The role of physical activity and sport in children and adolescents with autism spectrum disorder (ASD)
A narrative review
Abstract
Abstract:Background: Various health-related benefits of physical activity (PA) in children and adolescents have been reported, with suggestions that PA could effectively address certain deficits found in autism spectrum disorder (ASD). However, there remains insufficient engagement in PA among individuals with ASD, and barriers to accessing PA persist. Objective: This study aims to review PA interventions (types, frequencies, and durations) in ASD over the last five years and discuss their effects. Methods: Searches were conducted in the PubMed database from October to December 2022 using Mesh Terms: “adolescent” OR “children” AND “sport” OR “physical activity” AND “mental health” AND/OR “autism.” Results were critically appraised using PEDro and Cochrane’s ROB-2, categorized into five stages to assess potential bias. Results: A total of ten papers were included and appraised, examining various types of PA. Primary benefits observed in children and adolescents included the development of social skills, reduction of autistic traits, regulation of emotions, and management of behaviour and cognition. Conclusions: Evidence indicates that PA can effectively address some neuropsychological deficits in ASD. Additionally, managing and protecting against metabolic conditions through PA can significantly enhance overall health.
Introduction
Autism Spectrum Disorder (ASD) affects roughly 1% of children, with a higher prevalence among males, encompassing stereotypic behaviours, deficits in social and emotional skills, and certain cognitive functions [1, 2]. Many children with ASD experience disrupted sleep (80% prevalence), along with deficiencies in motor skills, spatial planning, and visual-motor tasks [2, 3, 4].
In 2020, the World Health Organization (WHO) updated its global guidelines on physical activity (PA) with specific recommendations for adolescents and children [5, 6]. PA has shown considerable benefits across various neuropsychological domains, enhancing self-esteem, happiness, communication, social functioning, emotion control, and behaviour [7]. This is especially crucial for neurodivergent children and adolescents, such as those with ASD, who encounter greater obstacles in accessing PA compared to the general population (23.05% vs. 15.91%) [7, 8, 9, 10]. These challenges stem from stigma, emotional factors (like shame and fear of exclusion), and social barriers [8, 9, 10]. Astonishingly, only 14% of children with ASD meet the recommended PA levels [11]. Particularly during adolescence, PA levels among children with ASD significantly decrease, with an average of merely ten minutes of activity daily (falling below 20% of WHO recommendations) [12].
Among the obstacles hindering PA access in ASD are deficits in coordination, balance, gait, postural stability, joint flexibility, and speed of movement [14]. These motor deficits are also linked to social skills, all of which can potentially improve through PA [14]. Additionally, about 74% of children with ASD are less likely to engage in organized sports due to perceived exclusion, compounded by difficulties in reciprocal interactions and interpreting social and emotional cues [1, 4]. Factors contributing to the observed inactivity pattern in ASD, as identified in thematic analyses, include experiences of rejection and bullying, such as “never being chosen first” [1, 8].
Previous studies have demonstrated that PA can significantly enhance various areas such as communication, inclusion, and motor skills. However, it is crucial to tailor these activities to suit children with ASD, integrating social cues, particularly in team sports [1, 12, 13, 14]. PA has been linked to a reduction in the severity of ASD symptoms, including repetitive behaviours, imitation, verbal communication challenges, social attention deficits, disrupted sleep patterns, and emotional struggles [1, 2, 3, 13]. Additionally, it shows promise in mitigating self-injury tendencies, stress, anxiety, or lethargy [12]. Regular PA also contributes to a reduction in the risk of chronic diseases [8] and potentially enhances drug metabolism when pharmacotherapy is involved [3].
The adjunctive role of PA exhibits promising results, expediting mental health rehabilitation and bolstering neuropsychological functions among children and adolescents with ASD [17]. Overall, PA holds significant promise as an adjunctive therapy, accelerating mental health rehabilitation, and improving neuropsychological functions in individuals with ASD [17].
Methods
This review, comparing the effect of PA on children and adolescents, was run between September and December 2022 using PICO (Table 1). As there was only one reviewer, registration with PROSPERO was not possible.
Inclusion/exclusion criteria
Peer-reviewed, experimentally controlled studies involving children diagnosed with ASD, utilizing valid and reliable investigative methods, and published in English, Polish, German, or Swedish within the last five years were included. The study’s focus was limited to the role of PA in ASD among adolescents and children, comparing it with placebo or other non-sport interventions, with a minimum of ten participants. Studies were excluded for several reasons: absence of ethical guidelines, incompleteness, lack of direct relevance, absence of peer review, being unpublished, comparisons involving two or more sports interventions, or having methodological errors (e.g., subjective assessment).
Information sources and search strategy
Repeated searches were conducted in the Cochrane Library and MEDLINE via PubMed using Boolean operators and Medical Subject Headings (MeSH) terms in combination with free text searches, adhering to language and timeline restrictions (see Table 2).
One reviewer (AZ) initially assessed the titles and abstracts of the studies obtained from electronic databases. Eligible studies were further evaluated against the predefined inclusion criteria and assessed for bias. The assessment of bias utilized tools such as PEDro [18] and the Cochrane tool for evaluating the risk of bias in randomized trials (Rob-2) [19]. To mitigate reviewer bias, the appraisal process was repeated independently and on separate occasions, altering the order of assessment.
The extracted data were organized into a structured table containing sections such as Study, Participants (Sample Size [n]), Intervention, Control, Other Characteristics, Intervention Type, Physical Activity Intervention, Time (min), Duration (weeks), Diagnostic Criteria, and Results.
Effect measures and synthesis methods
The search results were presented as a PRISMA flow diagram (Figure 1) [20], divided into three subsections.
Ethical considerations and self-bias
This study was conducted by a single reviewer.
Results
Ten articles were identified for inclusion [2, 3, 4, 7, 13, 14, 21, 22, 23, 24] from an initial pool of 23325 primary sources published in the last five years (Figure 1). A total of 579 records were screened, of which 83 were selected for further review, and 49 were assessed for eligibility (Figure 1). Assessment of bias across the reviewed articles revealed a prevailing tendency toward low to medium bias, signifying the overall robustness and quality of the studies (Tables 3, 5, 6) [4, 21, 24]. Notably, the absence of studies exhibiting medium/high or high levels of bias suggests a commendable quality standard among the selected articles.
The most frequent interventions identified were martial arts [21, 22]. Other interventions encompassed aquatic therapy involving aerobic and some resistance training [4], the ‘keep the ball game,’ rhythmic movements with music [2], Sports, Play, and Active Recreation for Kids (SPARK) [14], coordination and strength exercises [23], basketball [3], jogging [24], and the Treatment and Education of Autistic and Communication Handicapped Children (TEACCH) [7]. Additionally, one study did not specify the exact type of activities [13]. PA frequency varied from one to four times a week, with an average of 2.27 times and a median of twice a week (Table 4). PA duration ranged from 30 to 75 minutes, with an average of 47.8 and a median of 45 minutes (Table 4). The duration of interventions spanned from eight to 72 weeks, with an average of 21.9 and a median of twelve weeks (Table 4).
The studies suggested that PA can lead to improvements in emotional response [4, 21, 22, 24], adaptation to change [4], daily living skills [4], adaptive behaviours [4, 21, 23], social skills [2, 7, 14, 21], interaction [4, 7], communication [2, 14, 21], reduction of repetitive behaviours [21], coordination (dynamic balance) [14], balanced sleep patterns [3, 11, 13], some executive functions [7, 22], metabolic health [23], general perceived Quality of Life (QoL) [23], and reduction of autistic traits [22, 23] (Table 4).
Discussion
This review delves into the PA impact on individuals diagnosed with ASD, focusing on the correlation between varying doses and types of PA. Understanding how PA affects the multifaceted challenges within the ASD spectrum is pivotal for crafting effective interventions and support systems. The findings substantiate the role of PA as adjunctive therapy for ASD, as evidenced by multiple studies [2, 3, 7, 13, 14, 21, 22, 23, 24]. Notably, PA plays a crucial role in addressing social skills and emotional deficits [2, 3, 7, 13, 14, 21, 22, 23, 24]. Additionally, it significantly contributes to overall health by regulating metabolism and reducing the risk of chronic diseases, with direct impacts on mental health [26], a consistent finding supported by earlier research [25, 26]. Furthermore, the positive impact of PA on specific aspects such as balanced sleep patterns, executive functions, and metabolic health highlights the extensive implications of regular physical engagement [2, 3, 4, 7, 13, 14, 21, 22, 23, 24]. However, despite these benefits, there remains a concerning lack of sufficient PA among children with ASD [5, 6]. This discrepancy emphasizes the importance of promoting and implementing PA interventions effectively within this demographic to maximize their potential benefits.
Variations in the frequency, duration, and types of PA interventions across studies underscore the diversity in applied PA regimens [2, 3, 7, 13, 14, 21, 22, 23, 24]. While the studies highlight the beneficial effects of PA, the heterogeneity in intervention parameters poses challenges in establishing standardized protocols or guidelines for effective PA-based interventions [2, 3, 4, 7, 13, 14, 21, 22, 23, 24]. The results from the reviewed articles collectively suggest a promising array of positive outcomes associated with PA among individuals with neurodevelopmental conditions, particularly in various domains. Studies have highlighted the efficacy of specific activities such as combat sports in managing emotions [10, 21, 22]. Previous research by Bremer [26] and Bahrami [26] has also emphasized the positive effects associated with martial arts and horse riding [2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 24, 25, 26, 27, 28]. Moreover, team sports and games, with their inherent social cooperation aspects, have shown compelling results [2], and previously DeJesus [26] reported the effectiveness of rhythmic exercises in enhancing communication and overall psychological well-being [2], while aerobic exercises conducted just before lessons have been linked to improved academic performance in children [29].
However, there remains uncertainty surrounding the optimal dosage of sports for individuals with ASD, which may vary depending on the type of sport. Previous reviews have suggested that a beneficial effect typically requires a minimum frequency of three times per week [10]. However, among the reviewed studies, the most prevalent frequency observed was twice per week [3, 4, 22, 23]. One study tested a weekly PA intervention [21], while another did not specify the frequency, potentially indicating a methodological error [13]. Further categorization of activities based on their intensity levels - such as distinguishing between low, moderate, or high intensity - is necessary. Additionally, the duration of activities varied notably across studies, ranging from 45 to 90 minutes [10]. Hynes and Block [28] reported an average program length of 11 weeks, comprising 3.2 sessions per week, each lasting 50 minutes, suggesting various potentially effective procedures.
The COVID-19 pandemic significantly impacted children with ASD and their PA levels [30]. Although the internet is often blamed for contributing to sedentary behaviour, online sports activities provide an accessible option for youngsters who might face challenges with in-person activities or in the case of another lockdown [31]. Platforms like WhatsApp or Zoom can also assist children dealing with severe social difficulties, especially when initial exercise prescriptions are limited by psychological challenges [30].
Previous research [32, 33] showcased the positive influence of PA on motor skills and coordination among individuals with ASD. Structured physical activity programs, including aerobic exercises, yoga, and swimming, demonstrated improvements in gross and fine motor skills, contributing to enhanced daily functioning [32, 33]. Studies such as Schmitt [34] and Bremer [35] indicated that tailored PA facilitate sensory integration and regulation. Engaging in activities involving proprioceptive and vestibular stimuli proved beneficial in addressing sensory processing difficulties commonly observed in individuals with ASD, leading to improved self-regulation [34, 35]. The PA potential to foster social interaction and inclusion is an area of considerable interest [25, 33]. Group-based activities structured around shared interests or goals provided a platform for individuals with ASD to interact, facilitating social engagement and communication skills [25, 33].
Limitations
The reviewed studies exhibit limitations in cohort size and intervention duration (Table 4), suggesting a need for more advanced psychometric screening of participants [2]. For instance, studies centred on martial arts could benefit from incorporating scales measuring aggressive behaviours or employing alternative methods like facial expression analysis, eye movement recording, or monitoring changes in heart rate. Generalizability concerns prompt the necessity to explore demographic specifics within the studied populations, particularly considering the potential gender-related nuances in the impact of PA on individuals with ASD. Notably, several studies in this review demonstrated a considerable gender imbalance, with varying male-to-female ratios. For instance, Caputo’s study [4] comprised 11 out of 13 males in the intervention group and 7 out of 13 females in the control group. Haghighi [2] included 5 out of 8 males, while Morales [21] involved 11 out of 15 male participants. Phung’s study [22] notably included 28 out of 34 participants (82.4%) as boys, Zhao and Chen [7] had 14 out of 21, Tse [3] had 14 out of 19, and Tse [24] included 13 out of 15. However, some studies did not provide gender-specific information [13, 14]. The potential confounding influence of gender bias remains uncertain and requires further exploration.
Studies might also vary concerning the baseline physical activity levels among children. Introduction of assessment scales, such as The Physical Activity Questionnaire for Older Children (PAQ-C) utilized by Nguyen [13], could enhance the quality of future research.
None of the studies encompassed preschool children. While Sefen [27] suggested limited benefits of PA for preschoolers with ASD, Ketcheson [36] emphasized the importance of integrating motor programming in early intervention services. Notably, crucial potential benefits of PA, like addressing self-injury, impulsivity, attention deficits, anxiety, and depression, remained unexplored within the reviewed studies [12].
Comprehensive mechanistic understandings of PA effects through biological evidence remain relatively underexplored. Gaining insights into how PA influences various domains and providing biological evidence, such as blood tests, MRI scans, or EEG recordings could significantly strengthen the evidence base. However, resistance to such tests might arise among many children with ASD unless they are part of medication monitoring.
Future Research Suggestions
Future research should prioritize defining optimal parameters for PA tailored to individuals with ASD, aligning with WHO guidelines advocating for a minimum of 60 daily minutes of PA, while acknowledging variations based on the severity of ASD [5, 30]. Integrating biological research with PA studies can provide deeper insights into its effects, particularly regarding social interactions [28]. Investigating psychological factors influencing PA engagement and reviewing methodologies for better assessments remain critical. Efforts to improve accessibility, remove barriers, and integrate PA initiatives within educational and community settings are essential [38]. Longitudinal studies tracking sustained PA impacts within ASD interventions and community programs can significantly enhance well-being across the ASD spectrum. However, it is important to note that this standard may vary based on the type and severity of ASD [30]. Examining the potential of PA to alleviate early developmental challenges is another crucial avenue for exploration [27, 36]. Highlighting factors that encourage continued engagement with PA, including family involvement, community education, and the roles of PA educators, is pivotal [28]. Exploring how familial dynamics foster participation in sports and PA at home poses an intriguing area for investigation.
Reviewing the methodologies of current studies and evaluating both short and long-term effects of PA remains essential. Efforts should target enhancing accessibility and eliminating barriers at individual, social, and community levels [38]. This involves investing in inclusive gyms and parks, along with targeted programs for children, parents, and community education initiatives. Prioritizing the integration of PA initiatives within educational settings and community programs holds promise in significantly enhancing the overall well-being and quality of life for individuals across the ASD spectrum.
This discussion emphasizes PA as an invaluable tool in addressing diverse challenges faced by individuals with ASD. Tailored interventions, when meticulously designed and implemented, hold promise in fostering holistic development and improving the lives of those within the autism community. Beyond research findings, underscoring practical applications is crucial, and comprehensive reviews offer cost-effective ways to demonstrate PA efficacy to populations that could benefit from it.
Conclusions
This review asserts that PA stands as a promising adjunctive therapeutic approach for ASD. Various interventions, notably martial arts, showcase favourable outcomes across emotional, social, and health-related domains. However, the limited comparability of interventions and outcomes, coupled with the inclusion of only ten studies, introduces ambiguity regarding the precise position of PA. While biases generally fall within the low to medium range, concerns emerge due to the absence of standardized protocols, intervention heterogeneity, and the nuanced consideration of PA dosage. Addressing these intricacies is essential for a comprehensive understanding of PA’s efficacy in ASD interventions.
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