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 play
More social withdrawal
Bar-Haim, et al., 2006.
What does this mean for our kids with ASD?
Motor skills and ASD
Early on many researchers saw
motor deficits, as a minor
feature of ASD
Miyahara et al., 1997
Ghaziuddin 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 cooccurring 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%.
40 Boys with
HFA/Asperger’s
syndrome
55 Typically
Developing
Jansiewicz et al., 2006
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.
11 Children
with
AS
9 Children
with
Dev. Coord.
Disorder
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
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.
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
Atypical Dev.
PDD-NOS
•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
delay
common
Gross motor
skills relate to
social
recreational
games
Exclusion
from social
recreational
games
Social
withdrawal
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:
•Impairments in social
interaction
•Rigidity
•Turn taking/waiting
•Team work skills
Speech/Language
•Cooperation
•Patience
•Anxiety
•Personal space
•Rules, sequences of
events
OT will provide
input regarding:
•Fine Motor and eye-hand,
coordination (including:
reaching, grasping,
catching)
OT
Speech/Language
•Executive function and
staying “on task”
•Static control (“this is not a
falling down game”)
•Imitation, praxis (motor
planning, learning by
imitation)
•Sensory Integration
28
ABA will provide
input regarding:
•Restricted Repetitive
Behaviors (restricted
interests)
OT
•Not tolerating turn
taking, delays/waiting
•Tantrums
Speech/Language
ABA
•Transitions
•Visual supports
29
Physical Therapy will provide
input regarding:
•Coordination
OT
•Strength (Core and
extremity)
•Balance/Postural
Control
•Flexibility
ABA
Speech/Language
•Endurance
PT
•Speed & agility
30
Working together we can help
to get children with ASD
“off the bench”
OT
Speech/Language
ABA
PT
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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
•FITNESSGRAM®
measures:
1)Push-ups
2)Sit and Reach
3)One minute curl-up
4)Plank
5)Crab walk
6)3 minute step test
7)Shuttle run
CORRESPONDING
RECREATION GOALS
•Fitness goals
measured:
1)Upper body strength
2)Flexibility
3)Core strength
4)Core strength
5)Core strength
6)Endurance
7)Speed & agility
33
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.
34
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
Lifetime Fitness
Social Behaviors
Physical Activity Goals
•Grade K-Describe physical
activity goal setting
•Grade 1-Set physical activity
goals
•Grade2-Set and meet
physical activity goals
Safety
•Safe use of playground
equipment and physical
activity space
Cool down: Recurring Activity
•Stretch, 2 square (partner)
38
Session 10:
Post-Program Outcome Measures
ACTIVITY
•FITNESSGRAM®
measures:
1)Push-ups
2)Sit and Reach
3)One minute curl-up
4)Plank
5)Crab walk
6)3 minute step test
7)Shuttle run
•Parent Survey
•Parent Satisfaction Survey
CORRESPONDING
RECREATION GOALS
•Fitness goals
measured:
1)Upper body strength
2)Flexibility
3)Core strength
4)Core strength
5)Core strength
6)Endurance
7)Speed & agility
39
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
40
Group recreational activities that can
target the top ten focus areas include:
•
•
•
•
•
•
•
•
•
•
•
Soccer
T-Ball/Baseball
Dance
Gymnastics
Track/Relay races
Kick ball
Horseback
Martial Arts
Tennis
Golf
Playground
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Getting off the bench…
• Jason Mc Elwain
THE END