quinta-feira, 7 de maio de 2015



Current Perspectives on Physical Activity and Exercise Recommendations for Children and Adolescents With Autism Spectrum Disorders





Sudha M. Srinivasan, Linda S. Pescatello, Anjana N. Bhatcorresponding author

Autism spectrum disorders (ASDs) are a group of multisystem neurodevelopmental disorders characterized by impairments in social interactions and communication skills and the presence of repetitive and stereotypical behaviors and interests. Children with ASDs have impairments in social communication domains such as reduced eye contact, problems with social reciprocity, and verbal and nonverbal communication delays., Stereotypical behaviors and interests in children with ASDs may include adherence to inflexible routines and motor stereotypies such as hand flapping or body rocking. In addition to these core diagnostic impairments, children with ASDs may have a range of impairments in cognitive-behavioral and perceptuomotor domains. Cognitive and behavioral impairments may include attention problems, intellectual delays, anxiety, depression, aggression, temper tantrums, and self-injurious behaviors., In terms of sensory impairments, children with autism may have difficulties in modulating tactile, auditory, visual, and vestibular inputs, with hyperresponsiveness or hyporesponsiveness to sensory stimuli. Children with ASDs may also have pervasive gross motor impairments such as poor visuomotor and bilateral coordination, as well as postural impairments in static and dynamic balance.– In addition, many children with ASDs have systemic comorbidities such as gastrointestinal disorders and food sensitivities. Overall, ASDs are complex multisystem disorders characterized by a myriad of impairments in several domains.
Obesity is a highly prevalent comorbidity in children with ASDs and might lead to significant health consequences., Nevertheless, current interventions for individuals with autism do not appear to address issues related to obesity risk and prevention. In light of the growing prevalence of ASDs in recent years,this review highlights the important issues related to physical inactivity and obesity in individuals with ASDs and encourages clinicians to develop and implement effective exercise interventions for this population. The specific aims of this article are: (1) to provide estimates on the prevalence of obesity in children and adolescents with ASDs; (2) to explain the mechanisms by which impairments characteristic of individuals with ASDs could contribute to obesity; (3) to discuss the evidence on exercise and physical activity (PA) interventions that address overweight and obesity, physical fitness, and autism-related impairments; and (4) to provide recommendations for assessment and intervention for individuals with ASDs.

Prevalence of Obesity in Individuals With ASDs

Obesity is caused by a positive energy balance in the body due to increased energy intake or decreased energy expenditure, or both. The most common indicator to classify obesity in children is the body mass index (BMI), which is defined as the ratio of the weight (in kilograms) to the square of the height (in meters squared). Children with BMI at the 95th percentile or higher are classified as obese, and children with BMI at the 85th percentile or higher are considered overweight., There is growing evidence that obesity is a major concern not just in children who are typically developing but also in children with developmental disabilities such as ASDs, attention deficit hyperactivity disorder (ADHD), and Down syndrome.,–Children with ASDs are at least as likely to be overweight or obese as their peers who are developing typically. The prevalence of obesity in children with ASDs is 30.4% compared with 23.6% in age-matched children without ASDs. Among children with chronic disabilities, the prevalence of obesity is greater in children with ASDs than in children with other developmental disabilities, including ADHD and learning disability. The multisystem physical, psychosocial, and systemic impairments in this population may contribute to their higher obesity prevalence, (see Figure for details). Obesity is associated with long-term physical and psychosocial consequences, including diabetes, stroke, osteoarthritis, increased cardiovascular risk, stigma, and depression.,, Overall, obesity is a significant comorbidity in individuals with ASDs, and it serves as a call for clinicians such as physical therapists, occupational therapists, and physical educators to address issues related to overweight and obesity in their clients with ASDs.
Figure.
Contributing factors for obesity in children and adolescents with autism spectrum disorders (ASDs) and the direct and indirect pathways by which autism-specific impairments and environmental factors contribute to the development of obesity in individuals ...

Contributing Factors for Obesity in Children and Adolescents With ASDs

In this section, we will discuss the factors contributing to obesity in children and adolescents with ASDs using the framework proposed by Rimmer and colleagues for individuals with disabilities. We have customized this framework to highlight the antecedents of obesity relevant to children with ASDs (see Figurefor details). There are 4 potential factors contributing to obesity in individuals with ASDs: low physical activity levels, poor nutrition, medication use and metabolic abnormalities, and lack of knowledge or awareness (Figure). Physical activity levels and nutrition directly affect the balance between energy expenditure and intake and contribute to obesity in both children who are developing typically and those with disabilities. Additional indirect contributions to obesity in individuals with ASDs could come from the intake of certain medications, metabolic and hormonal abnormalities, and certain autism-specific impairments.

Physical Activity Levels in Individuals With ASDs

Children with disabilities are less likely to engage in sustained and vigorous exercise compared with children without disabilities., Specifically, physical activity levels in children with ASDs were significantly lower compared with their peers who were developing typically., They lacked involvement in team and non-team sports and engaged in more solitary physical activities such as bicycling and swimming. Limited physical activity levels in individuals with ASDs may be attributed to their impairments in motor, social communication, sensory, and behavioral domains.
Previous empirical reports suggest that more than 50% of children diagnosed with ASDs demonstrate movement difficulties based on standardized motor assessments., Poor motor skills including difficulties with motor coordination and balance in this subset of children with ASDs may limit their activity choices., For example, the inability to perform complex motor activities may lead to preferences for simple and sedentary activities such as watching television or using the computer., In addition, social communication impairments of children with ASDs could significantly impair their abilities to engage in “group” sports and form peer relationships. Sensory processing problems are common in autism, with various studies suggesting that 42% to 100% of children with ASDs may demonstrate problems in various sensory domains, including tactile, auditory, and visual modalities.,, Sensory modulation problems in children with autism may affect their competence in play and lead to avoidance of activities providing intense sensory stimulation. Similarly, behavioral problems or preferences such as highly restricted interests, adherence to inflexible schedules, and a preference for highly predictable, structured activities may limit the activity choices of children with ASDs., Finally, environmental factors at the family or community level, such as lack of time and resources or unsupportive peer groups, could affect the physical activity behaviors of individuals with ASDs., To summarize, the multisystem social communication, sensorimotor, and behavioral impairments in children with ASDs, as well as several environmental factors, may contribute to reduced physical activity profiles, thereby leading to obesity.

Nutritional Patterns in Individuals With ASDs

Nutritional problems such as overly selective food choices can contribute to obesity in children with ASDs. Bandini and colleagues compared the food intake patterns of 53 children with ASDs with those of 58 children who were developing typically and found that children with ASDs refused offered foods more (41.7% of foods offered) than children who were developing typically (18.9% of foods offered). Moreover, children with ASDs demonstrated a more limited food repertoire, measured over 3 days, compared with their peers who were developing typically. Nutritional patterns of individuals with ASDs could be affected by 3 autism-specific impairments: problems in sensory modulation, systemic gastrointestinal comorbidities, and social communication impairments. Children with autism may have oral, olfactory, and gustatory hypersensitivity, leading to aversion to foods of certain textures or smells and a reduced consumption of healthy foods.,
In addition, more than 70% of individuals with ASDs demonstrate gastrointestinal problems, including chronic constipation, abdominal discomfort, diarrhea, and reflux, as well as food allergies such as lactose intolerance and inflammatory reactions to gluten and casein. These systemic comorbidities could additionally compromise the nutritional habits of children with ASDs. Social communication impairments in this population may compound their nutritional problems, thereby contributing to the development of obesity. Specifically, children with autism who are high functioning may realize their difficulties in developing and maintaining friendships with peers, which, in turn, may lead to feelings of depression and isolation and a tendency for binge eating. Studies suggest that between 46% and 89% of individuals with ASDs demonstrate problematic feeding behaviors and food selectivity in that they may prefer diets that are energy-dense and starchy, such as sweetened beverages and pizza, and do not consume low energy-dense foods, such as fruits, vegetables, lean protein, and high-fiber foods.– Lastly, several environmental factors, including parent preferences for energy-dense diets or the use of high energy-dense, edible reinforcers, may influence the dietary patterns of children with ASDs.,, Taken together, there is substantial evidence suggesting that autism-specific impairments and environmental factors could contribute to the nutritional imbalance observed in individuals with ASDs.

Use of Prescription Medication and Metabolic Abnormalities in Individuals With ASDs

Long-term use of prescription medications could contribute to obesity in individuals with ASDs. Children and adolescents with ASDs are commonly prescribed psychoactive drugs, including antipsychotics, antidepressants, antianxiety drugs, and stimulants, for their behavioral or psychiatric symptoms. However, some drugs, such as the antipsychotic risperidone, often lead to significant weight gain., Risperidone treatment for 6 months led to weight gains of 8.2 kg in children with ASDs and 5.4 kg in adults with ASDs. It is proposed that antipsychotics have a potent serotonin-blocking action., Serotonin is the brain satiety factor that helps control feeding behaviors, and the blocking of serotonin may lead to increased appetite and significant weight gain., Similarly, antipsychotics may desensitize the leptin receptors in the brain and reduce the sensitivity of the satiety center to feedback signals from peripheral adipocytes, leading to overeating and weight gain.
Hormonal and metabolic imbalances in individuals with ASDs also could contribute to obesity. Specifically, individuals with ASDs may have an imbalance between proinflammatory and anti-inflammatory hormones. Proinflammatory mediators such as leptin secreted by the adipose tissue have been implicated in the development of obesity. Leptin is involved in the regulation of energy balance and body weight at the hypothalamic level, and higher levels of leptin are associated with increased fat mass and BMI in children.On the other hand, anti-inflammatory mediators such as transforming growth factor beta-1 (TGF-β1) and adiponectin secreted by the adipose tissue are known to exert protective effects against metabolic disturbances in the body. In some studies, children and adolescents with ASDs had higher plasma levels of leptin and lower levels of adiponectin and TGF-β1 compared with children without ASDs.– Taken together, the use of medications or the presence of hormonal and metabolic imbalances may contribute to energy imbalance and obesity in children and adults with ASDs.

Knowledge or Awareness in Individuals With ASDs

Children and adolescents with ASDs may not understand the long-term risks associated with obesity and the healthy lifestyle habits to counter them. This finding may be especially true for children with autism, who are low functioning and have cognitive impairments. Moreover, children with ASDs may have problems with self-regulation of eating and physical activity patterns. Parent or caregiver perceptions about the overall importance of physical activity also play a critical role in determining the physical activity profiles of their children. Parents of children with ASDs frequently reported that intense treatments such as applied behavioral analysis (ABA) for about 30 to 40 hours per week were quite stressful and time-consuming.,, Therefore, a heightened level of caregiver burden and predominantly sedentary activities during ABA therapies may lead to neglect of physical activity and nutrition in children and adolescents with ASDs.

Exercise and Physical Activity Interventions for Individuals With ASDs

Despite the growing evidence for obesity in individuals with ASDs, there is surprisingly little research assessing the efficacy of physical activity interventions for the treatment of obesity and promotion of physical fitness. A recent systematic review of exercise interventions for individuals with ASDs revealed that only 5 of the 18 studies assessed improvements in physical fitness, whereas the remaining studies focused on improvements in behavioral and cognitive skills. In this section, we review the existing literature on physical activity interventions aimed at enhancing physical fitness and reducing obesity and overweight as well as impairments related to autism in the behavioral, cognitive, and motor domains (Tabs. 1 and ​and22 and theeTable).
Table 1.
Studies on Improving Physical Fitness and Reducing Obesity: Details on Study Design, Participant Characteristics, and Intervention Characteristicsa
Table 2.
Studies on Improving Fitness and Reducing Obesity: Details on Dependent Variables, Test Measures, and Resultsa

Physical Activity Interventions to Address Obesity and Enhance Physical Fitness in Individuals With ASDs

Existing reviews on the positive effects of exercise interventions in individuals with ASDs have suggested that regular exercise has beneficial effects in alleviating social, behavioral, cognitive, and motor impairments of autism., However, these reviews did not provide any definitive conclusions or recommendations regarding the effects of exercise on cardiovascular and musculoskeletal fitness or obesity outcomes.
Our review of the literature revealed a total of 10 studies that targeted physical fitness or obesity in children and adolescents with ASDs. We have provided a comprehensive summary of individual study characteristics in Tables 1 and ​and2.2. Overall, these studies suggest that exercise promotes cardiovascular and musculoskeletal fitness but has limited effects on overweight or obesity status. Interestingly, despite the growing concern of obesity in individuals with ASDs, not all the studies listed in Tables 1 and ​and22 included systematic measures of obesity and body composition as preintervention-postintervention assessments. Moreover, only 2 studies exclusively targeted weight reduction in children and adolescents with ASDs., Pitetti and colleaguesimplemented a graded treadmill training protocol for 9 months in adolescents with developmental disabilities, including autism, and found a significant increase in calorie expenditure and a decrease in BMI in the group of children who received treadmill training compared with the children in the control group. Similarly, Hinckson and colleagues implemented a comprehensive 10-week, family-centered weight management program including components of physical activity and nutritional and psychological counseling for individuals with disabilities and their families. Although they did not find any significant improvements in body composition, parents reported positive changes in lifestyle habits of their children postintervention.The majority of the studies promoting exercise did not particularly focus on obesity outcomes, and most studies did not include both nutritional and exercise components in the intervention program.
Although the volume of literature on physical activity interventions for improving physical fitness in individuals with ASDs appears significant, the evidence is weakened by several shortcomings such as a lack of control groups or between-subjects designs, an emphasis on single-subject or within-subject designs, relatively small sample sizes (ie, 1–23 individuals with ASDs), and a dearth of long-term outcomes (ie, follow-up assessments present in only 2 of the 10 studies). The studies showed considerable variability in terms of intervention characteristics using the FITT (Frequency, Intensity, Time, and Type) model (see Tabs. 1 and ​and22 for details). Most studies provided exercise training 2 or 3 times a week with durations varying from 20 minutes to 1 hour. In terms of exercise type, both aerobic training and resistance training have been provided. Modalities used for aerobic training include treadmill, cycling, aquatic exercises, and exergaming.,– Studies typically implemented aerobic exercise at moderate to vigorous intensities. Programs that focused on resistance training mainly targeted upper limb and lower limb muscles using free weights, body weight, and machines., Overall, conclusions drawn from empirical evidence on efficacy of physical activity interventions to improve fitness and obesity status in individuals with ASDs, although promising, are currently limited due to the lack of rigorous study designs.

Physical Activity Interventions for Treating Autism-Related Impairments in Individuals With ASDs

Children with ASDs have received a variety of exercise interventions to reduce autism-specific impairments such as problem behaviors, stereotypical behaviors, and inattention, as well as to improve academic performance, social responding, peer relations, and perceptuomotor skills (see more details in the eTable). Several exercise modalities, including swimming, jogging, cycling, weight training, walking, and horseback riding, have been used., A meta-analysis of 16 studies suggested that, on average, exercise interventions led to a 37% improvement in overall symptomatology of autism, specifically, behavioral and academic improvements. In terms of behavioral skills of children with ASDs, vigorous intensity exercises such as jogging, roller-skating, hydrotherapy exercises, and exergames have been used to reduce the frequency of stereotypical behaviors,,, aggressive or self-injurious behaviors, and hyperactivity. In terms of academic performance, physical exercise preceding classroom lessons led to an increase in academic responding and on-task behaviors while reducing disruptive behaviors in class in children with ASDs.–Moreover, the amount of time spent in physical activity positively correlated with engagement in class. In terms of addressing social skills, aquatic and equine therapies have been used to reduce antisocial and aggressive behavior and improve social responding and peer relations in children with autism., Lastly, recreational pool exercises, and horseback riding have been used to facilitate gross motor coordination and balance in children with autism. Overall, there is considerable evidence from several studies that exercise interventions are effective in improving motor, social, and behavioral skills of individuals with ASDs.

Clinical Implications for Assessment and Treatment of Individuals With ASDs

Obesity in individuals with ASDs results from a variety of contributing factors at the individual and environmental levels. In the following sections, we provide recommendations for assessment and treatment of clients with ASDs for practicing clinicians. As discussed above, our critical review of the current literature on exercise in individuals with ASDs suggests that there is a lack of high-quality evidence supporting the use of exercise interventions for improving physical fitness and reducing overweight and obesity. Hence, we will largely draw upon literature from children who are developing typically and children with other pediatric developmental disabilities to provide recommendations for individuals with ASDs. We acknowledge that obesity is a complex problem and holistic interventions that address both sides of the energy balance equation at the personal and environmental level are necessary. The literature suggests that multifactorial programs promoting physical activity, nutritious diet, lifestyle education or modification, and parental or caregiver education are more effective in addressing obesity-related issues in children with developmental disabilities than programs that concentrate on a single component such as diet or exercise.,, Therefore, an effective treatment plan must involve a collaborative effort among the family, special educators and caregivers, physical therapists/occupational therapists/physical educators, and nutrition experts to ensure long-term improvements. However, as physical therapists and exercise physiologists, our recommendations for assessment and treatment in this section are aimed at the physical activity side of the energy balance equation.

Recommendations for Assessment

In this section, we briefly discuss various standardized tests and measures to assess obesity, cardiovascular and muscular fitness, and physical activity levels in children and adolescents. A comprehensive list of these measures is provided in Table 3. These tests and measures could be used to measure a child's or adolescent's baseline performance as well as changes during and after the exercise intervention. Common methods for obesity assessment in children and adolescents include BMI, waist circumference, and skinfold thickness measures. Different exercise tests and associated quantitative measures listed in Table 3 could be used to measure cardiovascular and muscular fitness in children and adults.
Table 3.
Measures for Assessing Physical Fitness and Physical Activity Levels in Children and Adolescents With Autism Spectrum Disordersa
Clinicians must choose exercise tests appropriately depending on the functional capacity, motor skill level, and intellectual level of the child or adolescent with ASD. For example, for children with poor trunk control, supported cycling might be a better modality to assess cardiovascular fitness than treadmill walking, which places greater demands on the postural system. Clinicians will have to modify the testing protocol for individuals with ASDs who are low functioning by choosing a familiar exercise modality and by providing verbal encouragement and hand-over-hand assistance to reduce their client's anxiety.,
It would be important to assess the activity levels of children and adolescents with ASDs at baseline and postintervention to evaluate the efficacy of physical activity and lifestyle-modification interventions. Quantitative measures for physical activity include heart rate monitoring, accelerometry, pedometry, electronic screen devices, and inclinometry. Qualitative measures of physical activity include diaries, logbooks, and survey questionnaires. These can be self-report assessments, or they can be completed by parents or teachers. Self-report questionnaires are not recommended for children under 10 years of age or for children who are low functioning due to their inability to accurately recall physical activity behaviors. Both quantitative and qualitative measures require about a week of data collection to obtain an accurate estimate of habitual physical activity levels., Each measurement, quantitative or qualitative, is associated with some degree of error. An ideal measurement would be one that is objective (ie, associated with the lowest degree of error and highest interobserver agreement). Clinicians and researchers should make efforts to reduce measurement error and improve the reliability of their measures and tools. We recommend that clinicians use a combination of quantitative and qualitative measures to obtain objective and reliable estimates of physical fitness and physical activity levels when developing interventions or monitoring progress.

Recommendations for Treatment

Current interventions for children with autism mainly target their core social communication and academic impairments. Such interventions include ABA, Teaching and Education of Autistic and Related Communication Handicapped Children (TEACHH), and Picture Exchange Communication System (PECS). These approaches primarily involve sedentary, tabletop activities in which children with ASDs practice social communication skills in highly structured and confined environments., Therefore, the onus is on clinicians to promote interventions based on movement and physical activity to not only address autism-specific impairments but also reduce obesity and enhance fitness. Although motor and physical activity deficits are not central to the disorder, it is likely that addressing the motor deficiencies and reduced physical activity levels may indirectly affect the core social communication impairments of individuals with ASDs by providing greater opportunities for socialization with peers, better attentional focus, and improved motor performance.,, Therefore, we recommend that motor and physical activity–related goals be included within the plan of care for individuals with ASDs, given the multisystem and systemic effects of exercise interventions.
There is strong evidence emerging from literature on children who are developing typically and individuals with developmental disabilities such as Down syndrome and cerebral palsy regarding the efficacy of aerobic and resistance training programs in improving physical fitness and achieving weight reduction.,– For example, a meta-analysis of 17 randomized controlled trials that implemented nonsurgical interventions for addressing obesity in children and adolescents between 2 and 18 years of age who were developing typically showed that physical activity interventions with durations ranging between 6 weeks and 24 months had a moderate-sized treatment effect (effect size=−0.52) on measures of adiposity, including percent body fat and fat-free mass. Similarly, a recent meta-analysis of 14 studies assessing the efficacy of exercise programs in individuals with intellectual disability indicated an overall positive effect of exercise on physiological measures of cardiorespiratory and musculoskeletal fitness, including volume of oxygen consumption (V̇o2), pulmonary ventilation (V̇e), and muscle force production.
A review of studies adhering to exercise guidelines recommended by the American College of Sports Medicine (ACSM) for improving cardiovascular fitness in individuals with Down syndrome showed that exercise programs were effective in increasing peak V̇o2, peak V̇e, maximum workload achieved, and time to exhaustion in this population. Given the lack of ACSM guidelines for exercise prescription in individuals with ASDs, our exercise recommendations for this population are largely based on studies in children who were developing typically and those with other developmental disabilities. We recommend an exercise program combining components of aerobic, resistance, flexibility, and neuromuscular training for maximum gains in fitness and body composition (details of FITT parameters of exercise are provided in Tab. 4).
Table 4.
Physical Activity Programs for Children and Adolescents With Autism Spectrum Disorders (ASDs)a
The majority of the evidence for exercise interventions in individuals with developmental disabilities including ASDs discussed above stems from studies conducted at the individual level. However, large-scale obesity treatment and prevention programs at the community and school levels have been implemented in children who are typically developing and to some extent in individuals with special needs.–
Children spend a large portion of their day in school; hence, school-based programs may be valuable in developing healthy lifestyle practices in children. A Cochrane review provided definitive evidence for the beneficial effects of school-based programs on duration of physical activity, television viewing, maximum V̇o2, and blood cholesterol levels of participants between 6 and 18 years of age. School-based interventions typically include components of health education, teacher training, changes to school curriculum or schedule to increase physical activity, provision of nutritious food, and parent education or counseling.,– The Activity Bursts in the Classroom (ABC) and Motivate, Adapt, and Play (MAP) programs in the United States as well as the modified Mind, Exercise, Nutrition…Do It! (MEND) program in New Zealand are examples of such programs.,, For example, the ABC program is a school-based intervention encouraging physical activity in children who are developing typically using multiple 10-minute activity breaks within the regular daily curriculum. These breaks were utilized to promote physical activities that could vary in complexity from basic breaks between classes to whole body movements for fitness to imaginary and learning-based play to facilitate the learning of art, music, math, and science concepts, thereby leading to improvements in physical fitness and academic performance. Community-based programs such as the “Best Buddies” program also have been implemented to improve fitness in children with disabilities. This is an inclusive physical education program that pairs a child with special needs with a peer who is developing typically (see details at the Best Buddies website).
Overall, there are only a handful of comprehensive programs for children with special needs, and hardly any for those with autism. Therefore, we recommend the implementation of multifactorial and multisystem community or school-level interventions to address physical fitness and obesity/overweight concerns in children with developmental disabilities.

Specific Recommendations for Clinicians Working With Individuals With ASDs

Working with individuals with ASDs is challenging; therefore, in this section we provide specific recommendations for clinicians working directly with children with ASDs (see Tab. 5 for details). The following discussion provides general guidelines; however, it is important to tailor the exercise program to the individual needs of each client to maintain interest and long-term adherence to a physically active lifestyle.
Table 5.
Specific Recommendations for Exercise Sessions Involving Children With Autism Spectrum Disorders (ASDs)
Our recommendations are based on principles taken from contemporary treatment approaches for individuals with ASDs, such as ABA, TEACHH, and PECS. These principles inform 2 important aspects of an exercise intervention: the structure of the exercise environment and the nature of the clinician's interaction, including instructions, feedback, and reinforcement (Tab. 5). The structure of the environment should be consistent, well demarcated, and limited in space depending on program needs and must encourage attentional focus and engagement., Children with ASDs will need graded prompting or feedback in the form of brief initial verbal instructions, associated visual cues using demonstrations or picture schedules, and hand-over-hand feedback when appropriate., Given the presence of motor impairments in more than 50% of children with ASDs,, they may need adaptive modifications to exercise equipment such as hand rails or harnesses for a treadmill or stabilizers or rollers for a bicycle., Moreover, the choice of exercise modality will depend on the motor and social impairments of the child. For example, for children with balance impairments, supported stationary cycling might be more appropriate than jogging due to lower demands on the postural system. Children with motor incoordination will benefit from sports activities enhancing upper-limb or whole body coordination in comfortable, noncompetitive, and nonintimidating environments. Furthermore, children with ASDs who are low functioning may require individual-level programs, whereas group-based programs may be more appropriate for children with a high level of functioning. Overall, we recommend that clinicians consider the individual needs of their clients and make appropriate modifications to the environment, exercise equipment, and the nature of their interactions to ensure their clients' success within the exercise program.

Limitations of the Current Research and Future Directions

Current research is restricted to documenting the prevalence of obesity and determining the PA levels and food patterns of individuals with ASDs. Few studies have examined the links between obesity and autism-specific impairments or developed effective obesity interventions in individuals with ASDs. There is a greater focus on using aerobic exercise to enhance PA and reduce the autism-specific impairments of individuals with ASDs, with little evidence for the effects of resistance or neuromuscular training. There is also limited literature on holistic, multifactorial interventions involving a team effort to address obesity issues. Moreover, current literature on exercise interventions for ASDs is limited due to small heterogeneous samples, lack of control groups, presence of confounding factors, and lack of long-term follow-up. Therefore, in the future, clinical researchers should use rigorous research designs to investigate the unique contributions of autism-specific impairments to obesity and develop multifactorial and multilevel obesity interventions for individuals with ASDs. We acknowledge that conducting high-quality, large-scale randomized controlled trials for systematically addressing issues of overweight and obesity and improving physical fitness in individuals with ASDs is a daunting task, but given the various health concerns associated with obesity, there is an urgent need for clinical researchers to bring issues related to physical fitness to the forefront in this population.

Supplementary Material

Footnotes

All authors provided concept/idea/project design and writing. Ms Srinivasan and Dr Bhat provided clerical support. Dr Pescatello provided consultation (including review of manuscript before submission).
The authors thank Jill Livingston for her help and support with the literature review for the manuscript. Dr Bhat thanks the National Institutes of Mental Health (grants R21MH089441 and R33MH089441) and Autism Speaks (grant 8137) for their funding support in developing novel, embodied interventions for children with autism spectrum disorders. The content of the manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

1. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed Washington, DC: American Psychiatric Association; 2000
2. Dawson G, Toth K, Abbott R, et al. Early social attention impairments in autism: social orienting, joint attention, and attention to distress. Dev Psychol. 2004;40:271–283 [PubMed]
3. Tager-Flusberg H. A psychological approach to understanding the social and language impairments in autism. Int Rev Psychiatr. 1999;11:325–334 [PMC free article] [PubMed]
4. Richler J, Bishop S, Kleinke J, Lord C. Restricted and repetitive behaviors in young children with autism spectrum disorders. J Autism Dev Disord. 2007;37:73–85 [PubMed]
5. Williams DL, Goldstein G, Minshew NJ. Neuropsychologic functioning in children with autism: further evidence for disordered complex information-processing. Child Neuropsychol. 2006;12:279–298[PMC free article] [PubMed]
6. Lecavalier L. Behavioral and emotional problems in young people with pervasive developmental disorders: relative prevalence, effects of subject characteristics, and empirical classification. J Autism Dev Disord. 2006;36:1101–1114 [PubMed]
7. Tomchek SD, Dunn W. Sensory processing in children with and without autism: a comparative study using the short sensory profile. Am J Occup Ther. 2007;61:190–200 [PubMed]
8. Fournier KA, Hass CJ, Naik SK, et al. Motor coordination in autism spectrum disorders: a synthesis and meta-analysis. J Autism Dev Disord. 2010;40:1227–1240 [PubMed]
9. Bhat A, Landa R, Galloway JC. Perspectives on motor problems in infants, children, and adults with autism spectrum disorders. Phys Ther. 2011;91:1116–1129 [PubMed]
10. Minshew NJ, Sung KB, Jones BL, Furman JM. Underdevelopment of the postural control system in autism. Neurology. 2004;63:2056–2061 [PubMed]
11. Buie E, Campbell DB, Fuchs GJ, III, et al. Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: a consensus report. Pediatrics. 2010;125:1–18 [PubMed]
12. Tyler CV, Schramm SC, Karafa M, et al. Chronic disease risks in young adults with autism spectrum disorder: forewarned is forearmed. Am J Intellect Dev Disabil. 2011;116:371–380 [PubMed]
13. Curtin C, Anderson SE, Must A, Bandini L. The prevalence of obesity in children with autism: a secondary data analysis using nationally representative data from the National Survey of Children's Health.BMC Pediatr. 2010;10:11. [PMC free article] [PubMed]
14. Autism and Developmental Disabilities Monitoring Network Surveillance Year 2008 Principal Investigators; Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders: autism and developmental disabilities monitoring network, United States, 2008. MMWR Surveill Summ. 2012;61: 1–19 [PubMed]
15. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics (Evanston). 2007;120:S164–S192[PubMed]
16. Krebs NF, Himes JH, Jacobson D, et al. Assessment of child and adolescent overweight and obesity.Pediatrics. 2007;120:193–228 [PubMed]
17. Bandini LG, Curtin C, Hamad C, et al. Prevalence of overweight in children with developmental disorders in the continuous National Health and Nutrition Examination Survey (NHANES) 1999–2002. J Pediatr. 2005;146(6):738–743 [PubMed]
18. Chen AY, Kim SE, Houtrow AJ, Newacheck PW. Prevalence of obesity among children with chronic conditions. Obesity. 2009;18:210–213 [PubMed]
19. Rimmer JH, Yamaki K, Lowry B, et al. Obesity and obesity-related secondary conditions in adolescents with intellectual/developmental disabilities. J Intellect Disabil Res. 2010;54:787–794 [PubMed]
20. Rimmer JH, Rowland JL, Yamaki K. Obesity and secondary conditions in adolescents with disabilities: addressing the needs of an underserved population. J Adolescent Health. 2007;41:224–229 [PubMed]
21. Rimmer JA, Rowland JL. Physical activity for youth with disabilities: a critical need in an underserved population. Dev Neurorehabil. 2008;11:141–148 [PubMed]
22. Macdonald M, Esposito P, Ulrich D. The physical activity patterns of children with autism. BMC Res Notes. 2011;4:422. [PMC free article] [PubMed]
23. Borremans E, Rintala P, McCubbin JA. Physical fitness and physical activity in adolescents with Asperger syndrome: a comparative study. Adapt Phys Act Q. 2010;27:308–320 [PubMed]
24. Potvin M, Snider L, Prelock P, et al. Recreational participation of children with high functioning autism.J Autism Dev Disord. 2013;43:445–457 [PubMed]
25. Manjiviona J, Prior M. Comparison of Asperger syndrome and high-functioning autistic children on a test of motor impairment. J Autism Dev Disord. 1995;25:23–39 [PubMed]
26. Green D, Charman T, Pickles A, et al. Impairment in movement skills of children with autistic spectrum disorders. Dev Med Child Neurol. 2009;51:311–316 [PubMed]
27. Reynolds S, Bendixen RM, Lawrence T, Lane SJ. A pilot study examining activity participation, sensory responsiveness, and competence in children with high functioning autism spectrum disorder. J Autism Dev Disord. 2011;41:1496–1506 [PubMed]
28. Dawson G, Watling R. Interventions to facilitate auditory, visual, and motor integration in autism: a review of the evidence. J Autism Dev Disord. 2000;30:415–421 [PubMed]
29. Ben-Sasson A, Hen L, Fluss R, et al. A meta-analysis of sensory modulation symptoms in individuals with autism spectrum disorders. J Autism Dev Disord. 2009;39:1–11 [PubMed]
30. Obrusnikova I, Miccinello DL. Parent perceptions of factors influencing after-school physical activity of children with autism spectrum disorders. Adapt Phys Act Q. 2012;29:63–80 [PubMed]
31. Bandini LG, Anderson SE, Curtin C, et al. Food selectivity in children with autism spectrum disorders and typically developing children. J Pediatr. 2010;157:259–264 [PMC free article] [PubMed]
32. Evans EW, Must A, Anderson SE, et al. Dietary patterns and body mass index in children with autism and typically developing children. Res Autism Spect Dis. 2012;6:399–405 [PMC free article] [PubMed]
33. Ledford JR, Gast DL. Feeding problems in children with autism spectrum disorders: a review. Focus Autism Other Dev Disabl. 2006;21:153–166
34. Ahearn WH, Castine T, Nault K, Green G. An assessment of food acceptance in children with autism or pervasive developmental disorder-not otherwise specified. J Autism Dev Disord. 2001;31:505–511[PubMed]
35. Schreck KA, Williams K. Food preferences and factors influencing food selectivity for children with autism spectrum disorders. Res Dev Disabil. 2006;27:353–363 [PubMed]
36. Irby MB, Kolbash S, Garner-Edwards D, Skelton JA. Pediatric obesity treatment in children with neurodevelopmental disabilities: a case series and review of the literature. Infant Child Adolesc Nutr. 2012;4:215–221 [PMC free article] [PubMed]
37. Oswald DP, Sonenklar NA. Medication use among children with autism spectrum disorders. J Child Adolesc Psychopharmacol. 2007;17:348–355 [PubMed]
38. Hellings JA, Zarcone JR, Crandall K, et al. Weight gain in a controlled study of risperidone in children, adolescents and adults with mental retardation and autism. J Child Adolesc Psychopharmacol. 2001;11:229–238 [PubMed]
39. Martin A, Scahill L, Anderson GM, et al. Weight and leptin changes among risperidone-treated youths with autism: 6-month prospective data. Am J Psychiatry. 2004;161:1125–1127 [PubMed]
40. Fujita-Shimizu A, Suzuki K, Nakamura K, et al. Decreased serum levels of adiponectin in subjects with autism. Prog Neuropsychopharmacol Biol Psychiatry. 2010;34:455–458 [PubMed]
41. Blardi P, de Lalla A, Ceccatelli L, et al. Variations of plasma leptin and adiponectin levels in autistic patients. Neurosci Lett. 2010;479:54–57 [PubMed]
42. Ashwood P, Enstrom A, Krakowiak P, et al. Decreased transforming growth factor beta 1 in autism: a potential link between immune dysregulation and impairment in clinical behavioral outcomes. J Neuroimmunol. 2008;204:149–153 [PMC free article] [PubMed]
43. Lang R, Koegel LK, Ashbaugh K, et al. Physical exercise and individuals with autism spectrum disorders: a systematic review. Res Autism Spect Dis. 2010;4:565–576
44. Sowa M, Meulenbroek R. Effects of physical exercise on autism spectrum disorders: a meta-analysis. Res Autism Spect Dis. 2012;6:46–57
45. 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. 2007;37:997–1006 [PubMed]
46. Hinckson EA, Dickinson A, Water T, et al. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil. 2013;34:1170–1178 [PubMed]
47. Lochbaum M, Crews D. Viability of cardiorespiratory and muscular strength programs for the adolescent with autism. Complement Health Pract Rev. 2003;8:225–233
48. Pan C-Y. The efficacy of an aquatic program on physical fitness and aquatic skills in children with and without autism spectrum disorders. Res Autism Spect Dis. 2011;5:657–665
49. Fragala-Pinkham MA, Haley SM, O'Neil ME. Group swimming and aquatic exercise programme for children with autism spectrum disorders: a pilot study. Dev Neurorehabil. 2011;14:230–241 [PubMed]
50. Anderson-Hanley C, Tureck K, Schneiderman RL. Autism and exergaming: effects on repetitive behaviors and cognition. Psychol Res Behav Manag. 2011;4:129–137 [PMC free article] [PubMed]
51. Hayakawa K, Kobayashi K. Physical and motor skill training for children with intellectual disabilities.Percept Mot Skills. 2011;112:573–580 [PubMed]
52. Yilmaz I, Yanarda M, Birkan B, Bumin G. Effects of swimming training on physical fitness and water orientation in autism. Pediatr Int. 2004;46:624–626 [PubMed]
53. Lancioni GE, O'Reilly MF. A review of research on physical exercise with people with severe and profound developmental disabilities. Res Dev Disabil. 1998;19:477–492 [PubMed]
54. McGimsey J, Favell J. The effects of increased physical exercise on disruptive behavior in retarded persons. J Autism Dev Disord. 1988;18:167–179 [PubMed]
55. Rosenthal-Malek A, Mitchell S. Brief report: the effects of exercise on the self-stimulatory behaviors and positive responding of adolescents with autism. J Autism Dev Disord. 1997;27:193–202 [PubMed]
56. Nicholson HK, Bray TJ, Heest MA, Van J. The effects of antecedent physical activity on the academic engagement of children with autism spectrum disorder. Psychol Schools. 2011;48:198–213
57. 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. 2011;23:187–193 [PubMed]
58. Pan C-Y. Effects of water exercise swimming program on aquatic skills and social behaviors in children with autism spectrum disorders. Autism. 2010;14:9–28 [PubMed]
59. Wuang YP, Wang CC, Huang MH, Su CY. The effectiveness of simulated developmental horse-riding program in children with autism. Adapt Phys Activ Q. 2010;27:113–126 [PubMed]
60. Dodd KJ, Shields N. A systematic review of the outcomes of cardiovascular exercise programs for people with Down syndrome. Arch Phys Med Rehabil. 2005;86:2051–2058 [PubMed]
61. American College of Sports Medicine. ASCM's Guidelines for Exercise Testing and Prescription. 8th ed Baltimore, MD: Lippincott Williams & Wilkins; 2009
62. Tsimaras V, Glagazoglou P, Fotiadou E, et al. Jog-walk training in cardiorespiratory fitness of adults with Down syndrome. Percept Mot Skills. 2003;96:1239–1251 [PubMed]
63. Dollman J, Okely AD, Hardy L, et al. A hitchhiker's guide to assessing young people's physical activity: deciding what method to use. J Sci Med Sport. 2009;12:518–525 [PubMed]
64. Hardy LL, Hills AP, Timperio A, et al. A hitchhiker's guide to assessing sedentary behaviour among young people: deciding what method to use. J Sci Med Sport. 2013;16:28–35 [PubMed]
65. Rothstein JM. On defining subjective and objective measurements. Phys Ther. 1989;69:577–579[PubMed]
66. Landa R. Early communication development and intervention for children with autism. Ment Retard Dev Disabil Res Rev. 2007;13:16–25 [PubMed]
67. Lovaas OI. Behavioral treatment and normal educational and intellectual functioning in young autistic children. J Consult Clin Psychol. 1987;55:3–9 [PubMed]
68. Mesibov GB, Shea V, Schopler E. The TEACCH Approach to Autism Spectrum Disorders. New York, NY: Springer; 2004
69. Bondy A, Frost A. Communication strategies for visual learners. In: Lovaas OI, editor. , ed. Teaching Individuals With Developmental Delays: Basic Intervention Techniques. Austin, TX: Pro-Ed; 2003:291–304
70. Shin I, Park E. Meta-analysis of the effect of exercise programs for individuals with intellectual disabilities. Res Dev Disabil. 2012;33:1937–1947 [PubMed]
71. Chanias AK, Reid G, Hoover ML. Exercise effects on health-related physical fitness of individuals with an intellectual disability: a meta-analysis. Adapt Phys Act Q. 1998;15:119–140
72. McGovern L, Johnson JN, Paulo R, et al. Treatment of pediatric obesity: a systematic review and meta-analysis of randomized trials. J Clin Endocrinol Metab. 2008;93:4600–4605 [PubMed]
73. Wu CL, Lin JD, Hu J, et al. The effectiveness of healthy physical fitness programs on people with intellectual disabilities living in a disability institution: six-month short-term effect. Res Dev Disabil. 2010;31:713–717 [PubMed]
74. Heller T, McCubbin JA, Drum C, Peterson J. Physical activity and nutrition health promotion interventions: what is working for people with intellectual disabilities? Intellect Dev Disabil. 2011;49:26–36[PubMed]
75. Johnson CC. The benefits of physical activity for youth with developmental disabilities: a systematic review. Am J Health Promot. 2009;23:157–167 [PubMed]
76. Lotan M, Isakov E, Kessel S, Merrick J. Physical fitness and functional ability of children with intellectual disability: effects of a short-term daily treadmill intervention. Scientific World Journal. 2004;4:449–457 [PubMed]
77. Rogers A, Furler B, Brinks S, Darrah J. A systematic review of the effectiveness of aerobic exercise interventions for children with cerebral palsy: an AACPDM evidence report. Dev Med Child Neurol. 2008;50:808–814 [PubMed]
78. Katz DL, Cushman D, Reynolds J, et al. Putting physical activity where it fits in the school day: preliminary results of the ABC (Activity Bursts in the Classroom) for fitness program. Prev Chronic Dis. 2010;7:A82. [PMC free article] [PubMed]
79. Zenzen W, Kridli S. Integrative review of school-based childhood obesity prevention programs. J Pediatr Health Car. 2009;23:242–258 [PubMed]
80. Davis K, Zhang G, Hodson P. Promoting health-related fitness for elementary students with intellectual disabilities through a specifically designed activity program. J Policy Pract Intellect Disabil. 2011;8:77–84
81. Dobbins M, DeCorby K, Robeson P, et al. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6–18. Cochrane Database Syst Rev. 2009;(1):1–108 [PubMed]
82. Best Buddies website. Available at: http://www.bestbuddies.org Accessed January 14, 2013
83. MacDonald M, Esposito P, Hauck J, et al. Bicycle training for youth with Down syndrome and autism spectrum disorders. Focus Autism Other Dev Disabl. 2012;27:12–21
84. Magnusson JE, Cobham C, McLeod R. Beneficial effects of clinical exercise rehabilitation for children and adolescents with autism spectrum disorder (ASD). J Exerc Physiol. 2012;15:71–79
85. Fragala-Pinkham M, Haley SM, O'Neil ME. Group aquatic aerobic exercise for children with disabilities.Dev Med Child Neurol. 2008;50:822–827 [PubMed]
86. Oriel KN, George CL, Blatt PJ. The impact of a community based exercise program in children and adolescents with disabilities: a pilot study. Physical Disabil: Educ Related Serv. 2008;27:5–20
87. Utter AC. Children's OMNI Scale of Perceived Exertion: walking/running evaluation. Med Sci Sports Exerc. 2002;34:139–144 [PubMed]
88. Barkley JE, Roemmich JN. Validity of a pediatric RPE scale when different exercise intensities are completed on separate days. J Exerc Sci Fit. 2011;9:52–57
89. Freedson PS, Cureton KJ, Heath GW. Status of field-based fitness testing in children and youth. Prev Med. 2000;31:77–85
90. Fragala-Pinkham MA, Haley SM, Rabin J, Kharasch VS. A fitness program for children with disabilities.Phys Ther. 2005;85:1182–1200 [PubMed]
91. Elliott RO, Jr, Dobbin AR, Rose GD, Soper HV. Vigorous, aerobic exercise versus general motor training activities: effects on maladaptive and stereotypic behaviors of adults with both autism and mental retardation. J Autism Dev Disord. 1994;24:565–576 [PubMed]
92. Allison DB, Basile VC, MacDonald RB. Brief report: comparative effects of antecedent exercise and lorazepam on the aggressive behaviour of an autistic man. J Autism Dev Disord. 1991;21:89–94; erratum 379 [PubMed]
93. Morrison H, Roscoe EM, Atwell A. An evaluation of antecedent exercise on behavior maintained by automatic reinforcement using a three-component multiple schedule. J Appl Behav Anal. 2011;44:523–541[PMC free article] [PubMed]
94. Celiberti DA, Bobo HE, Kelly KS, et al. The differential and temporal effects of antecedent exercise on the self-stimulatory behavior of a child with autism. Res Dev Disabil. 1997;18:139–150 [PubMed]
95. Levinson LJ, Reid G. The effects of exercise intensity on the stereotypic behaviors of individuals with autism. Adapt Phys Act Q. 1993;10:255–268
96. Kern L, Koegel RL, Dunlap G. The influence of vigorous versus mild exercise on autistic stereotyped behaviors. J Autism Dev Disord. 1984;14:57–67 [PubMed]
97. Prupas A, Reid G. Effects of exercise frequency on stereotypic behaviors of children with developmental disabilities. Educ Train Dev Disabil. 2001;36:196–206
98. Kern L, Koegel RL, Dyer K, et al. The effects of physical exercise on self-stimulation and appropriate responding in autistic children. J Autism Dev Disord. 1982;12:399–419 [PubMed]
99. Watters RG, Watters WE. Decreasing self-stimulatory behavior with physical exercise in a group of autistic boys. J Autism Dev Disord. 1980;10:379–387 [PubMed]
100. Powers S, Thibadeau S, Rose K. Antecedent exercise and its effects on self-stimulation. Behav Interv. 1992;7:15–22
101. US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for Americans. 6th ed Washington, DC: Government Printing Office; January 2005

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