Research in Developmental Disabilities 35 (2014) 1507–1517
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Review article
A systematic review on the effect of exercise interventions on challenging behavior for people with intellectual disabilities Marloes Ogg-Groenendaal a,*, Heidi Hermans a, Brigitte Claessens b a b
Amarant Groep, P.O. Box 715, 5000 AS Tilburg, The Netherlands Radboud University Nijmegen, Behavioral Science Institute, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 January 2014 Received in revised form 31 March 2014 Accepted 1 April 2014 Available online
Background: Challenging behavior, such as aggressive or self-injurious behavior, is a major concern for the health and well-being of people with intellectual disabilities (ID) and for their relatives, friends, and caregivers. The most common contemporary treatments have drawbacks, such as the adverse side effects of antipsychotics. Exercise interventions could be a good alternative, but little is known about its beneficial effects on challenging behavior in people with ID yet. Method: A systematic review of the literature was done and methodological quality of the selected studies has been judged on four points. With one-way Analysis of Variance (ANOVA), the effect of exercise interventions on challenging behavior was studied. The effect of low versus high intensity exercise interventions was studied with independent samples T-test using mean improvement scores. Results: Twenty studies studying the effects of exercise interventions on challenging behavior in people with ID have been found. A quantitative evaluation of the results showed a significant decrease in challenging behavior after participating in an exercise intervention (M = 30.9%, 95% CI: 25.0, 36.8). Furthermore, no significant difference was found between high (M = 32.2%) and low (M = 22.9%) intensity exercise interventions. Conclusions: The found decrease in challenging behavior shows that exercise seems to be recommendable as an effective treatment for people with challenging behavior and ID. However, most studies were of low methodological quality and more research is needed to optimize recommendations about the exact intensity, duration, frequency, and mode (group or individual) of exercise interventions for this group of people. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Intellectual disabilities Exercise Exercise intervention Challenging behavior Mental health
Contents 1. 2.
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Introduction . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Search and selection procedure . 2.2. Methodological quality . . . . . . . 2.3. Data analysis . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author. Tel.: +31 651439261. E-mail address: [email protected] (M. Ogg-Groenendaal). http://dx.doi.org/10.1016/j.ridd.2014.04.003 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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4.1. Working mechanisms. . . 4.2. Limitations . . . . . . . . . . . 4.3. Future research. . . . . . . . 4.4. Implications for practice Conclusion . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . References . . . . . . . . . . . . . . . . .
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1. Introduction Challenging behavior is observed in a substantial number of people with intellectual disabilities (ID). Individuals with ID are three to five times more at risk of displaying challenging behavior when compared to the general population (Emerson & Einfeld, 2011). The estimated prevalence rates of challenging behavior in people with ID vary from 10% to 19% (Emerson et al., 2001; Holden & Gitlesen, 2006; Jones et al., 2008; Lundqvist, 2013; Sigafoos, Elkins, Kerr, & Attwood, 1994). The term ‘challenging behavior’ is used to capture abnormal, disordered behaviors such as stereotypical behavior, self-injurious behavior, aggressive or disruptive behavior, and hyperactivity (Emerson & Einfeld, 2011). In several studies, it has been shown that the occurrence of challenging behavior is higher in people with more severe ID (Borthwick-Duffy, 1994; Bosch & Ringdahl, 2001; Cooper, Smiley, Allan, et al., 2009; Cooper, Smiley, Jackson, et al., 2009; Gardner, 2002; Holden & Gitlesen, 2006; Jones et al., 2008; Kiernan & Kiernan, 1994; Oliver, Murphy, & Corbett, 1987). In a Californian study that was done years ago, one or more types of challenging behavior were reported for 7.6% of the people with mild ID, 13.6% of those with moderate ID, 22.0% of those with severe ID and 32.9% of the people with profound ID (Borthwick-Duffy, 1994). In addition to the overriding effects of level of ID, challenging behaviors are also more likely to be seen in people with additional impairments, such as vision impairments, hearing impairments (Cooper, Smiley, Jackson, et al., 2009; Jones et al., 2008; Kiernan & Kiernan, 1994; Poppes, van der Putten, & Vlaskamp, 2010), or communication problems (Emerson et al., 2001; Holden & Gitlesen, 2006; Kiernan & Kiernan, 1994; Sigafoos, 2000). Besides the fact that challenging behavior may be harmful for the individual (e.g. eating inedible objects), these behaviors are also burdensome for caregivers or care staff (e.g. non-compliance, persistent screaming, overactivity), or objectionable to others (e.g. regurgitation of food, the smearing of feces) (Emerson & Einfeld, 2011; Lundqvist, 2013). Challenging behavior diminishes opportunities to integrate in the community (Matson, Cooper, Malone, & Moskow, 2008; Rojahn, Matson, Lott, Esbensen, & Smalls, 2001; Symons, 2008) and increases the risk of overmedication (Matson et al., 2000; Stolker, Scheifes, Egberts, & Heerdink, 2008), abuse (Rusch, Hall, & Griffin, 1986), and avoidance by parents or care staff (Hastings & Brown, 2002). Furthermore, it involves high costs for society because of higher staffing ratios in these residences (Robertson et al., 2004). Psychopharmacological interventions are the most commonly applied interventions for challenging behavior, but also restrictive measures (e.g., mechanical restraints and segregation) and behavioral approaches (e.g., functional displacement or extinction) are used (Emerson & Einfeld, 2011). In many Western countries, a significant reduction in the use of restrictive measures is pursued (Huckshorn, 2006; Inspectie voor de gezondheidszorg, 2008) along with the decrease of psychopharmacological interventions (Emerson & Einfeld, 2011; Gardner, 2002). Psychopharmacological treatments have limited efficacy, particularly when the challenging behaviors are severe (McClintock, Hall, & Oliver, 2003). Emerson and Einfeld (2011), mention several disadvantages of behavioral approaches: they often require detailed functional assessment, are complex to implement, are relatively slow acting, have a poor generalization and may be ineffective for some escapemotivated challenging behaviors (pages 123–127). These drawbacks, combined with the negative consequences of challenging behavior, stress the importance of studying alternative interventions with fewer disadvantages, such as exercise interventions. The effects of exercise interventions in the general population are well described. For example, the Physical Activity Guidelines Advisory Committee (2008) of the U.S. stated that regular physical exercise protects against the onset of depression, anxiety and feelings of distress and has a positive influence on the onset and symptoms of cognitive decline (Physical Activity Guidelines Advisory Committee, 2008). Another argument to pursue exercise interventions is that there are hardly any disadvantages or side effects of this particular intervention (Lox, Martin Ginis, & Petruzzello, 2010). In the limited studies performed with people with ID, an association between inactivity and challenging behavior has repeatedly been found (Beisser, 1970; Dodson & Mullens, 1969; Elliott, Dobbin, Rose, & Soper, 1994; Nunley, 1965; Paxton, 1970). In a literature review, Gabler-Halle, Halle, and Chung (1993) concluded that there is a strong and consistent positive correlation between participating in an exercise program and changes in behavior for people with ID. With this in mind, it is unfortunate that studies show that only 4–9% of people with ID are physically active (Emerson, 2005; Messent, Cooke, & Long, 1998). In the general worldwide population, almost 70% of the population engages in exercise activities (Hallal et al., 2012). In the exercise literature, positive effects of exercise on mental health in the general population are well-documented (Physical Activity Guidelines Advisory Committee, 2008). Explanations for its effects that might also apply to people with ID are the sense of mastery people get after exercising (Carmeli, Orbach, Zinger-Vaknin, Morad, & Merrick, 2008; Gencoz, 1997), the increased attention participants get during intervention (Bluechardt & Shephard, 1995; Carmeli et al., 2008; Ellis, MacLean, & Gazdag, 1989; Gabler-Halle et al., 1993), fatigue from physical exertion (Bachman & Fuqua, 1983; Kern, Koegel, & Dunlap, 1984), the homeostatic regulation of arousal by exercise (Allison, Basile, & MacDonald, 1991; Henderikse, Heuvel
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van den, & Gosenshuis, 2012; Zentall & Zentall, 1983), and the altered levels of brain neurotransmitters like endorphin, serotonin, norepinephrine and dopamine caused by exercising (Matos, Calmeiro, & Da Fonseca, 2009; Dinas, Koutedakis, & Flouris, 2011; Henderikse et al., 2012; Thoren, Floras, Hoffmann, & Seals, 1990). To our knowledge, no systematic review on the effects of exercise on challenging behavior has been done since 1993. Literature reviews since 1993 cover related topics, such as the benefits of exercise in people with ID on balance, muscle strength, quality of life (Bartlo & Klein, 2011), psychosocial benefits (Heller, McCubbin, Drum, & Peterson, 2011), cardiovascular fitness (Dodd & Shields, 2005), the assessment and treatment of challenging behavior for people with ID (Lloyd & Kennedy, 2014), and the relationship between challenging behavior and anxiety in people with ID (Pruijssers, van Meijel, Maaskant, Nijssen, & van Achterberg, 2014). However, these reviews do not focus on the main topic of this review, that is, the relation between exercise and challenging behavior in people with ID. The aim of this systematic review is first to determine if exercise interventions can lead to an observable and measurable reduction of challenging behavior in people with ID and second, to get insight into the state of affairs concerning the optimal intensity, duration, type, and frequency of effective exercise interventions.
2. Method 2.1. Search and selection procedure A systematic review was conducted using PubMed, PsychInfo, Web of Science, and Embase databases. The following key words were entered: ‘intellectual disability’, ‘mental retardation’, ‘development disability’, ‘cognitive impairment’, ‘challenging behavior’, ‘behavioral problems’, ‘self-injury’, ‘aggression’, ‘stereotypical behavior’, ‘sport’, ‘exercise’, ‘running’, ‘swimming’, ‘walking’, ‘jogging’, and ‘aerobics’. The English and American spelling and singular and plural have been used. All terms have been combined with no search limits. Additional articles were found by a manual search of articles in the journal ‘Research in Developmental Disabilities’, starting from 1987. Finally, the references of all articles have been checked for other relevant articles for the systematic review. Studies were included if (i) the effect of an exercise intervention on challenging behavior has been studied, (ii) the study was published between January 1980 and May 2013, and (iii) the majority of participants had ID. Excluded were studies not published in English or Dutch. The literature search and selection procedure have been performed independently by two researchers (MO and HH). The degree of agreement on the articles found that could be included in the review was 95%. For the purpose of this is review, challenging behavior has been categorized into: total challenging behavior (1), stereotypical behavior (2), aggressive/destructive behavior (3), self-injurious behavior (4), hyperactivity (5), and other (6). Total challenging behavior is defined as culturally abnormal behavior of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behavior which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities (e.g. self-injurious behavior, aggression) (Emerson, 1995). Stereotypical behavior is defined as repeated uniform body movements or postures that are obviously not part of some goal-directed art (e.g. bodyrocking, yelling) (Rojahn et al., 2001). Aggressive or destructive behavior is defined as an offensive action or a deliberate overt attack directed toward people or objects (e.g. hitting, pulling) (Rojahn et al., 2001). Self-injurious behavior is defined as behavior that can cause damage to the person’s own body and that occurs repeatedly and in an essentially unvarying manner (e.g. hair-pulling, regurgitating) (Rojahn et al., 2001). Hyperactivity is defined as rapid walking, running or other movement of the body that appears to cause disruption of the environment such as knocking over furniture (McGimsey & Favell, 1988). ‘Other’ includes all challenging behaviors that can’t be defined as stereotypical behavior, aggressive/destructive behavior, self-injurious behavior, or hyperactivity (e.g. lethargy). This categorization has been applied after inclusion. For the definition of exercise, the definition of Lox et al. (2010) was used: ‘any intervention in which a form of leisure physical activity is undertaken in order to achieve a particular objective, e.g., improved cardiovascular fitness or reduced stress’(Lox et al., 2010). A distinction is made between high and low intensity exercise interventions, in order to compare the efficacy of the different intensities in relation to challenging behavior. The intensity of exercise is usually expressed in percentage of VO2 or oxygen utilization. However, the oxygen utilization was only reported in a limited number of the selected studies. Therefore, the distinction between high and low intensity was based on the exercise content description. Walking, general motor training, stair-step machines, and ambulation training were indicated as low intensity exercise as they are usually associated with 3–6 MET1 (Ainsworth et al., 1993, 2000). Dancing, (trampoline) jumping, high-impact aerobics, basketball, soccer, and running or jogging were qualified as high intensity exercise, or the equivalent of more than 6 MET. Furthermore, to get more insight into the exercise effects on challenging behavior, three categories were formulated: immediate (within 2 h after exercise), short-term (between 2 and 24 h after exercise), and long-term effect on challenging behavior (more than 24 h after exercise).
1 A physiological measure expressing the energy cost of physical activities and is defined as the ratio of metabolic rate (the rate of energy consumption) during a specific physical activity to a reference metabolic rate.
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Table 1 Evaluating methodological quality of studies. Item
Criteria
Score
1
Number of participants
2
Presence of a control group
3
Follow-up measurement after >1 week
4
Completeness of data presentation
30 10–30 70 and does not meet the criteria for ID.) N = 1; male; M = 47 years; profound ID
4.9a,c
65.6a,b
59.0 (40.7–75.1)
27.8a,b
30.9a (3.7–57.1)
18.2a,b
ABS-II, Adaptive Behavior Scale part II; CBC, Classroom Behavior Checklist; ABC, Aberrant Behavior Checklist; CBCL, Child Behavior Checklist. a Score is calculated based on presented data in the article. b Confidence interval is irrelevant, because it is a case-study. c Confidence interval is irrelevant, because only the mean over the sample was available.
To study if exercise interventions lead to a measurable reduction of challenging behavior, and to get insight into the optimal exercise intensity based on the information in the selected studies, a bootstrapping method was adopted. Bootstrapping is a non-parametric method for assigning measures of accuracy to sample estimates (Efron & Tibshirani, 1993). This method was used because most of the included studies presented limited data. With one-way Analysis of Variance (ANOVA), the effect of exercise interventions on challenging behavior was studied. To give a more reliable view of the possible effects of exercise interventions in the studied population, 95% confidence intervals of the percentages of improvement for the individual studies were calculated. The effect of low versus high intensity exercise interventions on challenging behavior was studied with independent samples T-test using the mean improvement scores of the different intensities of the exercise interventions. For the six different categories of challenging behavior, with the different
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measurement points (immediate, short-term, or long-term effect), and for the different types of exercise interventions (group versus individual), the mean improvement scores were calculated. Because of limited data presentation in the studies, only descriptive statistics on challenging behavior categories could be presented. 3. Results In total, 51 studies were selected based on their title or abstract. Five articles could not be retrieved and were excluded. Of the remaining 46 articles, 26 were excluded. Reasons for exclusion were incomplete presentation of the results or no empirical data at all, or samples did not include people with ID. Finally, 20 studies were selected for the systematic review. Methodological quality of 17 studies was low and the other three studies had moderate methodological quality. The total population of the 20 studies included in this review comprised of 91 people with ID (34 males, 9 female, 48 unspecified) with a mean age of 18.2 years, ranging from 5 to 53 years. Twenty-seven of them had a mild or moderate ID, 29 had a severe or profound ID, and for 35 persons the level of ID was not specified. In six studies, subjects also had the diagnosis autism or autistic characteristics next to their ID (Allison et al., 1991; Elliott et al., 1994; Kern et al., 1984; Powers, Thibadeau, & Rose, 1992; Prupas & Reid, 2001; Watters & Watters, 1980). A detailed description of study sample per study is presented in Table 1. The 20 studies are subjected to the one-way ANOVA using the bootstrapping method. The results indicated that exercise interventions lead to a significant mean decrease in challenging behavior of 30.9% (95% CI: 25.0, 36.8). The improvement scores and 95% confidence intervals of the individual studies are presented in Table 1. By taking ‘study’ as a factor in the oneway ANOVA, it is shown that a substantial part of the variance of the results is caused by differences between studies and a smaller part is caused by differences within studies (F (19,90) = 17.173, p < 0.001). In other words, the differences in the results of the included studies are mainly caused by the properties of the studies and not by differences between subjects. In Table 1, an overview of the studies offering high and low intensity exercise interventions are shown. There was a decrease in challenging behavior by 22.9% from low intensity exercise and by 32.2% from high intensity exercise. Because Elliott et al. (1994) presented data of both intensities for all participants, two analyses have been done. A bootstrap test for independent samples with the sample of the study of Elliott et al. (1994) as high intensity group, showed that the mean difference between high and low intensity exercise was 5.6, p = 0.625, which was not significant. A bootstrap test for independent samples with the sample of the study of Elliott et al. (1994) as low intensity group, showed that the mean difference between high and low intensity exercise was 9.6, p = 0.332, which was also not significant. To study the effect of group versus individual exercise interventions, a comparison was made between nine studies that investigated the effect of individual exercise interventions and 10 studies that investigated the effect of group exercise interventions (see Table 1). From one study, the type of intervention was not described in the original study (Jones et al., 2007). Descriptive statistics show that the mean improvement score was 38.7% for individual interventions and 27.9% for group interventions. With descriptive statistics, a comparison was made between the effects of exercise interventions on the different categories of challenging behavior. The categories of challenging behavior studied are presented in Table 1. The mean improvement score after exercise intervention was 44.4% for total challenging behavior, 40.6% for stereotypical behavior, 16.4% for aggressive/destructive behavior, 23.1% for self-injurious behavior, 8.2% for hyperactivity and 55.9% for other forms of challenging behavior. The immediate improvement scores were retrieved from ten studies (Baumeister & MacLean, 1984; Cannella-Malone, Tullis, & Kazee, 2011; Elliott et al., 1994; Gencoz, 1997; Kern et al., 1984; Lancioni, Smeets, Ceccarani, Capodaglio, & Campanari, 1984; Morrissey, Franzini, & Karen, 1992; Prupas & Reid, 2001; Tarnowski & Drabman, 1985; Watters & Watters, 1980), the short-term improvement scores from seven studies (Ellis et al., 1989; Jones et al., 2007; McGimsey & Favell, 1988; Ozer et al., 2012; Powers et al., 1992; Whitaker & Saleem, 1994), the long-term improvement scores from ten studies (Allison et al., 1991; Bachman & Fuqua, 1983; Bachman & Sluyter, 1988; Baumeister & MacLean, 1984; Cannella-Malone et al., 2011; Ellis et al., 1989; Gencoz, 1997; Jones et al., 2007; Powers et al., 1992; Whitaker & Saleem, 1994). Some studies displayed immediate as well as short-term and/or long-term improvement scores. The mean improvement scores of the immediate, short-term and long-term effects were respectively 43.4%, 20.8%, and 49.2%. 4. Discussion With this systematic review, insight is given into the effect of exercise interventions on challenging behavior in people with intellectual disabilities (ID). Because of the low methodological quality of the majority of included studies, conclusions should be drawn with some caution. Nevertheless, exercise interventions are associated with a significant decrease in challenging behavior according to our analyses on 20 studies. These findings are in line with the earlier review of GablerHalle et al. (1993) in which an association was found between participation in an exercise program and positive behavioral changes for people with mild, moderate and severe ID. No significant difference was observed between low or high intensity exercise with respect to challenging behavior. Although, group interventions are most cost-efficient, there are indications that individual interventions are more effective than group interventions. Exercise interventions in general do have numerous positive side effects on physical and mental health and can thereby help to keep the care costs manageable. Based on the studies in this review, it is not possible to define
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which categories of challenging behavior benefit most from exercise interventions because the number of studies in each category was limited. From the selected studies, there was not enough information available on the optimal duration or frequency of exercise interventions for analysis. The exercise interventions were mostly provided once a day or every other day. However, there is some evidence that offering exercise multiple times a day is more effective than offering it once a day or once every few days (Cannella-Malone et al., 2011; Prupas & Reid, 2001). Future research should compare the effects of single versus multiple daily frequency exercise interventions over a period of time, and compare the results with a control group, preferably with a randomized control trial design. 4.1. Working mechanisms The effect of exercise on challenging behavior may partly be explained by the release of endorphins (De Matos et al., 2009; Dinas et al., 2011; Henderikse et al., 2012; Thoren et al., 1990). At the same time, this contradicts the absence of differences in the effects of low versus high intensity exercise on challenging behavior, because endorphins secretion increases with more intense exercise. Possibly, the effect is partly explained by the sense of accomplishment after exercise, but this should also have led to a larger effect in high intensity exercise compared to low intensity exercise. An explanation for these nonexpected results could be the non-optimal distinction between low-impact versus high-impact exercise. A distinction based on oxygen utilization would be more precise, but was not possible for the included studies. Therefore, the distinction was based on a description of the intervention, which was probably less accurate, because the intensity of exercise not only results from the form of intervention, but also from the level of fitness of the particular person. The three included studies that studied both high and low intensity exercise interventions in the same sample found more favorable results for the highintensity interventions (Bachman & Fuqua, 1983; Elliott et al., 1994; Kern et al., 1984), which is in line with what would be expected based on the endorphins and accomplishment theories. However, all three studies were considered of low methodological quality. More research on low versus high intensity exercise interventions is needed to draw any conclusions. A third explanation for the effect of exercise in reducing challenging behavior might be the increased attention that people receive during the intervention, as indicated by the finding that individual interventions yield better results than group interventions. A final explanation could be fatigue from physical exertion. However, in several of the included studies it was shown that exercise leads to a decrease in challenging behavior and to an increase in appropriate behavior while fatigue-related behaviors are absent (Bachman & Sluyter, 1988; Baumeister & MacLean, 1984; Kern, Koegel, Dyer, Blew, & Fenton, 1982; Tarnowski & Drabman, 1985). Therefore, fatigue does not seem to explain the found effects. 4.2. Limitations A limitation of this systematic review was the low methodological quality of most studies. Five studies have already been excluded during the selection procedure because of poor data presentation. Still, data presentation of included studies was often incomplete. Consequently, only limited statistical analyses were possible on the available data. Also, eighteen studies had a very small number of subjects (N < 10), from which five were case studies (Allison et al., 1991; Ellis et al., 1989; Powers et al., 1992; Tarnowski & Drabman, 1985; Whitaker & Saleem, 1994). Only two studies examined a larger amount of subjects and included a control group as well (Gencoz, 1997; Ozer et al., 2012). 4.3. Future research For future research, it is recommended to include larger samples and control groups as this allows for cause and effect analyses. Furthermore, it would be best if studies included blind observers, i.e. observers that are unaware of the purpose of the study to avoid observer drift, observer expectations, and observer reactivity to be reflected in the outcomes of the study (Cannella-Malone et al., 2011). Future research should also focus on the optimal intensity, duration and frequency of exercise interventions. A complete presentation of study results, with a detailed description of study design, sample description and individual and group results is necessary for analysis but also for enhancing the translation and implementation of study results into clinical practice. 4.4. Implications for practice Based on the results of this systematic review, exercise interventions can be recommended as an alternative treatment to challenging behavior in people with ID instead of the most common contemporary treatments (e.g., psychopharmacological interventions, restrictive measures and behavioral approaches). It was shown to be effective and to have numerous positive side effects and hardly any drawbacks. However, interventions which allow for little or no input from the participants can be perceived as intrusive and consequently may have a negative impact on quality of life, acceptability, and the efficacy of those treatments (Mayton, Carter, & Wheeler, 2014). Therefore it is advised to provide choices to the participants (CannellaMalone et al., 2011; Mayton et al., 2014), and to seek input from people with ID in regard to program development and implementation (Mayton et al., 2014). Van Schijndel-Speet, Evenhuis, Van Empelen, Van Wijck, & Echteld (2013) described
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the development of a day-activity program based on evidence-based guidelines to successfully increase physical activity among seniors with mild or moderate ID. Some of the important characteristics of their program were to embed the program in a routine day-activity schedule, to execute it in peer groups, to conduct it by specifically trained movement experts and staff, and to support the program by an educational program (Van Schijndel-Speet et al., 2013). Hutzler and Korsensky (2010) found in their systematic review that peer modeling, as well as video and audio reinforcement, appears to be important modalities in maintaining compliance to exercise programs for people with ID. Furthermore they state that social support frameworks should be involved in creating an activity promoting atmosphere and the activity climate should primarily focus on mastery and collaboration in contrast to competition (Hutzler & Korsensky, 2010). 5. Conclusion In summary, despite limitations of some studies included in this systematic review, there is evidence that exercise interventions are an effective treatment for challenging behavior for people with ID. Surprisingly, from the years 2000 to date, the number of reports on this topic has drastically diminished. Given the drawbacks and shortcomings in the most common treatments of challenging behavior in combination with the negative consequences of this behavior and the high care costs for people with challenging behavior, more research on this topic is important and highly recommended. Funding We certify that no party having a direct interest or involvement in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated. The content of this paper reflects only the author’s view. Amarant or Radboud University Nijmegen are not liable for any use that may be made of the information contained therein. Conflict of interest None. Acknowledgements We thank Pierre Souren (Radboud University Nijmegen) for statistical support. References Ainsworth, B. E., Haskell, W. L., Leon, A. S., Jacobs, D. R., Jr., Montoye, H. J., Sallis, J. F., et al. (1993). Compendium of physical activities: Classification of energy costs of human physical activities. Medicine and Science in Sports and Exercise, 25(1), 71–80. Ainsworth, B. E., Haskell, W. L., Whitt, M. C., Irwin, M. L., Swartz, A. M., Strath, S. J., et al. (2000). Compendium of physical activities: An update of activity codes and MET intensities. Medicine and Science in Sports and Exercise, 32(9 (Suppl.)), S498–S504. Allison, D. B., Basile, V. C., & MacDonald, R. B. (1991). Brief report: Comparative effects of antecedent exercise and lorazepam on the aggressive behavior of an autistic man. Journal of Autism and Developmental Disorders, 21(1), 89–94. Bachman, J. E., & Fuqua, R. W. (1983). 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Contents lists available at ScienceDirect
Research in Developmental Disabilities
Review article
A systematic review on the effect of exercise interventions on challenging behavior for people with intellectual disabilities Marloes Ogg-Groenendaal a,*, Heidi Hermans a, Brigitte Claessens b a b
Amarant Groep, P.O. Box 715, 5000 AS Tilburg, The Netherlands Radboud University Nijmegen, Behavioral Science Institute, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 January 2014 Received in revised form 31 March 2014 Accepted 1 April 2014 Available online
Background: Challenging behavior, such as aggressive or self-injurious behavior, is a major concern for the health and well-being of people with intellectual disabilities (ID) and for their relatives, friends, and caregivers. The most common contemporary treatments have drawbacks, such as the adverse side effects of antipsychotics. Exercise interventions could be a good alternative, but little is known about its beneficial effects on challenging behavior in people with ID yet. Method: A systematic review of the literature was done and methodological quality of the selected studies has been judged on four points. With one-way Analysis of Variance (ANOVA), the effect of exercise interventions on challenging behavior was studied. The effect of low versus high intensity exercise interventions was studied with independent samples T-test using mean improvement scores. Results: Twenty studies studying the effects of exercise interventions on challenging behavior in people with ID have been found. A quantitative evaluation of the results showed a significant decrease in challenging behavior after participating in an exercise intervention (M = 30.9%, 95% CI: 25.0, 36.8). Furthermore, no significant difference was found between high (M = 32.2%) and low (M = 22.9%) intensity exercise interventions. Conclusions: The found decrease in challenging behavior shows that exercise seems to be recommendable as an effective treatment for people with challenging behavior and ID. However, most studies were of low methodological quality and more research is needed to optimize recommendations about the exact intensity, duration, frequency, and mode (group or individual) of exercise interventions for this group of people. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Intellectual disabilities Exercise Exercise intervention Challenging behavior Mental health
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Introduction . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Search and selection procedure . 2.2. Methodological quality . . . . . . . 2.3. Data analysis . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author. Tel.: +31 651439261. E-mail address: [email protected] (M. Ogg-Groenendaal). http://dx.doi.org/10.1016/j.ridd.2014.04.003 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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4.1. Working mechanisms. . . 4.2. Limitations . . . . . . . . . . . 4.3. Future research. . . . . . . . 4.4. Implications for practice Conclusion . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . References . . . . . . . . . . . . . . . . .
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1. Introduction Challenging behavior is observed in a substantial number of people with intellectual disabilities (ID). Individuals with ID are three to five times more at risk of displaying challenging behavior when compared to the general population (Emerson & Einfeld, 2011). The estimated prevalence rates of challenging behavior in people with ID vary from 10% to 19% (Emerson et al., 2001; Holden & Gitlesen, 2006; Jones et al., 2008; Lundqvist, 2013; Sigafoos, Elkins, Kerr, & Attwood, 1994). The term ‘challenging behavior’ is used to capture abnormal, disordered behaviors such as stereotypical behavior, self-injurious behavior, aggressive or disruptive behavior, and hyperactivity (Emerson & Einfeld, 2011). In several studies, it has been shown that the occurrence of challenging behavior is higher in people with more severe ID (Borthwick-Duffy, 1994; Bosch & Ringdahl, 2001; Cooper, Smiley, Allan, et al., 2009; Cooper, Smiley, Jackson, et al., 2009; Gardner, 2002; Holden & Gitlesen, 2006; Jones et al., 2008; Kiernan & Kiernan, 1994; Oliver, Murphy, & Corbett, 1987). In a Californian study that was done years ago, one or more types of challenging behavior were reported for 7.6% of the people with mild ID, 13.6% of those with moderate ID, 22.0% of those with severe ID and 32.9% of the people with profound ID (Borthwick-Duffy, 1994). In addition to the overriding effects of level of ID, challenging behaviors are also more likely to be seen in people with additional impairments, such as vision impairments, hearing impairments (Cooper, Smiley, Jackson, et al., 2009; Jones et al., 2008; Kiernan & Kiernan, 1994; Poppes, van der Putten, & Vlaskamp, 2010), or communication problems (Emerson et al., 2001; Holden & Gitlesen, 2006; Kiernan & Kiernan, 1994; Sigafoos, 2000). Besides the fact that challenging behavior may be harmful for the individual (e.g. eating inedible objects), these behaviors are also burdensome for caregivers or care staff (e.g. non-compliance, persistent screaming, overactivity), or objectionable to others (e.g. regurgitation of food, the smearing of feces) (Emerson & Einfeld, 2011; Lundqvist, 2013). Challenging behavior diminishes opportunities to integrate in the community (Matson, Cooper, Malone, & Moskow, 2008; Rojahn, Matson, Lott, Esbensen, & Smalls, 2001; Symons, 2008) and increases the risk of overmedication (Matson et al., 2000; Stolker, Scheifes, Egberts, & Heerdink, 2008), abuse (Rusch, Hall, & Griffin, 1986), and avoidance by parents or care staff (Hastings & Brown, 2002). Furthermore, it involves high costs for society because of higher staffing ratios in these residences (Robertson et al., 2004). Psychopharmacological interventions are the most commonly applied interventions for challenging behavior, but also restrictive measures (e.g., mechanical restraints and segregation) and behavioral approaches (e.g., functional displacement or extinction) are used (Emerson & Einfeld, 2011). In many Western countries, a significant reduction in the use of restrictive measures is pursued (Huckshorn, 2006; Inspectie voor de gezondheidszorg, 2008) along with the decrease of psychopharmacological interventions (Emerson & Einfeld, 2011; Gardner, 2002). Psychopharmacological treatments have limited efficacy, particularly when the challenging behaviors are severe (McClintock, Hall, & Oliver, 2003). Emerson and Einfeld (2011), mention several disadvantages of behavioral approaches: they often require detailed functional assessment, are complex to implement, are relatively slow acting, have a poor generalization and may be ineffective for some escapemotivated challenging behaviors (pages 123–127). These drawbacks, combined with the negative consequences of challenging behavior, stress the importance of studying alternative interventions with fewer disadvantages, such as exercise interventions. The effects of exercise interventions in the general population are well described. For example, the Physical Activity Guidelines Advisory Committee (2008) of the U.S. stated that regular physical exercise protects against the onset of depression, anxiety and feelings of distress and has a positive influence on the onset and symptoms of cognitive decline (Physical Activity Guidelines Advisory Committee, 2008). Another argument to pursue exercise interventions is that there are hardly any disadvantages or side effects of this particular intervention (Lox, Martin Ginis, & Petruzzello, 2010). In the limited studies performed with people with ID, an association between inactivity and challenging behavior has repeatedly been found (Beisser, 1970; Dodson & Mullens, 1969; Elliott, Dobbin, Rose, & Soper, 1994; Nunley, 1965; Paxton, 1970). In a literature review, Gabler-Halle, Halle, and Chung (1993) concluded that there is a strong and consistent positive correlation between participating in an exercise program and changes in behavior for people with ID. With this in mind, it is unfortunate that studies show that only 4–9% of people with ID are physically active (Emerson, 2005; Messent, Cooke, & Long, 1998). In the general worldwide population, almost 70% of the population engages in exercise activities (Hallal et al., 2012). In the exercise literature, positive effects of exercise on mental health in the general population are well-documented (Physical Activity Guidelines Advisory Committee, 2008). Explanations for its effects that might also apply to people with ID are the sense of mastery people get after exercising (Carmeli, Orbach, Zinger-Vaknin, Morad, & Merrick, 2008; Gencoz, 1997), the increased attention participants get during intervention (Bluechardt & Shephard, 1995; Carmeli et al., 2008; Ellis, MacLean, & Gazdag, 1989; Gabler-Halle et al., 1993), fatigue from physical exertion (Bachman & Fuqua, 1983; Kern, Koegel, & Dunlap, 1984), the homeostatic regulation of arousal by exercise (Allison, Basile, & MacDonald, 1991; Henderikse, Heuvel
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van den, & Gosenshuis, 2012; Zentall & Zentall, 1983), and the altered levels of brain neurotransmitters like endorphin, serotonin, norepinephrine and dopamine caused by exercising (Matos, Calmeiro, & Da Fonseca, 2009; Dinas, Koutedakis, & Flouris, 2011; Henderikse et al., 2012; Thoren, Floras, Hoffmann, & Seals, 1990). To our knowledge, no systematic review on the effects of exercise on challenging behavior has been done since 1993. Literature reviews since 1993 cover related topics, such as the benefits of exercise in people with ID on balance, muscle strength, quality of life (Bartlo & Klein, 2011), psychosocial benefits (Heller, McCubbin, Drum, & Peterson, 2011), cardiovascular fitness (Dodd & Shields, 2005), the assessment and treatment of challenging behavior for people with ID (Lloyd & Kennedy, 2014), and the relationship between challenging behavior and anxiety in people with ID (Pruijssers, van Meijel, Maaskant, Nijssen, & van Achterberg, 2014). However, these reviews do not focus on the main topic of this review, that is, the relation between exercise and challenging behavior in people with ID. The aim of this systematic review is first to determine if exercise interventions can lead to an observable and measurable reduction of challenging behavior in people with ID and second, to get insight into the state of affairs concerning the optimal intensity, duration, type, and frequency of effective exercise interventions.
2. Method 2.1. Search and selection procedure A systematic review was conducted using PubMed, PsychInfo, Web of Science, and Embase databases. The following key words were entered: ‘intellectual disability’, ‘mental retardation’, ‘development disability’, ‘cognitive impairment’, ‘challenging behavior’, ‘behavioral problems’, ‘self-injury’, ‘aggression’, ‘stereotypical behavior’, ‘sport’, ‘exercise’, ‘running’, ‘swimming’, ‘walking’, ‘jogging’, and ‘aerobics’. The English and American spelling and singular and plural have been used. All terms have been combined with no search limits. Additional articles were found by a manual search of articles in the journal ‘Research in Developmental Disabilities’, starting from 1987. Finally, the references of all articles have been checked for other relevant articles for the systematic review. Studies were included if (i) the effect of an exercise intervention on challenging behavior has been studied, (ii) the study was published between January 1980 and May 2013, and (iii) the majority of participants had ID. Excluded were studies not published in English or Dutch. The literature search and selection procedure have been performed independently by two researchers (MO and HH). The degree of agreement on the articles found that could be included in the review was 95%. For the purpose of this is review, challenging behavior has been categorized into: total challenging behavior (1), stereotypical behavior (2), aggressive/destructive behavior (3), self-injurious behavior (4), hyperactivity (5), and other (6). Total challenging behavior is defined as culturally abnormal behavior of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behavior which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities (e.g. self-injurious behavior, aggression) (Emerson, 1995). Stereotypical behavior is defined as repeated uniform body movements or postures that are obviously not part of some goal-directed art (e.g. bodyrocking, yelling) (Rojahn et al., 2001). Aggressive or destructive behavior is defined as an offensive action or a deliberate overt attack directed toward people or objects (e.g. hitting, pulling) (Rojahn et al., 2001). Self-injurious behavior is defined as behavior that can cause damage to the person’s own body and that occurs repeatedly and in an essentially unvarying manner (e.g. hair-pulling, regurgitating) (Rojahn et al., 2001). Hyperactivity is defined as rapid walking, running or other movement of the body that appears to cause disruption of the environment such as knocking over furniture (McGimsey & Favell, 1988). ‘Other’ includes all challenging behaviors that can’t be defined as stereotypical behavior, aggressive/destructive behavior, self-injurious behavior, or hyperactivity (e.g. lethargy). This categorization has been applied after inclusion. For the definition of exercise, the definition of Lox et al. (2010) was used: ‘any intervention in which a form of leisure physical activity is undertaken in order to achieve a particular objective, e.g., improved cardiovascular fitness or reduced stress’(Lox et al., 2010). A distinction is made between high and low intensity exercise interventions, in order to compare the efficacy of the different intensities in relation to challenging behavior. The intensity of exercise is usually expressed in percentage of VO2 or oxygen utilization. However, the oxygen utilization was only reported in a limited number of the selected studies. Therefore, the distinction between high and low intensity was based on the exercise content description. Walking, general motor training, stair-step machines, and ambulation training were indicated as low intensity exercise as they are usually associated with 3–6 MET1 (Ainsworth et al., 1993, 2000). Dancing, (trampoline) jumping, high-impact aerobics, basketball, soccer, and running or jogging were qualified as high intensity exercise, or the equivalent of more than 6 MET. Furthermore, to get more insight into the exercise effects on challenging behavior, three categories were formulated: immediate (within 2 h after exercise), short-term (between 2 and 24 h after exercise), and long-term effect on challenging behavior (more than 24 h after exercise).
1 A physiological measure expressing the energy cost of physical activities and is defined as the ratio of metabolic rate (the rate of energy consumption) during a specific physical activity to a reference metabolic rate.
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Table 1 Evaluating methodological quality of studies. Item
Criteria
Score
1
Number of participants
2
Presence of a control group
3
Follow-up measurement after >1 week
4
Completeness of data presentation
30 10–30 70 and does not meet the criteria for ID.) N = 1; male; M = 47 years; profound ID
4.9a,c
65.6a,b
59.0 (40.7–75.1)
27.8a,b
30.9a (3.7–57.1)
18.2a,b
ABS-II, Adaptive Behavior Scale part II; CBC, Classroom Behavior Checklist; ABC, Aberrant Behavior Checklist; CBCL, Child Behavior Checklist. a Score is calculated based on presented data in the article. b Confidence interval is irrelevant, because it is a case-study. c Confidence interval is irrelevant, because only the mean over the sample was available.
To study if exercise interventions lead to a measurable reduction of challenging behavior, and to get insight into the optimal exercise intensity based on the information in the selected studies, a bootstrapping method was adopted. Bootstrapping is a non-parametric method for assigning measures of accuracy to sample estimates (Efron & Tibshirani, 1993). This method was used because most of the included studies presented limited data. With one-way Analysis of Variance (ANOVA), the effect of exercise interventions on challenging behavior was studied. To give a more reliable view of the possible effects of exercise interventions in the studied population, 95% confidence intervals of the percentages of improvement for the individual studies were calculated. The effect of low versus high intensity exercise interventions on challenging behavior was studied with independent samples T-test using the mean improvement scores of the different intensities of the exercise interventions. For the six different categories of challenging behavior, with the different
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measurement points (immediate, short-term, or long-term effect), and for the different types of exercise interventions (group versus individual), the mean improvement scores were calculated. Because of limited data presentation in the studies, only descriptive statistics on challenging behavior categories could be presented. 3. Results In total, 51 studies were selected based on their title or abstract. Five articles could not be retrieved and were excluded. Of the remaining 46 articles, 26 were excluded. Reasons for exclusion were incomplete presentation of the results or no empirical data at all, or samples did not include people with ID. Finally, 20 studies were selected for the systematic review. Methodological quality of 17 studies was low and the other three studies had moderate methodological quality. The total population of the 20 studies included in this review comprised of 91 people with ID (34 males, 9 female, 48 unspecified) with a mean age of 18.2 years, ranging from 5 to 53 years. Twenty-seven of them had a mild or moderate ID, 29 had a severe or profound ID, and for 35 persons the level of ID was not specified. In six studies, subjects also had the diagnosis autism or autistic characteristics next to their ID (Allison et al., 1991; Elliott et al., 1994; Kern et al., 1984; Powers, Thibadeau, & Rose, 1992; Prupas & Reid, 2001; Watters & Watters, 1980). A detailed description of study sample per study is presented in Table 1. The 20 studies are subjected to the one-way ANOVA using the bootstrapping method. The results indicated that exercise interventions lead to a significant mean decrease in challenging behavior of 30.9% (95% CI: 25.0, 36.8). The improvement scores and 95% confidence intervals of the individual studies are presented in Table 1. By taking ‘study’ as a factor in the oneway ANOVA, it is shown that a substantial part of the variance of the results is caused by differences between studies and a smaller part is caused by differences within studies (F (19,90) = 17.173, p < 0.001). In other words, the differences in the results of the included studies are mainly caused by the properties of the studies and not by differences between subjects. In Table 1, an overview of the studies offering high and low intensity exercise interventions are shown. There was a decrease in challenging behavior by 22.9% from low intensity exercise and by 32.2% from high intensity exercise. Because Elliott et al. (1994) presented data of both intensities for all participants, two analyses have been done. A bootstrap test for independent samples with the sample of the study of Elliott et al. (1994) as high intensity group, showed that the mean difference between high and low intensity exercise was 5.6, p = 0.625, which was not significant. A bootstrap test for independent samples with the sample of the study of Elliott et al. (1994) as low intensity group, showed that the mean difference between high and low intensity exercise was 9.6, p = 0.332, which was also not significant. To study the effect of group versus individual exercise interventions, a comparison was made between nine studies that investigated the effect of individual exercise interventions and 10 studies that investigated the effect of group exercise interventions (see Table 1). From one study, the type of intervention was not described in the original study (Jones et al., 2007). Descriptive statistics show that the mean improvement score was 38.7% for individual interventions and 27.9% for group interventions. With descriptive statistics, a comparison was made between the effects of exercise interventions on the different categories of challenging behavior. The categories of challenging behavior studied are presented in Table 1. The mean improvement score after exercise intervention was 44.4% for total challenging behavior, 40.6% for stereotypical behavior, 16.4% for aggressive/destructive behavior, 23.1% for self-injurious behavior, 8.2% for hyperactivity and 55.9% for other forms of challenging behavior. The immediate improvement scores were retrieved from ten studies (Baumeister & MacLean, 1984; Cannella-Malone, Tullis, & Kazee, 2011; Elliott et al., 1994; Gencoz, 1997; Kern et al., 1984; Lancioni, Smeets, Ceccarani, Capodaglio, & Campanari, 1984; Morrissey, Franzini, & Karen, 1992; Prupas & Reid, 2001; Tarnowski & Drabman, 1985; Watters & Watters, 1980), the short-term improvement scores from seven studies (Ellis et al., 1989; Jones et al., 2007; McGimsey & Favell, 1988; Ozer et al., 2012; Powers et al., 1992; Whitaker & Saleem, 1994), the long-term improvement scores from ten studies (Allison et al., 1991; Bachman & Fuqua, 1983; Bachman & Sluyter, 1988; Baumeister & MacLean, 1984; Cannella-Malone et al., 2011; Ellis et al., 1989; Gencoz, 1997; Jones et al., 2007; Powers et al., 1992; Whitaker & Saleem, 1994). Some studies displayed immediate as well as short-term and/or long-term improvement scores. The mean improvement scores of the immediate, short-term and long-term effects were respectively 43.4%, 20.8%, and 49.2%. 4. Discussion With this systematic review, insight is given into the effect of exercise interventions on challenging behavior in people with intellectual disabilities (ID). Because of the low methodological quality of the majority of included studies, conclusions should be drawn with some caution. Nevertheless, exercise interventions are associated with a significant decrease in challenging behavior according to our analyses on 20 studies. These findings are in line with the earlier review of GablerHalle et al. (1993) in which an association was found between participation in an exercise program and positive behavioral changes for people with mild, moderate and severe ID. No significant difference was observed between low or high intensity exercise with respect to challenging behavior. Although, group interventions are most cost-efficient, there are indications that individual interventions are more effective than group interventions. Exercise interventions in general do have numerous positive side effects on physical and mental health and can thereby help to keep the care costs manageable. Based on the studies in this review, it is not possible to define
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which categories of challenging behavior benefit most from exercise interventions because the number of studies in each category was limited. From the selected studies, there was not enough information available on the optimal duration or frequency of exercise interventions for analysis. The exercise interventions were mostly provided once a day or every other day. However, there is some evidence that offering exercise multiple times a day is more effective than offering it once a day or once every few days (Cannella-Malone et al., 2011; Prupas & Reid, 2001). Future research should compare the effects of single versus multiple daily frequency exercise interventions over a period of time, and compare the results with a control group, preferably with a randomized control trial design. 4.1. Working mechanisms The effect of exercise on challenging behavior may partly be explained by the release of endorphins (De Matos et al., 2009; Dinas et al., 2011; Henderikse et al., 2012; Thoren et al., 1990). At the same time, this contradicts the absence of differences in the effects of low versus high intensity exercise on challenging behavior, because endorphins secretion increases with more intense exercise. Possibly, the effect is partly explained by the sense of accomplishment after exercise, but this should also have led to a larger effect in high intensity exercise compared to low intensity exercise. An explanation for these nonexpected results could be the non-optimal distinction between low-impact versus high-impact exercise. A distinction based on oxygen utilization would be more precise, but was not possible for the included studies. Therefore, the distinction was based on a description of the intervention, which was probably less accurate, because the intensity of exercise not only results from the form of intervention, but also from the level of fitness of the particular person. The three included studies that studied both high and low intensity exercise interventions in the same sample found more favorable results for the highintensity interventions (Bachman & Fuqua, 1983; Elliott et al., 1994; Kern et al., 1984), which is in line with what would be expected based on the endorphins and accomplishment theories. However, all three studies were considered of low methodological quality. More research on low versus high intensity exercise interventions is needed to draw any conclusions. A third explanation for the effect of exercise in reducing challenging behavior might be the increased attention that people receive during the intervention, as indicated by the finding that individual interventions yield better results than group interventions. A final explanation could be fatigue from physical exertion. However, in several of the included studies it was shown that exercise leads to a decrease in challenging behavior and to an increase in appropriate behavior while fatigue-related behaviors are absent (Bachman & Sluyter, 1988; Baumeister & MacLean, 1984; Kern, Koegel, Dyer, Blew, & Fenton, 1982; Tarnowski & Drabman, 1985). Therefore, fatigue does not seem to explain the found effects. 4.2. Limitations A limitation of this systematic review was the low methodological quality of most studies. Five studies have already been excluded during the selection procedure because of poor data presentation. Still, data presentation of included studies was often incomplete. Consequently, only limited statistical analyses were possible on the available data. Also, eighteen studies had a very small number of subjects (N < 10), from which five were case studies (Allison et al., 1991; Ellis et al., 1989; Powers et al., 1992; Tarnowski & Drabman, 1985; Whitaker & Saleem, 1994). Only two studies examined a larger amount of subjects and included a control group as well (Gencoz, 1997; Ozer et al., 2012). 4.3. Future research For future research, it is recommended to include larger samples and control groups as this allows for cause and effect analyses. Furthermore, it would be best if studies included blind observers, i.e. observers that are unaware of the purpose of the study to avoid observer drift, observer expectations, and observer reactivity to be reflected in the outcomes of the study (Cannella-Malone et al., 2011). Future research should also focus on the optimal intensity, duration and frequency of exercise interventions. A complete presentation of study results, with a detailed description of study design, sample description and individual and group results is necessary for analysis but also for enhancing the translation and implementation of study results into clinical practice. 4.4. Implications for practice Based on the results of this systematic review, exercise interventions can be recommended as an alternative treatment to challenging behavior in people with ID instead of the most common contemporary treatments (e.g., psychopharmacological interventions, restrictive measures and behavioral approaches). It was shown to be effective and to have numerous positive side effects and hardly any drawbacks. However, interventions which allow for little or no input from the participants can be perceived as intrusive and consequently may have a negative impact on quality of life, acceptability, and the efficacy of those treatments (Mayton, Carter, & Wheeler, 2014). Therefore it is advised to provide choices to the participants (CannellaMalone et al., 2011; Mayton et al., 2014), and to seek input from people with ID in regard to program development and implementation (Mayton et al., 2014). Van Schijndel-Speet, Evenhuis, Van Empelen, Van Wijck, & Echteld (2013) described
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the development of a day-activity program based on evidence-based guidelines to successfully increase physical activity among seniors with mild or moderate ID. Some of the important characteristics of their program were to embed the program in a routine day-activity schedule, to execute it in peer groups, to conduct it by specifically trained movement experts and staff, and to support the program by an educational program (Van Schijndel-Speet et al., 2013). Hutzler and Korsensky (2010) found in their systematic review that peer modeling, as well as video and audio reinforcement, appears to be important modalities in maintaining compliance to exercise programs for people with ID. Furthermore they state that social support frameworks should be involved in creating an activity promoting atmosphere and the activity climate should primarily focus on mastery and collaboration in contrast to competition (Hutzler & Korsensky, 2010). 5. Conclusion In summary, despite limitations of some studies included in this systematic review, there is evidence that exercise interventions are an effective treatment for challenging behavior for people with ID. Surprisingly, from the years 2000 to date, the number of reports on this topic has drastically diminished. Given the drawbacks and shortcomings in the most common treatments of challenging behavior in combination with the negative consequences of this behavior and the high care costs for people with challenging behavior, more research on this topic is important and highly recommended. Funding We certify that no party having a direct interest or involvement in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated. The content of this paper reflects only the author’s view. Amarant or Radboud University Nijmegen are not liable for any use that may be made of the information contained therein. 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