Autism and Recreation:

Getting off the bench

Presented by: Maggie Reilly, PT., MBA, Director, Occupational and Physical Therapy Flora Howie, M.D., Medical Director, Autism Center

GOAL

• For children with autism spectrum disorder (ASD) to increase the skills needed to participate in gross motor activities with peers.

Gross motor skills defined

Gross motor skills are the abilities required in order to control the large

muscles of the body for walking, running, sitting, crawling, and other

activities.

Lessons from the playground

Children with average or high motor abilities were compared to children that had problems with balance, coordination, muscle tone, sense of the body in space and ability to imitate movements.

Motor problems were associated with:Less social playMore social withdrawal

What does this mean for our kids with ASD?

Bar-Haim, et al., 2006.

Motor skills and ASD

Early on many researchers saw motor deficits, as a minor

feature of ASD

Miyahara et al., 1997Ghaziuddin et al., 1998

Motor skills & ASD

• Green et al. studied 101 children with autism (low to avg. IQ’s) using the Movement Assessment Battery for Children and 79% percent of these children showed evidence of motor impairment. The Mean motor impairment score was highest for the gross motor skill of Board Balance.

• Green concluded:– Movement impairments are common in

children with ASD.

Green, D., et al., 2009

 

Motor skills and ASD

Early on many researchers thought motor delays were present because of a co-occurring problem such as a learning disability or lower IQ.

Miyahara et al., 1997

Ghaziuddin et al., 1998

Motor skills and autism

•In a study between a group of boys with autism and average range IQs and a group of typically developing boys, all the children with ASD were shown to have more impairment in motor skills. For example in the area of gait disturbance, it was 60% vs. 9%.

Jansiewicz et al., 2006

40 Boys with HFA/Asperger’s

syndrome

55 Typically Developing

Motor skills and Asperger’s syndrome (AS)

More recent research demonstrates that for children with ASD, an average IQ does not lower the risk for motor problems. In a study by Green, et al., 11 children with Asperger syndrome and a matched group of 9 children with developmental coordination disorder all with normal IQ’s were compared. All the children with Asperger syndrome turned out to be clumsier. 5 of the 6 most severely motor impaired children in the study were in the Asperger syndrome group.

Green, D., Baird, G., Barnett, A.L., Henderson, L., Huber, J., Henderson, S.E. (2002). The severity and nature of motor impairment in Asperger’s syndrome: A comparison with specific developmental disorder of motor function. Journal of Child Psychology and Psychiatry, 43,655–668

11 Children with AS

9 Children with

Dev. Coord.Disorder

Motor skills and ASD

These studies demonstrate that with ASD comes a higher chance of motor impairment compared to typically developing children or children with other developmental disorders and an average IQ does not lower the risk for motor problems.

Gross motor skills are key for recreation

• Gross motor skills, which represent primary skills needed for many group recreational activities, have a high likelihood of impairment among children with ASD.

Gross motor skills are key for recreation

• In a study by Manijova et al. • 50% of the Asperger syndrome group and 67%

of a high-functioning autism group showed clinically significant motor impairment.

• They were more likely to have a motor disability affecting both fine motor and gross motor areas.

Manjiviona, J., et al., 1995

Matson, J.L., et al., 2010

Even compared to children with other developmental disabilities, gross motor skills are more delayed in children with ASD

In a study comparing children with learning disabilities and AS, one particularly noteworthy result was the children with AS had worse gross motor skills in the area of ball skills. 

Miyahara et al., 1997

Gross motor skills & Social Skills:The problems start early

810 toddlers in the EarlySteps program in Louisiana

BISCUIT–Part 1: Social skills

Battelle Developmental Inventory–Second Edition: Gross and fine motor skills

 

Autism PDD-NOSAtypical Dev.

•Those with low gross motor skills exhibited more impairments in socialization across all 3 groups.

•Low fine motor skills only showed a significant negative affect on the autism group

Sipes M., et al 2011

Gross motor skills & Recreation

• Smyth and colleagues found that social games like football may relate more to gross motor dependent skills like balance than to fine motor dependent skills such as hand/eye coordination

• This was found to be true for a general population of children playing football on a school playground when their balance skills on the Movement ABC were extremely poor.

Smyth, M. M., Anderson, H. I. (2001). Football participation in the school playground: the role of coordination impairments.

British Journal of Developmental Psychology, 19, 369-379.

Things we have learned…

Motor delays can impair social skills.

Many children with ASD have motor impairments.

Many children with ASD have gross impairments.

Gross motor impairments can affect social skills, even at a young age.

Inclusion in social recreational games like football may relate more to gross motor skills.

What does all this mean for our kids with ASD?

Gross motor skills relate to social recreational games

Exclusion from social recreational games

Social withdrawal

Gross motor delay common

Delayed motor skills across the spectrum

What does all this mean for our kids with ASD?

The motor problems frequently seen in children with ASD only adds to

the struggles they have in developing and maintaining social

relationships

Solutions…

• Bar-Haim states we should consider a standard motor evaluation for children with ASD

• Green states that systematic assessment of movement abilities should be considered a routine investigation.

Bar-Haim et al., 2006

Green, D., et al., 2009

Solutions…

• Bhat and colleagues propose that delays in gross motor skills, balance motor skills, balance skills, imitation skills, postural skills can be targeted during group play with other children 2 or more at a time.

• Bar-Haim proposes the use of motor-oriented interventions for socially withdrawn children.

Bhat et al., 2011

Bar-Haim et al., 2006

Findings at the Autism Center

Among children diagnosed with ASD:

• Gross motor deficits: 63%

• Not in intervention services for the gross motor deficits: 85%

Call to Action

This speaks to the need for those of us who evaluate and care for children with autism to be proactive about developing motivating gross motor interventions such as recreational programs for children with ASD.

Autism Center Pilot Recreation Program

Recreation Program Structure

• Who will be in the pilot program?: 5 to 8 year olds with mild to

moderate autism, Asperger syndrome, or high functioning

autism with gross motor deficits

• How many children per group: 6

• How long is the program?: 5 weeks

• How many sessions?: 10 (2 sessions per week)

• How long is each activity session: 1 hr.

• How long is parent time?: 15 minutes

Recreation Program Structure

• Behavioral, communication, and sensory concerns identified as barriers to progress will also be addressed

• Before and after the program, testing will be completed to measure improvements in the fitness and skills needed for participation in group activities with peers 

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Recreation Program Structure

• We will target the gross motor skills required for recreational activities using a team approach.

• Core team: – physical therapist

– certified athletic trainer

– pediatric wellness coordinator

• Additional team members include:– behavior analyst (ABA)

– speech/language pathologist (SLP)

– occupational therapist (OT)

(For the pilot, these team members will be present the entire 1st cycle and the first 2 weeks of remaining 3 cycles.)

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SLP will provide input regarding:

Speech/Language

•Impairments in social interaction

•Rigidity

•Turn taking/waiting

•Team work skills

•Cooperation

•Patience

•Anxiety

•Personal space

•Rules, sequences of events

OT will provide input regarding:

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•Fine Motor and eye-hand, coordination (including: reaching, grasping, catching)

•Executive function and staying “on task”

•Static control (“this is not a falling down game”)

•Imitation, praxis (motor planning, learning by imitation)

•Sensory Integration

Speech/Language

OT

ABA will provide input regarding:

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Speech/Language

OT

ABA

•Restricted Repetitive Behaviors (restricted interests)

•Not tolerating turn taking, delays/waiting

•Tantrums

•Transitions

•Visual supports

Physical Therapy will provide input regarding:

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Speech/Language

OT

ABA

PT

•Coordination

•Strength (Core and extremity)

•Balance/Postural Control

•Flexibility

•Endurance

•Speed & agility

Working together we can help to get children with ASD

“off the bench”

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Speech/Language

OT

ABA

PT

Outcome Measures

Measure Pre-Program (Session 1)

Post-Program (Session 10)

FITNESSGRAM® X X

Parent Survey X X

Family Satisfaction Survey

X

Session 1: Pre-Program Fitness Measures

ACTIVITY CORRESPONDING RECREATION GOALS

•FITNESSGRAM® measures:1)Push-ups2)Sit and Reach3)One minute curl-up4)Plank5)Crab walk6)3 minute step test7)Shuttle run

•Fitness goalsmeasured:1)Upper body strength2)Flexibility3)Core strength4)Core strength5)Core strength6)Endurance7)Speed & agility

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Outcome Measures

• Parent Survey: Questionnaire to get parent ratings on the quality of their child's recreational experiences. Some items would be: My child has good balance (i.e. hopping, standing on one foot). My child is able to play on the playground independently. My child is comfortable with sounds on the playground (children's voices, music,

loud equipment). My child can work with a partner or participate on a team.

• Family Satisfaction Survey: Questionnaire to get feedback from the caretakers on the structure of the program. Some items would be: The time was convenient. The location was convenient. The locations were comfortable for physical activity.

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Recreation Sessions:Will progress to more social/group activities with each session.Core team will be primary staff after initial BA, SLP & OT input.

WEEK/SESSION ACTIVITY TEAM/ STAFF

Week 1/Session 1 Pre-Program Measures Core team & ABA, SLP, OT

Week 1/Session 2 Introduction to Playground Equipment Core team & ABA, SLP, OT

Week 2/Session 3 Introduction to Playground Equipment Core team & ABA, SLP, OT

Week 2/Session 4 Introduction to Playground Equipment Core team & ABA, SLP, OT

Week 3/Session 5 Obstacle Courses Core team

Week 3/Session 6 Obstacle Courses Core team

Week 4/Session 7 Group Games Core team

Week 4/Session 8 Group Games Core team

Week 5/Session 9 Community Partners Community partner

Week 5/Session 10 Post-Program Measures Core team

Session Schedule

Time (minutes) Activity

15 AC Team Prep time

10 Warm up

30 Activity

10 Cool down

10 Discussion/Clean up

15 Parent time

Curriculum

The Autism Center Recreation Program curriculum will target 4 core goals:

• Movement competency

• Cognitive abilities

• Lifetime fitness

• Responsible behaviors and values (social behaviors).

Next Generation Sunshine State Standards: Physical Education (draft 2013):

Example of Curriculum: Session 2: Introduction to playground equipment

Movement Competency Warm up: Recurring Activity•Walk around track•2 sets wall push-ups•2 sets jumping jacks•Stretch 2 square (partners)

Locomotor Skills: Examples•Grade K-Move in relation to others (chasing fleeing dodging). Locomotor skills (running, galloping)•Grade 1-Chase, flee, dodge to avoid or catch others•Grade 2- Chase, flee, dodge while maneuvering around obstacles

Cool down: Recurring Activity•Stretch, 2 square (partner)

Lifetime Fitness

Physical Activity Goals•Grade K-Describe physical activity goal setting•Grade 1-Set physical activity goals•Grade2-Set and meet physical activity goals

Social Behaviors

Safety•Safe use of playground equipment and physical activity space

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Session 10: Post-Program Outcome Measures

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ACTIVITY CORRESPONDING RECREATION GOALS

•FITNESSGRAM® measures:1)Push-ups2)Sit and Reach3)One minute curl-up4)Plank5)Crab walk6)3 minute step test7)Shuttle run•Parent Survey•Parent Satisfaction Survey

•Fitness goalsmeasured:1)Upper body strength2)Flexibility3)Core strength4)Core strength5)Core strength6)Endurance7)Speed & agility

Research shows that gross motor skills most affect success in

group recreational activities

The top 10 areas to focus on may include:

• Motor speed

• Postural control

• Gait

• Coordination

• Ball skills

• Dynamic and static balance

• Manual dexterity

• Endurance

• Strength

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Group recreational activities that can target the top ten focus areas include:

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• Soccer

• T-Ball/Baseball

• Dance

• Gymnastics

• Track/Relay races

• Kick ball

• Horseback

• Martial Arts

• Tennis

• Golf

• Playground

Getting off the bench…

• Jason Mc Elwain

THE END