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Comparison of the effects of perceptual-motor exercises, vitamin D supplementation and the combination of these interventions on decreasing stereotypical behavior in children with autism disorder

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Objectives: The aim of this study was to examine the combined effects of perceptual-motor exercises and vitamin D3 supplementation on the reduction of stereotypical behavior in children with autism disorder (ASD). Methods: In this study, 100 eligible children with age ranging from 6 to 9 years were randomly selected and divided into four groups: Group A—perceptual-motor exercises (n = 25); Group B—25-hydroxycholecalciferol (25 (OH) D) (n = 25); Group C—perceptual-motor exercises and 25 (OH) D (n = 25); and Group D—control (n = 25). Results: The stereotypes decreased from elementary level, 17% in Group A, 13% in Group B and 28% in Group C among the participants. There was no change in the stereotypical in the control group during the interventions. Also, the stereotypes in Group C showed the highest decrease, compared to the other three groups. Conclusions: We concluded that combination of perceptual-motor exercises and vitamin D3 supplementation in children with ASD leads to significant reduction in their stereotypic behaviors.
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Comparison of the effects of
perceptual-motor exercises, vitamin D
supplementation and the combination of
these interventions on decreasing
stereotypical behavior in children with
autism disorder
Hadi Moradi
1
, Mehdi Sohrabi
1
, Hamidreza Taheri
1
,
Ezzat Khodashenas
2
, and Ahmadreza Movahedi
3
1
Department of Motor Behavior, Faculty of Sport Sciences, Ferdowsi University of Mashhad, Mashhad, Iran
2
Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
3
College of Sport Sciences, University of Isfahan, Isfahan, Iran
Objectives: The aim of this study was to examine the combined effects of perceptual-motor exercises and
vitamin D
3
supplementation on the reduction of stereotypical behavior in children with autism disorder (ASD).
Methods: In this study, 100 eligible children with age ranging from 6 to 9 years were randomly selected and
divided into four groups: Group Aperceptual-motor exercises (n¼25); Group B25-hydroxycholecalciferol
(25 (OH) D) (n¼25); Group Cperceptual-motor exercises and 25 (OH) D (n¼25); and Group Dcon-
trol (n¼25).
Results: The stereotypes decreased from elementary level, 17% in Group A, 13% in Group B and 28% in
Group C among the participants. There was no change in the stereotypical in the control group during the
interventions. Also, the stereotypes in Group C showed the highest decrease, compared to the other
three groups.
Conclusions: We concluded that combination of perceptual-motor exercises and vitamin D
3
supplementation
in children with ASD leads to significant reduction in their stereotypic behaviors.
Keywords: Stereotypical, perceptual-motor exercises, vitamin D
3
, autism spectrum disorder
Introduction
Stereotypical behaviors are one of the main symptoms
in individuals with autism disorder (American
Psychiatric Association 2013). Patients with autism
show a variety of stereotypical behaviors. It seems that
stereotypical movements aim to provide sensory input
and hence are considered self-stimulating (Schmitz
et al.2017). The stereotypical movements are known as
very constant, repetitive, non-flexible, abnormal,
strange, and uncanny behaviors, performed mainly
without a specific purpose (Berkson and Davenport
1962, Rapp et al.2004).
The stereotypical behavior in individuals with autism
disorder causes significant disruptions in learning
process (Schmitz et al.2017), self-disturbing behaviors
(Bodfish et al. 2000), behavioral problems (Gabriels
et al. 2005), and delayed response to environmental
stimuli (Lovaas et al.1971). The movements often take
almost the entire attention of the child, so that he/she is
unable to follow and respond to other stimuli, and they
are highly resistant to treatment (Bodfish et al.2000).
Therefore, stereotypical behaviors are a major problem
for parents and doctors associated with these children,
so paying attention to these behaviors and implement-
ing appropriate methods to decrease these behaviors is
of great importance.
Despite the deficits and its effects on individuals
with autism, research has shown that the use of appro-
priate interventions can have a positive effect on these
deficits. Various treatment methods have been reported
Correspondence to: Mehdi Sohrabi, Department of Motor Behavior,
Faculty of Sport Sciences, Ferdowsi University of Mashhad, Mashhad,
Iran. Email: sohrabi@um.ac.ir
#The British Society of Developmental Disabilities 2018
DOI 10.1080/20473869.2018.1502068 International Journal of Developmental Disabilities 2018 VOL.0 NO.0 1
by researchers to improve deficits in individuals with
autism disorder, such as physical activities (Bahrami
et al. 2016), nutrition (Amminger et al.2007), social
stories (Gray and Garand 1993), games, and verbal
behavior training (Yoder 2006). Studies on physical
activities have confirmed the effect of these interven-
tions on improving the childrens academic skills, per-
ceptual function, social skills, self-harm behaviors, and
aggression (Allison et al.1991, Movahedi et al.2013,
Hilton et al.2014, Pan et al.2016). Research indicates
that the motor skills of young children with autism
spectrum disorder (ASD) are significantly delayed and
of poor quality (Green et al.2009). Low levels of phys-
ical activity can lead to an unhealthy body composition
and increased morbidity (Janssen and LeBlanc 2010),
thus potentially placing individuals with ASD at greater
risk for negative health outcomes. It is possible that low
levels of motor-skill proficiency may be one of the con-
tributing factors, in conjunction with social factors, to
the physical inactivity in children with ASD (Bremer
and Lloyd 2016). Therefore, the improvement of motor
skills may be crucial for children with ASD because it
enables them to share physical activity with their peers
and allows them to benefit from the benefits of physical
activity (Bremer and Lloyd 2016). Children with autism
have deficiencies in perceptual-motor processes (Jepsen
and VonThaden 2002). So it is very important for chil-
dren to have a rich and strong background of perceptual
motor experiences as a base of the motor and nervous
systems (Piek et al. 2006). The efficiency of exercise-
based interventions on stereotypic behaviors in individu-
als with autism has rarely been studied. Investigators
have not yet empirically studied the role played by per-
ceptual-motor exercises on reduction of stereotypic
behaviors in children with autism spectrum disorders, in
the present study our main goal was to determine
whether perceptual-motor exercises to children with aut-
ism disorder lead to reductions in their stereo-
typic behaviors.
Another factor that may play a role in childrens
development in the first years of life is the nutritional
effects at early ages. Neural structures are sensitive to
environmental and nutritional factors like vitamin D,
which play an important role during this period (Harms
et al. 2011). Vitamin D has been found to have a poten-
tial role in brain homeostasis and development, such as
neuronal differentiation, neurotransmission, and synap-
tic function (Cannell 2017, Wang et al.2016). Vitamin
D deficiency is reported to be widespread worldwide
(Palacios and Gonzalez 2014). Low levels of vitamin D
induce negative changes on anxiety and social behavior
(Pan et al.2014), immune system (Hewison 2010), and
degradation of cognitive function (Grung et al.2017).
Vitamin D deficiency is also involved in the incidence
of autism disorder (Wang et al.2016). Majority of stud-
ies have conclude that vitamin D level in children with
ASD is significantly lower than that in healthy individ-
uals (Du et al.2015, Fernell et al.2015, Saad et al.
2018). We can deduce that low vitamin D level is com-
mon and an ongoing condition in children with ASD,
even evolving toward the adult period (Jia et al.2018).
The brain of individuals with autism spectrum dis-
order has significantly lower concentrations of serotonin
compared to those without autism (Chugani et al.
1999). The disruption of the serotonergic system is one
of the most consistent observations associated with aut-
ism (Zafeiriou et al. 2009). Investigators have shown
that serotonin plays a major role in autism (Kane et al.
2012, Yang et al. 2012, Boccuto et al.2013b, Patrick
and Ames 2014). Researchers have shown that the dis-
turbances of brain key neurotransmitters including sero-
tonin play a role in the maintenance of stereotypic
behaviors (Schoenecker and Heller 2001). However,
further reduction of brain serotonin in individuals with
autism is exacerbated by the acute reduction of trypto-
phan and symptoms such as repetitive behaviors and
face recognition patterns, which revealed the
continued need for serotonin to modulate these behav-
iors (Daly et al.2012). Though vitamin D supplementa-
tion might improve symptoms in children with autism
spectrum disorder, yet, study in this area is limited
(Saad et al. 2016a, 2016b). Therefore, previous studies
suggest more studies to be carried out (Patrick and
Ames 2014).
Despite evidence that shows delay in motor skills
and inadequate levels of vitamin D as the main indica-
tors for diagnosis of autism spectrum disorder, few
researches have evaluated their impact as interventions
on the deficits of children with autism disorder. To our
knowledge, studies on stereotypical behaviors have
been conducted more in case studies or small research
projects (Jia et al.2015). In addition, no study has
examined various combinations of interventions on chil-
dren with autism. Therefore, this study is one of the
first studies to examine the combination of vitamin D
3
and perceptual-motor activities on reducing the stereo-
typical behavior of children with autism disorder. Given
that children with autism suffer from a wide range of
disorders, the cause of which has remained unknown to
date, the researchers suggest using a combination of
interventions to address the deficiencies in individuals
with this disorder. Hence, the present study sought to
examine two important interventions and combine these
two interventions on children with autism. Finally, the
main aim of this study was to compare the efficacy of
perceptual-motor exercises and vitamin D
3
supplemen-
tation and the combination of these two interventions
on reducing stereotypical behavior in children with aut-
ism disorder. The results of this study provided benefi-
cial empirical evidence for perceptual-motor exercises
and vitamin D
3
supplementation and combining these
Hadi Moradi et al. Comparison of the effects of perceptual-motor exercises, vitamin D supplementation
2International Journal of Developmental Disabilities 2018 VOL.0 NO.0
two interventions to improve stereotypical behavior in
individuals with autism disorder.
Methods
Participants
Participants were students ranging in age from 6 to 9
years (M ¼7.62 years, SD =1.15) from one of three
specialized institutions for youth with ASD who were
selected randomly to participate in the present study
(see Table 1 for additional demographic information
and baseline ASD-specific symptom severity). The chil-
dren were living with their own families, and attended
one of three institutions for students with autism. Each
participant had been formerly diagnosed as having ASD
using the Diagnostic and Statistical Manual of Mental
Disorders-Fifth Edition, Text Revision (DSM-5)
(American Psychiatric Association 2013). Participants
were screened by an experienced physician and were
found eligible to participate in the study. Participants
were 100 children with ASD whom were selected from
a sample of 250 children with autism. All participants
were in a good nutritional state. In total, 139 children
with ASD were excluded as they did not meet the inclu-
sion criteria. A total of 11 participants were also
excluded as their families declined to participate in
the study.
The inclusion criteria for this study are an autism
diagnosis confirmed by a psychologist along with a
medical team and based on diagnostic criteria DSM-
5, obtaining consent from parents, vitamin D serum
level less than 30 ng/ml, chronological age between
six and nine years, IQ more than 70, sound sense
of sight and hearing, lack of orthopedic and respira-
tory disorders, and lack of seizure attacks in the
last two years. Participants who had associated
gastrointestinal problems, children with feeding prob-
lems or malnutrition, genetic disorders, autoimmune
disorders, anemia, neurological diseases, and meta-
bolic disorders, children with known endocrine, car-
diovascular, pulmonary, and liver or kidney disease,
history of severe head trauma or stroke, as well as
any subjects receiving vitamin D-containing prepara-
tions and drugs that may affect vitamin D levels
were excluded.
None of the participants had officially received phys-
ical activity and vitamin D interventions in the last six
months. In addition, they were all following identical
treatment strategies at the autism center. All subjects
had a good nutritional status; children with feeding
problems or malnutrition were excluded from the study.
Then the participants were randomly assigned into four
groups: Group Aperceptual-motor exercises (n¼25);
Group Bvitamin D
3
supplementation (n¼25); Group
Cperceptual-motor exercises and vitamin D
3
supple-
mentation (n¼25); and Group Dp
\\lacebo (n¼25). Table 1 provides the characteris-
tics of the participants, including their chronological
age, gender, IQ, and the level of Vitamin D before the
interventions. This study has been carried out in
accordance with the code of Ethics of the World
Medical Association (Declaration of Helsinki) for
experiments involving humans. All procedures are
approved by the Ethical Committee of Ferdowsi
University of Mashhad, Iran. Informed consent had
been obtained from parents of all participants prior to
their inclusion.
Experimental interventions
I. Group A: Perceptual-motor exercises
The motor activities for this study were taken from
Perceptualmotor activities for children by Johnstone
and Ramon (2011). In designing this protocol, attempts
were made to use previous studies carried out in this
field (Kurtz 2007). The activities, content, and goals of
the intervention are listed in Table 2.
II. Group B: Vitamin D
3
supplementation
Group A consisted of 25 patients who were ran-
domly allocated to receive vitamin D
3
drops, 300 IU/kg/
day not to exceed 5000 IU/day (Saad et al. 2016a,
2016b) for 3 months.
Table 1. Participantscharacteristics (age, sex, autism severity, IQ, and 25 (OH) D levels) at the pre-intervention time.
Group A M±SD Group B M±SD Group C M±SD Group D M±SD p Value
ASD 25 25 25 25
Age (years) 1.03 ± 7.64 0.97 ± 8.04 1.22 ± 7.60 1.25 ± 7.20 0.08
Sex (male/female) male male male male
Autism severity 12.94 ± 53.20 14.96 ± 56.64 19.54 ± 55.68 19.58 ± 58.16 0.77
IQ 7.38 ± 91.92 6.96 ± 91.52 8.06 ± 92.84 6.45 ± 93.40 0.79
25 (OH) D levels (ng/ml) 5.02 ± 11.88 4.61 ± 12.60 4.79 ± 13.04 4.87 ± 11.52 0.67
Abbreviations: Group A: perceptual-motor exercises; Group B: vitamin D
3
supplementation; Group C: perceptual-motor exercises and
vitamin D
3
supplementation; Group D: Placebo; M: mean; SD: standard deviation
Autism severity: Sum of the GARS-2 (Gilliam Autism Rating Scale-Second Edition) three subscales (stereotypy, communication and
social interaction) raw scores
ANOVA test were used to check if there are differences between the 4 groups. Significant differences between the 4 groups were illus-
trated as p<0.05.
Significant: p<0.05
Hadi Moradi et al. Comparison of the effects of perceptual-motor exercises, vitamin D supplementation
International Journal of Developmental Disabilities 2018 VOL.0 NO.0 3
III. Group C: Perceptual-motor exercises and Vitamin
D
3
supplementation
This involved performing a combination of
Perceptual-motor Exercises and taking Vitamin D
3
for
3 months (Table 3).
IV. Group D: Placebo
Group D consisted of 25 patients who received a
matching placebo drops with the same taste and color
of vitamin D
3
drops for 3 months. The placebo con-
sisted of a combination of polysorbate 20, which is the
same fragrance ingredient used in vitamin D drops in
addition to glycerin, disodium edetate, and b-cyclodex-
trin in purified water.
Materials
a. Gilliam Autism Diagnostic Inventory-Second Edition
(GARS-2)
We used the stereotypy behavior subscale of Gilliam
Autism Rating Scale-2 (GARS-2) to evaluate changes
in participantsstereotypy behavior intensity (Gilliam
2006). Gilliam Autism Rating Scale-Second Edition has
been widely used in research studies and educational
program (Worley and Matson 2011). The stereotypy
subscale of GARS-2 contains 14 items that describe
specific, measurable, and observable stereotyped behav-
iors. It incorporates observations, parent or teachers
interviews, and questions completed by the examiner
according to their interpretation. The items of the sub-
scale ask caregivers how often a child: 1. Avoids estab-
lishing eye contact, looks away when eye contact is
made; 2. Stares at hands, objects, or items in the envir-
onment for at least 5 seconds; 3. Rapidly flicks fingers
or hands in front of eyes for periods of 5 seconds or
more; 4. Eats specific foods and refuses to eat what
most people will usually eat; 5. Licks, tastes or attempts
to eat inedible objects; 6. Smells or sniffs objects; 7.
Whirls, turns in circles; 8. Spins objects not designed
for spinning; 9. Rocks back and forth while seated or
standing; 10. Makes rapid lunging, darting movement
when moving from place to place; 11. Walks on tiptoes;
12. Flaps hand or fingers in front of face or at sides;
13. Makes high-pitched sounds; and 14. Slaps, hits, or
bites self or attempts to injure self in other ways.
Parents and teachers are asked to rate the individual
based on the frequency of occurrence of each stereo-
typed behavior under ordinary circumstances in a 6-h
period. The current study concentrated on the total raw
score in the stereotypy subscale of GARS-2. The
Table 2. Perceptual-motor exercises protocol.
Physical
exercises Length (min) Contains Target
Warm up 10 Jogging, stretching Warm up and stretching
Perceptual-motor
exercises
45 1. Jumping: Such as jumping back and forth on
the squares (30 x 30 cm), jumping succession,
crosswise jumping (a jump to the right and a
jump to the left), etc.
2. Hopping: Such as hopping back and forth,
opping in succession, crosswise hopping (a hop
to the right and a hop to the left), etc.
3. Static and dynamic balance: Such as standing
with the dominant foot on a hard surface,
walking on a balance beam with eyes opened,
etc.
4. Hitting ball with feet: Such as walking alongside
blue and red balls and hitting the red ones, etc.
5. Throwing ball to the target by hand: Such as
throwing a ball into the basket from a distance
of one meter or 1.5 meters, etc.
6. Throw and receive ball: Such as throwing a
plastic ball to a wall at a distance of one meter
and catching it by hand, etc.
Improvement of: Stability skills, Locomotor
skills, Manipulative skills, dynamic bal-
ance, static balance, motor planning,
motor coordination, eyehand coordin-
ation, eyefoot coordination, gross
motor coordination, body awareness,
tracking skills, transference, arm-leg
strength, body awareness, directionality,
throwing accuracy, precision, spatial
awareness, Kinesthetic awareness,
tactile awareness, Unilateral movement
Cool down 5 Walking slowly, stretching Cool down and recovery
Table 3. Vitamin D levels in ASD patients before and after vitamin D
3
supplementation.
Group
Before vitamin D therapy
(M ± SD)
After vitamin D therapy
(M ± SD)
pValue
(paired samples test)
A 5.02 ± 11.88 4.56 ± 12.04 0.61
Vitamin D levels (ng/ml) B 4.61 ± 12.60 6.48 ± 24.36 0.01
C 4.79± 13.04 5.76 ± 24.04 0.01
D 4.87 ± 11.52 3.95 ± 11.08 0.28
Group A: perceptual-motor Exercises; Group B: vitamin D
3
supplementation; Group C: perceptual-motor exercises and vitamin D
3
sup-
plementation; Group D: Placebo.
M: mean; SD: standard deviation
: Significant at p<0.05.
Hadi Moradi et al. Comparison of the effects of perceptual-motor exercises, vitamin D supplementation
4International Journal of Developmental Disabilities 2018 VOL.0 NO.0
subscale is both reliable and valid and has high psycho-
metric properties (Worley and Matson 2011).
B. Evaluation of the level of Vitamin D by the
Elecsys method
Serum 25(OH) D is considered to be adequate if it is
30 ng/mL, inadequate if it is between <30 and
>10 ng/mL, and deficient if it is 10 ng/Ml (Mostafa
and Al-Ayadhi 2012). After sampling the blood from
the participants, the Elecsys 2010 device made in the
German Roche Company was used to evaluate the lev-
els of Vitamin D. Investigators have found a debate
about values of the normal levels of vitamin D; if the
value should be equal to, or more than, 20 ng/ml, 30 ng/
ml, or higher even still (Holick et al.2011, Stubbs
et al.2016). Based on this technology and combined
with well designed, specific and sensitive immunoas-
says, Elecsys delivers reliable results (Connell et al.
2011). Children whose Vitamin D serum levels were
less than 30 ng/ml had the inclusion conditions to enter
the study. Serum Vitamin D levels were measured
before and 3 months after treatment (Table 4).
C. Raven IQ test
This test is comprised of abstract images which cre-
ate a logical sequence and is administered separately
(Raven et al.1996). This test has a high level of valid-
ity (0.80) and can be administered to groups (Raven
et al. 2008). This tool in the study was used to screen
and homogenize the general intelligence level of chil-
dren with autism.
Procedure
Each child who qualified to participate in this study had
been previously diagnosed with ASD by a clinician or
school psychologist according to the Diagnostic and
Statistical Manual of Mental Disorders (American
Psychiatric Association, 2013). At the initial assess-
ment, all parents completed a supplemental information
form in order to provide demographic data and a brief
developmental history of their child.
We administered stereotypical behavior subscale of
GARS-2 before intervention (pre-intervention) and
post-intervention (3 months) via interview with the
participantsparents, care givers and teachers and by
child direct observation. We organized a separate for-
mal meeting where we asked the participantsparents,
caregivers, and teachers to read over the statements
grouped with each number in the subscale. Then we
asked them to compromise and agree on the statement
within each group that best describes the way they have
been feeling about the child during the previous week.
In Group Perceptual-motor Exercises (Group A), to
ensure quality in program implementation, the physical
activity intervention was implemented as prescribed and
supervised by the primary researcher for each session.
The researcher received help from an instructor at the
Center of Autism. This instructor had 10 years of
experience with autistic children. If the instructor did
not implement the instructional sequence of each com-
ponent of the intervention as intended, the primary
researcher intervened to assist the instructor. If any par-
ticipant engaged in off-task behavior during the pro-
gram, the instructor managed the behavior, and the
primary researcher assisted the instructor when
required. The sessions were carried out in a therapy
room located at the Center of Autism. The course lasted
for 3 months and the sessions were thrice a week. Each
session was 60 minutes long. They included stretching
and jogging (10 minutes), main perceptual-motor
Exercises (45 minutes), and cool down (5 minutes)
(Table 2).
Children with ASD in Group Vitamin D
3
supple-
mentation (Group B), under the control of the
researcher, consumed Vitamin D
3
tablets (300 IU/kg/
day not to exceed 5000 IU/day (Saad et al. 2016a,
2016b) for 3 months). In Group C, both interventions
of Groups A and B were conducted for 3 months (The
protocol of Perceptual-motor Exercises was 36 sessions
(3 months) at 12 weeks and three sessions per week,
with each session lasting 60 minutes þreceive vitamin
D
3
drops, 300 IU/kg/day not to exceed 5000 IU/day for
3 months). Children with ASD in Group D also
received a matching placebo drops with the same taste
and color of vitamin D
3
drops for 3 months. The rate of
changes in the severity of stereotypical behavior was
evaluated using the stereotypical subscale of GARS-2
before and after the intervention (Table 3).
Table 4. Vitamin D levels in ASD patients before and after vitamin D
3
supplementation.
Group Pre-intervention Intervention Post-intervention (3 months)
A Stereotypy was assessed Participants were instructed Perceptual-motor
Exercises for 36 sessions
Stereotypy was assessed
B Stereotypy was assessed Vitamin D
3
supplementation (300 IU/kg/ day not to
exceed 5,000 IU/day)
Stereotypy was assessed
C Stereotypy was assessed Participants were instructed Perceptual-motor
Exercises for 36 sessions þVitamin D
3
supplemen-
tation (300 IU/kg/ day not to exceed 5,000 IU/day)
Stereotypy was assessed
D Stereotypy was assessed received placebos (matching placebo drops with
the same taste and color of vitamin D
3
)
Stereotypy was assessed
Abbreviations: Group A: perceptual-motor exercises; Group B: Vitamin D
3
supplementation; Group C: perceptual-motor exercises and
Vitamin D
3
supplementation; Group D: control
Hadi Moradi et al. Comparison of the effects of perceptual-motor exercises, vitamin D supplementation
International Journal of Developmental Disabilities 2018 VOL.0 NO.0 5
Statistics
We used a KolmogorovSmirnov test to assess the nor-
mality of distribution of the data. To study the changes
in stereotypy severity before and after the intervention,
paired t-test was used. Then, an analysis of covariance
(ANCOVA) test and a Bonferroni follow-up test were
used to determine the differences between the four
groups. For all statistical analyses, p0.05 was consid-
ered to indicate statistical significance. The data were
also presented as mean (±) and standard deviation (SD).
Results
Table 5 presents descriptive information about the
groups at the pretest and post-test stages.
First, t-test was used to determine whether the
groups have been affected by interventions over the
course of time. The results showed significant differen-
ces in the severity of stereotypy severity in the experi-
mental groups during interventions (p¼0.01) and
stereotypy severity significantly improved after the
intervention. However, in the control group, the differ-
ence was not statistically significant (p¼0.51)
(Table 5).
Table 6 provides the results of the ANCOVA test,
indicating a significant difference between the groups.
To carefully investigate the difference between the
four groups in the variable stereotypy severity, the
Bonferroni test was used. Here the estimations were as
follows: The severity of stereotypy severity in the three
experimental groups (group-A, B, and C) had a signifi-
cant difference compared with the control group
(p¼0.01). No significant difference was observed
between perceptual-motor exercises groups and the
group with vitamin D
3
supplements in the severity of
stereotypy severity (p¼1.00). The severity of stereo-
typy severity in the perceptual-motor exercises group
and the group with vitamin D
3
supplements was signifi-
cantly different from the other three groups (p¼0.01).
This represents a significant improvement in stereotypy
severity in the combination group, compared to the
other three groups (Table 6).
Discussion
The aim of this study was to compare the effects of per-
ceptual-motor exercises and vitamin D
3
supplementa-
tion and the combination of these interventions on the
improvement of stereotypical behaviors in children with
autism disorder. The findings showed a significant
reduction in the stereotypical behavior of ASD children
in the three experimental groups after the end of the
interventions. The stereotypical behavior reduced from
the elementary level 17% in the group of perceptual-
motor exercises, 13% in the group of vitamin D
3
sup-
plementation and 28% in the combined group of per-
ceptual-motor exercises and vitamin D supplementation
among participants. There was no significant change in
the reduction of stereotypical behavior in children with
autism disorder in the control group. The results also
showed that stereotypical behaviors in the combined
group (perceptual-motor exercises and vitamin D
3
sup-
plementation) significantly improved compared to the
other three groups.
The usefulness of physical interventions for improv-
ing the symptoms of children with autism disorder has
been confirmed in several studies (Brand et al. 2015,
Bremer and Lloyd 2016, Ketcheson et al. 2017).
Regarding the use of physical activities in improving
the stereotypical behavior, studies on these
Table 5. Results of the stereotypy subscale of GARS-2 in response to intervention.
Group PRI (baseline) POI (12 weeks) Magnitude of change Paired samples test
A 3.44 ± 15.84 2.69± 13.08 2.53 ± 2.76 0.01
SSGARS-2 B 3.88 ± 17.08 2.80 ± 14.76 2.07 ± 2.32 0.01
C 3.47± 17.40 2.82 ± 12.36 2.42 ± 5.04 0.01
D 3.19 ± 16.28 4.01 ± 15.92 2.69 ± 0.36 0.51
Abbreviations: SSGARS-2, stereotypy subscale of Gilliam Autism Rating Scale-Second Edition; Higher scores indicate a higher level
of stereotypy.
Group A: perceptual-motor exercises; Group B: Vitamin D
3
supplementation; Group C: perceptual-motor exercises and Vitamin D
3
sup-
plementation; Group D: control
PRI: pre-intervention; POI: post-intervention.
Data are mean ± SD.
: Significant at p<0.05.
Table 6. Summary of analysis of covariance.
Source Sum of squares d.f Mean square FSig. Effect size
SSGARS-2 Pretests 507.72 1 507.72 111.58 0.010.54
Group 238.09 3 79.36 14.44 0.010.35
Error 432.27 95 4.55
Abbreviations: SSGARS-2: stereotypy subscale of Gilliam Autism Rating Scale-Second Edition.
: Significant at p<0.05.
Hadi Moradi et al. Comparison of the effects of perceptual-motor exercises, vitamin D supplementation
6International Journal of Developmental Disabilities 2018 VOL.0 NO.0
interventions have shown that these interventions can
play a significant role in reducing the stereotypical
behavior in children with autism disorder (Bahrami
et al. 2012, Schmitz et al.2017). These findings show
the importance of physical activities and the formula-
tion of such programs in improving the deficits of chil-
dren with autism disorder. From the results of these
studies, it can be concluded that physical exercises not
only improve the physical status but also decrease the
incompatible patterns of autism behavior (Lancioni and
OReilly 1998).
Considering the effect of perceptual-motor exercises
on the improvement of stereotypical behavior in chil-
dren with autism disorder, several mechanisms can be
expressed. The first mechanism is related to the similar-
ity of motor activities and stereotypical behaviors.
According to some researchers, physical activities, as
an effective tool, is effective in reducing strain behav-
iors by providing a similar sensory feedback, through a
more appropriate way (Watters and Watters 1980).
Stereotypic behaviors are often hypothesized to occur
because the behavior itself produces pleasant internal
consequences for the individual (Rapp et al.2004).
This interpretation justifies the emergence and mainten-
ance of stereotypical movements in children with aut-
ism disorder. Based on this justification, stereotypical
movements are maintained through sensory feedback
produced after these movements and these movements
may be replaced or destroyed by movements that create
a similar feedback (Berkson 1983). Therefore, the more
trained movements overlap with mold movements, the
more the effect of these movements will be in reducing
or eliminating mold movements (Watters and Watters
1980). In this regard, Lang et al. (2010) argued that, as
a result of the similarity of physical activities by phys-
ical exercises with the stereotypical behaviors per-
formed by patients with autism disorder, the targeted
activities replace untargeted stereotypical activities in
these individuals (Lang et al.2010). Hence, perceptual-
motor exercises and the involvement of children with
autism disorder in activities such as throwing, receiv-
ing, coordination and balancing movements will
reinforce their intrinsic needs, so that they no longer
need to participate in performing stereotypical behavior
for them.
The second mechanism can be viewed from a neuro-
logical point of view. Studies on patients with autism
disorders have reported abnormal levels of neurotrans-
mitters such as serotonin and dopamine in these indi-
viduals (Volkmar and Anderson 1989). Serotonin plays
a major role in autism, as a neurotransmitter (Boccuto
et al.2013a, Yang et al.2012). According to animal
studies, a decrease in the level of serotonin results in
excessive growth of the cerebral cortex and behavioral
features which are similar to autism (Boylan et al.
2007, Hohmann et al. 2007). Such an evolutionary
defect in individuals with autism suggests that inad-
equate serotonin concentration prevents normal growth
of the brain in these individuals (Boylan et al.2007,
Rokade 2011) . Researchers have also shown that dis-
turbances in neurotransmitters such as serotonin and
dopamine play a role in the stereotypical behavior of
children with autism disorder (Schoenecker and Heller
2001). There is a large amount of evidence that links
stereotypy to the synthesis and metabolism of dopamine
and serotonin. Hyperserotoninaemia has been shown to
have negative correlations with declarative abilities and
self-injuries behaviors in individuals with autism dis-
order (Lanovaz 2011). However, it has been shown that
participation in physical activities can have a significant
effect on dopaminergic and serotoninergic systems and
thus, improve the synthesis of serotonin and dopamine
(Meeusen and De Meirleir 1995) and improve deficits
such as reduction of stereotypical behavior in children
with autism.
Concerning vitamin D supplementation, the results
showed that the application of vitamin D supplementa-
tion for 12 weeks significantly decreased stereotypical
behavior in children with autism disorder. The consist-
ent reduction of stereotypic behaviors of the partici-
pants of the vitamin D supplementation group in our
study may also be explained from a neurochemical
point of view. Vitamin D activates tryptophan hydroxy-
lase 2 (TPH2) in the brain and suppresses the transcrip-
tion of tryptophan hydroxylase 1 (TPH1) in the tissue
outside the bloodbrain barrier. In normal subjects,
TPH2 was greater than TPH1, but the levels of TPH1
were higher than autism, which increases gastrointes-
tinal inflammation, weakens the immune system, sero-
tonin neurotransmission and abnormal social behavior
in these individuals. Based on animal studies, lack of
TPH2 in ratsbrain serotonin synthesis presented
behavioral symptoms such as autism, including disrup-
tions in social behavior and communication and ten-
dency to stereotypical behaviors (Huang and Santangelo
2008, Kane et al.2012, Yang et al.2012, Boccuto
et al.2013b, Patrick and Ames 2014). In patients with
autism, as well, the further reduction of brain serotonin
is exacerbated by the acute reduction of tryptophan,
leading to symptoms such as repetitive behaviors and
facial recognition patterns that reveal the continued
need for serotonin to modulate these behaviors
(McDougle et al.1996, Daly et al.2012). Researchers
have shown that disturbances of brain key neurotrans-
mitters including serotonin play a role in the mainten-
ance of stereotypic behaviors (Schoenecker and Heller
2001). However, recent experimental studies have
shown that vitamin D can regulate the synthesis and
response to serotonin via TPH2, which can help
improve deficits in children with autism disorder
(Patrick and Ames 2014). In the present study, vitamin
D supplementation may have also increased the levels
Hadi Moradi et al. Comparison of the effects of perceptual-motor exercises, vitamin D supplementation
International Journal of Developmental Disabilities 2018 VOL.0 NO.0 7
of TPH2, which in turn results in more neurotransmis-
sion of serotonin in the brain and improves symptoms,
such as stereotypical behavior in children with autism
disorder. These data provide strong and convincing evi-
dence for a causal role of tryptophan-derived serotonin
in regulating many stereotypical behavior and support
the proposal that supplemental interventions affecting
the serotonin pathway may lead to improvements in a
wide range of stereotypical behavior in ASD (Patrick
and Ames 2014). For these reasons, dietary intervention
with vitamin D would boost brain serotonin concentra-
tions and help prevent and possibly ameliorate some of
the symptoms associated with ASD without
side effects.
Finally, the results of the study showed that a com-
bination of perceptual-motor exercises and vitamin D
supplementation in comparison to each of the groups
alone, led to a further reduction in stereotypical behav-
ior. In relation to the effects of the combination of per-
ceptual-motor Exercises and the consumption of
Vitamin D, several possible mechanisms could be men-
tioned. having adequate levels of Vitamin D may
improve neuromuscular function and ultimately
improve motor performance (Dhesi et al.2004, Lanteri
et al. 2013). Adequate levels of Vitamin D lead to the
creation of better morphological compliance of the
muscles through calcium absorption. This would lead to
better muscular function and activity (Todd et al.
2015). In this way, it could help in the perceptual-motor
Exercises of children with autism. Also, the use of vita-
min D in combined group in the present study has led
to better functioning of children in Motor activities to
perform exercises better and this can be effective in
improving the stereotypical behavior of children with
autism disorder. By the interpretation of the superiority
of the combined interventions, it can be stated that, on
the one hand, the effects of vitamin D supplementation
increased TPH2 and consequently increased neurotrans-
mission of serotonin in the brain (Patrick and Ames
2014), as well as the role of vitamin D in neurotrans-
mitter factors (Kalueff and Tuohimaa 2007). This vita-
min D-mediated production of serotonin would be
critical to produce serotonergic signals during neurode-
velopment, thus shaping the developing brain, and
throughout adulthood, where it plays a critical role in
regulating a variety of brain functions including stereo-
typical behavior. In addition, adequate vitamin D hor-
mone levels would suppress TPH1 expression, which
has important implications for lowering inflammation
and keeping autoimmunity at bay. Vitamin D could
also regulate the synthesis and response to serotonin
and oxytocin, as well as the response to vasopressin,
which could help improve social functioning and
stereotypical behavior in children with autism disorder,
as well. For these reasons, dietary intervention with
vitamin D would boost brain serotonin concentrations
and help prevent and possibly ameliorate some of the
symptoms associated with ASD without side effects.
On the other hand, Vitamin D
3
supplementation also
increased the effects of motor activities on neurotrophic
(Kalueff and Tuohimaa 2007) factors and increased the
learning of different skills (Pilc 2010, Griffin et al.
2011) such as motor coordination, balance and throwing
skills, as well as the replacement of motor activities
with stereotypical behaviors to relieve intrinsic feelings
in children with autism disorder, and improve stereotyp-
ical behaviors in children with autism disorder.
Although this study provides valuable information
about the effects of motor activity and vitamin D on
stereotypic behaviors of children with autism, some of
the limitations of this study should be considered.
Although we did not take any neurochemical and
physiological data in the present investigation, we
speculate that the perceptual-motor exercises and vita-
min D
3
supplementation may improve the synthesis and
metabolism of brain key neurotransmitters and conse-
quently may consistently decrease the stereotypic
behaviors in children with ASD. However, for more
precise conclusion in this context, it's better to investi-
gate neuropsychological and physiological factors using
accurate tools in future. We used fixed vitamin D
3
dos-
ing, but it may be more appropriate to titrate vitamin D
dosing based on baseline 25(OH) D levels and/or body
size. Although we analyzed results based on age (rang-
ing from 6 to 9 years), vitamin D
3
treatment effects
have been reported to be more pronounced in younger
children with ASD (Feng et al.2017) leading to the
suggestion that vitamin D
3
supplementation should start
in early infancy or during gestation (Stubbs et al.
2016). In this context, it is possible that there is a win-
dow of opportunity for adequate vitamin D
3
to provide
neuroprotection and that we included older children in
whom neuronal networks are established and therefore
less likely to benefit from supplementation. In this
study, groups B and D were blinded, but regarding to
the type of perceptual-motor activities intervention,
blinding in groups A and C was not possible. Finally, it
is possible that a higher dose of vitamin D would pro-
duce a greater change in children with ASD stereotyp-
ical behavior.
Conclusion
ASD is a severe, lifelong disorder with serious social
and financial consequences. Insufficient vitamin D due
to genetic and environmental factors is common in chil-
dren with autism spectrum disorder and may be a risk
factor for developing ASD. The results showed that the
combination of perceptual-motor exercises and vitamin
D
3
supplementation has a double effect in comparison
with any of the interventions alone on reducing the
stereotypical behavior of children with autism disorder.
Hence, the use of combined intervention can be an ideal
Hadi Moradi et al. Comparison of the effects of perceptual-motor exercises, vitamin D supplementation
8International Journal of Developmental Disabilities 2018 VOL.0 NO.0
strategy to decrease stereotypical behavior in children
with autism disorder. Vitamin D
3
supplementation can
be a worthwhile effort to reduce symptoms in ASD
with low vitamin levels. In addition, vitamin D
3
supple-
mentation during pregnancy may be preventive as a
preventive means for children with ASD or a measure
to reduce the prevalence of ASD. Supplementation of
vitamin D
3
, which is a confident and cost-effective
form of treatment, may significantly improve outcome
in some children with ASD, especially in younger chil-
dren. However, the exact mechanism how vitamin D
3
contributes to the etiology and treatment of ASD needs
further study. This study would suggest that when chil-
dren with ASD receive direct instructions on targeted
perceptual-motor exercises delivered within an evi-
dence-based framework, the results are positive.
However, considering all the facts in relation to the
roles of Vitamin D
3
and perceptual-motor exercises in
autism, further research is needed to provide a defini-
tive statement on this issue and a clarification of more
precise mechanisms.
Disclosure statement
No potential conflict of interest was reported by
the authors.
ORCID
Mehdi Sohrabi http://orcid.org/0000-0002-
4820-3486
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Hadi Moradi et al. Comparison of the effects of perceptual-motor exercises, vitamin D supplementation
International Journal of Developmental Disabilities 2018 VOL.0 NO.0 11
... However, the results of the randomized controlled trials (RCTs) are inconsistent. For example, Moradi et al. [28] showed that vitamin D supplementation was superior to a placebo in reducing the occurrence of stereotypical behavior; Mazahery et al. [29] showed a significant improvement in irritability and hyperactivity; and Javadfar et al. [30] showed significant alleviation of clinical symptoms as assessed by Childhood Autism Rating Scale (CARS), and the Autism Treatment Evaluation checklist (ATEC). Kerley et al. [31] reported that vitamin D supplementation had no effect on the primary outcomes of children with ASD. ...
... The main characteristics of the selected studies are illustrated in Table 1. Among the 8 selected studies, three were conducted in New Zealand [29,38,39], three were conducted in Iran [28,30,41], one was conducted in Ireland [31] and one was conducted in China [40]. Six studies recruited both male and female participants, and two studies recruited males only. ...
... Figure 2 shows the risk of bias in the included RCTs. Three studies that did not mention the random-sequence generation method were considered to have an unclear risk of randomization bias [28,40,41]. Four studies were considered to have an unclear risk of allocation concealment bias owing to insufficient information [28,31,40,41]. ...
Article
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The effect of vitamin D supplementation on individuals with autism spectrum disorder (ASD) is inconclusive. We aimed to conduct a meta-analysis of the available randomized controlled trials (RCTs) to explore whether vitamin D supplementation can improve core symptoms and coexisting conditions in children with ASD. Data were obtained by searching the PubMed, Embase, Web of Science, CINAHL and Cochrane Library databases up to February 2022 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Using a random-effects model, mean differences with 95% confidence intervals (CIs) were calculated through a meta-analysis. There were eight RCTs with 266 children with ASD in the present review, among which six RCTs were included in the meta-analysis. Children who received vitamin D supplementation showed a significant improvement in stereotypical behavior scores (pooled mean difference (MD): -1.39; 95% CI: -2.7, -0.07; P = 0.04) with low heterogeneity (I2 = 34%), and there was a trend toward decreased total scores on the Social Responsiveness Scale (SRS) and Childhood Autism Rating Scale (CARS, P = 0.05); however, there were no other significant differences in the core symptoms of ASD and coexisting conditions between groups as measured by the Aberrant Behavior Checklist (ABC). Vitamin D supplementation appears to improve stereotypical behaviors but does not improve other core symptoms and coexisting conditions. Further randomized controlled trials with large sample sizes and individualized doses are needed.
... The studies reported baseline levels of 23.6 ± 13.3 ng/mL [62], 21.68 ng/mL [63], and 10.84 ± 16.80 ng/mL and 8.19 ± 6.78 ng/mL, respectively, in the treatment and placebo groups of children with ASD [58]. The other studies only recruited vitamin D deficient children [64][65][66][67][68][69]. Saad et al. (2015) reported significantly lower 25(OH)D levels in children with severe ASD compared to children with moderate/mild ASD [55]. ...
... Therefore, these results remain inconclusive in establishing the independent effectiveness of vitamin D, attributed to certain limitations, including the presence of concurrent treatments and significant differences in baseline serum vitamin D levels between cases and controls. However, among the trials that did not present with these limitations, two showed favorable results [58,66], and three demonstrated limited or no favorable effects [63,68,69]. The main difference in the study protocols of these trials was the vitamin D supplementation approach. ...
... Similarly, the control group in the Ucuz et al. (2015) study also had baseline normal vitamin D levels, compared to deficient levels in the treatment group, which could ultimately mask the difference in improvement and explain the lack of significant differences between groups, despite the significant change within the treatment group. Additionally, one trial reported no differences within the treatment group [63], contradicting the reported outcomes in other studies [58,66]. Postulated reasons were the advanced age of the child or the fixed dosing. ...
Article
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Children with autism spectrum disorder (ASD) present with persistent deficits in both social communication and interactions, along with the presence of restricted and repetitive behaviors, resulting in significant impairment in significant areas of functioning. Children with ASD consistently reported significantly lower vitamin D levels than typically developing children. Moreover, vitamin D deficiency was found to be strongly correlated with ASD severity. Theoretically, vitamin D can affect neurodevelopment in children with ASD through its anti-inflammatory properties, stimulating the production of neurotrophins, decreasing the risk of seizures, and regulating glutathione and serotonin levels. A Title/Abstract specific search for publications on Vitamin D supplementation trials up to June 2021 was performed using two databases: PubMed and Cochrane Library. Twelve experimental studies were included in the synthesis of this review. Children with ASD reported a high prevalence of vitamin D deficiency or insufficiency. In general, it was observed that improved vitamin D status significantly reduced the ASD severity, however, this effect was not consistently different between the treatment and control groups. The variations in vitamin D dose protocols and the presence of concurrent interventions might provide an explanation for the variability of results. The age of the child for introducing vitamin D intervention was identified as a possible factor determining the effectiveness of the treatment. Common limitations included a small number of participants and a short duration of follow-ups in the selected studies. Long-term, well-designed randomized controlled trials are warranted to confirm the effect of vitamin D on severity in children with ASD.
... Following these results, the question about the effectiveness of Vitamin D supplements in curing ASD was raised. Moradi et al. [138] designed an interventional study and gave their participants 25-hydroxycholecalciferol (25 (OH) D) and in the follow-ups by comparing them with the control group, they realized that vitamin D3 supplementation could lead to a significant reduction in their stereotypic behaviors. Lee et al. [139] also compared numerous cases and agreed that vitamin D concentrations in early life may be associated with an increased risk of neurodevelopmental disorders, including ASD. ...
... Moradi et al. [138] 2018 Vitamin D 100 children with the age of 6-9 ...
Article
The effects of a sufficient amounts of vitamins and nutrients on the proper function of the nervous system have always been regarded by scientists. In recent years, there are many studies have been done on controling or improving the symptoms of neurological and behavioral disorders which is created by changes in the level of vitamins and other nutrition, such as omega-3 and iron supplements. Autism spectrum disorder (ASD) is a neurodevelopmental disorder that causes disruption individual communication, especially in social interactions. Its symptoms include anxiety, violence, depression, self-injury, trouble with social contact and pervasive, stereotyped, and repetitive behavior. ASD is most noticeable in early childhood. Attention Deficit Hyperactivity Disorder (ADHD) is a lasting pattern of inattention with or without hyperactivity that makes functional disrupt in daily life. ADHD symptoms included; impulsivity, hyperactivity, inattention, restlessness, talkativeness, excessive fidgeting in situations as sitting, meetings, lectures, or at the movies, boredom, inability to make decisions, and procrastination. The exact etiology of ADHD has not yet been found, but several observations have been assumed the reduced function of the brain lead to deficits in motor planning and cognitive processing. It has been shown that Pro-inflammatory cytokines and oxidative stress biomarkers could be increased in both ASD and ADHD. Several studies have been done to illustrate if vitamins and other dietary supplements are effective in treatment and prevention of ASD and ADHD. In this review, we aim to evaluate the effects of vitamins and other dietary supplements (e.g., melatonin, zinc supplements, magnesium supplements) on ASD and ADHD.
... In addition, five original studies (reported in seven manuscripts), in which the relation between vitamin D and ASD symptoms was investigated, were found [73][74][75][76][77][78][79] (see Table 7). In two larger scale RCTs, significant effects of vitamin D supplementation on respectively irritability and hyperactivity [76][77][78] and on stereotypical behavior were found [79]. ...
... In addition, five original studies (reported in seven manuscripts), in which the relation between vitamin D and ASD symptoms was investigated, were found [73][74][75][76][77][78][79] (see Table 7). In two larger scale RCTs, significant effects of vitamin D supplementation on respectively irritability and hyperactivity [76][77][78] and on stereotypical behavior were found [79]. In one cohort and one case control study, no significant associations were found between vitamin D supplementation at 2.5 years of age and ASD diagnosis at a mean age of 5.1 years [73]. ...
Article
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Autism spectrum disorder (ASD) is characterized by impairments in social interaction, communication skills, and repetitive and restrictive behaviors and interests. Even though there is a biological basis for an effect of specific nutrition factors on ASD symptoms and there is scientific literature available on this relationship, whether nutrition factors could play a role in ASD treatment is unclear. The goal of the current literature review was to summarize the available scientific literature on the relation between nutrition and autism spectrum disorder (ASD) symptoms in childhood, and to formulate practical dietary guidelines. A comprehensive search strategy including terms for ASD, nutrition factors (therapeutic diets, dietary patterns, specific food products, fatty acids and micronutrients) and childhood was developed and executed in six literature databases (Cinahl, Cochrane, Ovid Embase, PsycInfo, PubMed and Web of Science). Data from meta-analyses, systematic reviews and original studies were qualitatively summarized. A total of 5 meta-analyses, 29 systematic reviews and 27 original studies were retrieved that focused on therapeutic diets, specific food products, fatty acids and micronutrients and ASD symptoms during childhood. Results of the available studies were sparse and inconclusive, and hence, no firm conclusions could be drawn. There is currently insufficient evidence for a relation between nutrition and ASD symptoms in childhood, making it impossible to provide practical nutrition guidelines; more methodological sound research is needed.
... High-Dose VD Can Improve the Core Symptoms of ASD Jia et al. administered VD to children with ASD and found that high-dose supplementation with VD could improve the core symptoms of the disorder (32,(42)(43)(44). ...
Article
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Vitamin D (VD) deficiency during pregnancy and early brain development is an important environmental risk factor for autism spectrum disorder (ASD). Its specific mechanism of action is still unclear. However, one study on the correlation between metabolomics and VD levels in children with ASD has found that the whole-blood arginine (Arg) levels of children with ASD are significantly negatively correlated with serum VD levels, suggesting that the effect of VD on ASD may be related to the signaling pathway involving Arg. Arg is a precursor of nitric oxide (NO), and changes in its levels most directly affect NO levels and signal transduction pathways. NO, a biologically active free radical, is both a neurotransmitter and a neuromodulator in the central nervous system and is related to the pathogeneses of various neurological diseases. The NO signaling pathway is not only affected by VD levels but also closely related to ASD through a series of mechanisms, such as neurotransmitter imbalance, immune disorders, and oxidative stress. Therefore, the effect of VD on ASD may be achieved via regulation of the NO signaling pathway. The current review discusses the relationship among VD, NO, and ASD as suggested by a large body of evidence in the literature in an effort to provide clues for researchers on the pathogenesis of ASD and the mechanism of VD's impact on ASD.
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Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects several areas of mental development. The onset of ASD occurs in the first few years of life, usually before the age of 3 years. Proper nutrition is important to ensure that an individual’s nutrient and energy requirements are met, and it can also have a moderating effect on the progression of the disorder. A systematic database search was conducted as a narrative review to determine whether nutrition and specific diets can potentially alter gastrointestinal symptoms and neurobehavioral disorders. Databases such as Science Direct, PubMed, Scopus, Web of Science (WoS), and Google Scholar were searched to find studies published between 2000 and September 2023 on the relationship between ASD, dietary approaches, and the role of dietary components. The review may indicate that despite extensive research into dietary interventions, there is a general lack of conclusive scientific data about the effect of therapeutic diets on ASD; therefore, no definitive recommendation can be made for any specific nutritional therapy as a standard treatment for ASD. An individualized dietary approach and the dietician’s role in the therapeutic team are very important elements of every therapy. Parents and caregivers should work with nutrition specialists, such as registered dietitians or healthcare providers, to design meal plans for autistic individuals, especially those who would like to implement an elimination diet.
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Objective The aim of this systematic review and meta-analysis was to systematically investigate the intervention effect of physical exercise on disordered social communication in patients with autism spectrum disorders. Methods This systematic review and meta-analysis used the PubMed, Web of Science, the Cochrane Library, and Embase electronic databases to conduct a systematic search of literature describing randomized controlled trials (RCTs) on the effect of physical exercise on disordered social communication in autistic patients from the first year of inclusion to 21 January 2023. Results A total of 14 RCTs including 460 autistic patients were analyzed. A meta-analysis showed that physical exercise had a positive effect on social communication disorder (SMD = 0.45, 95% CI: 0.15, 0.74, p < 0.05) in autistic patients. Subgroup analysis showed that exercise programs with multiple components (SMD = 0.73, 95% CI: 0.39, 1.06, P < 0.001), a moderate duration (SMD = 0.73, 95% CI: 0.38, 1.08, P < 0.001), a moderate-high frequency (SMD = 0.84, 95% CI: 0.53, 1.14, P < 0.001), and a long duration (SMD = 0.77, 95% CI: 0.36, 1.18, P < 0.001) led to significant improvement. Conclusion Physical exercise can improve disordered social communication in patients with autism spectrum disorders. Specifically, early intervention, multi-component exercise, a moderate period, moderate and high frequency, long duration, and multi-participant programs were most effective. Systematic Review Registration https://www.crd.york.ac.uk/prospero/ RecordID= CRD42023422482.
Chapter
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Yetersiz beslenme ve engellilik durumu birçok ortak noktası nedeniyle yakından ilişkili iki kavramdır. Besine ulaşmanın zor olduğu durumlarda ya da yüksek düzeyde besin çeşitliliğinin bulunduğu fakat yetersiz beslenmenin yaygın olduğu ülkelerde yaşamını sürdüren çocuklarda gelişimsel bozukluklar, gecikmeler ve engellilik oranlarının yüksek olduğu bildirilmektedir. Bu oranların açıklayıcısı veya iki kavramın bağının oluştuğu noktalar ise yetersiz beslenmenin çocuklarda çeşitli farklı engellilik durumlarına neden olması veya katkıda bulunması ile birlikte; engellilik durumlarının da yetersiz beslenmeye neden olması veya katkıda bulunmasıdır. Özel gereksinimli çocuklarda beslenmenin önemi, gebelik döneminde annenin beslenmesine kadar dayandırılmaktadır. İlk 1000 gün boyunca, yani gebelikten 2. doğum gününe kadar optimal düzeyde beslenmenin, yeni doğanın sağlıklı gelişimi ve yaşamı için kritik öneme sahip olduğu yönünde görüş birliği vardır .......
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OSB, yaşamın ilk yıllarında ortaya çıkmakta ve etiyolojisi kesin olarak bilinmemektedir. OSB oluşumunda tek bir faktörden çok, genetik ve çevresel faktörlerin çoklu mekanizmalar halinde etkili olduğu ileri sürülmektedir (Risch & ark.,2014). Bir meta-analizde, genetik faktörlerin OSB oluşumunda %74-93 oranında katkıda bulunmakla birlikte yine de tek başına yeterli olmadığı belirlenmiştir (Tick & ark.,2016). Ebeveyn yaşının ileri olması, endokrin bozucu kimyasal ve radyasyon maruziyeti, ilaç alımı, civa/kurşun/alimünyum gibi çevresel toksinlerin OSB oluşumunda etkili olabileceği bildirilmiştir (Lyall vd., 2017 & Cekici ve Sanlier., 2019). Prematüre doğum, annenin gebelik boyunca başta folik asit olmak üzere yeterli vitamin ve mineral alamaması, bozulmuş otoimmünitenin OSB oluşumunda etkili mekanizmalar arasında sayılmaktadır (Lyall & ark., 2017; Cekici & Sanlier., 2019). Anne-çocuk arasındaki psikososyal bağın yetersiz olmasının da OSB gelişiminde etkili olabileceği düşünülmektedir (Özeren,2013). İlk 6 ay ve 2. yaşa kadar elzem olan anne sütü tüketiminin, OSB riskini azalttığını gösteren bulgular mevcuttur (Say, Babadağı & Karabekiroğlu, 2015; Huang & ark., 2021)...........
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Objective: This study was conducted to explore the effect of motor coordination on repetitive behaviors in children with Autism Spectrum Disorder (ASD) aged 5–15 years. Methods: The study employed the causal-comparative design, one of the correlational survey designs. The study was carried out with data obtained from parents of 241 children with ASD. The parents were administered the measurement tools of Gilliam Autism Rating Scale-2-Turkish Version to confirm the diagnosis of ASD, Demographic Information Form to obtain information about the child and the parent, Repetitive Behavior Scale-Revised-Turkish Version to evaluate the repetitive behaviors, and Developmental Coordination Disorder Questionnaire-07-Turkish Version to evaluate the motor coordination performance. The data were analyzed MANCOVA in the R package program. Results: The study results revealed that 72% of children with ASD had a risk of Developmental Coordination Disorder (DCD). The repetitive behaviors of children with and without DCD risk differed significantly. The severity and intensity of the repetitive behaviors of children with DCD risk were higher than those without DCD risk when age, gender, and comorbidity were taken under control. Conclusion: The motor coordination problems in children with ASD are effective on repetitive behaviors.
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An increasing amount of evidence points to the possibility that gestational and early childhood vitamin D deficiency [25(OH)D < 40 ng/ml] cause some cases of autism. Vitamin D is metabolized into a seco-steroid hormone that regulates about 3% of the 26,000 genes in the coding human genome. It is also a neurosteroid that is active in brain development, having effects on cellular proliferation, differentiation, calcium signaling, neurotrophic and neuroprotective actions; it also appears to have an effect on neurotransmission and synaptic plasticity. Children who are, or who are destined to become, autistic have lower 25(OH)D levels at 3 months of gestation, at birth and at age 8 compared to their unaffected siblings. Two open label trials found high dose vitamin D improves the core symptoms of autism in about 75% of autistic children. A few of the improvements were remarkable. The vitamin D doses used in these children were 300 IU/KG/day up to a maximum of 5000 IU/day (highest final 25(OH)D level reached was 45 ng/ml). The other study used 150,000 IU/month IM as well as 400 IU/day [highest final 25(OH)D level was 52 ng/ml]. These two open label trials were recently confirmed with a randomized controlled trial (RCT) using 300 IU/kg/day with a maximum of 5000 IU/day and resulted in effects similar to the two open label studies. In terms of prevention, a recent small study showed vitamin D supplementation during pregnancy (5000 IU/day) and during infancy and early childhood (1000 IU/day) significantly reduced the expected incidence of autism in mothers who already had one autistic child from 20% to 5%. Vitamin D is safe; for example, over the last 15 years, Poison Control reports there have been approximately 15,000 cases of vitamin D overdose. However only three of these 15,000 people developed clinical toxicity and no one died. Given those facts, practitioners might consider treating autism with 300 IU/kg/day, and seek to prevent autism by supplementing pregnant and lactating women (5000 IU/day) and infants and young children (150 IU/kg/day) checking 25(OH)D levels every 3 months. These doses will increase 25(OH)D blood levels to those recommended by the Endocrine Society. As the American Academy of Pediatrics recommends vitamin D supplementation during infancy and childhood, pediatricians and family practitioners should evaluate the current evidence on autism and vitamin D and act accordingly.
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Introduction: Autism Spectrum Disorder (ASD) is a prevalent neurological disorder in children characterized by restrictive, repetitive patterns of behavior that place an added burden on everyday functions. Aerobic exercise has the propensity to reduce stereotypic behaviors in children with ASD. This study sought to quantify the acute effect of exercise and assess the influence of duration and intensity on frequency of stereotypic behaviors in children with ASD. Methods: Participants in this study (N=7, Mage=13.0 ± 1.4 yrs, Mheight=1.64 ± 0.01m, Mweight=60.1 ± 13.7kg) underwent five separate days of treatments including a control (C), low intensity 10 min (10L), high intensity 10 min (10H), low intensity 20 min (20L), and high intensity 20 min (20H) conditions in which intensity was quantified using HR as well as RPE. Prior to and for 60 min following exercise, frequency of stereotypic behaviors was recorded. Results: Results indicated a reduction in behaviors in response to exercise compared to the C trial throughout all conditions except 20H. Interestingly, the most exhaustive exercise session led to increased stereotypic behaviors at all post time periods compared to the other exercise trials (p<.10). The 10L condition showed the greatest reduction at 60 min post compared to the 20H or the control trials' response (p<.05). Examining the behavioral responses to exercise using effect sizes indicated the 10L condition showed the greatest reduction in frequency throughout all 4 time points (ESrange= -.87 to -1.03) compared to baseline. Conclusion: While it appears high-intensity aerobic exercise may exacerbate stereotypic behaviors in children with ASD, low-to-moderate intensity exercise produces significant and large reductions in these behaviors. This provides an easily administered and cost-effective way to positively impact these individuals.
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Despite evidence suggesting one of the earliest indicators of an eventual autism spectrum disorder diagnoses is an early motor delay, there remain very few interventions targeting motor behavior as the primary outcome for young children with autism spectrum disorder. The aim of this pilot study was to measure the efficacy of an intensive motor skill intervention on motor skills (Test of Gross Motor Development-2), physical activity (accelerometers), and socialization (Playground Observation of Peer Engagement) in young children with autism spectrum disorder. A total of 20 children with autism spectrum disorder aged 4-6 years participated. The experimental group (n = 11) participated in an 8-week intervention consisting of motor skill instruction for 4 h/day, 5 days/week. The control group (n = 9) did not receive the intervention. A repeated-measures analysis of covariance revealed statistically significant differences between groups in all three motor outcomes, locomotor (F(1, 14) = 10.07, p < 0.001, partial η(2) = 0.42), object control (F(1, 14) = 12.90, p < 0.001, partial η(2) = 0.48), and gross quotient (F(1, 14) = 15.61, p < 0.01, partial η(2) = 0.53). Findings shed light on the importance of including motor programming as part of the early intervention services delivered to young children with autism spectrum disorder.
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Background: Vitamin D deficiency is widespread in the world including the vulnerable group of pregnant women. Vitamin D deficiency during pregnancy is hypothesized to contribute to the cause of autism. Further, it is hypothesized that vitamin D supplementation during pregnancy and early childhood will reduce the recurrence rate of autism in newborn siblings. Methods: To investigate the hypothesis an open label prospective study was performed prescribing vitamin D during pregnancy to mothers of children with autism at a dose of 5000IU/day. The newborn siblings were at high risk for the recurrence of autism. The newborn infants were also prescribed vitamin D, 1000IU/day to their third birthday. The newborn siblings were followed for three years and during that time, were assessed for autism on two separate occasions: at 18months and 36months of age. The results were compared to the reported recurrence rates in siblings of autistic children in the literature. Results: The final outcome was 1 out of 19 (5%) developed autism in contrast to the recurrence rate of approximately 20% in the literature. We did not have a control group, nor was there blinding. Conclusions: The results are promising, however, this is a preliminary study with very small numbers and was uncontrolled. Further study with larger numbers is indicated. The ethics of prescribing a low dosage of vitamin D such as 400IU D3/day to a control group of mothers in comparison to a large dose such as 5000IU D3/day are problematic in our opinion.
Book
This booklet contains vitally important normative (reference) data for the new test - the SPM plus - which was developed to compensate for the increase in scores that had occurred since the SPM was developed. As explained elsewhere (eg "The outstanding properties of the SPM+") the test has remarkable psychometric properties in that it is almost unique in offering an approximation to an interval scale. This makes it possible to conduct meaningful studies of such things as differential changes in scores of more and less able pupils. For copyright reasons, the full text cannot be uploaded here but see also "Uses and Abuses of Intelligence".
Book
Perceptual-Motor Activities for Children: An Evidence-Based Guide to Building Physical and Cognitive Skills provides a proven blueprint for improving perceptual-motor skills—the skills that require young learners to use their brains and their bodies together to accomplish tasks. When kids improve these skills, they not only improve their coordination and increase their body awareness but they also enhance their intellectual skills and gain a more positive self-image. This easy-to-use guide outlines a 32-week program of sequential station activities that will help pre-K and elementary school-aged children in various stages of development, particularly those who are lagging behind in their perceptual-motor skills. Developed and piloted by two educators who have refined the program since 2004, this program provides all you need to create a perceptual-motor learning laboratory for your students. The book includes: 200 station activities;evidence-based research proving the program’s effectiveness in improving physical and cognitive skills; complete instructions for creating a perceptual-motor learning laboratory in a variety of learning environments; expert guidance in developing lateral skills, balance, body image, tracking skills, spatial relations, locomotor skills, and manipulative skills. The station activities are purposeful and can be sequenced for building a lab or used independently for targeted skill development. They are formatted as activity cards that may be posted at the stations for easy reference. The activity cards include instructions and illustrations to help you set up quickly as well as skill criteria to enable you to informally assess your students’ performances. With the activity cards handy, volunteers and even student aides can easily help with setting up and monitoring readily available activities. Perceptual-Motor Activities for Children will help you guide children in developing lateral skills, balance, positive body image, tracking skills, spatial relations, locomotor skills, and manipulative skills. In doing so, children will improve not only their physical skills but their emotional, social, and cognitive skills as well.
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Autism spectrum disorder (ASD) is a group of dysfunctions in social interaction, communication, and behaviors. Studies have demonstrated that vitamin D deficiency during pregnancy and in individuals increased the risk of ASD. A genetic polymorphism study has pinpointed that genotype AA/A-allele of GC rs4588 in children is associated with ASD, which encodes the vitamin D binding protein. Translating the mentioned points into clinical practice, several clinical trials have demonstrated that vitamin D supplementation can improve the core symptoms in children with ASD. One paper also showed that possible prophylactic effect for the reoccurrence of ASD by vitamin D supplement during pregnancy and early childhood. Herein, this review aims to address the recent advances in this field and to clarify the possible role of vitamin D in ASD.
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The aim of the present randomized double-blind placebo control trial was to investigate if vitamin D supplementation had an effect on vitamin D status, executive functioning and self-perceived mental health in a group of Norwegian adolescents during winter time. Fifty adolescents were randomly assigned into an intervention group (vitamin D pearls) or a control group (placebo pearls). Before (pre-test in December/January) and after (post-test in April/May) the intervention period the participants were exposed to a test procedure, consisting of blood draw, completion of cognitive tests (Tower of Hanoi and Tower of London), and the Youth Self-report version of the Child Behavior Checklist. Multivariate data analysis showed that participants with low vitamin D status scored worse on the Tower of London tests and the more difficult sub-tasks on the Tower of Hanoi tests. They also had a tendency to report higher frequency of externalizing behavior problems and attention deficit. At pre-test, the overall mean vitamin D status measured as 25-hydroxy vitamin D was 42 nmol/L, defining deficiency (Intervention group = 44 nmol/L, Control group = 39 nmol/L). However, vitamin D supplementation caused a significant increase in vitamin D status resulting in a sufficient level in the Intervention group at post-test (mean 62 nmol/L). The results also revealed that the intervention group improved their performance on the most demanding sub-tasks on the ToH. Overall, the study indicates that vitamin D status in adolescents may be important for both executive functioning and mental health.
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Background: Autism spectrum disorder (ASD) is a frequent developmental disorder characterized by pervasive deficits in social interaction, impairment in verbal and nonverbal communication, and stereotyped patterns of interests and activities. It has been previously reported that there is vitamin D deficiency in autistic children; however, there is a lack of randomized controlled trials of vitamin D supplementation in ASD children. Methods: This study is a double-blinded, randomized clinical trial (RCT) that was conducted on 109 children with ASD (85 boys and 24 girls; aged 3-10 years). The aim of this study was to assess the effects of vitamin D supplementation on the core symptoms of autism in children. ASD patients were randomized to receive vitamin D3 or placebo for 4 months. The serum levels of 25-hydroxycholecalciferol (25 (OH)D) were measured at the beginning and at the end of the study. The autism severity and social maturity of the children were assessed by the Childhood Autism Rating Scale (CARS), Aberrant Behavior Checklist (ABC), Social Responsiveness Scale (SRS), and the Autism Treatment Evaluation Checklist (ATEC). Trial registration number: UMIN-CTR Study Design: trial number: UMIN000020281. Results: Supplementation of vitamin D was well tolerated by the ASD children. The daily doses used in the therapy group was 300 IU vitamin D3/kg/day, not to exceed 5,000 IU/day. The autism symptoms of the children improved significantly, following 4-month vitamin D3 supplementation, but not in the placebo group. This study demonstrates the efficacy and tolerability of high doses of vitamin D3 in children with ASD. Conclusions: This study is the first double-blinded RCT proving the efficacy of vitamin D3 in ASD patients. Depending on the parameters measured in the study, oral vitamin D supplementation may safely improve signs and symptoms of ASD and could be recommended for children with ASD. At this stage, this study is a single RCT with a small number of patients, and a great deal of additional wide-scale studies are needed to critically validate the efficacy of vitamin D in ASD.
Article
This study examined the effects of a 12-week physical activity intervention on the motor skill proficiency and executive function of 22 boys (aged 9.08 ± 1.75 years) with autism spectrum disorder. In Phase I of the 12 weeks, 11 boys with autism spectrum disorder (Group A) received the intervention, whereas the other 11 boys with autism spectrum disorder (Group B) did not (true control, no intervention). The arrangement was reversed in Phase II, which lasted an additional 12 weeks. The Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, and the Wisconsin Card Sorting Test were conducted three times for each participant (Group A, primary grouping: baseline (T1), post-assessment (T2), and follow-up assessment (T3); Group B, control grouping: T1-T2; intervention condition, T2-T3). The main findings were that both groups of children with autism spectrum disorder significantly exhibited improvements in motor skill proficiency (the total motor composite and two motor-area composites) and executive function (three indices of the Wisconsin Card Sorting Test) after 12 weeks of physical activity intervention. In addition, the effectiveness appeared to have been sustained for at least 12 weeks in Group A. The findings provide supporting evidence that physical activity interventions involving table tennis training may be a viable therapeutic option for treating children with autism spectrum disorder.