Home Exercise Program on Children Diagnosed with Autism

REVIEW OF LITERATURE

Introduction

        Exercise has been well-known to have a wide variety of benefits. It strengthens muscles and bones, improves physical and mental health, controls weight, and much more. One of the other countless positive impacts is decreasing stereotypical behaviors in individuals with autism spectrum disorder (ASD). Toscano et al. (11) defines ASD as a neurodevelopmental disability, characterized by deficits in social and emotional reciprocity, and by the presence of repetitive, restricted and stereotyped patterns of behavior and interests (p. 127). Individuals with ASD, particularly children, have difficulty controlling their behaviors. Unfortunately, sometimes they can get out of control in which the behaviors cause harm, physically and mentally, to their family, teachers, or peers. Thus, exercise can serve as an important tool to aid these children with ASD to diminish or control their behaviors.

Impact of Exercise on Children with ASD

        In our society, we have turned our back on this population. We have not provided them the necessary resources to improve their lives. Haegele, Zhu, and Kirk (5) completed a study on the physical fitness of children with visual impairments and children with both ASD and visual impairments. As expected, none of the 12 participants met the exercise recommendations by the U.S. Department of Health and Human Services, who suggests at least an hour of moderate-to-vigorous activity every day for children 6 to 17 years old (13). Thus, children with disabilities, including those diagnosed with ASD, are not getting the proper exercise needed for a healthy life. Ratcliff, Hong, and Hilton (9) discovered the split in activity levels among children with ASD and their neurotypical companions. As both groups of children increase in age, the gap expands. The researchers stated that physical activity intervention is essential, taking into mind that the earlier in age it is started, the better.

        Levinson and Reid (7) examined the impact of exercise on children with autism, specifically their behavioral tendencies. The researchers believed that exercise is an appropriate activity to reduce stereotypical behaviors, or repetitive nonfunctional behavior, in these children. The participants included 2 male children and 1 female child, all aged 11 years old. The two conditions that the subjects were tested with differed based on intensity: walking versus running. The measures recorded were heart rate and the length of distance accomplished in 15 minutes. The study was interested in how the different intensities would affect the number of stereotypical behaviors.

The experiment lasted for a total of 9 weeks, divided into three phases. The first phase established the baseline, consisting of three observations over 2 weeks. In the second phase, the subjects underwent the experiment, in which they went through a pre-exercise observation session (45 minutes), mild or vigorous exercise session (15 minutes), post-exercise observation session (45 minutes), and 90-minute post-exercise observation session (30 minutes). Depending on the subject's behavioral tendencies, the researchers applied either the mild or vigorous exercise program. This study discovered that the running phase of the experiment, also known as the higher intensity condition, produced a decrease in stereotypical behaviors for a couple of hours afterwards, whereas the walking condition did not see a decrease in these behaviors at all. Thus, the researchers concluded that a higher intensity of exercise will promote a greater reduction in stereotypical behavior. These results make sense, as children with autism who are fatigued will be less likely to carry out their verbal and motor behaviors, as their body is too tired to perform more movement.

        Elliott, Dobbin, Rose, and Soper (3) realized the benefit of strenuous, aerobic exercise on behavioral tendencies for individuals with disabilities. A small participant group of 6 adults with ASD was constructed. The control condition involved observation of behaviors in a leisure environment for 30 minutes. Then, the participants either did not exercise, performed moderate exercise, or strenuous, aerobic exercise.

The control group engaged in activities that possessed minimal risk of increasing the subjects' heart rate. Moderate exercise was operationalized as activities that increased the subjects' heart rates to numbers between 90 and 120 beats per minute after 20 minutes of the performed activity. Vigorous, aerobic exercise was affirmed if the activities caused the subjects' heart rates to be higher than 130 beats per minute after 20 minutes of the performed activity. At the end of each experimental condition, the participants were again observed of behaviors for 30 minutes in the same environment. Subjects experienced five sessions of each condition Subsequently, the researchers discovered that the strenuous, aerobic exercise reflected the greatest improvement on the participants' behaviors.

        The best predictor of future behavior is past behavior. If parents or guardians are able to implement interventions before the child can react inappropriately to a trigger, there is a chance it can decrease or diminish the potential challenging behavior. A prominent location to achieve a successful intervention is in the school setting. Children are in school for about 8 hours each day, so they are susceptible to experience a challenging behavior at some point during the day. Understandably, any type of behavior can be disrupting to the classroom. Thus, it is important for teachers to be trained on how to lessen a child's behaviors with antecedent interventions in order to most effectively fulfill that child's learning needs. An excellent antecedent intervention strategy is exercise.

Cannella-Malone, Tullis, and Kazee (2) saw that after implementing 8 exercise sessions throughout the day, behaviors, particularly difficult ones, decreased dramatically. The 8 exercise sessions were split into 2 20-minute exercise routines and 6 short exercise breaks. The 20-minute exercise routine occurred at the beginning of the school day and directly after lunch period. Activities during this session including jumping, stretching, and jogging movements. The remaining exercise sessions consisted of 1-5 minute exercise breaks at each hour of the school day. These breaks would happen at whichever subject the students were in attendance. A few examples of the exercises that took place during these breaks are jumping jacks, sit-ups, crab walk, and knee raises. The conclusions from this exercise schedule exhibited beneficial impacts on the children's behaviors.

Therefore, it depends on the individual and what exercise fits their needs, but there are multiple interventions of activity that can aid children with ASD in reducing their behavioral tendencies. A few fun or effective methods include exergaming, aquatic exercise, and structured physical activity programs and will be discussed below.

Exergaming

Anderson-Hanley, Tureck and Schneiderman (1) considered the use of exergaming to diminish repeated behaviors of individuals with ASD. They found that exergaming is fun and enjoyable for all children, but even better for children with ASD as their physical activity levels and attention levels are statistically low compared to their neurotypical peers (8). The study was able to recruit 12 students diagnosed with ASD. The control period involved the subjects to interact with a 20-minute video, along with 5 minutes of recording before and after the video to record them playing, to track executive functions.

The following week, the same participants were acquainted with the Dance Dance Revolution (DDR) game system, and interacted with it for 20 minutes. There was no indication of a set level of intensity for the children to exercise at. Afterwards, their actions of play were recorded for 5 minutes. Another subject pool was used, involving 10 children with ASD. For this group, they exercised for 20 minutes on a stationary bike, but with an interactive game on the screen. No level of intensity was described in the study. Again, 5-minute periods of activity were recorded before and after the main exergaming activity. The results illustrated the benefit of the DDR gaming system and cycling video game, for the children's behavior in the experiment session were significantly reduced compared to the control session. Thus, exergaming is a different, incredible method of implementing exercise for children with ASD. Not only is it beneficial to decrease their challenging behaviors, such as repetitive behaviors, but it also provides them with an activity that is fun and enjoyable to interact with.

Aquatic Exercise

        Shams-Elden (10) delved into the impact of exercises in a pool environment, and their effect on children with ASD. He acquired a final group of 10 children with ASD to participate in his study. The subjects went through an exercise program in the pool for 3 days per week, for 10 weeks. In the end, the data demonstrated the profound benefit of an aquatic exercise program for children with autism on their motor abilities.

In the various tests conducted, the children improved their physical skill set and abilities. Their motor skills were enhanced, which consequently reduced their number of behaviors. Nevertheless, this study illustrates the negative relationship between the children's physical abilities, or their independence, and their likelihood to engage in a challenging behavior to themselves or others. Therefore, water has an amazing effect on these individuals, decreasing body weight that relieves pressure off their joints, which in turn relaxes their body physically and mentally, resulting in decreased behavioral tendencies, such as aggression or self-injury. The children's psychological and physical abilities are improved, which aid in the improvement of their disability.

Structured Physical Activity Programs

A study completed by Zhao and Chen (14), investigated the impact of exercise on the social skills of children with ASD. A control group and experimental group of 25 children with ASD each were used in this experiment. Over a course of 12 weeks, the experimental group experienced exercise sessions  twice a week, one hour each session. The program targeted interacting with the other children in their group, such as high-fiving one another, playing catch with a partner, or talking to their companions. With the purpose of fostering communication and social skills in each child, each session consisted of a warm-up, small group activities, large group activities, and a cool-down. These sessions were consistent in content, instructor, and group assignment.

The aim of the study was to evaluate the structured physical activity program and to improve the children's social capability, as measured by the Assessment of Basic Language and Learning Skills- Revised, the Social Skills Improvement System Rating Scales, the Parent Semistructured Interview Guide, and the Volunteer Open-ended Questionnaires. For the control group, the subjects participated solely in their normal physical activity routine over the course of the study. The study conducted three checkpoints to track the progress of the physical activity program. The first occurred one week prior to the start of the program, the second occurred midway through the study, and the last occurred one week after the conclusion of the 12-week program. Unsurprisingly, the researchers' goals were successful, for their experimental group participants demonstrated that a carefully constructed physical activity program will aid in their advancement of interpersonal abilities. In other words, stimulating the child to increase their level of comfort of communicating with their fellow peers and authority figures (parents or teachers).

Another study was administered by Tse, Pang, and Lee (12). Researchers recruited participants from 3 nearby schools. The participants including children in the special education program who were diagnosed with ASD. Additional requirements to continue as a participant for the child were to be 9-12 years old, non-verbal IQ over a score of 40, ability to listen to instructions, 6 months of physical inactivity, and proof of motor stereotypies by a physician. This study was intended to indicate the effect of different exercises on stereotypic behavior, which was defined as a recurring physical or oral action.

Based on the criteria, the researchers were able to select 22 boys and 8 girls. Collection of stereotypic behavior data of the children was measured a day before the first session and a day following the final period of each condition. After observing the 30 children with ASD and their stereotypic behavior, they were placed in two situations. The first situation served as the control to compare with the experimental condition, where the children were read a story by a staff member. During this time, their stereotypic behavior was recorded and rated based on a Likert scale. This scale started at (0) for never observed and ended at (3) for frequently observed.  One month later, the children underwent the experimental situation in which they tapped a ball for 15 minutes, followed by stretching for 5 minutes. As with the control situation, their stereotypic behavior was recorded and rated on a Likert scale.

A fascinating result denoted that an exercise similar in mechanics as the stereotypic behavior, significantly decreased the numbers of that behavior. For example, the ball tapping exercise was more effective than the story-telling activity in decreasing the frequency of hand-flapping in children with ASD who conduct with this stereotypical behavior. This being known, any field related to working with children with ASD can implement similar exercises to the known stereotypy, so that it is directed to decrease their behavior. As a result, it will progressively aid the child in their overall health and social capability.

Home Exercise Program

Every parent/caregiver wants to the best for their child. When supporting a child with a disability, the best approach for the parent/caretaker is to provide as many available opportunities as possible to advance their development. When the parent/caretaker acquires a higher involvement in their child's progress toward greater abilities, the child demonstrates positive results. With improved competence, the child might be more likely to engage in more social activities, participate in extracurricular activities, or improve school performance.

Caring for a child with a disability, both physically and mentally, is stressful and burdensome, and time-consuming. A lot of energy is required to assist the child in their daily needs, appointments, and activities. The more severe the disability, the greater need of investment. Jeevannavar, Madinkar, and Jeevannavar (6) illustrate the positive relationship between parental/caretaker involvement in a home exercise program and the future outcomes for their child with a developmental delay. Both the parent/caretaker and the child benefit from the program by lowering the parents'/caretakers' stress levels and encouraging abilities in the child.

The researchers in this study performed a cross sectional study. They recruited 81 parents/caretakers who engaged in a home exercise therapy program for their child diagnosed with a developmental delay and aged between 3 months to 16 years. The parents/caretakers completed two questionnaires, one that evaluated their stress levels and another that assessed their level of compliance with the home therapy program. Statistical analyses of the questionnaires indicated a negative relationship between the level of stress and the level of compliance. In other words, the higher the level of the parent's/caretaker's stress, the lower the level of compliance with the home exercise physical therapy program. Thus, if a parent/caretaker is more involved and cooperative in the prescribed home exercise physical therapy program for their child with a developmental delay, they are less likely to experience high levels of stress. As a result, the parents/caretakers are more capable to take care of themselves and their child, while also promoting the best future and possibilities for their child.

Summary of Research

        All in all, children with ASD are struggling. Outsiders may see a child with ASD having a behavior as misbehaving, when that child may be frustrated or have a sensory need. This population is being overlooked. They are not receiving the proper help they need to attain their best lives. A step in doing so to reach that goal is helping them with their social and physical health. Huge disparities between children with ASD and their neurotypical peers are the abilities to communicate and be physically and mentally healthy. An important method to narrow the gap is to implement exercise programs for children with ASD.

        These studies have demonstrated that with the correct measures, children with ASD will gain multiple and various benefits. Their health will be improved, their ability to communicate with their family and friends will increase, and their behavioral tendencies will decrease. Excellent approaches that will create a fun and efficient environment for children with ASD, but also resulting in decrease in stereotypical behaviors, consist of exergaming, aquatic exercise, and structured physical activity programs.

Exergaming allows the children to exercise, but not having them realize it. They receive all the benefits of exercise, but their mind is focusing on completing a mission or winning a race. Kids love to play video games, but this activity has a twist on it. It makes them physically and mentally work to complete the game, allowing their body and mind be put to work. In some games, the children need to work together to win, thus improving their social skills.

With aquatic exercise, the soothing feel of the water calms down children with ASD. An added benefit is that the water alleviates the pressure off the children's joints, permitting them to roam freely in the water and not worry about pain or discomfort. Also, the pool environment provides an opportunity for the children to either swim and play with others, or swim independently until they are ready to interact with others.

Structured physical activity programs provide individualized and focused plans for children with ASD, targeting what they need and how to accomplish that goal. As time progresses, the children can acquire more skills and work better with others.

In the future, research needs to develop a general exercise program that parents or caretakers can conduct at home for their child with ASD. Most of these studies were completed with professionals in a controlled setting. Children with ASD engage in behaviors throughout the day, not always at school or their day program. It would helpful for those not professionally trained to be equipped with basic exercises that will aid them in diminishing their child's stereotypical behaviors. Not only will the program benefit the child, but also the parent/caretaker in dealing with the stresses of caring for their everyday needs.

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