of a longitudinal study focused on brain
maturation from early childhood to early adulthood (see Lange et al., 2014; Zielinski et al.,

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2014; Travers et al.. 2014). The advantages of such a design is that it mimics clinical
reality for a large age-span of individuals with ASD but the disadvantages are that because
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of the greater likelihood for lower levels of intellectual ability in the ASD sample, it
becomes impossible to truly match on that dimension. For neurodevelopmental disorders
where intellectual ability may directly relate to the disorder, some argue that minimal to no
front- end control should be imposed on the TD sample (see Dennis et al., 2009).
Therefore, for the current study ASD participants with a much broader range of intellectual
ability were recruited than was the case for the TD sample. Accordingly, analyses initially
statistically controlled for age and intellectual differences between the ASD and TD
samples.

Method
Subjects and Assessment
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Ascertainment—ASD and TD participants were recruited over a 10-year period (1997–

2007) predominantly from community sources. The subset for this investigation was
selected from the larger sample based on age within the reference norms of the Beery-VMI,
having complete Beery-VMI data from the time of initial assessment, and closeness of
matching on age and handedness. All facets of this investigation were undertaken with the
understanding and written consent of each subject or legal guardian, with the approval of
the University of Utah or Brigham Young University Institutional Review Boards, where
testing was performed, and in compliance with national legislation and the Code of Ethical
Principles for Medical Research Involving Human Subjects of the World Medical
Association. Additional details regarding participants have been previously published
(Alexander et al., 2007; Bigler et al., 2003).
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Participant groups—All participants were male, 3–26 years of age, thus precluding
analysis of potential sex differences. Fifty-six participants comprised the ASD group and
36 participants comprised the TD group.

Idiopathic autism sample—Autism was rigorously diagnosed for all 56 ASD

participants using the Autism Diagnostic Interview–Revised (ADI-R; Lord, Rutter, &
LeCouteur, 1994), a semistructured, investigator-based interview with good reliability and
validity, and the Autism Diagnostic Observation Schedule–Generic (ADOS-G; Lord et al.,
2000), a semi-structured play and interview session also with good reliability and validity
designed to elicit social, communication, and stereotyped repetitive behaviors characteristic
of autism. Forty-eight subjects met ADI–R, ADOS–G, and the Diagnostic and Statistical
Manual of Mental Disorders–Fourth Edition (DSM–IV; American Psychiatric Association,
1994) criteria for Autistic Disorder and eight met criteria for Pervasive Developmental
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Disorder Not Otherwise Specified. History, physical exam, fragile-X gene testing, and
karyotype performed on all subjects excluded medical and genetic causes of autism.

Control sample—The 36 control subjects had no developmental, neurological, or clinical

history for major psychiatric disorders. All control subjects completed an assessment with
the ADOS-G and were rigorously assessed to demonstrate that they did not have an autism
spectrum disorder.

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Measures
Visual-motor integration—VMI was measured using the Beery-Buktenica
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Developmental Test of Visual-Motor Integration (Beery VMI) (Beery, 1989; Beery, 1996;
Beery & Beery, 2004). Given the longitudinal nature of the parent project, the 3rd, 4th, and
5th editions of the Beery VMI were used during the various stages of data collection. The
stimuli in the various editions did not change. The Beery VMI is comprised of drawings of
geometric forms that increase in difficulty. The forms are copied with paper and pencil and
scored based on objective scoring criteria outlined in the test manuals according to how
accurately they were copied when compared to the original. The Beery VMI has been
demonstrated to have good reliability and validity as reported in the manual. Raw scores
were converted to age-appropriate standard scores based on the standardization sample
reported for the corresponding version of Beery VMI used. No significant group differences
were observed between the three versions for either the ASD or TD sample.
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IQ—Various measures of intellectual functioning were utilized given the age range of
participants in the study and because of changes in IQ test instruments over the 10 years of
recruiting subjects for the parent project. For the present investigation, FSIQ, VIQ, and PIQ
were measured using the Wechsler Intelligence Scale for Children–Third Edition (WISC–III;
Wechsler, 1991), Wechsler Intelligence Scale for Children–Fourth Edition (WISC–IV;
Wechsler, 2003), Wechsler Adult Intelligence Scale– Third Edition (WAIS-III; Wechsler,
1997), or Differential Ability Scales (DAS; Elliott, 1990). A VIQ minus PIQ comparison
was made between ASD and TD participants because some have suggested that IQ profile
analyses may be predictive of phenotypic differences in development (Margolis et al.,
2013). For example, lower VIQ may reflect greater language impairment, whereas lower
PIQ may reflect greater perceptual-motor impairment (Charman et al., 2011). It should be
noted that the most up-to-date, age-specific norms were used.
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Social Responsiveness Scale—To determine the severity of autism spectrum

characteristics, the Social Responsiveness Scale (SRS) was utilized (Constantino, 2002). The
SRS is a 65-item other-report rating scale that provides an understanding of an individual’s
social impairments including social awareness, social information processing, ability to
reciprocate social communication, anxiety/avoidance, and preoccupations. Higher scores
indicate more severe impairments. The SRS was normed on individuals whose ages ranged
from 4–18 years old.

Handedness—Handedness was measured using the Edinburgh Handedness Inventory

(Oldfield, 1971). A score of +100 signifies complete right handedness and −100 indicates
complete left handedness.
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Statistical Analyses
Independent samples t tests were conducted to derive descriptive statistics using group
means. Pearson correlations were computed along with analysis of covariance (ANCOVA)
to better understand the relation between Beery VMI performance and IQ variables. Pearson
correlations of Beery VMI and SRS were also computed.

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Clinical impairment on standardized neuropsychological measures is often conservatively

defined as falling two standard deviations below the mean of a normative sample and less
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conservatively defined as falling 1.5 standard deviations below the mean of a normative
sample (Lezak et al., 2012; Strauss et al., 2006). A frequency count was used to determine
how many participants in each group performed at or below these two levels of impairment
based on normative data derived from the Beery VMI manuals.

Results
Sample Characteristics
During sample characteristics analyses, pairwise deletion was used to maximize power in
the overall sample. No significant differences between ASD and TD groups were observed
in age or handedness. As expected, and indicated in Table 1, significant differences were
observed between groups in VMI, FSIQ, PIQ, and VIQ. No significant differences were
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found for the computed variable VIQ-PIQ across groups.

VMI and IQ Relationships

Results for Beery VMI performance are summarized in Table 1. The ASD group performed
significantly below the TD group (p ≤ .001), resulting in a large effect size difference
(Cohen’s d = 0.76). Additionally, the ASD group displayed a greater number of Beery VMI
scores toward the lower end of the range of scores. For instance, six of the 56 (11%) ASD
participants scored at or below the conservatively defined impaired range (i.e., ≥ 2 S.D.
below the normative sample mean; standard score < 71) whereas none of the TD
participants scored two standard deviations or more below the mean of the normative
sample. When the impaired range was defined less conservatively (< 1.5 S.D; standard score
< 78), 12 of the 56 (21%) ASD participants and one of the 36 (3%) TD participants scored
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at or below the impaired range.

Pearson correlations for VMI performance and IQ are summarized in Table 2 while Table 3
summarizes the frequencies of the IQ tests used in the study. All IQ variables in both ASD
and TD groups were correlated with one another as expected. Interestingly, none of the IQ
variables were significantly correlated with Beery VMI performance in the ASD group,
whereas FSIQ and PIQ were significantly correlated with VMI performance in the TD
group, and the VIQ correlation trended toward significance (p = 0.06).

Twelve ASD participants but no TD participants exhibited FSIQ standard scores below 80.
Analyses were repeated (see Table 4) with these 12 ASD participants removed and included
only the participants with matching FSIQ scores within ±5 points (ASD n = 22, TD n = 22).
This FSIQ-restricted analysis resulted in a non-significant difference between groups on
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Beery VMI performance (VMI restricted FSIQ d = 0.54). The difference between the non-
restricted and restricted FSIQ effect sizes was 0.22. Additionally, no significant differences
were observed in the group of participants with restricted FSIQ scores in FSIQ, PIQ, VIQ,
and VIQ - PIQ whereas in the original, non-FSIQ-restricted analysis all IQ variables but the
VIQ - PIQ variable were significantly different.

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Pearson correlations were then performed on the subset of 12ASD participants with FSIQ
below 80 and the subset of ASD participants with a FSIQ above 79 (see Figures 1 and 2 for
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broad graphic representation of all data and Figures 3 through 6 for specific representations
of age, Beery VMI, and FSIQ relationships). Interestingly, significant correlations were
observed between Beery VMI, FSIQ, and PIQ but not VIQ for those with a FSIQ below 80
but no significant correlations between Beery VMI and IQ variables were observed for those
with a FSIQ above 79 (see Table 5). Although the ages in the two groups were considerably
different, the age-specific normative data used in the study limit any potential age-related
confounds. To further test this, partial correlations controlling for age were undertaken, with
no meaningful changes observed. As indicated above, Figures 1–6 and Table 5 illustrate the
relationships between data. Of specific interest is that in the ASD group with FSIQ <80,
relatively strong correlations were observed in VMI performance such that the higher the
FSIQ the higher the VMI scores. In contrast, no such correlation was observed in the ASD
group with FSIQ >79 suggesting that FSIQ is a predictor of VMI performance only in the
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lower functioning group. Similarly, age in the ASD group with FSIQ <80 appears to be
associated with FSIQ such that the older the individual the higher the FSIQ score; where
this relationship was not observed in the ASD group with FSIQ > 79. It should be noted,
however, that the sample size in the FSIQ group was somewhat small and thus this trend
may be overturned if a larger sample was observed. Interestingly, it can be seen in Figures 1
and 2 that in the ASD group with FSIQ <80 there is no relationship between age and VMI
score whereas in the ASD group with FSIQ >79 there appears to be a trend such that the
older the individual was the lower they tended to score on the VMI tasks.

An ANCOVA was performed on a listwise subset of participants (ASD n = 54, TD n = 35)

to further understand the relation between IQ variables and VMI performance. The
interaction between group and covariate was not statistically significant; therefore the
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ANCOVA reported here excludes the interaction term. When FSIQ was statistically
controlled, the main effect for group Beery VMI performance was non-significant [F(1, 86)
= 2.34, p = .13, η 2 = .027].
p

SRS and VMI Relationships

SRS T-scores in the Awareness, Cognition, Communication, Motivation, Mannerisms, and
SRS Total domains were analyzed (see Table 6). All SRS scores for the ASD group were
normally distributed showing no skewness or kurtosis. As expected, all SRS scores, with the
exception of the Awareness scale, for the TD group were skewed left and leptokurtic. This
skewness and kurtosis was expected given the higher level of functioning across the SRS
domains in the TD group. As expected, all SRS variables were significantly different
between groups with ASD participants’ level of functioning being rated consistently poorer
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across all variables.

Partial correlations between SRS domains and Beery VMI were performed. All SRS
domains were significantly correlated with each other in both groups with the exception of
the correlation between Awareness and Motivation in the TD group. None of the SRS
domains were significantly correlated with Beery VMI performance in either group (see
Table 7). However, correlations between Beery VMI and the Cognition and the

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Communication domains trended toward significance in the TD group (r = +.33, p = .073;

and r = +.36, p = .053, respectively).
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Additional independent-samples t tests were performed to determine if level of functioning

per the SRS Total Scale and Cognition domain were associated with significant differences
in Beery VMI scores within the ASD group. Lower level of function on the SRS Total
Scale and Cognition domain was defined conservatively as being 3 S.D. above the mean
(with higher scores indicating lower levels of functioning). This allowed for a good split
between the ASD participants who scored >3 S.D. above the mean and those who scored <
3 S.D. below the mean (see Table 8). No significant differences between higher and lower
functioning ASD participants based on the SRS Total score were observed in Beery VMI
performance. Similarly, no significant differences between higher and lower functioning
ASD participants based on the SRS Cognition domain were observed in Beery VMI
performance.
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Discussion
The objectives of the current study were to examine and describe the visuomotor
performance in an all-male ASD sample with ages that ranged from childhood to early
adulthood and to better understand how these findings related to IQ and level of
functioning. At a group level, the ASD sample exhibited an overall attenuation in VMI
performance associated with reduced FSIQ, VIQ, and PIQ when compared to age-matched
TD controls. Our sample purposefully included a large range of intellectual abilities which
reflected the broad range of cognitive phenotypes observed in autism (Dissanayake et al.,
2009). A large effect size difference in Beery VMI performance suggested decreased VMI
in the ASD subjects; however, this appeared to be driven by a subgroup of ASD participants
with overall lower intellectual ability. Only one TD participant had a Beery VMI score < 1.5
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S.D. below the normative sample mean, whereas twelve (21%) individuals in the ASD
sample did. The differences in VMI performance appeared to be driven by a subset of ASD
participants with lower FSIQ such that when those with FSIQ scores < 80 were removed
from the analysis, the effect size was decreased by d = 0.22 and a significant difference
between ASD and TD Beery VMI performance was no longer observed. Additional support
for the notion that FSIQ contributes considerably to Beery VMI performance was seen
when significant differences were no longer observed in the entire sample after statistically
controlling for FSIQ. It should be noted that four different IQ measures were used in the
current study.
However, the DAS was the most frequently used IQ test administered in both groups (i.e.,
46 of 54 in the ASD group, and 29 of 35 in the TD group). Therefore, it is unlikely that
differences in visual-spatial emphasis between IQ measures considerably impacted the
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results.

The relation between IQ as a marker of general cognitive ability and Beery VMI
performance in ASD is complex. There is a substantial literature that shows ASD
individuals perform more poorly than controls on a wide variety of neuropsychological
measures (see Duffield et al., 2013; Geschwind, 2009; Gidley-Larson & Mostofsky, 2008;
Gilbert, Meuwese, Towgood, Frith, & Burgess, 2009; Keary et al., 2009; Minshew,
Goldstein, & Siegel, 1997; Polsek, Jagatic, Cepanec, Hof, & Simic, 2011; Takarae, Luna,

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Minshew, &

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Sweeney, 2008; Southwick et al., 2011). All areas of cognitive functioning including VMI
derived metrics, are likely related, under the umbrella of what has been referred to
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as ”general intelligence” or “g” (Deary, 2012.). The design of this investigation was not
intended to explore how performance on VMI measures related to “g” other than reporting
VMI-IQ correlations. How motor abilities, and in particular VMI abilities may be separated
from general cognitive ability needs to be addressed in future studies. Since those with
lower intellectual ability performed worse on VMI measures whether their visuomotor
impairment was truly a reduction in perceptual-motor functioning or simply a byproduct of
lowered “g” could not be answered. How to separate VMI performance from some aspect of
“g” awaits further investigation. When the entirety of the current sample was considered,
FSIQ correlated positively with Beery VMI in both the ASD and TD groups yet was only
significant within the TD group. This suggests a divergence between ASD and TD in the
interrelation of cognitive and perceptual-motor abilities, likely reflecting a difference in
cerebral organization. However, when correlations between Beery VMI and IQ variables
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were performed in the subset of 12 ASD participants with FSIQ scores below 80, significant
correlations were observed between Beery VMI, FSIQ, and PIQ, while no significant
correlations were observed in Beery VMI and IQ variables in the remaining 42 ASD
participants who exhibited FSIQ scores at or above 80. This finding suggests a further
complexity in the phenotypic relationship in ASD individuals who exhibit lower levels of
overall cognitive abilities and those with higher levels of overall cognitive functioning.

Interestingly, within ASD participants age was related to VMI performance such that older
age was associated with lower VMI scores. Recently, we have shown that cortical volume
and thickness have different developmental trajectories between those with typical
development and ASD (Lange et al., 2014; Zielinski et al. 2014). Factors related to cellular
pruning and issues of neural connectivity are major discussion points involving the origins
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of ASD (see Thomas, Davis, Karmiloff-Smith, Knowland & Charman 2015). Indeed,
Courchesne, Campbell and Solso (2011) have shown some age-related accelerated brain
volume loss in autism after adolescence, but how such factors may influence VMI
performance has not been examined.

To further add to the complexity, the relation of Beery VMI performance to core ASD
symptoms based on SRS findings was not significant. That is, increased levels of social
impairment as reflected in SRS scores was not an indicator of worse Beery VMI scores. Of
course, VMI is but a subset of a larger repertoire of motor skills which may relate to severity
of social impairment (MacDonald, Lord, & Ulrich, 2014). For example, Reiersen,
Constantino and Todd (2008) found that the combination of ASD and motor problems
associated with comorbid attention-deficit hyperactivity disorder was associated with higher
SRS findings. The notion that motor impairment and by extension VMI may affect social
Author

functioning may be appreciated in Given the above discussion on intellectual findings with
Beery VMI yet no relation with level of social impairment, it appears that the lowered
visuomotor ability in ASD occurs primarily as a function of lower FSIQ below 80. Thus, the
lower Beery VMI scores observed when the entire ASD group was compared to the TD
participants, was driven by those with FSIQ <80. As with the study by Wilson and
colleagues (2014), once intellectual abilities are controlled in individuals characterized as

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 Green et al. Page 11

‘high-functioning’ differences in cognitive functioning with TD samples are either

minimalized or eliminated.
Author

Reinvall et al. (2013) found deficits in ASD in Visuomotor Precision and Design Copying
on the Finnish version of the NEPSY-II with similar findings by Mayes and Calhoun in their
2003 and 2007 studies using the DTVMI. As shown in the present study, VMI performance
was attenuated at the group level. However, more than three-fourths of the ASD participants
in the current ASD cohort did not exhibit VMI performance deficits (i.e., performance
within 1.5 S.D. of the normative sample) which is consistent with Minshew and colleagues’
(1997) observations in their ASD sample.

Methodological differences also highlight potential similarities and distinctions across

different ASD and VMI studies. The Minshew et al. (1997) and Williams et al. (2006)
studies restricted FSIQ to be 80 or above as an inclusion criterion. In the current study,
when post-hoc analyses were conducted restricting FSIQ to above 80, the pattern of results
Author

changed considerably suggesting that significant differences were primarily related to

overall cognitive ability. This was further supported when statistically controlling for FSIQ
resulted in non-significant differences in VMI performance. Both the Minshew et al. and the
Williams et al. studies used male and female participants (12% females in both the autism
and control group in the Minshew et al. investigation; 18% females in the autism group and
30% females in the control group in the Williams et al. study). Since potential differences in
cognitive performance have been observed between males and females with ASD
(Holtmann, Bölte & Poustka, 2007, Zwaigenbaum et al. 2012), it is plausible that sample
differences may have affected findings. In both the Minshew et al. and the Williams et al.
studies, the samples were well matched on FSIQ, PIQ, and VIQ, and thus no significant
differences between groups were found on these variables. In the current study, all subjects
were male and matched on age whereas IQ was free to vary for initial analyses and then
Author

restricted and matched to sample in post-hoc analyses.

Differences in network functioning and neural organization have been associated with ASD
(Nielsen et al., 2013; Zielinski et al., 2012) and specifically within motor circuits relevant to
motor integration (Müller, Kleinhans, Kemmotsu, Pierce & Courchesne, 2003; Turner,
Frost, Linsenbardt, McIlroy, Müller (2006); therefore, it was not unexpected that differences
in between group and within group patterns in IQ-Beery VMI performance would be
present. Future studies linking VMI performance with neuroimaging variables and network
analyses could potentially reveal other differences between those with ASD and TD. For
example, several studies have demonstrated neuroimaging abnormalities in ASD involving
the structural and functional relations of several brain regions likely critical for VMI
performance. These include the corpus callosum (Alexander et al., 2007; Prigge et al.,
Author

2013), frontal-parietal dysconnectivity (Just, Keller, Malave, Kana, & Varma, 2012),
atypical white matter microstructure development (Cheng et al., 2010; Wolff et al., 2012),
cerebellar connectivity (Mostofsky et al., 2009), medial prefrontal cortical abnormalities
(Gilbert, Meuwese, Towgood, Frith, & Burgess, 2009) and a distributed specificity of
cortical structural abnormalities including many of these implicated brain regions (Zielinski
et al., 2012; Zielinski et al., 2014). Investigating these regions with multimodal
neuroimaging methods may yield additional insights into why VMI ability appears to be
attenuated in at

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 Green et al. Page 12

least a subset of individuals with ASD and whether this may reflect differences in white
matter microstructure and/or abnormalities within motor and perceptual networks.
Author

There are limitations to the current investigation. For example, the sample did not include
females and so generalizability is limited. Additionally, although the role of visuomotor
impairment in lower functioning ASD as a function of FSIQ and social ratings was
explored in a subset of ASD participants, the relationship between these variables needs to
be more clearly understood. How to investigate the heterogeneity of cognitive phenotypes
in ASD and deal with intellectual disparities between TD and ASD samples represents a
major experimental design and statistical debate.

In summary, the findings of the current study suggest that VMI performance is attenuated
in ASD at the group level compared to controls. However, this group difference was driven
by a minority subset within the ASD group such that 79% of the participants with ASD had
Beery VMI performance that was comparable to controls. The current study also suggests
Author

that visuomotor impairment found in ASD is not associated with overall level of autism
symptom severity measured with the SRS. Given that some level of visuomotor impairment
was present in more than 20% of our sample, there is a need for further research to explore
the clinical significance and neurobiological underpinnings of visuomotor impairment in
ASD. Moreover, future research may clarify whether these measures can be useful in ASD
subset phenotyping and selection for therapeutic intervention.

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Figure 1.
Scatterplot Matrix of ASD Participants with FSIQ Standard Score below 80
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Author

Child Neuropsychol. Author manuscript; available in PMC 2017 January

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Author
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Figure 2.
Scatterplot Matrix of ASD Participants with FSIQ Standard Score above 79
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Child Neuropsychol. Author manuscript; available in PMC 2017 January

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Figure 3.
Scatterplot of ASD Participants with FSIQ Standard Score below 80 by Age
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Child Neuropsychol. Author manuscript; available in PMC 2017 January

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Figure 4.
Scatterplot of ASD Participants with FSIQ Standard Score above 79 by Age
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Figure 5.
Scatterplot of ASD Participants with FSIQ Standard Score below 80 by Beery VMI
Standard Score
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Child Neuropsychol. Author manuscript; available in PMC 2017 January

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Figure 6.
Scatterplot of ASD Participants with FSIQ Standard Score above 79 by Beery VMI Standard
Score
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Child Neuropsychol. Author manuscript; available in PMC 2017 January

 Table
Sample Characteristics Using Pairwise Deletion

Green et
ASD TD

Variable n Mean SD Range n Mean SD Range t p d

Age (years) 56 10.57 4.76 3–24 36 11.90 5.10 4–26 1.28 .20 0.27
Handedness 56 60.18 57.72 −100–100 36 70.00 39.60 −80–100 1.07 .29 0.20
Beery VMI 56 92.61 17.85 60–141 36 105.17 14.95 75–143 3.59* .001 0.76
Child Neuropsychol. Author manuscript; available in PMC 2017 January

FSIQ 54 94.20 20.81 49–137 35 116.69 14.95 85–153 5.53* .001 1.24

PIQ 53 97.77 20.19 50–133 35 115.03 15.08 88–152 4.58* .001 0.97

VIQ 48 93.73 23.20 51–145 35 114.74 15.50 81–151 4.94* .001 1.06

VIQ-PIQ 48 −6.25 20.05 −52–26 35 −0.29 11.20 −29–20 1.72 .90 0.37

ASD = Autism Spectrum Disorder. TD = Typically Developing. Handedness = Edinburgh Handedness Inventory based on a scale from −100 (left-handed) to 100 (right-handed). FSIQ = Full Scale IQ. PIQ
= Performance IQ. VIQ = Verbal IQ.
*
p < 0.001.

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 Table
Correlation Matrix of Beery VMI and IQ Using Listwise Deletion

Green et
ASD (n = 48) TD (n = 35)

Variable FSIQ PIQ VIQ FSIQ PIQ VIQ

Beery VMI .25 .21 .11 .49* .48* .32

FSIQ – .85* .88* – .89* .83*

Child Neuropsychol. Author manuscript; available in PMC 2017 January

PIQ – – .57* – – .73*

Beery VMI = Beery-Buktenica Developmental Test of Visual-Motor Integration. ASD = Autism Spectrum Disorder. TD = Typically Developing.
*
p < 0.003.

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 Green et al. Page 27

Table 3

Frequencies of IQ Tests
Author

ASD TD

Test n n
DAS 46 29
WISC-III 2 1
WISC-IV 1 0
WAIS-III 5 5

ASD = Autism Spectrum Disorder. TD = Typically Developing. DAS = Differential Ability Scales. WISC-III = Wechsler Intelligence Scale for
Children–Third Edition. WISC-IV = Wechsler Intelligence Scale for Children–Fourth Edition. WAIS-III = Wechsler Adult Intelligence Scale–
Third Edition. WASI = Wechsler Abbreviated Scale of Intelligence.
Author
Author
Author

Child Neuropsychol. Author manuscript; available in PMC 2017 January 01.

 Table
Sample Characteristics of Groups Matched on FSIQ Standard Scores above 79

Green et
ASD (n = 22) TD (n = 22)

Variable Mean SD Range Mean SD Range t p d

Age (years) 11.55 4.52 6–23 12.42 4.63 4–26 0.63 0.53 0.19
Handedness 65.65 52.94 −100–100 74.13 33.67 −60–100 0.63 0.53 0.19
Beery VMI 95.18 14.20 62–121 102.59 13.34 75–129 1.78 0.08 0.54
Child Neuropsychol. Author manuscript; available in PMC 2017 January

FSIQ 110.23 16.00 80–137 110.72 13.77 85–142 0.11 0.91 0.03
PIQ 105.64 21.77 81–133 107.45 12.93 88–146 0.52 0.61 0.10
VIQ 111.86 16.03 65–145 109.50 14.22 81–133 0.34 0.74 0.25
VIQ-PIQ −6.23 20.99 −51–22 −2.04 12.13 −29–18 0.81 0.42 0.24

ASD = Autism Spectrum Disorder. TD = Typically Developing. Handedness = Edinburgh Handedness Inventory based on a scale from −100 (left-handed) to 100 (right-handed). FSIQ = Full Scale IQ. PIQ
= Performance IQ. VIQ = Verbal IQ.

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Correlation Matrix of Beery VMI and IQ for ASD Participants with FSIQ < 80 and >79

Green et
ASD: FSIQ < 80 (n = 12) ASD: FSIQ > 79 (n = 41)

Variable FSIQ PIQ VIQ FSIQ PIQ VIQ

Beery VMI 0.66* 0.61* −0.05 0.02 −0.04 −0.25

FSIQ – 0.92** 0.48 – 0.73** 0.84**

Child Neuropsychol. Author manuscript; available in PMC 2017 January

PIQ – – 0.25 – – 0.36*

Beery VMI = Beery-Buktenica Developmental Test of Visual-Motor Integration. ASD = Autism Spectrum Disorder.
*
p <.05,
**
p = <.01.

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 Table
SRS Characteristics

Green et
ASD (n = 50) TD (n = 30)

Variable Mean SD Range Mean SD Range t p d

Awareness 73.40 12.43 46–94 42.90 7.57 30–59 13.64* 0.001 2.96

Cognition 79.54 13.52 43–103 41.30 5.13 36–54 17.97* 0.001 3.74
Child Neuropsychol. Author manuscript; available in PMC 2017 January

Communication 80.14 10.93 53–107 41.40 4.84 36–56 21.76* 0.001 4.58

Motivation 73.26 17.24 42–106 43.43 6.98 37–63 10.84* 0.001 2.27

Mannerisms 84.68 13.37 55–117 42.53 3.64 40–51 21.03* 0.001 4.30

Total 83.20 12.91 51–109 40.97 4.81 34–53 20.85* 0.001 4.33

ASD = Autism Spectrum Disorder. TD = Typically Developing.

*
p <.001.

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 Table
Pearson Correlation Matrix of Beery VMI and SRS Domains

Green et
ASD (n = 55) TD (n = 33)

Variable Awa Cog Com Mot Man Tot Awa Cog Com Mot Man Tot

VMI .10 .00 .17 .18 .06 .13 .22 .33 .36 .00 −.02 .27
Awa – .67** .76** .50** .62** .80** – .45* .43* .35 .45* .67**
Child Neuropsychol. Author manuscript; available in PMC 2017 January

Cog – – .76** .56** .66** .86** – – .71** .48** .60** .82**

Com – – – .69** .68** .94** – – – .48** .63** .86**
Mot – – – – .54** .80** – – – – .39* .73**
Man – – – – – .82** – – – – – .74**

VMI = Beery-Buktenica Developmental Test of Visual-Motor Integration. ASD = Autism Spectrum Disorder. TD = Typically Developing. Awa = Aware, Cog = Cognition, Com = Communication, Mot =
Motivation, Man = Mannerisms, Tot = Total.
*
p <.05,
**
p <.01.

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 Table
Comparisons of High and Low ASD Scorers on SRS Total and SRS Cognition

Green et
High SRS Total (n = 29) Low SRS Total (n = 22)

Mean SD Mean SD t p d
96.05 15.37 91.69 20.15 0.84 0.4 0.24

High SRS Cognition (n = 25) Low SRS Cognition (n = 26)

Child Neuropsychol. Author manuscript; available in PMC 2017 January

Mean SD Mean SD t p d
95.32 16.4 91.89 19.96 0.67 0.51 0.19

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