Valid when valued: A community-engaged framework and toolkit to improve identification of autistic people’s motor difficulties in research and practice

Abstract

Many autistic people experience clinically-significant motor differences that pose lifelong physical health risks including physical inactivity, cardiometabolic disease, falls and injuries, and chronic pain. These differences amplify existing cognitive and social-emotional features of autism and limit daily living skills, which in turn negatively impacts mental health and participation. Yet, professionals often overlook or mischaracterize autistic people’s motor difficulties, in part because non-motor factors can affect assessment outcomes. Most standardized motor assessments presume typical communication, sensory processing, regulation, and tolerance of unfamiliar testing environments, leading to construct-irrelevant variance and potential misinterpretation of results. This risk increases when examiners lack autism-specific experience or use rigid administration practices without appropriate adaptation.

Adopting a neurodiversity-affirming framework improves validity, equity, and uptake of motor assessment across research, education, and clinical contexts. Here, we present an Adapted Motor Assessment Toolkit for Autism with implementation examples grounded in the Movement Assessment Battery for Children–Third Edition. An interdisciplinary team of clinicians and researchers developed and refined the toolkit in partnership with autistic people and parents of autistic children. The toolkit enables preservation of core task demands and scoring while adapting assessment practices to support accessibility and improve validity of results. Adaptations span five domains: pre-assessment preparation, sensory supports, procedural adaptations, communication supports, and motivation/engagement.

The toolkit helps examiners to identify support needs, implementing adaptations, interpreting results, and determining whether normative comparisons remain appropriate. Neurodiversity-affirming assessment practices enable earlier identification of motor differences, inclusion of more diverse participants in research, and tailored intervention and prevention planning to advance physical health equity across the lifespan.

Many autistic people exhibit significant motor differences that negatively affect their developmental and physical health across the lifespan, including greater postural instability, atypical coordination, reduced muscle tone and strength, and difficulty with manual dexterity^1–3. Gross and fine motor differences can make everyday tasks like walking, handwriting, and dressing–which require balance, coordination, and manual dexterity–difficult to a clinically-significant degree^4,5. Yet, autistic people’s motor differences often go undiagnosed or unaddressed⁵. Motor differences in autism represent more than merely delayed skills that come online in later development. They play a key role as determinants of lifelong physical health, learning, daily living, and participation. As such, unaddressed motor problems represent a critical hidden health equity issue for the community.

Unaddressed motor difficulties lead to wide-ranging risks including limited developmental opportunities for participation in activities that promote healthy development in many domains of ability^6–15. Motor difficulties lead to reduced physical activity and fitness^16,17; downstream cardiometabolic conditions¹⁸; fall and injury risk^19,20; reduced mobility; and chronic pain²¹. Prior work extensively describes the negative effects of clinically-significant motor difficulties on mental health, social-emotional development, and opportunities for learning and participation^22–25. Despite their importance for overall well-being and quality of life, negative effects of motor differences on autistic people’s physical health receive markedly less attention²⁶. Early, accurate identification of motor differences enables implementation of timely supports, in turn mitigating later physical, developmental, and mental health consequences²⁷.

Physical therapists, occupational therapists, and physicians rely on standardized assessments to determine the nature and magnitude of motor differences and to inform their recommendations for care²⁸. If motor assessments fail to capture the true ability (or disability) of a patient, clinicians may unwittingly use incomplete or inaccurate data to inform decision-making. Limited data may lead to missed opportunities for support or accommodation at best, or serious morbidity and mortality at worst. Clinicians may also lack information about the full range and context of patients’ non-motor support needs and how these interact with motor ability. This prevents them from holistically considering patients in context of their full range of ability and disability across all domains. Restricted perspective limits clinicians’ ability to engage in person-centered planning, patient empowerment, and shared decision-making about whether to seek accommodation or intervention²⁹. Accurate, accessible assessment serves a crucial function for autistic people seeking appropriate resources and supports to facilitate their learning, participation, and well-being.

Where Current Motor Assessment Practices May Fall Short for Autistic People

Person-, instrument-, and examiner-centered factors all influence assessment outcomes³⁰. Current motor assessment practices may fail to accurately detect and characterize motor differences if examiners neglect autistic people’s access needs or modify assessments without maintaining construct validity^31,32.

Person-centered factors affecting assessment outcomes include sensory, cognitive, and social communication differences. Autistic people’s motor differences often exist within a constellation of features that may also include sensory and cognitive processing differences. Tolerance for new environments and sensory stimulation vary widely from day-to-day for an autistic person, and between autistic people across this diverse community^33,34. This may lead to variability in performance on motor assessments, particularly in the absence of adaptations. Cognitive and social communication demands may also artificially suppress or negate motor scores in standardized assessment contexts^35–37. For example, one-on-one assessment with an examiner produces different performance than assessment in the context of group-based play³⁷. It is important to ensure that motor assessment are accessible and appropriate for many different populations, including those with non-motor support needs that may affect performance. Instruction comprehension difficulties may lead to inaccurate measurement of motor ability, because if a person does not fully understand what is being asked, their motor execution will suffer regardless of actual motor capacity³⁶. Anxiety and demand avoidance may also affect performance if the structured, evaluative nature of standardized testing triggers stress responses that directly interfere with motor output (e.g., increased muscle tension, reduced coordination, freezing). Sensory sensitivities triggered by testing environments with fluorescent lighting, unfamiliar textures of equipment, or auditory distractions may also degrade performance independently of motor ability. Reduced motivation or engagement may also result from the lack of ecological relevance inherent to many standardized assessment tasks.

Instrument-centered factors affecting assessment outcomes include availability of appropriate normative samples, detailed adaptation guidance, and specific testing conditions. Test developers normed many standardized motor assessments on neurotypical populations assumed to use typical communication strategies, engage in typical sensory processing, comply with examiners in accordance with typical social norms to receive credit for an item, and tolerate unfamiliar environments^36,38–41. Some also include neurodiverse norms (e.g., for particular diagnostic groups or without distinction between neurodivergent and neurotypical populations)⁴¹. However, even when neurodiverse norms exist, test manuals rarely offer extensive guidance on how to adapt the assessment process, environment, or materials to address differences in cognitive, social-communication, or sensory processing. For this reason, the testing conditions themselves may conflate non-motor factors with motor performance. Factors including the number of practice trials³², use of communication supports⁴², and physical assistance³⁰ can affect performance depending on the nature of the assessment tool³⁰. Examiners must carefully balance accessibility and construct validity when adapting assessments to ensure that results remain interpretable in relation to functional skills and in normative scores.

Examiner-centered factors assessment outcomes include experience³⁸, comfort interpreting scores⁴³, and personal attitudes^43,44. Not all examiners find it straightforward to identify a wide range of support needs, make appropriate adaptations while maintaining test validity, and interpret scores in relation to functional skills and norms^45,46. In particular, novice examiners may find this process more difficult than experts with ample autism-related experience^45–47. Examiners’ personal attitudes also affect assessment practices and interpretation of results^43,44. For example, some examiners may interpret refusal to perform a task or use of atypical communication strategies as defiance or inability to perform a task⁴⁴. Others may recognize these behaviors as signs of sensory overwhelm and address them via adaptation. Guidance on how to assess individuals who may deviate from neurotypical characteristics while still engaging in ethical, empowering practices^48,49 is either minimal or absent completely. Failure to appropriately adapt assessments may reduce the validity of the resulting data and disproportionately disadvantages autistic people with communication and sensory processing differences, anxiety, and other support needs.

Assessments that artificially suppress scores or result in failed administration may affect eligibility for services or result in inappropriate assignment of supports or interventions that do not meet the person’s real need. In contrast, adapted assessments help to strip away these confounding layers and may yield a more accurate representation of a person’s motor ability, improving construct validity by ensuring that the assessment measures motor ability rather than anxiety, comprehension, or sensory tolerance. Evidence from motor development and other fields demonstrates that autism-informed approaches to assessment yield far more positive results for both the examinee and examiner^50,51.

Neurodiversity-Affirming Assessment as a Validity Imperative

The autistic community deserves better than a “one-size-fits-all” approach to motor assessment, where examiners apply standardized tools without consideration of threats to construct validity^41,52,53. We must urgently address the potential validity threats that disproportionately affect accurate measurement of autistic people’s motor ability, including construct-irrelevant variance (also referred to as construct contamination), biases in clinician referrals (or lack thereof) for motor assessment based on judgments of ability to complete them, and variability in examiners’ ability to adapt assessment processes to meet diverse autistic support needs.

Providing visual supports, for example, may improve autistic people’s performance^51,54. Yet, visual supports alone may not meet the needs of all autistic people⁵⁵. The sensory tolerability of the assessment environment, individual endurance and regulation, and communication differences outside of the verbal or visual domain may also require adaptation to varying degrees. Neurodiversity-affirming practice requires respecting autistic ways of moving, communicating, and regulating, including during the assessment process. Adaptation of motor assessment represents a step forward in methodological rigor and person-centered practice, not a watering-down of established measures.

Failure to adapt motor assessment practices to autistic people’s diverse support needs places them at serious risk of under-identification or misclassification of motor difficulties that play a major role in later physical, developmental, and mental health⁵⁶.

Goals of the Proposed Framework & Toolkit

Notable gaps in existing practice guidance motivated the development of this toolkit, including a lack of community-informed motor assessment frameworks; limited practical tools for adaptation across research, education, and clinical settings; and little guidance on lifespan-oriented motor assessment protocols for autistic people that extend beyond childhood into adolescence and adulthood.

Goals of the proposed framework and toolkit include (1) improved identification and characterization of autistic motor differences and (2) increased validity, equity, and uptake of neurodiveristy-affirming motor assessment practices across settings. Intended users include both novice and expert researchers and professionals with appropriate training to administer standardized motor assessments, as well as trainees seeking to expand their skills for later application.

Reframing Motor Assessment Through a Neurodiversity Lens

Most existing adaptations to motor assessment practices for autistic people center on communication-specific support needs^31,35,43. Respect for persons, a guiding principle for both researchers and health professionals, requires that we reframe motor assessment through a neurodiversity lens that respects differences and addresses the diversity of support needs that autistic people experience.

Adaptations to standardized assessment practices must shift from a framework of compliance to one of access and collaboration. At the theoretical and developmental stage, adaptation requires solicitation of stakeholder input at multiple levels including identification of domains for adaptation, description of specific strategies, and development of respectful examples to illustrate implementation. At the implementation stage, adaptation requires education for examiners who may be unfamiliar with neurodiversity as a construct, and/or for those hesitant to adopt new strategies.

Examiners with limited experience assessing neurodiverse examinees may feel unsure about the domains of support need a person may experience, or how to specifically identify and adapt an assessment to meet them^45–47. Uncertainty or inexperience may lead examiners to avoid administering motor assessments altogether, or to rely solely on qualitative observations of naturalistic movement in a limited context⁴³. Both of these outcomes place autistic people, especially those with complex or higher support needs, at disproportional risk for physical and developmental health problems related to unidentified or unaddressed motor differences.

Adoption of a neurodiversity-affirming framework for motor assessment also requires examiners to intentionally create opportunities to familiarize themselves with examinees (and their caregivers, as applicable) before an assessment and to discuss observations in context after assessment. Preparatory interaction and information-gathering enables examiners to plan adaptations to meet examinees’ individual support needs and develop an informed intervention or management plan (Figure 1).

Figure 1.

Recommended adaptation to motor assessment process for autistic people 338×190mm (150 × 150 DPI)

Framework & Toolkit Development Process

While some experts call for development of new autism-specific motor assessment tools³⁹, we suggest that established motor assessments are appropriate with reasonable preparation and adaptation and careful interpretation of results. Adaptation of established tools maintains our ability to compare results across different studies and populations, and reduces potential redundancy or duplication of effort.

Some motor assessments aim to measure motor process, or the manner in which a person performs a skill (e.g., TGMD), while others aim to measure motor product, or whether or not a person achieves a skill regardless of process (e.g., MABC)⁵⁷. Both process- and product-oriented measures demonstrate high test-retest reliability and serve complementary but very different purposes^38,58. Process-oriented measures more effectively discriminate higher and lower levels of a skill, especially among neurotypical people; product-oriented measures offer more effective discrimination between neurotypical and neurodivergent performance– and as such, they are a good first-line evaluation tool for identifying clinically-significant motor differences–but they also provide more opportunity for a neurodivergent person to demonstrate ability in a particular domain even if they achieve a movement in an atypical manner³⁸. Notably, the MABC-3 encourages examiners to record qualitative observations of the process, or manner of performance, in addition to using formal product scores⁵⁹. On both process- and product-oriented measures of motor ability, careful application of adaptations improves test accuracy among autistic youth without affecting underlying validity or appropriateness of comparison to normative data^51,60–62.

Many product-oriented measures provide general instructional guidance but not specific scripts, whereas process-oriented measures tend to provide the exact language for examiners to use. Standardized elements of product-oriented measures include specific test materials (e.g., balance beam of a particular width and length, pegboard and pegs of a particular size, non-slip mats) and measurements or orientations (e.g., distances for taped lines, foot or hand positioning), but do not include or exclude specific visual supports used by the examinee. Product measurements often include number of successful trials, duration of a movement, or number of errors. Practice trials provide examiners with the opportunity to restate instructions, adjust positioning, or demonstrate correct performance as needed. This standardized but somewhat flexible assessment structure enables examiners to adjust to the individual examinee’s support needs to ensure that the assessment captures their true performance rather than artifact introduced by unmet cognitive, sensory, or social support needs, while retaining core elements of each task to ensure that the target construct remains intact. It also enables examiners to compare results to normative data as a means of identifying a clinically-significant motor difference without over-emphasizing whether the person performed the skill in a neurotypical manner (i.e., process). In this way, product-oriented assessments offer clinicians the opportunity to frame deviation from normative scores as differences that may benefit from support, accommodation, or person-centered intervention based on individual goals, rather than as deficits that require correction to a neurotypical standard.

For this reason, we ground our recommendations in the context of the Movement Assessment Battery for Children – Third Edition (MABC-3)⁵⁹. The MABC-3 provides valuable insights into key motor domains of manual dexterity (e.g., drawing circles, turning pegs in a pegboard, threading beads), aiming and catching (e.g., catching with one hand, throwing at a target), and balance and locomotion (e.g., tandem stance, walking backwards, hopping) in a product-oriented manner with demonstrated predictive validity³⁸. Qualitative observations of process also add value to interpretation of assessment results, and examiners may record them on the test form. Unlike many motor assessments, the MABC-3 spans a wide age range from early childhood to young adulthood (3–25 years). The battery comprises two complementary instruments examiners may use in parallel: a standardized test that qualified professional administers and a checklist the examinee or a caregiver familiar with the examinee’s motor ability in specific contexts completes. Use of these instruments together provides a comprehensive overview of how motor difficulties experienced by an autistic person manifest in a controlled assessment setting and in their everyday life. Prior studies used the previous edition of the MABC to assess autistic motor skills with and without adaptation^61,63; the new edition and proposed toolkit extend this approach to meet the needs of a wider community.

Neither the MABC-3 test nor the checklist requires language production, and the MABC-3 test requires minimal language comprehension, making this battery a useful tool for minimally-speaking autistic examinees or those with significant communication differences. While examiners typically provide some level of verbal instruction, they may attempt to overcome any differences in verbal communication via modeling a movement, gesturing to materials or to a body part, and physical cueing (e.g., tapping on the assessed limb). Current international recommendations for detection of clinically-significant motor development problems include the MABC combined with the Developmental Coordination Disorder Questionnaire^64,65. Clinicians can also use this battery in combination with developmental history-taking to support co-diagnosis of developmental coordination disorder (DCD) and autism⁶⁶.

Complementary online training accompanies the MABC-3, aiding novice examiners in delivering the assessment with high fidelity without requiring travel to an on-site training. The MABC-3 also includes task demonstration videos that allow neurodiverse examiners with varying levels of motor ability to administer the assessment, even if they cannot perform the task themselves, and prior studies also found high intra-examiner reliability^67,68. The assessment requires minimal space and includes easily cleaned and transported materials, making it ideal for use across many contexts. Despite its myriad strengths for use in assessing autistic movement, a non-adapted administration of the MABC-3 may pose challenges. Sensory sensitivities, communication differences, understanding of concepts of time/speed, and anxiety may interfere with test performance^69,70. Verbal instructions carry an inherent risk of miscommunication, for example, “as fast as you can” could cause a person to complete the task in a manner that entirely disregards accuracy and results in a lower score than if the person had moved more slowly. This underscores the need for an adaptation toolkit that supports inclusive, accurate, and respectful assessment practices.

While we specifically focus on adaptation of the MABC-3, other standardized motor assessments may better suit a particular individual or purpose^35,52 (though notably, few cover as wide an age range as the MABC-3). The strategies in this framework and toolkit also apply to other measures because they aim to reduce barriers to valid assessment for autistic individuals, such as difficulty understanding instructions, sensory overwhelm, or heightened anxiety. In doing so, these adaptations enable the examinee to more easily access their full motor ability and reduce the risk of construct-irrelevant variance. When adaptations solely support comprehension, regulation, and comfort–without altering the motor demands or scoring criteria of the tasks–use of normative data remains appropriate⁵⁹. Examiners who make substantial changes to an assessment task beyond these recommended adaptations should exercise caution in using normative data. In all cases, it is essential to document any adaptations used in the relevant sections of the assessment report, to support transparency and interpretation.

Authors’ Positionality & Meaningful Partnership with the Autism Community

We are a neurodiverse group of researchers and clinicians from varied ethnic backgrounds representing the fields of developmental and clinical psychology, kinesiology, physical education, and occupational therapy. We have extensive experience assessing the movement ability and physical and developmental health of children, adolescents, and adults with and without neurodevelopmental conditions including autism, developmental coordination disorder, intellectual disability, Down syndrome, cerebral palsy, and others. We work at universities in the United States, the United Kingdom, Israel, and Italy, and span career stages from Assistant Professor, Senior Lecturer, Associate Professor, Professor, and Reader Emerita. Henderson and Barnett are authors of the MABC-3, as well as other tools and clinical practice guidelines related to assessment of motor development.

We developed the Adapted Motor Assessment Toolkit for Autism through collaborative synchronous and asynchronous conversation and writing, informed by professional expertise and community members’ lived experiences.

We engaged in meaningful partnership^71–74 with the autism community in developing informal adaptations to our motor assessment procedures, specifically incorporating insights from parents of autistic children and autistic adults at multiple levels over the course of several years. We then sought specific input on respectful language choices, recommended adaptation strategies and implementation examples in this toolkit from members of the University of Michigan Motor & Visual Development Lab’s Community Advisory Team (MVD-CAT), a rotating group of 10–15 autistic adults with diverse identities and support needs. Members of the MVD-CAT receive compensation for their time and effort spent collaborating with the lab to develop more accessible research practices related to motor, visual, and cognitive assessment. Both speaking and non-speaking autistic people may participate in the team, provided that they communicate through some means about meeting topics (e.g., speaking or using an augmentative and alternative communication device during meetings, using virtual meeting chat or reaction features, sending asynchronous email input before or after meetings). MVD-CAT activities follow AASPIRE⁷³ and other best-practice guidelines⁷⁴ for community-engaged research.

Members of the MVD-CAT generated ideas during several quarterly virtual meetings that we incorporated into the toolkit. Two meetings specifically focused on barriers and facilitators for motor assessment in June and November 2025. We provided information in advance of these meetings, broad open-ended questions/discussion prompts guided the conversation/chat during the meeting, and some community members chose to give their feedback via email or 1:1 video or phone calls with members of the team after the meeting. Following the June meeting, we held an open house for MVD-CAT members and a separate group of autistic community members affiliated with one of the team members. We gave a brief presentation about movement assessment, and then did interactive demonstrations as part of an experiential tour of rooms/stations set up for mock assessments. We then reconvened in a conference room and talked with the group about what felt accessible/inaccessible or comfortable/uncomfortable, and what they would like to see done differently. We incorporated these recommendations and feedback into the lab’s protocol and training materials, and ultimately into the toolkit where relevant.

In November 2025, we held another MVD-CAT meeting specifically focused on the toolkit. We used the nominal group technique^55,75 to reach consensus on the toolkit domains, strategies, and examples. We introduced the concept of the toolkit and explained our goals. We presented some of the domains that seemed to be emerging from earlier community-generated recommendations/requests and clinician/researcher input. We then asked team members to take a moment for silent reflection and generation of ideas, and then asked them each to share their ideas, especially whether anything felt missing, inaccurate, or disrespectful. Team members suggested reorganization of some themes and the addition/removal of others, revision of strategies, and revision and addition of examples, all of which we did, following serial discussion and consensus. All group members agreed during the clarification and discussion stage that the team should not remove any of the proposed toolkit domains. They also agreed that all domains held equal importance because of the heterogeneity of support needs within the autism community. Several group members expressed discomfort with the traditional nominal group technique stage of ranking elements’ importance, because they felt that individual support needs should dictate the importance of a given domain. Since the group reached consensus in discussion, we eliminated the traditional voting/ranking stage. During the idea sharing and discussion stages, members could raise concerns about an idea to the group or privately to facilitators. Members could also request exclusion of an element or veto an idea, but no one exercised this option.

After this process, two team members read through the final draft of the toolkit and suggested minor edits, which we incorporated before submission. Team members also reviewed early drafts of the toolkit for face validity and respectful language, and provided a combination of verbal and written feedback on later drafts depending on their availability and interest. All members had an opportunity to contribute to the domains of the toolkit, the strategies recommended, and the examples provided for context, and we incorporated their input after serial discussion and consensus.

Throughout the fall of 2025, we also consulted with several expert clinicians and researchers who had extensive experience administering motor assessments to autistic children, adolescents, and adults. These stakeholders reviewed and provided feedback on early drafts of the toolkit based on their own experiences.

Throughout the development process, this project met the standard of consultative with some community members and experts, engaging with others, and co-productive with a select few who have been in relationship with our research team for many years⁷². The recommendations in this toolkit reflect many hours of conversation in informal contexts just as much as formal meetings, and are an attempt to address a community-identified set of problems/needs encountered in healthcare and research settings.

Perspectives of the authors, experts, and MVD-CAT members all converged on key priorities of respecting individual differences in support needs, collaborating with patients/participants to create accessible assessment environments, and maintaining assessment validity while offering procedural flexibility. By leveraging the diverse interpersonal and interdisciplinary expertise of self-advocates, researchers, and clinicians, we identified several key domains that examiners could reasonably adapt to make motor assessment practices more accessible and appropriate for autistic people (Table 1).

Table 1:

Overview of Key Adaptation Domains

Pre-Assessment Preparation

Social Stories & Visit Guides

Determining Support Needs

Determining Motivation Factors

Assessment at Optimal Times

Meeting Sensory Support Needs

Visual

Auditory

Proprioceptive

Other

Procedural Adaptations

Familiar & Adapted Environments

Splitting Assessment into Two or More Sessions

Familiarization with Examiner Before Assessment

Support Person/Caregiver Presence

Reducing Trials from 2 to 1

Flexible Task Order

Movement / Sensory Breaks

Communication & Instruction Adaptations

Visual Schedule with Symbols or Photos

Plain Language and Reduced Verbal Instructions

Slow Demonstration

Positive Verbal / Physical / Social Reinforcement

Physical Support

Videos for Demonstration

Motivation & Engagement Strategies

Choosing a Reward

Bringing a Comfort Object from Home

Involving Preferred Object in the Session

See Appendix A: Adapted Motor Assessment Toolkit for Autism, which includes a description of purpose, strategies, and implementation examples for each of the key adaptation domains listed above.

Adapted Motor Assessment Toolkit for Autism: MABC-3 Application

The Adapted Motor Assessment Toolkit for Autism (see Appendix A) serves as a complementary, practical guide to the special considerations and guidelines already provided in standardized motor assessment manuals. The toolkit organizes strategies into five key adaptation domains: Pre-Assessment Preparation, Meeting Sensory Support Needs, Procedural Adaptations, Communication & Instruction Adaptations, Motivation & Engagement Strategies. This structured approach allows examiners to easily identify and implement strategies that promote a more accessible and effective assessment experience for autistic individuals. Designed to be flexible and user-friendly, the toolkit equips clinicians, educators, and researchers in providing appropriate individualized support while maintaining the level of standardization required to ensure the validity of the assessment. By reducing barriers to participation and valuing autistic identity, it promotes greater accessibility, enhances diagnostic accuracy, and facilitates effective support planning (Figure 1).

Here, we specifically describe the application of this toolkit to improve MABC-3 assessment accessibility for autistic examinees across the full age range (3–25 years). Examiners should interpret MABC-3 results in conjunction with other data sources, including observations of daily activities, complementary assessments, and detailed documentation of how examinees engage with the tasks and adaptations during testing.

Pre-Assessment Preparation

Prior to the assessment, examiners must familiarize themselves with the examinee’s support needs and preferences in each of the five adaptation domains (Table 1), including identifying preferred or comforting objects, activities, and topics. Consultation with the examinee and/or parents, educators, or significant others who are familiar with the examinee in the pre-assessment preparatory stage supports a person-centered, purposeful approach to adaptation.

Pre-assessment preparation should include an intake process that, at minimum, identifies any co-occurring conditions that may affect participation. Co-occurring conditions and the medications used to manage them may cause muscle spasticity, vision differences, pain, balance problems, or other issues that could affect the person’s assessment tolerance and endurance. These may not be top of mind for an examinee or their caregiver at intake unless specifically prompted, either because of their inconsistent presentation or because the examinee assumes intake questions refer only to autism-related characteristics.

It may be necessary to provide a social story⁷⁶ or other pre-visit materials (e.g., videos, images, handouts)⁷⁷ to prepare for the visit and provide context to aid in the determination of a person’s support needs, which may not be evident until they have a full understanding of the environment and tasks. It may be necessary to adjust these materials through consultation with the examinee and/or their caregiver as support needs become more apparent; this process should be iterative and as personalized as possible to meet needs when the examinee, their caregiver, or the examiner identifies them.

Notably, while the original Social Stories⁷⁶ approach emphasized adherence to neurotypical social norms, our intent is simply to use the structure of images coupled with simple first-person narrative descriptions of what a person will experience in a situation. Through a neurodiversity-affirming lens, examiners should use this type of resource to provide information that supports informed decision-making, comfortable engagement, and reduced anxiety for the examinee, not to shape their behavior to meet a particular set of neurotypical expectations. We specifically recommend inclusion of language about well-being in such a resource, for example, “It is okay to take breaks, make noises, or move your body if you need to. We want you to feel safe and comfortable. We are here to help if you need something!”

MABC-3 Test

Examiners typically administer the MABC-3 according to the administration manual⁵⁹, which describes standardized positions of materials and scoring processes, offers verbatim instructions and allows adjustments if necessary, but does not provide specific guidance on sensory, cognitive, or social-communication adaptations to tasks. An assessor using the toolkit would instead select the appropriate adaptations, note them on the record form for later consideration in interpretation of results, and proceed with the adapted administration using strategies descripted in the toolkit.

Here, we offer three examples of adaptations to standardized MABC-3 tasks, one from each of the three test domains: manual dexterity, aiming & catching, balance & locomotion (for the full toolkit, see Appendix A).

1. Manual Dexterity – Drawing Circles: During the visit, the examiner notices that the examinee shows signs of fatigue and frustration in response to fine motor tasks like shoe untying/tying and writing. They become concerned about whether the participant will tolerate repeated trials of the manual dexterity tasks. During the first attempt of the drawing circles task, the participant seems engaged, attempts to complete the task quickly and accurately, and appears to give their best effort. However, after completing the first attempt, they refuse the second trial, complaining of fatigue and frustration at the examiner for asking them to repeat something at which they already tried their best. The examiner decides to limit fine-motor tasks to one well-observed trial to preserve motivation and allow the examinee to show their best effort.

2. Aiming & Catching – Throwing & Catching with One Hand: The examiner demonstrates the entire task first. The examinee produces a different type of movement during the practice trials, suggesting that they did not understand the task. The examiner then demonstrates the entire task slightly slower with clear, slightly exaggerated movements, pausing between segments of the task to offer verbal explanation of each step in the instructions (e.g., “Stand here, with your feet on the mat. Great! Now throw the ball at the wall – try to catch it!”). The examiner then asks the examinee to redo the practice trials, watching for indications of task comprehension.

3. Balance & Locomotion – Standing on a Board: Before the visit, the examiner discusses tactile preferences with the examinee and their caregiver(s) to determine what type and amount of physical contact is acceptable to the examinee (e.g., tapping to cue a body part, offering a hand or arm for stability). The examinee says they don’t mind if the examiner touches them but they are ticklish, and the caregiver adds that unexpected or light touch often causes the examinee significant discomfort and distress. The examiner notes in the examinee’s file that they should only use firm touch to physically support stability. On the day of the visit, the examiner reviews proprioceptive support needs noted at intake (e.g., unexpected/light physical touch). During the assessment, the examiner offers help getting into task starting positions, but does not touch the examinee without permission. The examiner notes that the examinee has a difficult time situating their feet in the correct starting position. When instructions include verbal cues for a particular body position, the examiner first points to and then firmly touches the limb (if acceptable to the examinee) to provide a proprioceptive cue to move into the correct position. When the examinee still struggles to position their feet, the examiner kneels down, offers their shoulder for stabilization and uses their hands to help move the examinee’s feet into the correct starting position.

Use of the toolkit to support adaptation planning enables examiners to reduce barriers to participation without altering the core demands of the assessment. Adaptations presented in the toolkit address elements of the assessment related to task comprehension, general anxiety, sensory comfort, and attention, not motor product. The recommended adaptations maximize the likelihood of capturing an individual’s true performance without providing a degree of physical or instructional support that would artificially inflate scores or enable movements that would otherwise be impossible for the person to achieve. A similar approach used for children with low vision demonstrated that the MABC-2 was robust to adaptation, maintaining internal consistency and inter-rater reliability when adaptations centered on accessibility of visual stimuli and test materials⁷⁸. Comparison to normative data remains appropriate provided that adaptations center on accessibility and comprehension of the task, not coaching or providing strategies or feedback that may alter performance⁵⁹.

After completing an assessment, we recommend that examiners complete the non-motor section of the MABC-3 Test form. In particular, consider the question, “Did this characteristic, trait, or other non-motor difficulty actually interfere with the performance you have observed while testing?”. If the examiner knows that the examinee struggles with concentration generally, they should take this into account and note whether concentration likely played a role in performance even after implementing toolkit adaptations. Examiners should also reflect on and document any positive non-motor observations during the visit, such as showing persistence or enjoyment from success.

Specific strategies and implementation examples for each adaptation domain appear in Appendix A.

MABC-3 Checklist

MABC-3 Test scores measure motor ability in the context of other abilities. Adaptations applied in the assessment context may facilitate a more accurate characterization of motor ability than non-adapted administration, but the manifestation of these abilities in other more- or less-supported contexts may differ. Examiners should seek additional information from the examinee or from others who spend extended periods of time with them to understand how their motor learning and performance affects daily living. Intervention and support planning processes benefit from comparison of information gathered from these two very different sources.

The MABC-3 Checklist serves as a structured means of gathering information about motor ability in the context of daily living. The Checklist is complementary to the Test, not a stand-alone screening tool used to determine a need for administration of the Test.

The most appropriate MABC-3 Checklist respondent varies depending on the age and level of independence of the examinee. A self-report version is available for autistic people aged 12 years and older who are able to respond independently; a caregiver report may augment it if appropriate. A caregiver-report version is available when the examinee’s developmental or language level necessitates support from a parent, caregiver, childcare professional, or teacher. At present, limited data exists comparing different respondents, but qualitative comparison across multiple respondents may add valuable insights during interpretation of the overall assessment results. Examiners should exercise particular care when discussing any discrepancies between self-reports of autistic people and caregiver reports or examiner observations during the MABC-3 Test, so as not to de-value the importance of lived experience within one’s own body⁷⁹.

Respondents can complete the Checklist at any time during the referral and assessment process. It is important to remember that respondents’ level of experience observing or experiencing neurotypical movement varies, and many (though not all) autistic people may have autistic caregivers and/or others in their close social circle who may also have movement differences. When completing the Checklist, respondents often benefit from the presence of an experienced examiner or clinician to guide them through the questions and answer any questions relating to the appropriate frame of reference. These questions may include whether to respond based on comparison to a neurotypical versus autistic peer, comparison to the examinee at a younger age, or comparison to the degree of difficulty the examinee experiences in other domains of ability. Responses should reflect the level of difficulty the examinee appears to experience with motor-related tasks, independent of the potential effects of other domains of ability.

The Checklist also includes two global questions requiring the respondent to rate the examinee’s overall motor difficulty with movement and coordination on a three-point scale (not at all, a little, a lot) and the degree to which non-motor factors make it harder for the examinee to perform and learn movement activities. Responses to these global questions sometimes differ from item-level scores, particularly depending on the respondent’s theoretical understanding of motor learning and the relationship between motor, cognitive, and emotional abilities. Examiners should not view such differences as a limitation, but rather as an opportunity for meaningful discussion between the examiner and the respondent/examinee. These discussions can support the development of a more comprehensive and shared understanding of the examinee’s motor ability within the context of other domains of ability, and inform the examiner’s judgment of whether motor difficulties play a primary or secondary role for the examinee. This issue may be especially relevant when assessing autistic individuals, for whom non-motor factors (e.g., sensory processing, regulation, anxiety, or contextual demands) may strongly influence perceptions of motor performance across settings. In addition to providing detailed data on examinees’ motor skills, the checklist includes a third, novel section addressing the impact of motor difficulties on everyday life. This section provides a useful starting point for planning support and/or intervention.

Implications Across Assessment Settings

Adoption of a neurodiversity-affirming framework and autism-specific adaptation toolkit developed in partnership with the autistic community, researchers, and clinicians adds methodological rigor and value to motor assessment practices. Improved accessibility of these practices improves data quality across all settings, and aids examiners in determining an examinee’s true level of motor ability and its functional impact on daily living.

In previous research, the systematic exclusion of people with higher or more complex support needs from motor development research led to limited samples that do not reflect the diversity of the autistic community⁵. Autism-specific adaptation strategies support the inclusion of autistic people with higher or more complex support needs in research, in turn leading to more representative literature. In education, limited availability of expert examiners presents a challenge to comprehensive, early identification of motor support needs, particularly among children who met early developmental milestones and “graduated” from home- or preschool-based early intervention support systems. An autism-specific adaptation toolkit facilitates adoption of these practices by even novice examiners in primary and secondary school settings, in turn broadening the care system available to support effective individualized education planning and adapted or inclusive physical education planning. In clinical practice, rates of diagnostic prevalence and care for motor difficulties are far lower than the rate of clinically-significant motor differences documented in research studies⁵⁶. Adapted assessment practices support collaboration between clinicians and examinees that enhances diagnostic clarity and care planning, in part by facilitating more accessible, affirming experiences⁸⁰.

Implications for Health Equity & Well-Being

Failure to update research and clinical practices to a more accessible, neurodiversity-affirming approach places autistic people at continued risk of serious physical and developmental health consequences resulting from unaddressed motor difficulties^{19,26,79,81–83}. Ensuring that autistic people do not experience health disparities related to unaddressed motor differences is an ethical imperative that may be partially-addressed by adoption of a neurodiversity-affirming framework for motor assessment. Such an approach can improve early detection of motor-related health risks, inform tailored physical activity plans and motor interventions, support efforts to prevent injury and improve mobility, and enhance our understanding of the link between motor ability and lifespan health trajectories in autism. Accurate, accessible practices for identification of motor difficulties are a crucial contributor to health equity, given that autistic people experience disproportionate physical health risks related to motor ability including limited physical activity and fitness^16,17, poorer cardiometabolic health¹⁸, and increased falls and injuries^19,20. Continued use of non-adapted standardized assessment practices may perpetuate disparities in timely initiation of support and intervention, leading to serious future health problems and limited opportunities for participation and independence.

Since clinicians infrequently assess or diagnose motor difficulties among autistic youth, it follows that many autistic adults are living with clinically-significant motor differences in the absence of information, intervention/support, or management strategies to minimize negative effects on health and daily living. There is a particularly urgent need to systematically screen and assess young, middle, and older autistic adults who may already be at high risk for injurious falls¹⁹.

We chose to focus our discussion on physical health, given the relatively limited attention paid to this domain of autistic well-being compared to social-emotional, cognitive, and behavioral outcomes. However, we stress that motor competence underpins every aspect of daily living, learning, and participation, which in turn affect overall thriving. Helping those with movement difficulties to turn the pages of a book, dress themselves, make a cup of tea for a neighbor, or play board games with a loved one is as important as helping them to ride a bike, run to catch a bus, play physical games or sports, or exercise to reach fitness goals.

Autistic people recognize the impact of their motor difficulties across all aspects of life, and express frustration with the limitations they experience in comfortably, safely engaging in preferred activities^79,84. Fine and gross motor competence, recreational motor competence, and general fitness all serve important roles in participation and health. Professionals must recognize and value the inextricable relationship between autistic people’s physical, developmental, and mental health, and prioritize valid, accessible approaches to assessment that yield actionable information to support person-centered, neurodiversity-affirming care.

Limitations and Future Directions

Time constraints, infrastructural or procedural issues that limit pre-assessment contact, training gaps, and the availability of resources/items for adaptation (e.g., communication cards, intake form to identify support needs, etc.) may pose barriers to uptake of this approach.

There remains a need for empirical studies to validate the application of the proposed toolkit across multiple standardized motor assessments, and to determine its effectiveness as a training and support tool to close the gap between novice and expert examiners. We plan to conduct a series of case studies to determine feasibility of the toolkit across multiple practice settings (e.g., occupational therapy, physical therapy, psychology) and to develop toolkit training materials in collaboration with community stakeholders using similar processes to those described here. We will then incorporate examiner and community member feedback to improve the toolkit prior to conducting reliability studies on adapted administrations. After establishing construct validity, feasibility, and acceptability of the toolkit, we intend to engage in cross-cultural validation of the toolkit in partnership with the autism community to extend the applicability of the toolkit to other countries and identity groups.

Neurodiversity-affirming practice does not end with an assessment, and so it is equally important to develop guidance on interpretation, reporting, and recommendation/referral practices for motor differences. We intend to work with our Community Advisory Team members and other clinical and community partners to develop complementary recommendations for how to interpret autistic people’s motor performance in the context of an adapted assessment, report information back to the examinee and/or their caregiver(s) in a non-pathologizing neurodiversity-affirming manner, and use assessment results to inform person-centered planning focused on participation and well-being.

Of note, reward/compliance-based approaches to assessment (e.g., inducements, persuasion, coercion) are common in health-related research and practice. While these are perhaps not inherently problematic (e.g., promising a lollipop for taking medicine), they can easily become problematic depending on the implementation. We recommend that examiners carefully consider at least the following elements to determine whether this type of approach is appropriate, and to maximize empowerment of autistic people⁴⁸: (1) the degree and manner of compliance required for completion, (2) the potential risk of coercion or removal of agency, (3) what safeguards are in place to prevent trauma, pain, or other forms of psychological or physical harm, (4) the purpose of assessment and who requested it, and (5) whether new information about the individual can improve support and access. While there is not a checklist or litmus test, candid discussions about these elements among professionals and community members can help to guide decision-making.

Motor assessment often occurs in contexts such as adapted physical education, neurology, or developmental behavioral pediatrics where examiners routinely collect other physical health metrics. Thus, opportunities exist to extend elements of the toolkit to other domains of health assessment. Opportunities also exist to extend the upper age limit of motor assessments into middle adulthood, closing the current gap between tools used for young people and those used for older people.

From Measurement to Meaning

Unaddressed motor differences pose a major physical health equity risk for autistic people. Inaccessible, rigid motor assessment practices may fail to fully characterize the motor profile of autistic people, particularly those with high or complex support needs. This perpetuates current disparities in access to assessment, diagnosis, and intervention/support. Downstream consequences of unaddressed motor differences include limited developmental opportunities for participation in activities that promote healthy development across many domains of ability^{9,11,12,14,15}.

Through meaningful partnership with the autism community, we identified five key domains in which adaptation may improve the comfort and validity of motor assessment. Co-production of guidance for research and clinical practices, as in the case of the Adapted Motor Assessment Toolkit for Autism, is essential for ethical physical health research.

Valid assessment begins with respecting autistic people’s diverse preferences, support needs, and abilities. Person-centered planning must begin with the assessment context, prioritizing an examinee’s comfort and comprehension over compliance and control. We designed the Adapted Motor Assessment Toolkit for Autism as a resource to support examiners seeking to engage in neurodiversity-affirming assessment practices while maintaining validity and rigor. Assessment of young children or people with high or complex support needs poses significant cognitive and logistical challenges for even the most experienced examiner. For a novice examiner, or for an examiner with limited experience working specifically with autistic people, children, or people with high or complex support needs, the toolkit may offer a means of identifying relevant adaptations without adding undue complexity, time burden, or decision fatigue^29,31. This may help to reduce potential stigma or anxiety associated with working in communities that require more support, in turn increasing their access to care⁴⁵.

The scope of practice of a physical therapist, occupational therapist, or physician includes interpreting the results of assessments to determine whether intervention or adaptation offers the greatest benefit to the patient. Clinicians should weigh the potential benefit of intervention against the potential for discomfort, distress, or reduced agency. In some instances, temporary discomfort from physical therapy to address an underlying balance issue may lead to safer, more stable walking, in turn reducing longer-term risks of things like severely injurious falls, limited mobility and participation, and obesity or cardiometabolic outcomes related to a sedentary lifestyle. In other words, neurodiversity-affirming does not necessarily mean intervention-avoiding. Rather, it means acknowledging that someone’s support needs or approach for a given activity may differ, giving them a supported opportunity for informed decision-making about whether to seek accommodation/intervention, and respecting that their goals may not always align with standard clinical practices/recommendations. Ideally, clinicians will use the results of motor assessments to support a person-centered, shared decision-making approach to care.

By adopting a neurodiversity-affirming approach to motor assessment, examiners demonstrate respect and rigor. Increased validity, equity, and uptake of neurodiveristy-affirming motor assessment practices across settings can support more tailored, collaborative care planning. This positions autistic people and their caregivers (e.g., clinicians, educators, support people) to more effectively manage the physical health risks associated with motor difficulties, reduce negative health outcomes across the lifespan, and access opportunities for participation that can improve their well-being.

Appendix A: Adapted Motor Assessment Toolkit for Autism

NOTE: Some autistic people may not find part or all of the assessment accessible even with the recommended adaptations. When assessment is not possible, examiners should make qualitative observations (e.g., of natural movement in the assessment room or in other living, learning, recreational, or vocational settings) and use a self- or caregiver-reported measure to assess the functional impact of movement differences (e.g., MABC-3 Checklist).

Pre-Assessment Preparation

Adaptation	Purpose	Strategies	Implementation Examples
Social Stories & Visit Guides	Prior to a visit, help examinees mentally and emotionally prepare for the assessment experience by building familiarity with the setting, examiner, and types of tasks. During a visit, help examinees maintain familiarity with procedural sequence, spaces/materials, and personnel.	Provide a visual social story76 or visit guide to read at home 1–2 days before the visit. Include photos or drawings of the space, tools, and activities. Tailor social stories to the examinee’s identity and use human-like characters or photos of people that examinees will encounter. Use flexible words like ‘may’ and ‘can’ instead of absolutes, and describe the process by which the examinee can ask for support, for a break, or to discontinue. Note: We recommend sending a social story in advance because sometimes people do not know what their exact support needs will be until they have a better understanding of the environment and tasks they will encounter.	The examiner creates a social story template for an MABC-3 assessment visit that begins with a photo of the building entrance and waiting room, a description of welcome procedures, and photos of the assessment room and materials. The examiner then tailors the social story by selecting photos depicting people of similar age and physical characteristics to the examinee and examiner(s), and removing or adding relevant information specific to the examinee’s visit. The examiner sends the social story to the examinee or their caregiver prior to the visit, and provides a digital or print copy to refer to during the visit.
Determining Support Needs	Prior to a visit, at minimum, determine and address visual, auditory, proprioceptive, social, and communication support needs.	Offer an opportunity for discussion, provide an intake form, and/or administer one or more standardized assessments (e.g., self-or caregiver-report questionnaires, non-motor observational assessments, etc.) to identify any sensory or social-communication support needs relevant to the motor assessment context. Note: The selection of standardized assessments requires consideration of time burden, comprehension, and validity. Examiners may need multiple tools to build a thorough picture of a person’s sensory processing differences and support needs. Examiners may find overall scores, subscale scores, and even item-level responses valuable context when planning supports	The examiner sends an intake form and the Sensory Profile–2 to the examinee or their caregiver prior to the visit. The examiner reviews these data, along with results of the Autism Diagnostic Observation Schedule assessment administered in a previous encounter, to understand the examinee’s specific sensory sensitivities and social-communication style, and makes a proposed plan for supporting their needs. The examiner offers a pre-visit discussion to confirm or adjust the plan as needed.
Determining Motivation Factors	Prior to a visit, determine what factors motivate the examinee and help them to maintain engagement.	Offer an opportunity for discussion or provide an intake form to determine motivators. Questions might address favorite themes/topics, characters from books or TV/movies/games, hobbies, play styles, colors, or routines as appropriate for the examinee’s developmental level.	The examiner sends an intake form to the examinee or their caregiver prior to a visit. The intake form includes questions about what types of activities the examinee enjoys or finds challenging, what types of things help them to stay on task, and what topics or themes excite them. The examiner reviews these data, and makes a proposed plan for integrating examinee-specific motivators into the visit. The examiner offers a pre-visit discussion to confirm or adjust the plan as needed.

Meeting Sensory Support Needs

Adaptation	Purpose	Strategies	Implementation Examples
Visual	Address the examinee’s visual support needs, identified during pre-assessment preparation, in the context of the testing environment and procedures. Manage the potential onset of migraine due to variability of light quality or intensity.	Adapt the environment, procedures, or communication supports to address visual support needs (e.g., photosensitivity, low vision, visual distraction or peering behaviors). Provide physical supports for stability during significant changes in lighting context (e.g., from a dark to light room) to reduce fall risk. Inquire about past history of migraine and potential triggers (if applicable) to inform selection and adaptation of the assessment environment.	To address photosensitivity, the examiner chooses a space with dimmable non-fluorescent lighting and window and/or light coverings. The examiner allows the use of sunglasses or a hat to block excess light. To address visual distraction, the examiner chooses a private space or a space with curtains or room dividers, and the team minimizes other activity in the space. The examiner uses brightly-colored and/or preferred items to direct attention. The examiner presents visual stimuli clearly and for enough time to ensure that peering behaviors do not interfere. To address low vision, the examiner uses high-contrast testing materials (e.g., as provided in the MABC-3 kit), large print on any forms or written instructions, and materials that do not require red/green color distinction. The examiner pauses to allow the examinee to engage in visual stimulatory behaviors as needed. (e.g., looking at lights through fingers, blinking rapidly).
Auditory	Address the examinee’s auditory support needs, identified during pre-assessment preparation, in the context of the testing environment and procedures. In particular, reduce environmental noise that may interfere with focus and/or comfort for some autistic people.	Adapt the environment, procedures, or communication supports to address auditory support needs. Schedule assessments during quiet periods, such as when other people are outside or in another room. Plan ahead to find assessment times with minimal background noise.	The examiner conducts the assessment in a quiet space to reduce distraction and discomfort, paying careful attention to any specific triggers noted at intake (e.g., high-frequency noises, door slamming). The examiner notes times during which indoor and/or outdoor sounds peak and avoids these times when scheduling the visit. The examiner offers noise-cancelling headphones, ear-muffs, or a fabric headband. The examiner pauses to allow the examinee to engage in auditory stimulatory behaviors as needed (e.g., listening to a preferred song, squealing).
Proprioceptive	Address the examinee’s proprioceptive support needs, identified during pre-assessment preparation, in the context of the testing environment and procedures. Respect tactile sensitivities, especially those related to physical contact and clothing/footwear that may cause distraction or distress.	Adapt the environment, procedures, or communication supports to address proprioceptive support needs. Discuss tactile preferences prior to the visit to determine what type and amount of physical contact is acceptable to the examinee (e.g., tapping to cue a body part, offering a hand or arm for stability). Allow flexibility in clothing/footwear while maintaining safety. For activities that require shoes, provide alternatives or adaptations (e.g., soft footwear, sandals, clogs with a heel strap). Note: Removing or asking to remove one’s shoes require varying degrees of self-advocacy. We recommend explaining why an examinee needs shoes (e.g., so that you do not trip, so you can hop safely), offering shoes-off breaks, and/or completing seated tasks without shoes. If the examinee can not tolerate shoes at all, the examiner should note that it was a non-standard administration. Any of these options is acceptable as long as the examiner is aware of when comparison to normative data is appropriate and when it is not.	The examiner reviews proprioceptive support needs noted at intake (e.g., unexpected physical touch, difficulty judging body position in space). During the assessment, the examiner offers help getting into task starting positions, but does not touch the examinee without permission. When instructions include verbal cues for a particular body part or position in space, the examiner also points to or gently touches (if acceptable to the examinee) to provide a proprioceptive cue. The examiner asks the examinee to wear closed-toe athletic shoes to the visit. The examinee shares that they find athletic shoes very uncomfortable. The examiner communicates with the examinee about alternative options in advance and determines that it would be safe and appropriate for the examinee to wear sandals or clogs with a heel strap. Note: Most motor assessments standardize footwear as a test condition. Substantial changes (e.g., testing without shoes) may alter the task and interpretation of results. Examiners should use their judgment to determine appropriate footwear (e.g., absence of a heel or other features that may affect performance) and exercise caution when interpreting results in comparison to normative data.
Other	Address any other sensory needs that support general emotional and behavioral regulation (e.g., interoceptive, vestibular). Proactively create a safe environment for the examinee to manage any unexpected physical symptoms (e.g., spasticity, cramping, fatigue, visual aura) by providing cushioned surfaces for rest, time to recover physical capacity and attention, and a responsive and supportive demeanor rather than stigmatizing reactions to limit embarrassment.	Discuss general regulatory needs and strategies with the examinee or their caregiver(s). Use this information to shape materials, pacing, and environmental conditions.	The examinee’s caregiver notes that the examinee is most regulated in the morning about an hour after medication but before they get hungry for lunch. They get dizzy riding in the car. The examiner schedules the visit for 10–11:30 AM, plans for a 15–30 minute rest period upon arrival and a potential 5–10 minute snack break during the assessment, and encourages the caregiver to bring snacks. The examiner encourages the examinee’s caregiver to bring any other items that may support regulation and coping during the assessment (e.g., fidgets, weighted vests, stuffies, etc.). The examiner plans to use these items functionally during the assessment and to support transitions away from them when necessary (e.g., by using a timer for play/rest breaks).

Procedural Adaptations

Adaptation	Purpose	Strategies	Implementation Examples
Familiar and Adapted Environments	Decrease anxiety and increase cooperation by using a space the examinee knows well. Familiar environments reduce the novelty and unpredictability of assessment settings.	Conduct sessions in a familiar environment (e.g., the examinee’s living, learning, or recreation spaces), or with familiar objects or people nearby, or in an environment introduced through a social story in advance. Minimize unnecessary changes to layout or lighting, and whenever possible, communicate expected changes in advance.	The examiner schedules the assessment in a classroom known to the examinee. The examiner moves the minimum number of chairs and desks to clear a safe space for tasks, and closes the blinds on windows facing the hall and outdoors to reduce distraction. The examiner sends a social story in advance showing the room’s appearance with these adaptations.
Splitting Assessment into Two or More Sessions	Reduce cognitive, emotional, and sensory load by limiting the duration of individual assessment sessions to match the examinee’s endurance. Spreading tasks over time may improve examinees’ comfort, performance, and cooperation.	Discuss endurance in advance with the examinee or their caregiver(s). Plan to divide the assessment into smaller segments based on the examinee’s capacity and daily rhythm, allowing for flexibility across multiple days. During the visit, monitor for signs of fatigue, overstimulation, or stress.	The examiner schedules the assessment for a single visit, but notes that the examinee exhibits signs of overwhelm and fatigue after about 30 minutes. The examiner offers a break, and attempts to resume the assessment, but the examinee continues to show signs of fatigue. The examiner discontinues the assessment and makes a plan to resume the next day or after a longer break (preferably within the same week) when the examinee fully recovers. The examiner determines that two additional visits of 20–30 minutes may be necessary to complete the assessment if the examinee’s endurance remains consistent.
Assessment at Optimal Times	Identify and address any personal daily patterns of regulation that affect examinees’ ability to sustain attention or complete intensive physical tasks, or varying levels of tolerance for social engagement.	Schedule assessments during times when the examinee typically has access to their full cognitive, attentional, and physical ability. Intensive intervention sessions or recreation/physical activity can reduce examinees’ capacity to tolerate subsequent motor assessment. Schedule assessments during periods when fewer people are present in assessment or waiting areas to reduce unnecessary social and sensory demands.	The examiner avoids scheduling the assessment for immediately after the examinee’s occupational therapy sessions on Tuesday mornings and or their Tae Kwon Do classes on Wednesday afternoons. The examiner schedules the assessment to begin 15 minutes before their clinic’s standard business hours begin. This reduces the social and sensory demands associated with arrival and check-in at a peak time.
Familiarization with Examiner Before Assessment	Reduce anxiety and increase trust by building rapport before formal assessment begins.	Spend informal time interacting with the examinee through play, parallel activities, or casual conversation, as appropriate for their developmental level and preferences. Observe the examinee’s comfort signals and tailor the pacing accordingly. Separate familiarization visits may aid in building rapport and comfort. In-person visits best support familiarization before the assessment; virtual or phone visits may be an appropriate alternative. Observe the examinee’s interactions with others to gain insight into their communication style, degree of independence, and preferred topics or activities.	The examiner offers a pre-assessment familiarization visit, during which the examinee meets office staff, sees the space, and briefly meets the examiner. During the assessment visit, the examiner notices initial signs of avoidance in the waiting room. The examiner observes the examinee’s interactions with the caregiver/support person who accompanied them to the visit, and notices that they reference several favorite TV characters in conversation. The examinee appears most comfortable with one particular staff person. The examiner begins the visit with a brief play-based interaction that engages the staff person and incorporates the examinee’s preferred characters, in order to increase familiarity and comfort.
Support Person/Caregiver Presence	Reduce anxiety and increase emotional security by allowing the presence of a trusted adult who already has a relationship with the examinee.	Let the examinee choose whether a known adult (e.g., a teacher or aide) remains present or nearby during the assessment. Use this support selectively to avoid distraction.	The examinee refuses to enter the assessment room. The examiner attempts to improve comfort and reduce anxiety by referring to the social story, engaging in play/conversation to build rapport, and considering whether any sensory or social triggers seem to interfere. When these strategies fail, the examiner offers an opportunity for the examinee’s support person to sit in the assessment room. The examinee expresses relief, and agrees to enter the room. The examiner directs the support person to an appropriate location in the room, and explains that they should not intervene in the assessment, their role is only to offer a reassuring presence. In limited cases, the examiner may deem it appropriate to ask the support person to model aspects of the assessment process like listening, completing tasks quickly, or stopping something when asked. Note: For some examinees, the presence of another person may increase anxiety or disruptive behavior. Examiners should continuously monitor for this possibility.
Reducing Trials from 2 to 1	Prevent fatigue and disengagement by minimizing repetitive motor demands that may overwhelm the examinee, especially when the examinee has limited attention or sensory regulation.	Observe which tasks trigger sensory overload or fatigue early in the assessment. Prioritize quality of engagement over quantity of trials, particularly when first attempts yield valid data.	The examiner notices that during fine-motor activities, the examinee refuses a second trial or demonstrates reduced quality due to frustration. The examiner decides to limit fine-motor tasks to one well-observed trial to preserve motivation and allow the examinee to show their best effort.
Flexible Task Order	Sustain engagement and reduce distress by allowing adaptable task sequencing.	Allow the examinee some choice in task order, especially if they appear fatigued or resistant. Alternate between seated and standing tasks if an examinee appears restless.	The examinee becomes restless midway through the session. The examiner determines that task order will not affect the validity of the assessment. The examiner allows the examinee to choose the order of remaining tasks to engage their interest and provide a sense of autonomy. Note: Some motor assessments standardize task order as a test condition, or have an adaptive structure (e.g., Peabody Developmental Motor Scales, Bruininks-Oseretsky Test of Motor Proficiency). Changes to task order may alter the validity of the assessment and interpretation of results. Examiners should use their judgment in altering task order and exercise caution when interpreting results in comparison to normative data.
Movement / Sensory Breaks	Prevent physical and cognitive overload by allowing examinees to self-regulate through physical activity between tasks.	Offer a sensory room or area to support regulation if the examinee becomes overstimulated. Offer short, structured movement opportunities if the examinee exhibits signs of restlessness that interfere with the assessment. Examiners should not discourage fidgeting and restlessness unless they interfere with the assessment or pose a safety risk, since movement often serves a regulatory purpose for autistic people.	The examiner sets up a designated sensory area with toys that can provide a calming retreat in case of overstimulation. The examiner shows it to the examinee at the beginning of the visit, and reminds them that they can use it if needed. The examinee fidgets disruptively and exhibits signs of inattentiveness. The examiner suggests a short movement break, offering options like jumping, stretching, and dancing. The examiner encourages the examinee to choose movements that make their body feel good, and facilitates a “Simon Says” call-and-response structure to maintain engagement and build rapport.

Communication & Instruction Adaptations

Adaptation	Purpose	Strategies	Implementation Examples
Visual Schedule with Symbols or Photos	Help the examinee understand the visit structure, anticipate transitions, and reduce anxiety about what comes next. Predictability can improve emotion regulation and cooperation during assessment.	Introduce any visual supports (e.g., picture cards, visual schedule, items) at the beginning of the session. Icons, photos, or actual objects can represent visit elements; representations should be as closely matched to real activities, items, people, or spaces as possible. Allow the examinee to track their own progress by removing or marking each task as the examinee complets it.	The examiner maintains a set of laminated cards with photos of objects and spaces to represent assessment tasks (e.g., placing pegs) and visit activities (e.g., bathroom break). They place the relevant cards in order on a ring, in a pocket chart on the wall, or printed as images on a sheet of paper for reference during the visit. The examinee engages with the visual schedule by turning cards over or placing a sticker/mark next to tasks after completing them. The examiner or examinee can re-order cards as needed to support attention and desire for autonomy.
Simple Language and Reduced Verbal Instructions	Improve comprehension and reduce cognitive load by avoiding complex phrasing. Many people benefit from fewer words and greater consistency in verbal prompts, regardless of their age or cognitive ability.	Use brief, clear commands with supportive nonverbal cues (e.g., gestures, modeling, or touch prompts if tolerated). Repeat consistently and avoid changing phrasing across tasks.	Instead of giving lengthy explanations, the examiner uses brief phrases paired with tactile feedback. The examiner says, ‘Hold tight!’ while gently squeezing the active hand around an item during a fine motor task. The examiner also uses visual communication supports as needed to adapt to the examinee’s level of receptive language ability, and pauses to allow time for processing.
Slow Demonstration	Facilitate understanding by allowing time for sensory and cognitive processing. Autistic individuals may need extended observation time to grasp task structure and sequence.	Demonstrate each task at a slower pace if needed, with clear, slightly exaggerated movements. Offer repeated demonstration if needed. Autistic examinees may reproduce the movement exactly as demonstrated, and in doing so, may score lower than their true ability if they misinterpret instructions. Show the task in a typical manner at full speed at least once, and avoid exaggerating movements to a degree that would affect performance on timed tasks.	During a balance task, the examiner demonstrates the action slowly two times and once at regular speed to clarify pacing and coordination expectations. The examinee mimics the task accurately after observing both versions. During a multi-step task, the examiner breaks instructions down into steps (e.g., “Stand here, with both feet on the mat.” then “Great! Now jump with both feet onto the next mat.”), pausing to check comprehension between each step to ensure the examinee has time to understand one component of a task before adding another.
Positive Verbal / Physical / Social Encouragement	Increase motivation, self-confidence, and cooperation by providing consistent, affirming feedback throughout the session.	Praise effort and engagement (e.g., “You focused so well!” or “Great effort!”). Maintain a warm tone and highlight small successes to build momentum.	The examinee has low initial motivation. The examiner encourages even partial successes initially (e.g., “I like how hard you’re trying, your throws are getting better!”) until the examinee becomes more engaged. The examiner’s encouragement targets following instructions, effort, and attention, not only performance, and they pair it with physical and social gestures (e.g., high-fives, clapping). The examiner may offer to engage in a lighthearted competition to foster motivation and reduce pressure, depending on the examinee’s temperament and interest.
Physical Support	Provide additional physical support for examinees who have limited body awareness and/or control, especially with respect to postural stability during balance tasks.	Use physical cueing (e.g., gently touching a limb) to indicate which side the examinee should use for a task. Offer physical support to help examinees to get into a correct starting position, especially for balance or hopping/jumping tasks. For examinees with fall risk indicators, a history of falls, or limited locomotor mobility, the examiner or a support person should stand nearby to ‘spot’ the examinee during standing tasks to prevent falls or injury.	The examiner notices that the examinee confuses right and left. The examinee does not like unexpected touch, so the examiner tries pointing to the correct limb to indicate which side the examinee should use. The examinee still exhibits difficulty, so the examiner explains that they will gently touch the correct limb. The examiner offers their hands or arm for the examinee to grasp for additional stability as they move their feet into the tandem position for a balance task. The examinee declines. The examiner offers a clipboard or puppet as alternative physical anchoring options. The examinee hesitates when asked to perform a hopping task. They express concern about ankle and knee stability and balance, since they have not hopped in many years. The examiner offers to hold the examinee’s hands for support while they try hopping a few times, to determine comfort and feasibility with the task before independent performance.
Videos for Demonstration	Facilitate understanding of tasks through clear, visual instruction when live modeling is not feasible.	Use short, pre-recorded video demonstrations of task performance only if a live adult or peer model is unavailable.	The examiner has difficulty with catching, so they use the Movement ABC-3 Demonstration Videos to support instruction for selected tasks as needed.

Motivation & Engagement Strategies

Adaptation	Purpose	Strategies	Implementation Examples
Choosing a Reward	Increase motivation and sustained participation by providing a clear, tangible reward that the examinee can take home (e.g., toy, snack), or offer the examinee a favorite activity (e.g., tablet game, time playing with comfort item) at designated timepoints or at the end of the session.	Allow the examinee to select a reward before the assessment begins. Keep the item (e.g., comfort item) or a symbol of the reward (e.g., picture of a snack) visible but out of reach until the session ends. For some examinees, keeping the reward visible will be more distracting than keeping it in a different space. Comfort items, food, and tablets can be particularly distracting and difficult to disengage from after a break. Examiners should use their judgment about the manner and timing of rewards based on pre-visit information and early interactions, remaining cautious to not engage in undue coercion.	The examiner presents three choices for a post-assessment reward: a snack, a small fidget toy, or time to play a preferred game. They remind the examinee periodically throughout the assessment that the reward will be theirs once they finish all tasks. The examinee struggles to wait until the end of the session, so the examiner offers opportunities to earn tokens toward the final reward (e.g., coins, stickers, check marks on a list) as a means of providing intermittent support for engagement throughout the assessment.
Bringing a Comfort Object from Home	Increase the examinee’s sense of psychological safety and reduce anxiety about the transition to an unfamiliar setting by allowing them to bring a familiar object from home.	Encourage the examinee to bring a small comforting object that can stay with them throughout the assessment. If the object creates distraction, explain that the object must sit quietly in a chair in the assessment room until it is break time, or make up a story about how the object is going to “take a nap in the other room”, as appropriate for their developmental level. For adolescents and adults, a fidget toy or phone may function as a comfort object.	The examinee holds a plush toy on their lap during seated tasks, in a manner that does not affect performance. This tactile comfort prevents escalation of stress and helps the examinee remain focused. During standing tasks, the examinee begins to toss the toy into the air and loses focus. The examiner gently redirects the examinee to set the object on a nearby countertop until they complete a task and hands it to them during breaks.
Involving Preferred Objects in the Session	Increase motivation and creativity by incorporating imaginative play that includes a preferred toy or object.	Allow the examinee’s comfort object or preferred character toys to ‘help’ with the task or pretend to complete the task first. Personification may enhance connection to the activity.	The examiner uses the examinee’s stuffed dinosaur to demonstrate a task first, or the dinosaur takes a turn after the examiner demonstrates. Then the dinosaur prompts the examinee to take a turn.