Content uploaded by Damien Sheehan
Author content
All content in this area was uploaded by Damien Sheehan on Mar 04, 2021
Content may be subject to copyright.
Downloaded from https://journals.lww.com/nsca-scj by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3YeLEAQtdJ83VdS1xJ2XoEOHGYjbLFaKttvI8lMuqgPI= on 09/28/2020
Downloadedfromhttps://journals.lww.com/nsca-scj by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3YeLEAQtdJ83VdS1xJ2XoEOHGYjbLFaKttvI8lMuqgPI= on 09/28/2020
Exercise Programming for
Children With Autism
Spectrum Disorder:
Recommendations for
Strength and
Conditioning Specialists
Craig Coffey, BSc,
1
Marie Carey, BSc,
1
Sharon Kinsella, PhD, MISCP,
1
Paul J. Byrne, PhD, CSCS,
1
Damien Sheehan, MSc, CSCS,
1
and Rhodri S. Lloyd, PhD, CSCS*D
2,3,4
1
Department of Science and Health, Institute of Technology Carlow, Carlow, Ireland;
2
Youth Physical Development
Centre, School of Sport and Health Sciences, Cardiff Metropolitan University, Wales, United Kingdom;
3
Sport
Performance Research Institute, New Zealand (SPRINZ), AUT University, Auckland, New Zealand; and
4
Centre for
Sport Science and Human Performance, Waikato Institute of Technology, Hamilton, New Zealand
ABSTRACT
The purpose of this article is to
introduce strength and conditioning
specialists to autism spectrum disor-
der (ASD) and to identify the many
benefits of delivering exercise pro-
grams to children with ASD. In addi-
tion, the article aims to inform strength
and conditioning specialists on how
to minimize some of the inherent
challenges associated with the deliv-
ery of such programs by highlighting
critical issues for practitioners to
consider when designing and imple-
menting exercise programs for chil-
dren with ASD.
INTRODUCTION
Autism spectrum disorder (ASD)
is a complex neurological disor-
der with a globally estimated
rate of 1 in every 160 children (11).
The diagnostic criteria of ASD are
divided into 2 domains. One domain
focuses on deficits in communication
and social interaction, which persist
across multiple contexts. It consists of
impairments in social-emotional
exchange, nonverbal communication,
and developing relationships with
others. The second domain is related
to repetitive patterns of behavior, such
as motor movements (e.g., hand flap-
ping and body rocking), insistence on
sameness, and restricted interests (1).
These characteristics are evident from
a young age and impact all aspects of
life, such as at home, in school, and in
the community. The severity of ASD is
determined by the level of support
required (1). It is essential to note that
ASD has a broad spectrum of symp-
toms, and no 2 individuals may neces-
sarily exhibit the same range of ASD
symptoms.
PHYSICAL ACTIVITY LEVELS OF
CHILDREN WITH ASD
Low levels of physical activity present
as a significant health concern for chil-
dren with ASD. There is research re-
porting that children with ASD are
significantly less physically active than
children without ASD (29,52). A
national survey in the United States
compared physical activity levels
between children with (n5915) and
without (n541,879) ASD and found
that children with ASD are 60% less
likely to participate in regular physical
activity for more than 3 days a week
(29). Inactivity among children with
ASD may contribute to the higher
prevalence of obesity that exists among
this population. Previous research indi-
cates that children with ASD are 72%
more likely to be obese than children
without ASD (29). Failure to accrue
Address correspondence to Craig Coffey,
craig.coffey@itcarlow.ie
KEY WORDS:
special populations; neurotypical;
autistic; program design; guidelines
Copyright ÓNational Strength and Conditioning Association Strength and Conditioning Journal | www.nsca-scj.com 1
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
adequate amounts of physical activity,
and the heightened risk for obesity
among children with ASD, may pre-
dispose this population to many health
risks. Such health risks include asthma,
diabetes, high cholesterol, high blood
pressure, mobility issues, and mental
health conditions (43,44,57). Strength
and conditioning specialists should be
well versed in exercise prescription and
coaching strategies, which places these
specialists in a position to help limit or
reverse the harmful health risks associ-
ated with inactivity. However, there
are several factors to consider when
designing and delivering exercise pro-
grams to children with ASD. These
factors include the environment in
which the program will be completed,
how the strength and conditioning
specialist will communicate and
instruct the exercise, and the exercise
interest of the child.
BARRIERS TO EXERCISE AMONG
CHILDREN WITH ASD
Children with ASD face unique chal-
lenges that may limit their opportuni-
ties and abilities to participate in
exercise. Children with ASD, parents,
and teachers have reported on these
barriers, citing interpersonal, intraper-
sonal, and environmental factors that
impact exercise participation. Adoles-
cents with ASD have stated the chal-
lenges that they experience when
participating in exercise. These chal-
lenges are in relation to motor skills,
social interaction, sensory processing,
and environmental factors (2). Individ-
uals with deficits in social interaction
and communication have found partic-
ipation in group-based exercise chal-
lenging (51). Adolescents with ASD
have spoken of increased anxiety
toward exercise participation because
of complex social demands and inci-
dents of bullying and isolation during
the inclusive exercise program (2,20).
Motor deficits have also been identi-
fied as significant barriers to exercise
participation (20,36). Motor deficits
are in relation to motor coordination,
postural control, hypotonia, and diffi-
culties with the planning of motor
skills (15,32,41,46). These movement
impairments may hinder the partici-
pation of children with ASD in exer-
cise programs not adapted to their
needs (17).
Environmental factors such as lighting,
sound, and area size also need to be
considered because they may nega-
tively affect children with ASD partici-
pating in exercise. This is because
there is a high prevalence of sensory
processing abnormalities in children
with ASD (9). Sensory processing is
the ability to process sensory informa-
tion and respond appropriately to sen-
sory stimuli (28). Children with ASD
may be hypersensitive or hyposensitive
to certain sensory stimuli (28). Exercise
environments may be highly sensory-
stimulating, such as a sizeable crowded
area of an exercise hall, and children
with ASD have been reported to
respond negatively to increased audi-
tory, visual, and tactile stimuli of these
settings (20,30). Hyposensitiveness
may be noted as an underresponsive-
ness to an environment; these individ-
uals may see, hear, and feel the area in a
more muted way than others (12). Par-
ents of children with ASD have also
reported a lack of structured programs
outside of schools that provide the sup-
port necessary to meet the needs of
their child (37). Additional challenges
that have also been noted include
financial issues, time constraints, and
transportation (34).
BENEFITS OF EXERCISE FOR
CHILDREN WITH ASD
Despite the previously noted barriers,
there is extensive literature to support
the benefits of exercise for children
with ASD. Improvements in stereo-
typical behavior, social interaction
and communication, academic func-
tioning, sensory processing, disruptive
behavior, and mental health have all
been reported (8,21,49). Exercise has
also shown to improve physical fitness
levels among children with ASD.
Exercise interventions have led to
improvements in body mass index,
aerobic fitness, muscular strength
and endurance, flexibility, balance,
and motor skills (16,21,27,42,61).
The benefits, as mentioned earlier,
have been derived from a variety of
exercise programs incorporating dif-
ferent training modalities including
walking/jogging (39,42), horseback
riding (7), swimming (40,61), martial
arts (3,33), cycling (56), and yoga and
dance (24,45). Previous research indi-
cates that a range of exercise modes
can have a beneficial effect on children
with ASD. However, more research is
required to establish the effects of tra-
ditional strength and conditioning
programs, which are specifically tai-
lored to suit the needs and abilities
of this population.
PRACTICAL CONSIDERATIONS
FOR THE DELIVERY OF AN
EXERCISE PROGRAM
Because of the numerous benefits of
exercise for children with ASD, com-
bined with the high levels of inactivity
and obesity reported among these chil-
dren, it is crucial that this population is
encouraged to participate in exercise.
To effectively enable children with
ASD to enjoy and engage in exercise,
strength and conditioning specialists
should consider several behavioral
modification techniques when plan-
ning and delivering exercise programs
for this population. These modification
strategies aim to improve engagement,
motivation, desired outcomes, and
long-term adherence to an exercise
program. Not all children with ASD
will present with the same challenges
toward exercise participation. Strength
and conditioning specialists should
evaluate each child’s specific needs
before beginning an exercise program
through observation, consultation with
family members, and health care pro-
fessionals who work closely with the
child. Each of the following recom-
mendations may not be suitable for
all children, and the strength and con-
ditioning specialist must decide which
modification techniques are appropri-
ate for each child.
ENVIRONMENT
The environment in which exercise
programs take place is crucial for chil-
dren with ASD. It is recommended
that exercise programs are
Exercise and Children With ASD
VOLUME 00 | NUMBER 00 | SEPTEMBER 2020
2
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
implemented in consistent settings, as
some individuals with ASD may strug-
gle with change and disruption in their
routine (31). Changing to unfamiliar
environments may lead to an increase
in anxiety for some children and
reduce their participation. An adjust-
ment period is recommended before
exercise begins to allow children time
to adjust to the unfamiliar setting and
sensory stimuli (60). The equipment
layout within the setting may also have
a disruptive influence on the child with
ASD, as it may be distracting and visu-
ally overwhelming. It is recommended
to set up equipment when it is required
for a particular task and cleared away
before moving on to the subsequent
task (50). Furthermore, a wide-open
space may also be distracting for some
children. The use of room dividers is
recommended to limit the space,
which may help promote attentiveness
and engagement (31,47).
Research has reported that over 96%
of children with ASD report hypersen-
sitivity and hyposensitivity across
numerous realms, which may lead
children to be overresponsive or
underresponsive to certain stimuli
(22). It is recommended to investigate
what level of sensory sensitivity the
children may have before starting any
exercise program to minimize these
stimuli as much as possible (19). It
has been observed that the environ-
ment in which exercise is completed
may provide sensory challenges com-
monly reported by children with ASD
(20). Examples of how to alter sensory
stimuli for children that are hypersen-
sitive to certain stimuli during exercise
can be seen in Figure 1. For hyposen-
sitive children, it is recommended to
use weighted vests or sensory diets
when children become underrespon-
sive to improve their focus (48,54). A
sensory diet is a combination of activ-
ities with sensory stimulation to meet
the needs of the child, intending to
keep the child calm and alert, prevent-
ing challenging behaviors allowing the
child to feel in control, and improving
their activities of daily living (25). From
a strength and conditioning specialist
point of view, some examples that
could be included in a sensory diet of
a child could be jumping on a trampo-
line, rolls on a yoga ball, or an isometric
exercise hold, for example, the plank.
Children may display challenging
behavior when they become oversti-
mulated and should be allowed to leave
the exercise setting, accompanied by a
teacher, to use a sensory room or quiet
room to self-regulate. Once the child
has self-regulated, they are encouraged
to rejoin the exercise class.
There is debate as to whether group
or individual exercise programs pro-
duce more benefits for children with
ASD. Individual interventions may
allow the strength and conditioning
specialist to tailor the program to
the individual’s specific needs and
interests (47). Individual interven-
tions may reduce stress and anxiety
for children with ASD as they
decrease social interaction demands,
along with decreasing the unpredict-
ability associated with many group
activities. Participating in individual
interventions may result in the child
lacking the social interaction and
communication benefits that have
been associated with group exercise
programs (3,33,40,62). Nonetheless, a
meta-analysis comparing individual-
and group-based exercise programs
indicated that individual programs
produced greater effects on social
skills compared with group programs
(49). Individual programs may not be
available or practical. Group-based
physical activity sessions may be the
only programs offered. Specialized
classes, consisting of only children
withASD,havebeenshowntobe
more beneficial for social functioning,
improvements in muscular strength
and endurance, and motor skill devel-
opment, compared with classes that
include children with and without
ASD (21).
COMMUNICATION AND
INSTRUCTION
Individuals with ASD may communi-
cate using a variety of methods, includ-
ing verbal and nonverbal forms of
communication. In a recent study,
including 165 children with ASD
between the ages of 4–6 years, 15%
were categorized as nonverbal, and
an additional 10% were reported to
be minimally verbal (35). Some chil-
dren with ASD lack verbal communi-
cation skills but communicate
effectively through visual aids (14).
Using visual aids is a critical method
of achieving effective communication
during exercise.
VISUAL SUPPORTS
Visual supports are any visual presenta-
tions that may support an individual
throughout their day (22). Visual sup-
ports may be the use of a picture or a
video demonstrating the activity to be
completed. In a strength and condition-
ing program for children with ASD,
visual supports may be useful for com-
municating a specific type of exercise
(6). Preferably, this visual support
Figure 1. Sensory stimuli recommendations.
Strength and Conditioning Journal | www.nsca-scj.com 3
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
should portray a child of a similar age
and sex (14). Research has demon-
strated the value of incorporating visual
supports into the delivery of exercise
programs for children with ASD. Pre-
vious research successfully incorporated
visual supports into a cycling interven-
tion for children with ASD, where
visual supports were used to assess
self-efficacy and engage nonverbal par-
ticipants in goal setting, self-monitoring,
and self-reinforcement (56). The use of
visual support of exercise movements
may aid in the understanding of the
required movements.
The use of pictures and videos is an
effective means of communicating with
children with ASD (10). Pictures may be
used in the exercise class to show differ-
ent stages of an activity. Pictures of the
exercise(s) should be displayed as a ref-
erence throughout the exercise. In con-
junction with pictures, The Story
Creator application (Innovative Mobile
Apps Ltd) may be used to show critical
phases of each exercise, which the chil-
dren can imitate (10). The Story Creator
can include videos, pictures, and written
text of the exercises. Within the story-
board for each exercise, the video can be
embedded, along with audible and visual
text, describing what is required of the
child. Through this, learning is rein-
forced, and participation is increased
while underpinning self-efficacy in the
child’s ability to perform a task (56).
Instructions on how and when to use
visual aids with exercises can be seen
in Tables 2 and 3.
Activities for children with ASD should
be planned and scheduled by the
strength and conditioning specialist
before the exercise session (60). Although
there is a need for flexibility for the intro-
duction of new exercises, children with
ASD respond well to routine and struc-
ture (19). This routine can be reinforced
through the use of a visual schedule or a
visual “To Do” list. A visual schedule
involves a series of pictures to depict a
sequence of activities or events (23).
When used as part of an exercise pro-
gram, the visual schedule provides chil-
dren with a clear structure of the class.
Children may experience less anxiety if
they can anticipate what exercise is com-
ing next, therefore improving participa-
tion(19).Whenanexerciseis
performed, a child can move the exercise
off the “To Do” list and place it on the
“Done” list. This act may foster a sense of
achievement, along with the physical
activity, increasing the child’s self-
efficacy and self-determination (56). This
may improve motivation and engage-
ment in physical activity. A written sched-
ule may be sufficient for some children;
however, using pictures with simple writ-
ten instructions may be more suitable for
others. It is vital to maintain consistency
throughout the program and to keep the
classes familiar to what the child knows.
This is completed by advancing existing
exercises gradually. Although consistency
in the classes is essential and should be
reinforced through visual schedules, prac-
titioners must make modifications to the
exercise selection to progress or regress
an exercise depending on the ability of
the children.
PHYSICAL PROMPTS AND TOKEN
REWARDS
Physical prompts have previously been
used to aid in the completion of a task.
Successful completion of a task may be
achieved with the use of prompting,
which are instructions to initiate a task
(38). Yanardaǧet al. suggested the use of
a prompt before the instruction of the
activity is given (e.g., “you get a sticker
for good catching in this exercise”). The
sticker is given after the performance of
a successfully completed skill (60).
While strength and conditioning spe-
cialists may provide more specific feed-
back linked to a technical cue, such as
“Great looking forward and keeping
your eyes on the ball when catching.”
When working with children with
ASD, the coach should provide basic
feedback. Tokens may be used to pro-
mote good behavior. With the use of a
token system, the child gains some con-
trol with a choice opportunity such as
“if I listen to all instructions and try my
best, I will get a token for my favorite
toy” (60). This is based on techniques
used in applied behavioral analysis,
Table 1
Needs analysis
Needs analysis
Questions to parents before
exercise
Does your child have a repetitive movement, repetitive habit, or calming movement?
What are your child’s likes?
What are your child’s dislikes?
What was your child’s previous experience of exercise like?
What is your child most interested in presently?
Does your child have any aversions to visual, auditory, or tactile sensations?
Any other information you feel might be relevant for me to know about your child?
Questions before exercise Is the area suitable for the exercises being performed today and suitable for the sensory needs of
the child(ren)?
Are all videos and pictures for instruction ready for display?
Is all equipment ready? Preferably, equipment should be put out when being used and when
instructions have been provided to the children.
Exercise and Children With ASD
VOLUME 00 | NUMBER 00 | SEPTEMBER 2020
4
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
which has been used to decrease inap-
propriate behavior and improve the
teaching and maintaining of skills (53).
A similar token system used to encour-
age children with ASD to participate in
exercise was used in a recent study (62).
This consisted of stickers that could
later be traded for a gift or a favorite
toy (62). Research has shown that
prompts and tokens may increase
behavioral outcomes for individuals
with developmental disabilities (5,58).
VERBAL INSTRUCTION
It is recommended to use instructions
that are concise and have minimal jar-
gon (19). Verbal instructions should be
phrased positively instead of negatively.
Some children with ASD have been
known to respond to the final words
of a sentence, not taking the full meaning
into account. For example, it is preferable
to say, “Put the weight down slowly” as
children may respond to the final word
“slowly” rather than, “don’t drop the
weight”whereachildmayfocuson
“drop.” Finally, it is recommended that
the strength and conditioning specialist
uses language that is as simple as possible
(18). With many children with ASD, it is
best to avoid overusing metaphors when
coaching. This is recommended because
of the tendency for some children with
ASD to interpret language literally (59).
A welcoming verbal phrase or a gesture
may enhance motor skill competence
and execution with this initial connection
(18,60). Positive verbal feedback should
be used, such as “great catching” or “good
jumping” to motivate the child and main-
tain engagement with the activity (4,60).
Verbal communication should be clear
and concise. For the exercise instructions,
thelanguageusedshouldbethesameas
whatiswrittenonthepictureorinThe
Story Creator application. Consistency is
vital to enhance understanding, learning,
and performance.
EXERCISE PROGRAMMING FOR
CHILDREN WITH ASD: A
PRACTICAL EXAMPLE
Although all training programs are
context-specific and will be dependent
onthenatureofthechildreninthe
group, in addition to the time, facilities,
and human resources available, the fol-
lowing section details a sample exercise
program that can be implemented by
practitioners. Before the beginning of
any exercise program, it is recommended
that practitioners ask the parents/guard-
ians of the children to provide informa-
tion on the likes and dislikes of their child
as well as identifying any repetitive move-
mentstheyengagein(Table1).This
Figure 2. Jumping ladders.
Figure 3. Snatch the bacon.
Strength and Conditioning Journal | www.nsca-scj.com 5
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
Table 2
Sample exercises at the commencement of an exercise program
Phase of the session Exercise AMSC targeted Instructions
Warm-up Traffic
lights
Acceleration, deceleration,
and reacceleration
Green cone 5run
Yellow cone 5walk/slow motion
Red cone 5stop
Jumps and
landing
Jumping, landing, and
rebounding mechanics
Instruct children to perform a safe “motorbike” landing. Encourage landing with feet apart, knees
bent, and arms forward like holding motorbike handles.
Main phase Reaction
game
Throwing, catching, and
grasping
Commands children must follow and identify, e.g., heads, shoulders, knees, and toes. As soon as the
command “ball” is called, children must grasp the ball rapidly.
Bean bag
scramble
Throwing, catching, and
grasping
On “go,” children run to the center, grasp a bean bag, return to the start position, and throw the bean
bag into their hula hoop.
Army crawl Upper-body pulling Children lie prone and move in an army crawl movement, pulling with their upper body to move
forward.
Crab walks Antirotation and core
bracing
Move in a crab walking motion. This can be performed both forward and backward. Progress to the
introduction of a ball moving with their feet.
Balloon
keep up
Upper-body pushing The aim is for the children to maintain the balloon in the air using any part of their body, e.g., head,
hands, and feet.
Cool down Popcorn Upper-body pulling and
pushing
Place the bean bags on the parachute and instruct the children to lift the parachute up and down, to
make the bean bags pop like popcorn.
Stretches Flexibility stretches: butterfly stretch, alternate leg toe touch (seated), knee hug, cobra stretch, toe
touch (standing), and quad stretch.
Exercise and Children With ASD
VOLUME 00 | NUMBER 00 | SEPTEMBER 2020
6
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
Table 3
Example of exercise at Week 8
Phase of the session Exercise Targeted Instructions
Warm-up Traffic lights Acceleration, deceleration, and reacceleration Green cone 5run
Yellow cone 5walk/slow motion
Red cone 5stop
Blue cone 5bunny hops
White cone 5bear crawl
Floor is lava Lower-body unilateral, jumping, landing, and
rebounding mechanics
With all hoops placed around in a circuit, children jump from hoop to hoop, not
making contact with outside the hoop.
Main phase Reaction
game
(partners)
Throwing, catching, and grasping One ball placed between partners. Following and pointing out commands (e.g.,
heads, shoulders, knees, and toes). When “ball” is called, both the children
must reach to grasp the ball as fast as possible.
Color
targets
Throwing, catching, and grasping Children have their own ball and run around the room bouncing, throwing, and
catching the ball. Children are instructed to throw the ball at a colored target
and catch the ball.
Inch worm Upper-body pulling In pairs, one child lies prone on the ground and the other child stands about a
foot from their partner’s head with their back to their partner. The child on the
ground holds onto their partner’s ankles and pulls forward. Their partner
moves forward, and the children repeat the movement pattern.
Crab soccer Antirotation and core bracing, upper body and
lower body
Moving in a crab walking motion, forward, backward, and side to side. Two
teams of 3 play soccer while remaining in the crab walk position.
Volleyball Upper-body pushing, acceleration, deceleration,
and reacceleration, lower-body bilateral and
unilateral
Two teams of 3 on either side of the room, divided by a centerline. Children
must keep the balloon in the air similar to volleyball, scoring a point when the
balloon touches the surface on the opposite side of the centerline.
Cool down Popcorn Upper-body pulling and pushing Place bean bags on the parachute and instruct the children to the lift the
parachute up and down to make the bean bags pop like popcorn.
Stretches Flexibility stretches: butterfly stretch, alternate leg toe touch (seated), knee hug,
cobra stretch, toe touch (standing), and quad stretch.
Strength and Conditioning Journal | www.nsca-scj.com 7
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
approach should assist the strength and
conditioning specialist in developing an
exercise program that is individualized
to the unique ASD needs of the children
within the group.
The warm-up period may be used as a
time to prepare children for the exercise
class. This time is essential for acquiring
the attention of the children and main-
taining their engagement with the exer-
cise class. The warm-up may also act as
an “icebreaker,” enabling the children to
familiarize themselves with the strength
and conditioning specialist and the
exercise environment (55). The warm-
up may consist of movements such as
walking, running, and jumping
sequences such as ladder hops (Fig-
ure 2). Games can also be included, such
as tag, snatch the bacon (Figure 3), and
“mirroring.” Mirroring is where children
mimic each other in performing various
movements (Tables 2 and 3).
The main phase of the exercise class
may be used to introduce the athletic
motor skill competencies to be intro-
duced and performed. Skills and move-
ment patterns may be performed and
corrected in this main phase section.
With the introduction of new exercises
to children with ASD, structure is the
key to participation and engagement.
The familiarity of routine is accompa-
nied by self-efficacy, which breeds a
desire to complete the exercises and
overall session (18). When exercises
are completed and appropriate behav-
iors exhibited, these behaviors should
be acknowledged through positive rein-
forcement (60). Progression of the main
phase activities may occur in 3 stages:
learning the components of the activity,
compiling the components of the activ-
ity to complete a race, and being able to
play a game with others in the activity
class. An example of how exercises can
be progressed is provided in Tables 2
and 3. Bean bag scramble is a throwing
and catching activity introduced by
throwing a beach ball a short distance
back and forth to a partner. This can be
progressed by changing the weight and
size of the ball and increasing the
throwing distance. A race can then be
introduced to challenge the children to
throw the ball back and forth several
times without dropping the ball. Finally,
the task can be progressed into “bean
bag scramble,” where the intention of
the game is to throw the bean bag at
various targets for points (Figure 4).
The cool-down period is a time for
reflection (26), which may be used to
praise children for their excellent work
in class and prepare them for the next
class. The reduced tempo of the cool-
down period and quiet stretching allows
children to prepare to move from an
activity class back into the classroom
environment. The cool down may con-
sist of static stretches that are held for
20–30 seconds. Stretches may include
the butterfly stretch (seated groin
stretch), seated alternate toe touch (elon-
gation of hamstrings and reaching for
toes), cobra stretch (refer to Figure 5),
lying knee hug (hip and lower back
stretch), and quad stretch (standing
quadriceps stretch and improving bal-
ance) (13).
CONCLUSION
There is no “one-size-fits-all” approach
for implementing exercise programs
with children with ASD. Every child is
different regarding interests, competen-
cies, and understanding of exercise. It is
essential to understand each child as well
as possible before the commencement of
the program. The implementation of
exercise programs for individuals with
ASD should take into consideration
the nature of the environment, commu-
nication, and instruction style. With
these 3 factors considered, children
Figure 4. Bean bag scramble.
Figure 5. Cobra stretch.
Exercise and Children With ASD
VOLUME 00 | NUMBER 00 | SEPTEMBER 2020
8
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
may be more likely to participate in
exercise. Routine and structure may
assist a child with being at ease within
the exercise setting, resulting in familiar-
ity rather than a disruption to routine.
Positive reinforcement will empower a
child to interact more and will build self-
efficacy. Future research may need to
review the application of current recom-
mendations to coaching individuals
with ASD of an adult population. A
further study may be required to inves-
tigate and report on compliance levels
to exercise, such as pedometer or accel-
erometer data. More research may
include information on sensory diets,
which may be used in the exercise clas-
ses. The recommendations provided in
this article can aid strength and condi-
tioning specialists and physical educa-
tion teachers when implementing
exercise and physical education classes
for children with ASD. These recom-
mendations may also be incorporated
into a community setting and help inte-
grate children and adults with ASD in
sport participation.
Conflicts of Interest and Source of Funding:
The authors report no conflicts of interest
and no source of funding.
Craig Coffey is
a postgraduate
doctoral student
in the Depart-
ment of Science
and Health,
Institute of Tech-
nology Carlow.
Marie Carey is a
postgraduate stu-
dent in the
Department of
Science and
Health, Institute
of Technology
Carlow.
Sharon
Kinsella is the
Program Director
of BSc in Sports
Rehabilitation
and Athletic
Therapy in the
Department of
Science and
Health, Institute
of Technology Carlow. Sharon Kinsella is
also a Chartered Physiotherapist.
Paul J. Byrne is
the Program
Director of BSc.
Strength and
Conditioning in
the Department
of Science and
Health, Institute
of Technology
Carlow.
Damien
Sheehan is an
assistant lecturer
in the Depart-
ment of Science
and Health,
Institute of Tech-
nology Carlow.
Rhodri Lloyd is
a reader in Pedi-
atrics Strength
and Conditioning
in the Youth
Physical Devel-
opment Centre,
School of Sport
and Health Sci-
ences, Cardiff
Metropolitan University,
REFERENCES
1. American Psychiatric Association.
Diagnostic and Statistical Manual of Mental
Disorders. 5th Edition. Washington, DC:
American Psychiatric Publishing, 2013.
Available at: http://encore.llu.edu/iii/
encore/record/C__Rb1280248__SDSM-
V__P0,2__Orightresult__X3;
jsessionid5ABB
7428ECBC4BA66625EDD0
E0C5AAFA5?lang5eng&suite5cobalt%
5Cnhttp://books.google.com/books?
id5EIbMlwEACAAJ&pgis51.
2. Arnell S, Jerlinder K, Lundqvist LO.
Perceptions of physical activity
participation among adolescents with
autism spectrum disorders: A conceptual
model of conditional participation. J Autism
Dev Disord 48: 1792–1802, 2018.
3. Bahrami F, Movahedi A, Marandi SM,
Sorensen C. The effect of karate
techniques training on communication
deficit of children with autism spectrum
disorders. J Autism Dev Disord 46: 978–
986, 2016.
4. Barbera ML. The Verbal Behavior
Approach: How to Teach Children with
Autism and Related Disorders. London,
United Kingdom: Jessica Kingsley
Publishers; 2007.
5. Beiers K, McLaughlin T. Increasing social
interactions using prompts and rewards for
adolescents with ASD in an ice hockey
practice context. Educ Res Q 39: 40–56,
2016.
6. Bittner MD, Rigby BR, Silliman-French L,
Nichols DL, Dillon SR. Use of technology to
facilitate physical activity in children with
autism spectrum disorders: A pilot study.
Physiol Behav 177: 242–246, 2017.
7. Borgi M, Loliva D, Cerino S, et al.
Effectiveness of a standardized equine-
assisted therapy program for children with
autism spectrum disorder. J Autism Dev
Disord 46: 1–9, 2016.
8. Bremer E, Crozier M, Lloyd M. A systematic
review of the behavioural outcomes
following exercise interventions for children
and youth with autism spectrum disorder.
Autism 20: 899–915, 2016.
9. Caminha RC, Lampreia C. Findings on
sensory deficits in autism: Implications for
understanding the disorder. Psychol
Neurosci 5: 231–237, 2012.
10. Coffey C, Kinsella S, Sheehan D,
Faigenbaum A. The use of an iPad with a
storyboard to aid exercise participation in
children with autism. In: TEL Quality
Matters—People, Policies and Practices.
Carlow, Ireland: Irish Learning Technology
Association (ITLA) EdTech Conference,
2018.
Strength and Conditioning Journal | www.nsca-scj.com 9
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
11. Elsabbagh M, Divan G, Koh YJ, et al.
Global prevalence of autism and other
pervasive developmental disorders. Autism
Res 5: 160–179, 2012.
12. Elwin M, Ek L, Schro
¨der A, Kjellin L.
Autobiographical accounts of sensing in
Asperger syndrome and high-functioning
autism. Arch Psychiatr Nurs, 2012.
13. Faigenbaum A, Lloyd R, Oliver J. Essentials
of Youth Fitness. Champaign, IL: Human
Kinetics, 2020.
14. Fittipaldi-Wert J, Mowling CM. Using visual
supports for students with autism in
physical education. J Phys Educ Recreat
Danc 2009.
15. Fournier KA, Hass CJ, Naik SK, Lodha N,
Cauraugh JH. Motor coordination in autism
spectrum disorders: A synthesis and meta-
analysis. J Autism Dev Disord 40: 1227–
1240, 2010.
16. Fragala-Pinkham M, Haley SM, O’neil ME.
Group aquatic aerobic exercise for children
with disabilities. Dev Med Child Neurol 50:
822–827, 2008.
17. Green D, Charman T, Pickles A, et al.
Impairment in movement skills of children
with autistic spectrum disorders. Dev Med
Child Neurol 51: 311–316, 2009.
18. Groft-Jones M, Block M. Strategies for
Teaching Children with Autism in Physical
Education. Teaching Elementary Physical
Education 17: 25–28, 2006.
19. Groft-Jones M, Block M. Strategies for
Teaching Children with Autism in Physical
Education Adapted Physical Education
Teacher Training View Project
Sensitization towards People with
Disabilities through Physical Education
and Para-Sports View Project. 2006.
20. Healy S, Msetfi R, Gallagher S. “Happy and
a bit nervous”: The experiences of children
with autism in physical education. Br J
Learn Disabil 11: 818–833, 2013.
21. Healy S, Nacario A, Braithwaite RE,
Hopper C. The effect of physical activity
interventions on youth with autism
spectrum disorder: A meta-analysis.
Autism Res 11: 818–833, 2018.
22. Hume K, Wong C, Plavnick J, Schultz T.
Use of Visual Supports With Young
Children With Autism Spectrum Disorders.
New York, NY: Springer, 2014.
23. Knight V, Sartini E, Spriggs AD. Evaluating
visual activity schedules as evidence
based-practice for individuals with autism
spectrum disorders. J Autism Dev Disord
45: 157–178, 2014.
24. Koenig KP, Buckley-Reen A, Garg S.
Efficacy of the get ready to learn yoga
program among children with autism
spectrum disorders: A pretest-posttest
control group design. Am J Occup Ther 66:
538–546, 2012.
25. Kumari Sahoo S, Senapati A. Effect of
sensory diet through outdoor play on
functional behaviour in children with ADHD.
Indian J Occup Ther 46: 49–54 , 2014.
26. Lloyd RS, Oliver JL. Strength and
Conditioning for Young Athletes: Science
and Application. 2nd ed. London:
Routledge, 2019.
27. Magnusson JE, Cobham C, Mcleod R.
Beneficial effects of clinical exercise
rehabilitation for children and adolescents
with autism spectrum disorder (ASD).
J Exerc Physiol 15: 71–79, 2012.
28. Marco EJ, Hinkley LBN, Hill SS, Nagarajan
SS. Sensory processing in autism: A
review of neurophysiologic findings.
Pediatr Res 69: 48–54, 2011.
29. McCoy SM, Jakicic JM, Gibbs BB.
Comparison of obesity, physical activity,
and sedentary behaviors between
adolescents with autism spectrum
disorders and without. J Autism Dev
Disord 46: 2317–2326, 2016.
30. Menear KS, Smith S. Physical education
for students with autism. Teach Except
Child 40: 32–37, 2008.
31. Mesibov GB, Shea V, Schopler E, et al. The
Teacch Approach to Autism Spectrum
Disorders. New York, NY: Springer, 2004.
32. Ming X, Brimacombe M, Wagner GC.
Prevalence of motor impairment in autism
spectrum disorders. Brain Dev 29: 565–
570, 2007.
33. Movahedi A, Bahrami F, Marandi SM,
Abedi A. Improvement in social dysfunction
of children with autism spectrum disorder
following long term Kata techniques
training. Res Autism Spectr Disord 7:
1054–1161, 2013.
34. Must A, Phillips S, Curtin C, Bandini LG.
Barriers to physical activity in children with
autism spectrum disorders: Relationship to
physical activity and screen time. J Phys
Act Heal 12: 529–534, 2015.
35. Norrelgen F, Fernell E, Eriksson M, et al.
Children with autism spectrum disorders
who do not develop phrase speech in the
preschool years. Autism 19: 934–943,
2015.
36. Obrusnikova I, Cavalier AR. Perceived
barriers and facilitators of participation in
after-school physical activity by children
with autism spectrum disorders. JDev
Phys Disabil 23: 195–211, 2011.
37. Obrusnikova I, Miccinello DL. Parent
perceptions of factors influencing after-
school physical activity of children with
autism spectrum disorders. Adapt Phys
Act Q 29: 63–80, 2012.
38. Odom SL, Strain PS. A comparison of
peer-initiation and teacher-antecedent
interventions for promoting reciprocal
social interaction of autistic preschoolers.
J Appl Behav Anal 19: 59–71, 1986.
39. Oriel KN, George CL, Peckus R, Semon A.
The effects of aerobic exercise on
academic engagement in young children
with autism spectrum disorder. Pediatr
Phys Ther 23: 187–193, 2011.
40. Pan C-Y. Effects of water exercise
swimming program on aquatic skills and
social behaviors in children with autism
spectrum disorders. Autism 14: 9–28,
2010.
41. Pan CY. Motor proficiency and physical
fitness in adolescent males with and
without autism spectrum disorders. Autism
18: 156–165 2014.
42. Pitetti KH, Rendoff AD, Grover T, Beets
MW. The efficacy of a 9-month treadmill
walking program on the exercise capacity
and weight reduction for adolescents with
severe autism. J Autism Dev Disord 37:
997–1006, 2007.
43. Rimmer JH, Rowland JL, Yamaki K. Obesity
and secondary conditions in adolescents
with disabilities: Addressing the needs of
an underserved population. J Adolesc Heal
41: 224–229, 2007.
44. Rimmer JH, Yamaki K, Lowry BMD, Wang
E, Vogel LC. Obesity and obesity-related
secondary conditions in adolescents with
intellectual/developmental disabilities.
J Intellect Disabil Res 54: 787–794, 2010.
45. Rosenblatt LE, Gorantla S, Torres JA, et al.
Relaxation response–based yoga improves
functioning in young children with autism: A
pilot study. J Altern Complement Med 17:
1029–1035, 2011.
46. Rutkowski EM, Brimer D. Physical
education issues for students with autism.
J Sch Nurs 30: 256–261, 2014.
47. Schultheis SF, Boswell BB, Decker J.
Successful physical activity programming
for students with autism. Focus Autism
Other Dev Disabl 15: 159–162, 2000.
48. Smith T, Mruzek DW, Mozingo D. Sensory
integrative therapy. In: Controversial
Therapies for Developmental Disabilities:
Fad, Fashion and Science in Professional
Practice. Mahwah NJ: Lawrence Erlbaum
Associates Publishers, 2005. pp. 331–
350.
Exercise and Children With ASD
VOLUME 00 | NUMBER 00 | SEPTEMBER 2020
10
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
49. Sowa M, Meulenbroek R. Effects of
physical exercise on autism spectrum
disorders: A meta-analysis. Res Autism
Spectr Disord 6: 46–57, 2012.
50. Srinivasan SM, Pescatello LS, Bhat AN.
Current perspectives on physical activity
and exercise recommendations for
children and adolescents with autism
spectrum disorders. Phys Ther 94: 875–
889, 2014.
51. StanishH,CurtinC,MustA,etal.
Enjoyment, barriers, and beliefs about
physical activity in adolescents with and
without autism spectrum disorder.
Adapt Phys Activ Q 32: 302–317,
2015.
52. Stanish HI, Curtin C, Must A, et al. Physical
activity levels, frequency, and type Among
adolescents with and without autism
spectrum disorder. J Autism Dev Disord
47: 785–794, 2017.
53. Steege MW, Charles Mace F, Perry L,
Longenecker H. Applied behavior analysis:
Beyond discrete trial teaching. Psychol
Sch 44: 91–99, 2007.
54. Stephenson J, Carter M. The use of
weighted vests with children with autism
spectrum disorders and other disabilities.
J Autism Dev Disord 39: 105–114, 2009.
55. Tapp LM. From warm up to wrap up:
Twenty-one great safety training activities.
In: ASSE Professional Development
Conference. American Society of Safety
Engineers, 2007.
56. Todd T, Reid G, Butler-Kisber L. Cycling for
students with ASD: Self-regulation
promotes sustained physical activity. Adapt
Phys Act Q 27: 226–241, 2010.
57. Tyler CV, Schramm SC, Karafa M, Tang
AS, Jain AK. Chronic disease risks in young
adults with autism spectrum disorder:
Forewarned is forearmed. Am J Intellect
Dev Disabil 116: 371–380, 2011.
58. Weiss J, Diamond T, Demark J, Lovald B.
Involvement in Special Olympics and its
relations to self-concept and actual
competency in participants with
developmental disabilities. Res Dev Disabil
24: 281–305, 2003.
59. Whyte EM, Nelson KE. Trajectories of
pragmatic and nonliteral language
development in children with autism
spectrum disorders. J Commun Disord 54:
2–14, 2015.
60. Yanardag M, Yilmaz I, Aras O. Approaches
to the Teaching Exercise and Sports for the
Children with Autism. International Journal
of Early Childhood Special Education 2:
214–230, 2010.
61. Yilmaz I, YanardaǧM, Birkan B, Bumin G.
Effects of swimming training on physical
fitness and water orientation in autism.
Pediatr Int 46: 624–626, 2004.
62. Zhao M, Chen S. The effects of structured
physical activity program on social
interaction and communication for children
with autism. Biomed Res Int 2018: 1–13,
2018.
Strength and Conditioning Journal | www.nsca-scj.com 11
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
