Training Program For Autism
Written by: Catherine O’Brien Autism Spectrum Disorder (ASD) is a developmental disorder associated with impaired social ability, difficulty interacting with others and tendency to engage in repetitive or unusual behaviors. People with ASD may experience sensitivity to certain stimuli like texture, light, and noise. As is indicated by the name, autism spectrum disorder can vary in severity and presentation as it occurs on a continuum. According to the Center for Disease Control and Prevention, ASD effects approximately 1 out of every 68 children and is more common (4x) in males. According to the National Institute of Mental Health, children with ASD may also experience trouble sleeping and insomnia. As a result of interrupted or inefficient sleep, parents and caregivers also suffer from sleep trouble. Given the prevalence of autism spectrum disorder, there is a wealth of research investigating opportunities to mitigate some of the symptoms and comorbid conditions associated with the diagnosis. I am excited to discuss research that examines the effects of exercise on social behaviors, sleep and athletic / coordination abilities in children with ASD. 1
Research Research conducted by Pan (2010) examined the effect of water exercise swimming program (WESP) on both aquatic skills and social behaviors in children with ASD. Participants were 16 children between ages 6-9 who were diagnosed with autism. The participants varied slightly in their diagnosis with 8 participants considered mild or high-functioning and 8 participants were identified as having Asperger’s syndrome. Participants were divided into two groups. The first group was placed in water exercise swim program (WESP) for 10 weeks and then received just their normal treatment/ activity for 10 weeks. The second group spent the first 10 weeks in regular treatment followed by 10 weeks of WESP treatment. The children were tested for aquatic ability and social skills three separate times. The first measurement occurred at baseline upon study entry, the second occurred after the first 10 weeks whether they had regular treatment/ activity or WESP treatment, and the final measurement was taken after the second 10-week period. WESP included warmup activities, small group instruction, group games and activities and cool down. The Humphries Assessment of Aquatic Readiness (HAAR) measured mental adjustment, introduction to water environment, rotations, balance and control and independent movement in the water. Participants were also measured on social behavior skills including social competence, peer relations, self-management, academic behavior and antisocial behavior like irritability, aggressive / defiant behavior.
Not surprisingly, WESP treatment led to statistically significant improvement aquatic ability. More interestingly, there was also a significant effect of WESP on academic and antisocial behavior such that following the 10 week WESP treatment, participants had higher scores for academic behavior and social competence and lower scores for hostile/ irritable and antisocial behavior. A second research study conducted by Brand et al. (2015) examined the effect of aerobic exercise on sleep behavior and motor skills in children with autism spectrum disorder. Participants in Brand et al.’s study were 10 children, age 7-13 who qualified as having autism spectrum disorder. Participants attended three 2
training sessions per week for three weeks. During each of the sessions the children participated in 30 minutes of aerobic exercise on a bicycle followed by 30 minutes of coordination training. This training included throwing a ball, balancing, jumping etc. Sleep was measured objectively by EEG analysis 4 times – at the start of the study, at the conclusion of the study, one night during the study following a day where the participant engaged in the physical activity and one night during the study following a day with no physical activity.
Additionally, Sleep polygraphs were used to assess total sleep time, sleep efficiency, slow wave sleep, REM sleep, sleep onset latency and number of times awakening after sleep onset. Parents / caregivers measured child’s sleep subjectively using the Insomnia Severity Index which includes parameters such as difficulty falling asleep, maintaining sleep and worrying about sleep. Finally, researchers examined mood state of children on morning following physical exercise compared to morning following no exercise. Not surprisingly, the physical exercise intervention improved motor skills over time. Unfortunately, there was no significant effect of physical exercise on subjective sleep or objective sleep over time. That is, sleep scores before and after the study were similar. However, there was as significant effect of physical exercise on objective sleep on nights following physical exercise such that children slept better following nights with physical activity. Additionally, sleep logs revealed improved mood in mornings following physical activity. Pan and Brand et al.’s research is important because it provides support for the use of physical exercise for the remediation of some of the symptoms and comorbid disturbances in children with ASD. Simply, for children with autism spectrum disorder, physical exercise can improve social behavior, mood and sleep. This research is also important because parents and caregivers of children with ASD often suffer from disturbed sleep as a result of their child’s insomnia. As such, improving sleep quality and duration for children with ASD would in turn benefit caregivers, affording them a better night sleep as well. Future research may explore more long term intervention as the present research did not find a significant effect of physical exercise over time. It is possible a longer intervention may produce more long lasting and sustainable results. 3
Building An Autism Friendly Workout Plan
Written by: Catherine O’Brien Autism spectrum disorder (ASD) refers to a group of developmental disorders that vary in severity. As it is a spectrum disorder, there are mild and severe forms of ASD. According to the Center for Disease Control and Prevention (CDC), Autism Spectrum Disorder affects 1 in 68 children. The National Institute of Mental Health indicates that ASD is marked by the following characteristics: 1. Social problems that include difficulty communicating and interacting 2. Repetitive behaviors and limited interests/activities 3. Symptoms are recognized within the first two years of life 4. Symptoms impair individual’s ability to function in various social situations (i.e. school, work, etc.) Given the prevalence and impairments associated with ASD, it is not surprising that researchers are constantly investigating therapies to help individuals with ASD. Exercise interventions have been explored and have produced very interesting results that suggest physical exercise can help remediate some of the symptoms 4
associated with ASD. There are many challenges with applying these learnings, however.
Obstacles: 1. Decreased interest 2. Increased sensitivity to stimuli 3. Difficulty maintaining focus Research done by Collins et al (2016) found that, compared to typically developing children, children with autism displayed lesser interest in leisure activity. Children with ASD did not enjoy formal and physical activities as much as typically developing children. This research highlights the importance of understanding activity patterns and interest when working with children with ASD. As such, exercise programs for children with ASD need to be designed with the disorder in mind. The structure and rules that may appeal to a child without ASD, may prove stressful for a child with ASD. Sensations of environmental stimuli may also influence the level of enjoyment and participation among children with ASD.
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Understanding the decreased levels of enjoyment, it is no surprise that research has found decreased levels and frequency of physical activity among adolescents with ASD. Stanish, Curtin, Must Phillips, Maslin, and Bandini (2017) conducted research examining physical activity levels, frequency and, type among adolescents with and without ASD. Their results showed that, on average, adolescents with ASD completed 20 minutes less of moderate and vigorous physical activity compared to typically developing adolescents.
ASD Friendly Workout Plan: In order to combat the challenges associated with designing an exercise program for a child with ASD, Eric Chessen, the founder of Autism Fitness, provides some helpful tips. According to the Autism Society, creativity and full body movement are of utmost importance. Chessen, says that the focus should be on movement-based exercises as this type of exercise “teaches the body to function as a cohesive, optimized unit” (Chessen, Autism Society, 2014). In this way, he recommends “animal-based movement patterns” including bear walks, crab walks, frog hops, and gorilla steps. Chessen also stresses the importance of generalization. That is, teaching and practicing movements that have utility outside of the physical fitness realm. For children with ASD, developing basic movements like running, jumping, climbing, pulling, pushing and throwing are important to develop. Creativity is an important ingredient in any fitness regimen for children with ASD. As mentioned above, sensitivities to various types of stimuli and limited focused attention require that the movements are easy to remember and have modifications for children who, for example, may not want to touch the grass, turf etc.
Strategies: 1. Focus on full body movement rather than specific muscle areas. Chessen recommends animal-based movements like the crab walk and frog hop. 2. Get creative! Tie the physical activity to a task to build purpose behind the movement and reinforce the activity. 3. Have modifications at the ready. Be prepared to modify movements and activities for children who are particularly sensitive to certain stimuli in the environment. 4. Incorporate group exercise focused on teamwork and helping when possible to improve social behavior. 6
Exercise Helps Individuals With Autism
Written by: Julia Basso – PhD Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that typically emerges before the age of 3. ASD is characterized by a variety of symptoms including impaired social interactions, problems with communication, and engagement in repetitive behaviors. Other issues that can co-occur with ASD include depression, anxiety, difficulties in emotional regulation, and problems with paying attention. Currently, scientists think that ASD results from issues in information processing, arising from errors in how the brain’s cells are connected and organized throughout the brain, especially in the region of the prefrontal cortex (an area involved in mood, social behavior, and cognitive functioning). Approximately 1% of the world population is currently living with autism, and the Center for Disease Control estimates that 1 in 68 babies born in the United States will be diagnosed with ASD, with significantly higher levels in boys than girls (1 in 42 boys versus 1 in 189 girls) (Center for Disease Control, 2014).
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Stay On Task And Engaged Currently, no known cure exists for ASD, and many of the medications used to treat ASD have serious side effects, including sedation and weight gain. Because of this, physicians, scientists, and families are turning to alternative treatments. Exercise is one of them. Dr. Stephen M. Edelson, executive director of the Autism Research Center, says that, “One of the most effective treatments for autistic people is exercise.” He notes that research is showing that exercise is associated with, “decreases in stereotypic (self-stimulatory) behaviors, hyperactivity, aggression, self-injury, and destructiveness” in people with autism. Along with improvements in motor behaviors, exercise has been shown to help in the classroom. In children with ASD, exercise has been shown to enhance the ability to stay on task and engage in classroom activities as well as increase overall academic performance. Importantly, exercise in children with ASD helps to improve social skills.
The Results Are Undeniable Compared to individuals without ASD, those with ASD spend significantly less time engaging in physical activities (29 versus 50 minutes per day) and fewer meet the Physical Activity Guidelines for Americans (14 versus 29%) (Stanish et al., 2017). As individuals with ASD often suffer from weight gain and other physical health issues, it is imperative that we encourage these individuals to participate in physical activity. When it comes to the long-term effects of exercise on ASD symptoms, few longitudinal randomized controlled studies have been conducted. What has been done, however, suggests that exercise is beneficial for individuals with ASD. In one study, children with ASD (ages 6 to 9) were exposed to a 10-week water exercise swimming program (Pan, 2010). Participation in the exercise program (compared to engagement in regular treatment/activity) not only enhanced aquatic skills, but importantly decreased antisocial behaviors including spinning, rocking, and delayed echolalia or the verbal repetition of previously heard messages. 8
When it comes to the long-term effects of exercise on ASD symptoms, few longitudinal randomized controlled studies have been conducted. What has been done, however, suggests that exercise is beneficial for individuals with ASD. In one study, children with ASD (ages 6 to 9) were exposed to a 10-week water exercise swimming program (Pan, 2010). Participation in the exercise program (compared to engagement in regular treatment/activity) not only enhanced aquatic skills, but importantly decreased antisocial behaviors including spinning, rocking, and delayed echolalia or the verbal repetition of previously heard messages.
What Type of Exercise Is Best? Another more recent study asked whether just a single bout of exercise could be beneficial to improve symptoms in individuals with ASD (Schmitz et al., 2017). Not only that, but the researchers sought to determine which type or “dose� of workout was best. They examined four doses of aerobic exercise: 1) a 10-minute low-intensity workout 2) a 10-minute high-intensity workout 3) a 20-minute low-intensity workout 4) a 20-minute high-intensity workout Before and 60 minutes after exercise or rest, a variety of stereotypic behaviors were assessed. Excitingly, all exercise regiments decreased stereotypic behaviors, except 20 minutes of high-intensity exercise, which actually exacerbated stereotypic behaviors. The most beneficial workout for ameliorating ASD symptoms was the 10-minute low-intensity aerobic workout, suggesting that a little exercise goes a long way! Future high-quality studies will be needed to determine whether exercise can be suggested as an evidence-based treatment in children with ASD (Dillon et al., 2017). In the meantime, if you have a child or grandchild with autism, get exercising together. Many children with ASD enjoy sitting at home and engaging in sedentary behaviors such as playing video games. Exercise can be a way to get out of the house and enjoy a healthy activity that you can bond over.
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Adaptive Learning Jackie Ceonzo, Executive Director and Founder of SNACK & Friends, Inc (Special Needs Activity Center for Kids) suggests that sports can be learned and enjoyed by children with ASD. She says that, “They just need to be taught in an adapted fashion…For example, in teaching baseball, start with teaching them to run from home plate to first base. The bases can serve as visual cues. Maybe add some arrows to point out the right direction to move around the bases. A sticker, a high five, or other reinforcers may be needed at the end of a successful run.” If heading outside to exercise seems out of the question, think about combining exercise and video gaming. Video game systems such as the Wii have a variety of interactive exercise games such as Just Dance, EA Sports Active, Exerbeat, and Zumba Fitness World Party. You can see a list of the best Wii exercise games here. Many phone apps are even available that make exercise into a game, such as Zombies, Run, an interactive walking/jogging/running game that allows you to, “Run in the real world and become a hero in another.” The idea is that you are one of the few remaining souls who have survived a zombie epidemic, and you are running to “one of humanity’s last remaining outposts.” Along the way, you collect supplies, rescue survivors, and get exercise! There is even an app that teaches individuals with autism to exercise, called ExerciseBuddy. As an another idea, think about measuring heart rate as you engage in a workout – tracking heart rate from workout to workout could serve as an additional game.
In conclusion, even a single 10-minute bout of low-intensity aerobic exercise can help improve symptoms in individuals with ASD. If 10 minutes is initially too much, start with half that and build from there. As fitness increases, you can try exercising in 10 minute bouts throughout the day to help boost the benefits. Most importantly, make exercise fun. Getting fit can become a game that the whole family can enjoy!
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Low Intensity, Short Workouts Benefit Individuals With ASD
Written by: Catherine O’Brien Autism Spectrum Disorder (ASD) is typically diagnosed in toddlers. As discussed in my earlier article about ASD, the disorder is characterized by various behaviors that impair communication and social interactions. These stereotyped or self-stimulating (SSB) behaviors refer to repetitive and / or restrictive patterns and may include repetitive speech or repetitive motor movements (spinning, rocking, flapping etc.). Because ASD is often diagnosed in young children, it is no surprise that there is an emphasis on ASD therapies for kids. While there is no known cure or course of treatment for ASD. Previous research has indicated that aerobic exercise can remediate some of the symptoms and behaviors associated with the disorder. This is a very important learning in the field of autism research but there is still more to be investigated. There are many variables associated with exercise including type, frequency, duration and intensity. The present study, conducted by Olin et al. (2017), focused on duration and intensity. The purpose of the present study was to identify the optimal intensity and duration of exercise for diminishing SSBs. 11
The Study Participants in the study were school age children (mean age 13yo) diagnosed with ASD. All participants experienced each of the study’s five conditions; a control condition and 4 exercise conditions. Participants were randomly assigned the order in which they would experience the conditions. The interventions occurred on the same day and at the same time each week and took place in the usual physical education gymnasium so as to control for any effect related to time of day or discomfort with a new environment. At their first exercise intervention, participants were given the choice of treadmill, elliptical or stationary bike. They would use the same machine for all subsequent exercise sessions. The exercise conditions varied in duration (10 or 20 minutes) and intensity. As such, the four exercise groups were 10 min & high intensity (10H), 10 min & low intensity (10L), 20 min & high intensity (20H) and 20 min & low intensity (20L). In the low intensity conditions, participants exercised at 50 – 65% of their max heart rate and in the high intensity conditions, participants exercised at 70 – 85% of their max heart rate. In the control group, participants engaged in no activity.
Behaviors A video camera was discretely set up in the classroom to monitor participant’s behaviors before and after the intervention. They were observed for 15 minutes prior to the intervention and for 60-minutes post exercise. Scorers watching the video were instructed to record occurrences of self-stimulating behaviors. In order to eliminate bias, observers were blind to the treatment condition so they did not know which intervention the subjects had just experienced. For the control group, results demonstrated no difference between SSB pre and SSB in the first 45 minutes following the control intervention. There was, however, a spike in SSB in the 60min post measurement. In this way, the control group participants actually demonstrated an increased frequency of SSB. Interestingly, the 20H condition led to an increase in SSB post exercise. The figure 12
below shows that the 20H condition was the only condition that led to a significant increase in SSB from pre to post intervention. Results indicated that the 10L intervention was most successful in diminishing SSB compared to more intense and longer interventions and compared to control. “The 10L session yielded the greatest reduction of all conditions at every time point post exercise, with the largest difference from the control occurring in the latter part of the 60-minute post exercise observation period� p.986.
The Findings The findings support previous research in that it demonstrated the positive effects of exercise on reducing stereotypical behaviors in individuals with ASD. This research provides new insight and demonstrates that the intensity and duration of exercise play a significant role in self-stimulating behavior reduction. Low intensity and short duration exercises were associated with the greatest improvement in SSB while the more intense and longer duration exercise actually caused an increase in SSB.
Takeaway This research is important because it helps establish guidelines and directions for creating ASD friendly workouts. From my perspective, the fact that the most effective intervention was the low intensity and short duration is quite exciting. Individuals with ASD can have difficulty maintaining focus and, as such, shorter duration workouts are more realistic. While more research is still needed in order to understand the relationship between exercise and ASD therapy, the present study provides promising and applicable results for those who have ASD or work with / care for individuals with ASD.
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Effects Of Outdoor Activity On Children With Autism
Written by: Catherine O’Brien In previous articles, I have discussed the role of exercise in reducing stereotypical behaviors in children with autism. The research has shown that the intensity and duration of exercise are key variables in reducing stereotyped behaviors. Previous research on typically developing populations has examined the role of exercise environment on physiological and psychological outcomes. As such, I thought it appropriate to discuss similar research related to the ASD population. Research conducted by Zachor, Vardi, Baron-Eitan, Brodai-Meir, Ginossar and Ben-Itzchak examined the effectiveness of outdoor adventure programs for young children with autism spectrum disorder.
The Study The aim of the present study was to examine the effectiveness of outdoor adventure activities on improving social interactions and communication in children with ASD. 14
Participants for the study were children, ages 3-7, who had been previously diagnosed with ASD. Participants were recruited from seven ASD special education kindergartens. Four of the seven kindergartens were randomly assigned to the outdoor adventure program while students in the other three were placed in a control group. Each of the classrooms adhered to the same educational protocols based on the appropriate behavioral and developmental principles. Children were measured on the Social Responsiveness Scale (SRS), the Vineland Adaptive Behavior Scale (VABS) and the Teachers’ Perceived Future Abilities Questionnaire. The SRS measures social abilities like social awareness, social motivation, social cognition, social communication and autistic mannerisms and higher scores indicate greater impairment. The VABS is designed to measure adaptive behaviors across four key domains including communication, daily living skills, socialization, and motor skills. Finally, the Teachers’ Perceived Future Capabilities Questionnaire measures the “teachers’ perception of the changeability of her students with ASD and inquired into the teacher’s prediction of the students’ future socio-communication and learning skills (p. 551). Participants and their teachers completed these measures prior to the intervention and then again post-intervention.
The Program Classrooms assigned to the outdoor adventure condition participated in a 13-week program that met once a week. The sessions were approximately 30 minutes long and took place in a local park. The adventure sessions began with an opening song after which children moved through four activities/ stations. The activities were: 1. 2. 3. 4.
A two-way climbing rope ladder A rope elevator A rope bridge A hammock and rope swing 15
A more detailed description of the activities and their purposes can be found in the chart below.
Finally, the session ended with a closing meeting in which participants were asked about their experience using prompts like “how was it?”, “What activities did you enjoy doing?”. Children in both the outdoor and control groups were similar in age, cognitive ability and VABS scores (communication, daily living skills, socialization, and motor skills). The two groups were also similar in measures of social responsiveness at baseline.
The Results Their results revealed a statistically significant time x group interaction for the social responsiveness measure (SRS) in social cognition, social communication, social motivation and autistic mannerisms. While the outdoor adventure group showed a reduction in SRS standard scores over time, the control group showed an increase in SRS standard scores. In this way, the control group actually experienced an increase in the autistic 16
mannerisms domain of the SRS. Similarly, results showed a significant time x group interaction for the VABS subdomain scores. As a reminder, the VABS measures communication, daily living skills, socialization, and motor skills and higher scores suggest better functioning. The two subdomains that yielded significant results were communication and daily living skills. They found no change over time in the Teacher’s Perceived Future Capabilities questionnaire.
Was It Effective? These results demonstrate that the outdoor adventure program was effective. The outdoor adventure group demonstrated a trajectory toward a reduction in ASD symptoms while the control group experienced the opposite trend. Zachor et al.’s results are consistent with that of previous research which has found that, over time, symptoms of ASD can become more severe. As such, the seemingly protective effect of the outdoor adventure program is quite exciting. Improvement of social skills and reduction of symptoms are obvious very important goals to work toward, but staving off an increase in symptom severity is significant as well.
Takeaway Activities that rely on communication, trust, and teamwork may set children with ASD on a path toward reduced symptoms. Additionally, ASD symptom severity can naturally increase over time, so engaging in these types of activities may have a protective element. Thoughts for future research- The outdoor adventure program used in the present study focused on communication, motor coordination, social skills and teamwork. In this instance, it did not seem that the outdoor element had much of an effect or was taken into account in the analyses. I think it would be interesting to explore whether the outdoor environment (as opposed to a similar course presented indoors) had any effect on the improvement of ASD symptoms.
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References Brand, S., Jossen, S., Holsboer-Trachsler, E., Gerber, M. (2015) Impact of aerobic exercise on sleep and motor skills in children with autism spectrum disorders – a pilot study. Neuropsychiatric Disease and Treatment, 11, 1911-1920. Center for Disease Control and Prevention. Autism Spectrum Disorder (ASD). Retrieved January 29, 2017 from https://www.cdc.gov/ncbddd/autism/data.html The National Institute of Mental Health. Autism Spectrum Disorder. Retrieved January 29,2017 from https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml Pan, C., (2010) Effects of water exercise swimming program on aquatic skills and social behaviors in children with autism spectrum disorders. Sage Publications and the National Autistic Society, 9-28. Young, S., Furgai, K. (2016) Exercise effects in individuals with autism spectrum disorder: a short review. Autism Open Access, 6, 1-2. Eversole, M., Collins, D. M., Karmarkar, A., Colton, L., Quinn, J. P., Karsbaek, R., . . . Hilton, C. L. (2016). Leisure activity enjoyment of children with autismspectrum disorders. Journal of Autism and Developmental Disorders, 46(1), 10-20. Stanish, H.I., Curtin, C., Must, A., Phillips, S., Maslin, M., and Bandini, L.G. (2017). Physical activity levels, frequency, and type among adolescents with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 47: 785794. Chessen, E. (2014). How to create exercise programs for the ASD population. Autism Society. Retrieved on July 22, 2017 from http://www.autism-society.org/ news/not-create-exercise-programs-asd-population/ Dillon, S. R., Adams, D., Goudy, L., Bittner, M., & McNamara, S. (2016). Evaluating exercise as evidence-Based Practice for individuals with Autism Spectrum Disorder. Frontiers in public health, 4.
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Schmitz, O. S., Mcfadden, B. A., Golem, D. L., Pellegrino, J. K., Walker, A. J., Sanders, D. J., & Arent, S. M. (2017). The Effects of Exercise Dose on Stereotypical Behavior in Children with Autism. Medicine and science in sports and exercise, 49(5), 983990. Oling, S.S., McFadden, B.A., Golem, D.L., Pellegrino, J.K., Walker, A.J., Sanders, D.J. and Arent, S.M. (2017). The Effects of exercise dose on stereotypical behavior in children with autism. Official Journal of the American College of Sports Medicine: Medicine & Science in Sports and Exercise, p. 983-990. Zachor, D.A., Vardi, S., Baron-Eitan, S., Brodai-Meir, I., Ginossar, N, and Ben-Itschak, E. (2016). The effectiveness of an outdoor adventure program for young children with autism spectrum disorder: a controlled study. Developmental Medicine and Child Neurology, 59: 550-556.
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