11/8/2016
Considerations for SchoolBased Sports Programs for
Students with Autism
How many of you are working with
children with Autism?
SUSAN RONAN, PT, DPT, PCS
NEW YORK MEDICAL COLLEGE
Autism
Questions?
U.S. prevalence: 500,000 - 1 million children, aged 6-17 yrs. (CDC, 2016)
How many of you are working in schools?
Socioeconomics: (Durkin, 2010 et.al.; Halsell, 2014; King, Bearman, 2014)
How many of you are working in schools with brain breaks or
“movement breaks”?
Common characteristics of children with Autism: (Autism Speaks, 2010)
Does the physical education program at the school include
vigorous exercise for students with Autism?
Participation considerations for students
with Autism
Fitness participation challenges
◦ 1 in 68 children
◦ M:F prevalence: 4.5:1
◦ Effects all socioeconomic strata
◦ Possible increased incidence in lower socioeconomic neighborhoods
◦ difficulties with social interaction, communication
◦ Highly focused interests and/or repetitive activities
Fitness
Communication and social interaction
Socioeconomic factors
Limited activity and higher risk of Nutrition:
obesity secondary to:
◦ Restrictive food choices
◦ Decreased peer interaction
◦ Restricted repetitive movements
Impairments in
◦ Balance
◦ Endurance
◦ Motor execution
◦ GI
◦ Metabolism
◦ Hormonal
Health Issues
◦ Obesity
◦ Cholesterol
◦ Diabetes
◦ Early maturation
(Pan et.al., 2016; Li, et.al., 2014; Matsushima, et.al., 2016; Rimmer, et.al., 2010)
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Communication & Social Interaction
Socioeconomics
Difficulty with social skills
Peer inclusion/ Acceptance
Anxiety in group situations
•Participation Challenges:
• Neighborhood safety/ accessibility
• Parent/ care provider availability for transportation
• Access to sports programs
(CDC, 2016; Autism Speaks, 2014)
(Durkin, et.al., 2010; Halsell, 2014; King, Bearman, 2011)
Considerations for Aerobic Programs & Outcomes
for children with Autism: What do we know?
Are better results seen in group exercises or individual exercises?
oIndividual
Are there recommended durations for the program?
o 6 weeks to 24 months
Which areas improve with exercise?
◦ communication
◦ social
◦ motor skills
Quality of Life
Decreased QOL may be related to
repetitive behavior,
social responsiveness
adaptive behaviors. (Kuhlthau, et.al. 2010)
QOL tools tend to favor
◦ Social interaction
◦ Parent report (Tavernor, et.al)
(Sowa, Meulenbroek, 2012; Sudha, et.al. 2014)
Research Objectives
To examine the effects of a 4-month school-based running,
walking, rolling program for children with Autism.14
◦ Endurance
◦ Socialization
◦ Communication
◦ Eye contact
◦ Quality of life
Hypotheses
Students will have improved BMI following the 4 month program.
Students with ASD will demonstrate improved endurance following the 4 month
program as measured by the Six Minute Walk Test (6MWT) and Energy Expenditure
Index (EEI).
Students will demonstrate improved eye contact during interpersonal interactions
following the 4 month program as measured through the Social Responsiveness
Scale 2 (SRS 2)
Students will demonstrate more effective communication behaviors following the 4
month program as measured by the Social Responsiveness Scale (SRS 2).
Students and/or parents will report an improved quality of life following the 4
month program, as measured by the Peds QOL.
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Methods
Methods: Program & Procedure
Research Design: Quasi-Experimental
Participants:
Recruitment
Program: 4 month exercise program embedded within adaptive gym
class, carried out by physical educators.
◦ Students with Autism Spectrum Disorder (ASD) enrolled in 5 NYC DOE
Elementary schools
◦ Exclusion criteria: students without ASD
◦ Informed consent was obtained from parents/guardians
◦ Assent was obtained where possible
◦ Subjects in 2 schools comprised control group
◦ Participated in program during following control phase
◦ Subjects in 3 schools comprised program group
Data collection: by research assistant at baseline, midterm and final
IRB authorization from NYC Department of Education
Methods:
Outcome Measures
Methods: Study TimeLine
7/15
8/14
9/13
10/13 11/12 12/12
◦ Twice per week; 20 minutes/class
◦ Teachers provided with timeline and checklist for program
◦ Laps completed were recorded over the length of the study
◦ Students received certificates and written encouragement from AI when
milestones reached
1/11
2/10
3/11
4/10
5/10
Variable
Measure
Autism Severity
Gilliam Autism Rating Scale -3 (GARS-3)
Communication
Social Responsiveness Scale (SRS-2)
Quality of Life
Peds Quality of Life (Peds QOL)
Fitness
BMI: wt (kg)/ height (m)
BP
HR (Resting, Exercise)
6 Minute Walk Test (6 MWT), Distance and velocity
Energy Expenditure Index (EEI; (HR amb- HRresting)/ amb velocity)
6/9
Program: Baseline to Midterm: September-October 2015
Program: Midterm to Final: October-December 2015
Program: Baseline to Midterm: January-February 2016
Program: Midterm to Final: February-April 2016
Amended Slide
Gilliam Autism Rating Scale 3 (GARS-3)
Measure of Autism Severity
Completed by parent or teacher
6 subscales:
◦ Restrictive/Repetitive Behaviors
◦ Social Interaction
◦ Social Communication
◦ Emotional Responses
◦ Cognitive Style
◦ Maladaptive Speech
Categories:
◦ Not ASD
◦ Level 1
◦ level 2
◦ Level 3
(Gilliam 2014)
Social Responsiveness Scale-2 (SRS-2)
Completed by parent or teacher
65 questions
Interpersonal Behavior
◦ Social:
◦
◦
◦
◦
Awareness
Cognition
Communication
Motivation
Sensitivity=.97, Specificity=.97, ROC/AUC=.93) (Gilliam, 2014).
Reliability: Cronbach’s alpha coefficients > .80
Reliability coefficient for the Autism Index > 0.90
Interrater reliability intraclass coefficients .80, and .84 for the
Autism Indexes.
◦ Example: Q 16: “Avoids eye contact or has unusual eye contact.”
◦ Responses: 1= Not true, 2= Sometimes true, 3= Often true, 4= Almost always true
Restricted/ Repetitive Behaviors
Constantino, Gruber 2012; Constantino, et.al. 2003)
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Peds QOL 4.0
Fitness Parameters
Completed by parent and student
23 item scale
•Physical Functioning
•Emotional Functioning
•Social Functioning
•School Functioning
•Example: “Other kids do not want to be my friend.”
•Responses: Never, Almost never, Sometimes, Often, Almost Always
Completed by teacher and/or research assistant
BMI: wt (kg)/ height (m)22
BP
HR (Resting, Exercise, Post Exercise)
6 Minute Walk Test (6 MWT) 23,24
Energy Expenditure Index (HRamb- HRresting)/ amb velocity 25
(PT Treatment of Childhood Obesity, 2016)
(Varni, 2014; Varni, et.al. 2014; Varni, et.al., 2006)
Data Analysis Plan
Results
De-identified data provided to NYMC personnel
Descriptive and inferential statistics were performed using
Stata 13
(Stata.corp, 2013)
Results: Participants n = 94 students
Results: Participants
Baseline Data
TOTAL SAMPLE
CONTROL GROUP
5 schools
2 schools
94 students
39 students
◦
◦
◦
◦
◦
Age: mean 9.2 (2.2) range: 5-14
Grades: K-8
Males 80 Females 14
Height: mean 1.4 m (.14)
Weight: mean 37.8 kg (14.6)
MANY MISSING DATA POINTS
◦
◦
◦
◦
◦
Age: mean 8.6 (2.4) range: 5-12
Grades: K-8
Males 24 Females 3
Height: mean 1.4 m (.16)
Weight: mean 39.8 kg (23.4)
NO 6 MWT DATA COLLECTED
Variable
n
Mean (SD)
Age (years)
Height (m)
Weight (kg)
Resting systolic bp
78
77
77
86
9.2 (2.2)a
1.4 (0.14)a,b
37.8 (14.6)a,b,c
98.5 (12.6)c
(mmHg)
Resting diastolic bp
86
60.2 (10.7)
83
85
373.4 (77.3)a
95.7 (15.6)a
45
126.8 (26.0)a
45
77
0.43 (0.32)a
19.4 (4.9)
(mmHg)
6MW distance (m)
Resting heart rate
(bpm)
Walking heart rate
(bpm)
EEI
BMI
a: p-value <0.05 for school; b: p-value <0.05 by GARS 4 score; c: p-value <0.05 by GARS 6 score
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Results: Participants n = 94 students
Results: Participants n = 94 students
Baseline Data (continued)
Baseline Data (continued): GARS
Variable
n
value
Sex - male
Peds QL - parent
Peds QL - subject
80
85%
2
84.2 (22.3)
56
100 (0)
Variable
Results: Participants n = 94 students
n (%)
Variable
1 (3)
6 score - severity 0
1 (5)
4 score - severity 1
3 (10)
6 score - severity 1
4 (20)
4 score - severity 2
16 (55)
6 score - severity 2
12 (60)
4 score - severity 3
9 (31)
6 score - severity 3
3 (15)
n (%)
Fitness at baseline:
•Blood Pressure: n=86
Baseline Data (continued): SRS
Variable
n (%)
4 score - severity 0
Variable
n (%)
Variable
n (%)
t-score com: 1 - wnl
t-score: 1 - wnl
18 (50)
21 (58)
q16 – 1
18 (39)
t-score: 2 - mild
4 (11)
t-score com: 2 - mild
2 (5)
q16 – 2
13 (28)
t-score: 3 - moderate
9 (25)
t-score com: 3 - moderate
8 (22)
q16 – 3
12 (26)
t-score: 4 - severe
5 (14)
t-score com: 4 - severe
5 (14)
q16 – 4
3 (6)
• 6MWT: n=83
• Systolic 98.5 (12.6); range 65- 133
• Diastolic 60.2 (10.7); range 41-96
• 373.4 (77.3); range 209.2-595.5 27
• Mean Ambulation Velocity: n=83
• 62.2 (12.9); range 34.9-99.2
•Heart Rate: n=85
• Resting: 95.7 (15.6); range 65-138
• EEI: n=45
• .43 (.32); range .015 -1.58)
•BMI: n=77
• 19.4 (4.9); range 10.2- 43.9
AMENDED SLIDE
Fitness Results –
Wilcoxon signed-rank tests, total sample
AMENDED SLIDE
Fitness Results –
Wilcoxon signed-rank tests, by GARS
GARS severity level 4 – score 2
Variable
n
BMI
Ambulation HR (bpm)
systolic bp (mmHG) - rest
diastolic bp (mmHG) - rest
6MW distance (m)
Ambulation Velocity
(m/min)
EEI
43
10
68
68
40
40
10
baseline
final
18.5 (4.0)
18.8 (3.8)
125 (32.6) 151.4 (42.0)
99.2 (12.8)
98.4 (11.1)
60.6 (10.9)
61.8 (11.9)
416.0 (48.7) 467.8 (82.7)
69.3 (8.1)
78.0 (13.8)
0.4 (0.3)
0.6 (0.4)
Z statistic
p value
Variable
n
baseline
final
Z statistic
p value
-1.20
-1.78
-0.049
-0.58
-3.95
-3.93
0.23
0.07
0.96
0.56
<.001*
<0.001*
6MW distance (m)
Ambulation Velocity
(m/min)
13
13
412.2 (46.2)
68.7 (7.7)
450.6 (81.8)
75.1 (13.6)
-2.14
-2.14
0.03*
0.03*
Variable
n
baseline
final
Z statistic
p value
-1.38
0.17
6MW distance (m)
Ambulation Velocity
(m/min)
8
8
410.4 (51.6)
68.4 (8.6)
452.6 (72.2)
75.4 (12.0)
-2.11
-2.10
0.04*
0.04*
GARS severity level 6 – score 2
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SRS Results –
Wilcoxon signed-rank tests,
total sample: baseline vs. final
Fitness Results –
Wilcoxon signed-rank tests, by school
School 2
Variable
n
baseline
final
Z statistic
p value
6MW distance (m)
Ambulation Velocity
(m/min)
15
15
439.9 (64.0)
73.3 (10.7)
504.0 (73.9)
84.0 (12.3)
-3.36
-3.35
<0.001*
<0.001*
SRS Results –
Wilcoxon signed-rank tests,
GARS-3, 4 severity level 3: baseline vs. final
Variable
n
Z statistic
p value
t-score
t-score awareness
t-score cognition
t-score communication
t-score motivation
t-score restrictive repetitive
behavior
18
18
18
18
18
18
2.44
2.82
2.84
2.99
3.66
2.60
0.01*
0.005*
0.005*
0.003*
<0.001*
0.01*
SRS Results –
Wilcoxon signed-rank tests,
School 3: baseline vs. final
Variable
n
Z statistic
p value
Variable
n
Z statistic
p value
t-score awr
t-score cog
t-score mot
t-score rrb
5
5
5
5
1.94
2.02
2.03
2.02
0.05**
0.04*
0.04*
0.04*
t-score
t-score awr
t-score cog
t-score com
t-score mot
t-score rrb
SRS – q16
14
14
14
14
14
14
13
1.99
2.12
3.30
2.95
3.21
3.02
2.42
0.05**
0.03*
0.001*
0.003*
0.001*
0.003*
0.02*
Discussion
Discussion
For total sample significant improvements in :
◦ Mean 6MW distance
◦ Mean ambulation velocity in 6min
◦ SRS total t-score; awr, cog, com, mot, rrb scores
BMI did not change significantly
Blood pressure & eei did not change significantly
(Sowa, 2012; Kuhlthau, 2010; Lang, 2010; Bartels, 2012; Kotte, 2014;
CDC, childhood obesity, 2014)
Students in school 2 demonstrated significantly improved:
◦ 6MW distance
◦ Ambulation velocity in 6 minutes
Students in school 3 demonstrated significantly improved:
◦ t-score (total)
◦ t- awr, cog, com, mot, rrb
◦ srs – question 16
(Matsushima, 2016; Aldridge, 2012; Eapen, 2014)
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Amended Slide
Limitations
Conclusion
Not all groups who signed on completed the data collection
(small n)
Population who provided consent may not represent the racial
and ethnic diversity of individuals with autism in the NYC area.
What is the contribution of additional services, education,
medication?
What does QOL mean anyway?
(Srinivasan, Pescatello, Shat, 2014)
• Research findings are consistent with literature
Thank You
References
CIGNA Foundation
See PDF
• Health policy considerations
• Vigorous exercise breaks?
• Available in the public school system?
Achilles Kids Program
Principals
Teachers
Students
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