children and teens with autism spectrum disorder .5

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Children and Teens With

Autism SpectrumDisorder: Considerationsand Basic Guidelines forHealth and FitnessProfessionalsMelissa M. Tovin, PT, PhDDepartment of Physical Therapy, Nova Southeastern University, Fort Lauderdale, Florida

A B S T R A C T

THE PURPOSES OF THIS ARTICLE

ARE TO INTRODUCE THE READER

TO AUTISM SPECTRUM DISORDER

(ASD), TO ESTABLISH THE IMPOR-

TANCE OF PHYSICAL ACTIVITY IN

THIS POPULATION, AND TO HIGH-

LIGHT SOME OF THE UNIQUE

CHALLENGES FACED WHEN

WORKING WITH CHILDREN AND

TEENAGERS WITH ASD IN THE

HEALTH AND FITNESS SETTING. THE

AUTHOR PROVIDES SOME BASIC

GUIDELINES AND RECOMMENDA-

TIONS TO SUPPORT PROFESSIO-

NALS WHEN DEVELOPING

EXERCISE PROGRAMS TO ACHIEVE

POSITIVE OUTCOMES AND LONG-

TERM ADHERENCE. AN IN-DEPTH

DISCUSSION OF ETIOLOGY, DIAG-

NOSTICS, CLINICAL PRESENTATION,

AND TREATMENT IS BEYOND THE

SCOPE OF THIS ARTICLE.

INTRODUCTION

Overall public awareness ofautism and autism spectrumdisorder (ASD) has increased

dramatically over the past decade. This

is partly because of public awarenesscampaigns but mostly a result ofthe dramatically rising incidence in theUnited States and throughout the

world. Most people today know some-one whose life is affected by autism insome way. According to the mostrecent estimates by the Centers for Dis-ease Control and Prevention (CDC),1 in 88 children is diagnosed withASD, and the disorder is nearly 5 timesmore common among boys (1 in 54)than among girls (1 in 252) (11,12).

ASD is a general term for a group ofdevelopmental disabilities that causesignificant difficulties in social interac-

tion, verbal and nonverbal communi-cation, and behavior (5,9). Disabilitiesthat fall under the diagnostic categoryof ASD include autism, pervasivedevelopmental disorder not otherwisespecified and Aspergers syndrome.According to some resources, ASDalso includes Retts syndrome and child-hood disintegrative disorder (5,9). ASDis usually diagnosed in childhood and isa lifelong condition. Aside from thecharacteristic difficulties mentioned

above, individuals with ASD may also

present with other issues and comorbid-ities, including impaired motor coordi-nation, depression, anxiety, attentiondeficit disorder, sensory processing dis-

order (SPD), seizure disorder, and intel-lectual disability (1,22,37). Because ofthe spectral nature of ASD, clinical pre-sentation varies widely among individ-uals affected by the disorder.

IMPORTANCE OF PHYSICALACTIVITY AND FITNESS INCHILDREN AND TEENAGERS WITHAUTISM SPECTRUM DISORDER

Like their typically developing peers,children and teenagers with ASD ben-efit greatly from physical activity. Phys-

ical activity is essential in maintaininghealth and well-being, and preventingchildhood obesity. Childhood obesityhas more than tripled in the past 30years (7). In 2008, more than one-thirdof children and adolescents were over-weight or obese (28,31). Current esti-mates indicate that 17% of children

K E Y W O R D S :

autism; autism spectrum disorder;exercise; physical activity; specialpopulations; children; teens

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and adolescents aged 219 years areobese (8).

There is evidence that obesity rates areeven greater in children with ASD

(38,39), and some research indicatesthat children with autism are 40% morelikely to be obese than children with-out autism (13). Childhood obesity isthe result of eating too many caloriesand not getting enough physical activ-ity (7), and this holds true for childrenwith ASD (21). Children and teenagerswith ASD, however, are at greater riskfor becoming overweight or obesebecause of the unique challenges theyface that limit their opportunities andabilities to exercise. Social and commu-

nication impairments, behavioral issues,sensory processing difficulties, andmotor incoordination may preclude par-ticipation in school-based or recrea-tional physical activities. Obesity ratesare greater for older children withautism because recent studies indicatethat they are significantly more physi-cally inactive than younger children(21), and this can have important ram-ifications as these children transition intoadulthood, such as the development of

diabetes or other obesity-related healthissues.

One of the biggest barriers to physicalactivity for youth with ASD is the pri-mary social-behavioral impact of thedisorder. Individuals with ASDhave difficulty interacting with peersbecause of poor social skills (29). Theyoften fail to recognize or understandsocial cues and lack verbal and nonver-bal communication. They often engagein repetitive and self-stimulatorybehaviors, which interfere with the

activity at hand, and may distractothers around them. These childrenoften have difficulty engaging withtheir peers in unstructured physicalplay at school, on playgrounds, or thebackyard. Difficulty with social interac-tions and a lack of cooperative skillsimpact group dynamics, and childrenwith ASD often require social cues forappropriate interactions (27). They mayalso be prohibited from participating inorganized recreational sports because of

staff concerns regarding behaviors, or

staffs inability to deal with themeffectively.

Sensory processing impairments poseanother barrier to effective participa-

tion in physical activity. The presenceof sensory processing disorder (SPD)in most children and adults with ASDis well documented, although the sever-ity of symptoms varies greatly (19,20).SPD is an umbrella term for a range ofdifficulties (or dysfunctions) in sensoryfunctioning (23), and a detailed discus-sion of the complexities and varying pre-sentations of the disorder are beyond thescope of this article. In very simpleterms, sensory processing is theability of the central nervous system to

process information gathered throughthe senses, integrate it with informationstored in the brain from previous expe-rience, make a meaningful response andself-regulate. There are 3 components ofsensory functioning: sensory responsive-ness, sensory reactivity, and arousal (23).

For the purposes of this article, the dis-cussion will be limited to a briefdescription of sensory responsivenessand reactivity as observed in youthwith ASD. Sensory reactivity is a phys-

iological response to sensory informa-tion in the environment. Someindividuals may be overreactive to sen-sory stimuli, including sound, touch,smell, movement, and visual informa-tion. Some individuals may be under-reactive. Sensory responsiveness is theobservable behavior caused by sensoryinput. Although simplified, a goodexample to illustrate sensory overres-ponsive behavior is when a child covershis ears and cries in response to a sound,such as a ringing phone or school bell.

The reaction does not match the inten-sity of the stimuli. Aside from overt sen-sory responses, SPD can also manifestin other ways, such as self-stimulatorybehaviors (e.g., hand flapping, twirling,rocking), sensory avoidance behaviors,difficulty with attention and focus, poormotor planning, difficulty in organizingand sequencing tasks, difficulty in fol-lowing verbal instructions, low motiva-tion, poor self-esteem, and difficulty inself-monitoring. Each of these can

impact an individuals ability to perform

physical activities and participate ingroup sports.

Bullying by peers is also a potentialbarrier to participation in group phys-

ical activities for this population (17).Decreased motor skills, poor social com-munication, and low self-confidence cancause these children to be targeted forbullying during group physical activity,which can further magnify the socialimpact of the disorder. Peer bullyingnot only facilitates physical inactivity, itfurther socially isolates youth with ASD.

THE BENEFITS OF PHYSICALACTIVITY

The benefits of physical activity for

youth with ASDs reach beyond thosealready well documented for the non-disabled population. As with all youth,physical activity at recommendedlevels improves health and well-being,improves physical fitness, and preventscomorbidities including obesity. Thereis additional evidence that childrenwith ASD experience other positive ef-fects from exercise, including improvedmotor function and exercise capacity(35), reduced self-stimulatory behaviorssuch as rocking, spinning, and hand

flapping (34,40,47), and improved self-esteem, mood, and attention (32,36).Even more exciting is the positiveimpact of exercise on social interactionand participation. The positive effects ofphysical activity and exercise men-tioned above can ultimately lead toimproved ability and desire to partici-pate in peer group physical activitiesand sports. This type of engagementcan improve social and communicationskills, improve self-esteem, reduce depres-sion, reduce social stress, and facilitateself-management skills (24,33). Improvedendurance, strength, and motor skills cangive these youth self-confidence to par-ticipate in community/recreational peeractivities, an important step toward inde-pendence as an adult.

EXERCISE GUIDELINES

The general guidelines for exercisetraining for youth with ASD are basi-cally the same as with all youth. TheCDC and the U.S. Department of

Health and Human Services developed

Children and Teens With ASD

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National Physical Activity Guidelinesrecommending that children get a mini-mum of 60 minutes of moderate-to-vig-orous physical activity each day, which

may occur in bouts of.

10 minutes(10,42). Vigorous-intensity aerobicactivity, however, should be per-formed at least 3 days per week.

Physical activity should also includemuscle strengthening activities (e.g.,gymnastics, push-ups, or free weights)(10). When planning strengtheningactivities, professionals should considerstrength and conditioning guidelinesfor children as outlined by the NationalStrength and Conditioning Association

(30). A well-rounded program shouldalso emphasize core strengtheningactivities, as a strong core can facilitateimproved balance and coordinationrequired for higher-level motor skills(3,4,18).

Although exercise testing guidelinesare basically the same as for adults, itis important to remember that child-rens physiological response to exercisediffers from adults. These are describedclearly in American College of SportsMedicine (ACSM) Guidelines forExercise Testing and Prescription (2).Aerobic fitness in this population maybe difficult to determine because of thedisorders impact on social understand-ing, motivation, motor function, andfocus. The following tests are relativelyeasy to administer and serve as a base-line to mark progress: or 1-mile walk/run. 3-, 6-, or 12-minute walk test. 600-yard walk/run.Professionals can use the ACSM FITT

model to guide program design anddetermine frequency, intensity, time,and type of exercise (2). As with allchildren, it is helpful to include activi-ties, props, games, and music to moti-vate and encourage participation.

Although exercise testing and trainingguidelines are the same for childrenwith ASD and healthy nondisabledchildren, there are some special con-siderations and strategies to makeexercise training more successful in

this population.

SPECIAL CONSIDERATIONS

As discussed, the 3 main characteristicsof ASD are impairments in social inter-action, communication, and behavior.

These are the key areas to be awareof when engaging individuals withASD in physical activity or recreationalactivities (27). Strategies to addressthese key areas are discussed in the fol-lowing section. Two other importantconsiderations when working with thispopulation are the presence of seizuredisorder and impaired cognition.

Approximately one-third of childrenwith ASD have seizure disorders(16,45,46). Fitness and health professio-nals working with this population must

identify the presence of seizures andwhether they are controlled throughmedication. This information shouldbe gathered from the family whenobtaining health history, medical clear-ance, and consent to participate ina physical exercise program. Parentsmaybe fearful that physical exertion willtrigger a seizure. Most children withmedically controlled seizures, however,can safely participate in physical activ-ity. The literature is inconclusive regard-

ing the impact of physical exertion onseizures. Some studies report cases inwhich children may have exercise-related seizures (26,41), whereas otherstudies suggest reduced incidence ofseizures with increased physical activity(14,15,25). Regardless, child-specificprecautions regarding physical exertionand seizures must be discussed with thephysician and family before programinitiation. Professionals must also beaware that some antiseizure medica-tions may alter exercise response and

even cause impairments that impactbalance and gait. Although childrenwith seizures can engage in most phys-ical activities, certain activities, such asswimming, must be monitored forsafety. Activities that have a potentialfor impact injury to the head should alsobe avoided, although evidence forincreased seizures from head trauma isinconclusive (6).

Another important consideration forworking with this special population

is the childs cognitive status, which

can impact ability to follow instruc-tions, level of independence, and over-all safety to the child and those aroundhim. Health and fitness professionals

must determine the appropriate levelof supervision needed for a child orteen with ASD based on cognitivelevel, as well as the age of the child.The use of simple instructions andvisual aids may be helpful in obtainingchild understanding and improve theirability to perform the exercises correctlyand safely. The special considerationsfor children with ASD, as discussedabove, are presented in (Table 1).

PRACTICAL SUGGESTIONS ANDSTRATEGIES FOR SUCCESS

There are several ways fitness andhealth professionals can implementstrategies to improve motivation, reducecharacteristic behaviors, improve out-comes, and obtain long-term compli-ance to exercise programs in childrenand teenagers with ASD. These chil-dren are each unique in their presenta-tion of characteristic behaviors andspecific challenges they face when itcomes to participating in physical activ-ity and exercise programs. Professionals

should evaluate each childs specificneeds through observation, as well asconsultation with family members andother health providers who work withthe child, to design an individualizedprogram. Each of the following sugges-tions may not apply to each child withASD, and it is up to the professional todetermine which strategies are appropri-ate for the child. Program planning isalso a process, often through trial anderror, and modifications based on thechilds response. Nevertheless, with

careful, flexible planning, this populationcan be successfully trained and benefitgreatly.

SPDs and associated behaviors canimpact learning, attention, and physi-cal performance. Vigorous aerobicactivities, such as running, jumping,biking, and swimming, provide propri-oceptive sensory input. Intense propri-oceptive input can provide short-termreduction of sensory behaviors andimprove attention and focus. Begin

an exercise routine with these types

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of activities before initiating exercisesthat require more control and focus.For example, have the child jog ona treadmill for 20 minutes before

working on resistance machines orsport-specific skills like throwing andcatching.

Anxiety, repetitive behaviors, and adesire for rigid/predictable schedulesare common in individuals with ASD.Provide children with a detailed sched-ule of activities at the start of each ses-sion, as well as a prescribed exerciseroutine to follow at home. This exter-nal structure helps alleviate anxiety byletting the child know whats next, andimproves cooperation and motivation.

It can also facilitate self-management inolder children. Written instructionsmay be sufficient for higher functioningchildren; however, using pictures alongwith brief written instructions canimprove understanding in younger ormore impaired children. For example,if incorporating free weights or resis-tance machines in an exercise program,include an image of the machine ora picture/video clip of the child per-forming the exercise correctly using

the equipment or weights. Schedulesfor exercise routines can also be incor-porated into a visual calendar the childcan keep and refer to at home.

Several behavioral management tech-niques and motivational strategies haveevidence to support their success inchildren with ASD (43,44). One well-documented approach, most applied bybehavioral analysts, is a positive rein-forcement system. In this system, extrin-sic reinforcers are used to rewarddesired behaviors. Over time, and with

progress, the rewards are delayed andeventually faded until the child canmanage his own behavior and/or feelmotivated by intrinsic rewards, such asa feeling of accomplishment. Incorpo-rating an extrinsic positive reward sys-tem is an effective strategy for achievingcompliance with an exercise program.Discuss appropriate and meaningfulrewards with the parent or caregiver.Rewards can be immediate or delayed,based on the level of the child. Exam-

ples of reinforcers and a description of

Table 1Questions to consider when planningexercise andfitness training for youth

with autism spectrum disorder

Does the child have seizure

disorder? If so, are there specificactivities that induce seizures?Are the seizures controlled withmedication? What medications?

Check with the physician for special

precautions regarding the seizures,though physical activity is usually notcontraindicated. In some cases, the familyand physician may identify specific typesof activities that trigger the seizures.

If the child is taking the medications, checkside effects (e.g., balance problems) andimpact on exercise response.

Determine appropriate response in the eventof a seizure during exercise. In some cases,seizures are mild, and the child cancontinue to exercise. In some cases, the

seizures can be physically draining, andexercise should be discontinued for theday.

Consider safety when selecting physicalactivities/exercise modes (e.g., swimmingwould require close supervision at alltimes).

Avoid activities that have a potential for headinjury (e.g., boxing).

Does the child have anxiety abouttransitions or schedule changes?

Use visual schedules and follow an exerciseroutine so the child knows what to expect.

Use flow sheets and checklists so the child

can mark his/her progress through theroutine and from session to session.

Does the child require an extrinsicreward system for motivation,compliance, and behaviormanagement?

Use a positive reward system to reinforcegood behavior/exercise goal achievement.

Select strategies/reinforcers based on needsof each individual child.

Does the child have sensoryprocessing issues?

Start exercise sessions with heavy workactivities and aerobic exercise to provideproprioceptive input (e.g., jump rope,trampoline, sprints, treadmill walk/run,vertical jumps, agility drills, and corestability exercises).

Consider the childs responsiveness to stimuliand plan sessions and location accordingly(e.g., noisy gym, bright lights, and crowds).

Use visual aids and written aids to improveunderstanding.

Does the child have cognitiveimpairments?

Select simple motor activities that do notrequire multiple steps.

Keep verbal instructions short and simple.

Use visual aids and written aids to improveunderstanding.




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when and how to apply them are pre-sented in Table 2. No matter what typeof reward system thechild requires, pro-vide consistent and frequent positive

praise to let the child know exactly whatthey did well (e.g., I like the way youmoved on to the next machine withouta reminder, or You did a good job ofcontrolling the weight and slowly low-ering it back down.).

Progress charts and checklists allowthe child to note those tasks that havebeen successfully completed, as well asdocument improvement over time (i.e.,number of repetitions, resistance, dis-tance, time) and provide a sense of

accomplishment. This sense of accom-plishment can boost self-esteem andmotivation to continue the program.It also supports self-organization, self-

direction, and independence in olderchildren/teenagers by giving thema tool to perform their routine withlittle prompts from an adult.

Another strategy that benefits mostchildren with ASD is to keep visualor verbal instructions short and simple.This is especially important for childrenand teenagers with more severelyimpaired language, difficulties in pro-cessing auditory information, and/orimpaired cognition.

CONCLUSIONS

The incidence of ASD is growing at analarming rate. Professionals in fitnessand health settings will likely interact

with individuals with ASD and shouldtherefore have a basic understandingof the disorder, special considerations,and strategies related to exercise train-ing. Professionals should encouragethe recommended levels of physicalactivity because improved fitness canbenefit this population greatly. This arti-cle provides information and strategiesthat can be easily and immediatelyapplied to improve outcomes andadherence in this special population.

Table 2Suggested guidelines for extrinsic positive reward system

Type ofrewardstrategy

When to use How to apply Examples of rewards/reinforcersa

Immediate To improve motivation; to managebehaviors. Typically indicated inyounger or lower functioningkids who are unable to focus onlong-term goals.

Provide specific verbal praise withan immediate reward periodicallythroughout session (e.g., aftereach exercise activity; aftera specified amount of time).

Edibles (while this is not the bestchoice, it is very effective for somekids. Select healthy options. Getparent approval or have parentprovide the food. A few pieces of

popcorn, a fruit chew, small pretzel,or carrot sticks are some examples).

Stickers, stamps, tickets, toy coins, toydollar bills (these work well aloneor once the child accumulatesspecified amounts, he/she cantrade them in for bigger prizes).

Favorite song.

Delayed(shortterm)

This strategy works well with kids/teens who are beginning todemonstrate some behaviorcontrol but still need someextra support/reinforcements

for consistency.

Provide specific verbal praisethroughout session. Providethe reinforcer at the end of thesession.

Toys (child can choose a small toyfrom a treasure box).

Fun activity or game (child can choosea short activity to do either at theend of the session or when they get

home, such as 510 minutes ofvideo game or computer time,a game of Simon Says, ora few minutes on the trampoline).

Delayed(longterm)

For higher functioning kids/teenswho are generally motivatedand cooperative during sessionsbut still need reinforcement forconfidence and long-termcompliance.

Set exercise-related goals that aremeasurable (time period, level ofdifficulty, amount of resistance)and agree on reward. Have thechild keep a visual record ofprogress toward goals usingflow sheet or checklist. Oncegoals are met, provide reward.

Gift card (small amount) to favoritestore.

Certificate of achievement.Ticket to movie.

aProvided by the fitness/health professionals or parents.



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Conflicts of Interest and Source of Funding:The author reports no conflicts of interestand no source of funding.

Melissa M.Tovin is an asso-ciate professor inthe Departmentof Physical Ther-apy at NovaSoutheasternUniversity.

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