Hand Leading in Autism: Associations With Neurocognitive Profiles and Adaptive Abilities

Hand-leading (HL) gestures used to obtain assistance or direct another person's actions are often reported at elevated rates in autistic children. Yet, their developmental significance and relation to children's broader cognitive and adaptive profiles remain poorly understood. This study examined the presence and developmental correlates of HL gestures in a sample of toddlers and young children referred for autism evaluation.

Participants were 156 toddlers and young children aged 18-48 months (111 autistic [86 male, 25 female]; 45 non-autistic with other developmental concerns [28 male, 17 female]). Children were assessed using the Mullen Scales of Early Learning to derive verbal and nonverbal developmental quotients (DQs) and a nonverbal-verbal difference score. Adaptive functioning was measured using the Vineland Adaptive Behavior Scales. Autism symptoms were indexed using the Autism Diagnostic Observation Schedule (ADOS-2) and a DSM-5-based caregiver interview/clinician checklist. HL gestures, defined as physically directing others, were operationalized by creating a composite score of items from the ADOS-2 and caregiver/clinician reports, which was scaled from 0 to 100 and dichotomized to indicate clear use of HL gestures.

HL gestures were observed more frequently in autistic than non-autistic children. Within the autism group, HL gesture use was associated with higher autism symptom severity and lower verbal DQ but was unrelated to age, sex, nonverbal ability, or adaptive functioning. Higher nonverbal-to-verbal developmental abilities uniquely predicted greater HL gesture use. Use of HL gestures also predicted stronger daily living but not adaptive communication or socialization skills.

Use of HL gestures appears more closely linked to language level than to general developmental delay. They may reflect adaptive, goal-directed communicative strategies rather than autism-specific social-communication impairments, particularly among those with relatively stronger nonverbal than verbal abilities.

These findings highlight heterogeneity in autistic communication profiles and support viewing HL gestures as functional behaviors that may scaffold early daily living skills.