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Effects of Exercise Interventions on Stereotypic Behaviors of Children with Autism Spectrum Disorder Adamson, Sarah; Block, Laurie; Adamson, Sarah; Petrus, Chris; Shahnefried, Maryam; Harris, Susan 2006-10-05

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The Effects of Exercise Interventions on Stereotypic Behaviors of Children with Autism Spectrum Disorder By: Sarah Adamson Laurie Block Sarah Einarson Chris Petrus Maryam Sharifnejad Supervisor: Susan Harris School of Rehabilitation Sciences Department of Physical Therapy  Overview „ „ „ „ „ „ „ „  Purpose Introduction Methods Results Discussion Conclusion Limitations Recommendations  Purpose To conduct a systematic review of studies examining the effect of exercise interventions on stereotypic behaviors of children with autism spectrum disorder (ASD)  Introduction Autism Spectrum Disorder (ASD): „ refers to individuals with: „ a specific autism diagnosis „ Similar core deficits:  Pervasive Developmental Disorder–Not Otherwise Specified (PDD-NOS) „ Asperger Syndrome „ Childhood Disintegrative Disorder „ Rett Syndrome „  Introduction ASD: „ „ „ „  Increasing in prevalence1 Current prevalence: >1 in 200 2 Four times as many males as females affected3 More prevalent in the pediatric population than each of cancer, diabetes, spina bifida, or Down syndrome4  Introduction ASD - Possible Causes5 Genetic „ Neuroanatomical differences „ Pre-natal factors „ Exposure to environmental toxins „ Viral infections „ Immune system deficiencies „  Introduction ASD – triad of features6 „  impairments in socialization  „  impairments in verbal and nonverbal communication  „  stereotypic and repetitive patterns of behaviours  Introduction Interventions7: „ „ „ „ „  Sensory integration therapy Sensory stimulation techniques Auditory and visual interventions Sensorimotor handling techniques Physical exercise  Goals: „ „  To treat the three features of ASD To facilitate the academic, leisure and self-care skills of children with autism  Introduction Benefits of Exercise: „ „ „  Overall positive effects shown in adults with autism8 Few articles on exercise and stereotypic behaviours of children with autism Aerobic exercise may cause physiologically changes that modulate stereotypic behaviours in persons with autism7  Introduction PICO: „  Population: children under 19 years of age, with a diagnosis of autism or ASD  „ „ „  Intervention: exercise interventions Comparison: N/A Outcome: reduction of stereotypic behaviours  Methods Comprehensive Search Strategy: „ „ „  Searching electronic databases Hand-searching reference lists Communicating with experts in the fields of pediatric physical therapy and autism  Methods Electronic databases searched:  „  MEDLINE EMBASE PsycINFO PEDro ERIC CINAHL Cochrane Database of Systematic Reviews Cochrane Controlled Trials Register  „  Search terms:  „ „ „ „ „ „ „  autism, autism spectrum disorder, exercise, physical activity and physical education  Methods The Web of Science database was used to perform: „ author searches „ journal searches including: Journal of Autism and Developmental Disorders „ Pediatric Physical Therapy „ Physical and Occupational Therapy in Pediatrics „ Developmental Medicine and Child Neurology „ European Academy of Childhood Disability „  Methods First Search / Papers First Index was searched to find published papers from: „ „ „ „ „  Congresses Symposiums Conferences Expositions workshops and meetings  Methods Grey Literature: „ Hand-searching of relevant articles „ Contacting key individuals for assistance in finding relevant studies  Methods Study Selection: „ Search Limits „  „  English, Human Subjects  Title Screen „  Excluded if they were related to medications, genetics, cognition, memory, communication, or executive functioning  Methods Study Selection (cont’d): „ Abstract Screen (reviewed by 2 authors) „ Excluded if did not adhere to the following criteria: „ intervention study using either exercise or  physical activity as the independent variable „ frequency of stereotypic behaviours as the dependent variable „ children under 19 years old „ subjects stated to have autism or autism spectrum disorder  Methods Study Selection (cont’d): „ Full-text Screen Entire studies reviewed by two independent authors „ Exclusion criteria same as abstracts „  Methods Data Extraction: „ An adapted version of the AACPDM Study Data Extraction Summary Form9 was used „ This form included analysis of: evidence level „ quality of the study „ descriptive information about the study „ outcome of interest „  Methods Levels of Evidence: „ The AACPDM Level of Evidence9 „ Harris Level of Evidence for Single Subject Designs (Adapted from AACPDM)  Methods Study Quality Assessment: Three scales were used for the analysis of study quality: „ AACPDM Study Quality Scale „ The Clinical Relevance Tool for Case Studies Modified from van Tulder „ Quality, Rigour or Evaluative Criteria for Single Subject Research Designs  Methods Data Synthesis: „ Studies were classified into three tables to clearly depict: „ study quality and design type „ population characteristics „ intervention type „ outcome of interest „ results  Results „  Preliminary studies = 200  „  Seven relevant studies  Cochrane Database of Systematic Review (n=5) MEDLINE (n=43)  EMBASE (n=121)  Cochrane Central Register of Controlled Trials (n=2) CINAHL (n=9)  Potentially relevant citations identified through electronic searches (n=200) Citations excluded after title screening (n=158) Abstracts retrieved for review (n=42) Studies excluded after abstract screening (n=29) Full articles retrieved for detailed review (n=13) Studies excluded after full text review (n=6) Relevant studies included in systematic review (n=7)  ERIC (n=20)  Evidence Level and Quality of the seven studies „  Quality: range 2 to 5 (out of 7), mean 3.9, mode 5 „ 42% moderate, 58% weak „  „  Evidence: range II to V „ 2 level II, 2 level IV, 3 level V „  Brief summary of seven studies „ „ „ „ „  Study designs: „ 4 single subject, 2 group designs, 1 case study Stereotypic behaviours: „ As defined within each study Interventions: „ 6 jogging, 1 hydrotherapy Subjects: „ 26 total, male and female, age range 4 to 15 Diagnosis of each subject: „ ASD or autism, many stated to have high levels of stereotypic behaviours  Brief summary of seven studies „  „  „  Post-exercise stereotypic behaviours: „ All studies measured using time sampling Results of exercise on stereotypic behaviours : „ All studies reported a decrease in stereotypic behaviours „ Three studies documented this effect over time „ Effect was temporary Results of exercise on other simple cognitive/play tasks: „ Mixed findings for improvement  Discussion 7 articles: „3: Exercise on stereotypic behaviour and academic performance „1: Hydrotherapy „3: Vigorous vs mild exercise  Exercise effects on stereotypic behaviours / academic performance „  Watters & Watters (1980)11 „ Level IV, 5 „ IV: Effects of jogging, TV watching, academic classroom activities „ No change in academic performance „ Stereotypic behaviours decreased post-exercise „ Jogging only IV affecting stereotypic behaviours  „  Moderate evidence based on quality scale Higher Level of study design needed  „  Exercise effects on stereotypic behaviours / academic performance „  Rosenthal-Malek (1997)12 „ Level IV, 5 „ IV: 20 minutes of jogging, academic precondition (classroom activity) „ Exercise had significantly improved outcomes as compared to academic precondition „ Jogging: decrease in stereotypic behaviour; increase in on-task behaviour; increase in academic performance  „  Moderate support Stronger Level of study design needed  „  Exercise effects on stereotypic behaviours / academic performance „  Kern et al. (1982)13 „ Level II,3 „ Intervention: Jogging (mildly strenuous); 5-10 min initially, 20 min by end of experiment „ Decrease in stereotypic behaviour post-jogging „ Increase in academic responding and ball playing frequency post-jogging  „  Weak support, based on quality scale  Hydrotherapy Effect on Stereotypic Behaviours „  Bumin et al. (2003)14 „ Level V, 2 „ Halliwick method of hydrotherapy „ Decrease in stereotypic behaviours  „  Weak support, based on quality scale Additional studies needed  „  Vigorous vs. Mild Exercise „  Kern et al. (1984)15 „ Level II, 5 „ Jogging vs. ballplaying „ Jogging decreased stereotypic behaviours; ballplaying no effect  „  Moderate support  Vigorous vs. Mild Exercise „  Celiberti (1997)16 „ Level V, 3 „ Jogging vs. walking „ Jogging decreased stereotypic behaviours, walking no effect  „  Weak support Stronger study design needed  „  Vigorous vs. Mild Exercise „  Levinson & Reid (1993)17 „ Level V, 3 „ Jogging vs. walking „ Jogging decreased stereotypic behaviours „ Walking had no effect  „  Weak support Stronger study design needed  „  Evidence Applied „ „  More intensive aerobic activity is of greater effect on stereotypic behaviours Difficult to develop exercise prescription due to: Study design heterogeneity „ Varied forms/monitoring of exercise „  „  Duration of decreased stereotypic behaviours post-exercise: up to 1.5 hrs  Literature Findings „  „  „ „  Lack of Research in area: „ 7 articles examining exercise effects on stereotypic behaviours Dates of Publication: „ 7 articles; 1980-2003 „ 23 year span, no timeline set as exclusion criteria Poor study designs (evidence level II-V) Overall weak study qualities (mean quality score 3.9/7)  Limitations of Systematic Review „  English language only  „  Published articles only  Conclusion/ Recommendations „  Purpose: „  „  To assess the link between exercise and stereotypic behaviours in children with ASD  The literature suggests: exercise decreases stereotypic behaviours in this population. „ higher intensity exercise is more effective in decreasing self stimulation than lower intensity activity „  Conclusion/ Recommendations „  „  Clinical implications for pediatric physiotherapists: „ Consider the literature „ Difficult to determine specific prescription of exercise for children with ASD. Further research required: „ Exercise prescription for children with ASD „ Longer exercise interventions and long-term effects of exercise „ Other physiotherapy treatments for children with ASD „ Improved study design and study quality  ?? Questions ??  References 1. 2. 3. 4.  5.  6. 7. 8.  9.  10.  Newschaffer CJ, Falb MD, Gurney JG. National autism prevalence trends from United States special education data. Pediatrics 2005 Mar;115(3):e277-82. Fombonne E. Modern Views of Autism. Can. J. Psychiatry 2003;48:503-505 Fombonne E. The epidemiology of autism: a review. Psychol Med 1999 Jul;29(4):769-86. Filipek PA, Accardo PJ, Baranek GT, Cook EH Jr, Dawson G, Gordon B, Gravel JS, Johnson CP, Kallen RJ, Levy SE, Minshew NJ, Ozonoff S, Prizant BM, Rapin I, Rogers SJ, Stone WL, Teplin S, Tuchman RF, Volkmar FR. The screening and diagnosis of autistic spectrum disorders. J Autism Dev Disord 1999 Dec;29(6):439-84. Autism Society of Canada. Research into Causes. Available at: Accessed June 12, 12 2006. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR (fourth edition, text revision). Washington DC: American Psychiatric Association, 2000. Baranek GT. of sensory and motor interventions for children with autism. J Autism Dev Disord 2002;32(5):397-422. Efficacy Elliott Jr RO, Dobbin AR, Rose GD, Soper HV. Vigorous, aerobic exercise versus general motor training activities: effects on maladaptive and stereotypic behaviours of adults with both autism and mental retardation. J Autism Dev Disord 1994;24(5):565-576. O’Donnell, Darrah, Adams, Roxborough, Damiano. AACPDM methodology for developing evidence tables and reviewing treatment outcome research: 2004 Version (revised 2005). American academy for cerebral palsy and developmental medicine 2005; Harris SR (unpublished). Level of Evidence for Single Subject Designs, 2006.  11 12 13 14 15 16  17 18  Watters RG, Watters WE. Decreasing self-stimulatory behaviour with physical exercise in a group of autistic boys. J Autism Dev Disord 1980;10:379–387. Rosenthal-Malek A, Mitchell S. Brief Report: The Effects of Exercise on the Self-Stimulatory Behaviours and Positive Responding of Adolescents with Autism. J Autism Dev Disord 1997;27(2):193-201. Kern L, Koegel LR, Dyer K, Blew PA, Fenton LR. The effects of physical exercise on self-stimulation and appropriate responding in autistic children. J Autism Dev Disord 1982;12:399–419. Bumin G, Uyanik M, Yilmaz I, Kayihan H, Topcu M. Hydrotherapy for Rett Syndrome. J Rehabil Med, 2003;35:44-45. Kern L, Koegel RL, Dunlap G. The influence of vigorous versus mild exercise on autistic stereotyped behaviours. J Autism Dev Disord 1984;14:57–67. Celiberti DA, Bobo HE, Kelly KS, Harris SL, Handleman JS.The differential and temporal effects of antecedent exercise on the self-stimulatory behaviour of a child with autism. Res Dev Disabil 1997;18(2):139-150. Levinson LJ, Reid G. The effects of exercise intensity on the stereotypic behaviours of individuals with autism. Adapted Physical Activity Quarterly 1993;10(3):255–268. Dadds M, Schwartz S, Adams T, Rose S. The effects of social context and verbal skill on the stereotypic and task-involved behaviour of autistic children. J Child Psychol Psychiatry 1988 Sep;29(5):669-676.  


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