Journal of Physical Activity and Health, 2015, 12, 636 -641 http://dx.doi.org/10.1123/jpah.2013-0312 © 2015 Human Kinetics, Inc.
ORIGINAL RESEARCH
Social Environmental Influences on Physical Activity of Children With Autism Spectrum Disorders Michaela A. Schenkelberg, Richard R. Rosenkranz, George A. Milliken, and David A. Dzewaltowski Background: Children with Autism Spectrum Disorders (ASD) may be at greater risk for not meeting physical activity (PA) guidelines than neurotypical children (NT). The purpose of this study was to explore setting (free play versus organized) and social group composition influences on PA of children with ASD during summer camp. Methods: Data were collected on 6 ASD and 6 NT boys (aged 5 to 6 years) attending an inclusive summer camp. During free play and organized activity, research assistants observed the camp’s social environment and children’s PA using a modified version of the Observational System for Recording Physical Activity of Children—Preschool version. Results: In free play, children with ASD spent significantly less time in Moderate-Vigorous PA (MVPA) while with a peer (1.2%), compared with a peer group (11.5%) or alone (13.2%). They demonstrated significantly more Light-Moderate-Vigorous PA (LMVPA) while in a solitary social context (68.2%) compared with alone with an adult (25.8%), alone with a peer (34.8%), or with a peer group (28.2%). No significant differences were noted during organized activity. Conclusion: Features of the social environment may influence PA levels of children with ASD. Specifically, certain social group contexts may be more PA-promoting than others depending on the setting. Keywords: developmental disability, free play, organized play
U.S. public health recommendations state that children aged 6 to 17 years should engage in at least 60 minutes of moderate-tovigorous physical activity (MVPA) daily.1 Preschoolers (aged 3 to 5 years) should engage in light and MVPA (LMVPA) for 15 minutes per waking hour for 12 waking hours, which corresponds to 3 hours of PA per day.2 Less than 50% of children aged 6 to 11 meet guidelines3 and many preschoolers are not achieving adequate amounts of PA.4 One population that may be at greater risk for not meeting PA guidelines is children with Autism Spectrum Disorder (ASD).5,6 ASD affects 1 in 88 children in the U.S.,7 and is characterized by deficits in communication, social interactions, and restricted, repetitive behaviors and interests.8 Some studies suggest children with ASD are less physically active overall than NT peers.6,9 Low levels of participation in PA may be due to environmental variables, such as lack of developmentally appropriate programs, lack of resources, and inadequate staff training,10,11 or individual ASD characteristics, such as a desire for sameness, a focus on narrow interests, a lack of motivation, and preference for sedentary activities,8,10–12 independently influencing PA. However, environmental variables may interact with ASD characteristics to influence PA. For example, children with ASD have been found to demonstrate less PA in settings such as recess13,14 but more PA in afterschool settings.6,15 Understanding the environments, both social and physical, that are PA-promoting for children with ASD may provide useful information for developing or improving PA interventions for this population. Summer camp is one setting that has not been studied in the PA and ASD literature. This setting affords various opportunities for free play and organized activity as well as interaction within several social environmental contexts. The purpose of this study was to compare setting (free play versus organized) and
social group composition influences on PA (LMVPA, MVPA) of young children with ASD during an inclusive summer camp. We hypothesized that children with ASD would have lower LMVPA and MVPA than NT children in both settings, children with ASD and NT children would have greater LMVPA and MVPA in the free play setting compared with organized setting, and in both settings, children with ASD would have less LMVPA and MVPA in social group environments compared with solitary contexts.
Schenkelberg ([email protected]) and Dzewaltowski are with the Dept of Kinesiology, Kansas State University, Manhattan, KS. Rosenkranz is with the Dept of Human Nutrition, Kansas State University, Manhattan, KS. Milliken is with the Dept of Statistics, Kansas State University, Manhattan, KS.
Measures
636
Methods This exploratory pilot study used a factorial cross-sectional design to examine social environmental influences on PA of young children. This design allowed for further examination of whether associations were moderated by diagnosis (ASD, NT) and setting (free play, organized) during which PA took place. The study was approved by Kansas State University’s Institutional Review Board (IRB).
Participants and Setting Young children (aged 5 to 6 years) attending an inclusion-based summer camp located in Kansas were eligible for participation. Parental consent was received for all children attending the camp (aged 5 to 12 years; n = 58), however only 18 children (ASD = 6, NT = 12) met our age requirement and were selected for participation. Children with ASD (autism, n = 5; pervasive developmental disorder, not otherwise specified (PDD-NOS), n = 1) were matched on age and male gender with NT children (n = 6), and the remaining children (NT) were excluded. Demographic information for the 12 participants (mean age = 5.4, SD = 0.52 years) after exclusion is illustrated in Table 1.
Parent Survey. A parent survey used demographic questions from
the Behavioral Risk Factor Surveillance System (BRFSS)16 and the 2009–2011 National Survey of Children’s Health with Special Health
Physical Activity and Autism 637
Table 1 Descriptive Characteristics of Study Participants ALL (n = 12)
NT (n = 6)
ASD (n = 6)
100 (12)
100 (6)
100 (6)
Not eligible
66.7 (8)
66.7 (4)
66.7 (4)
Free/Reduced
33.3 (4)
33.3 (2)
33.3 (2)
Non-Hispanic Caucasian
75.0 (9)
83.3 (5)
66.7 (4)
Racial/ethnic minority
25.0 (3)
16.7 (1)
33.3 (2)
Age, years (SD)
5.5 (.52)
5.3 (.52)
5.7 (.52)
Demographic variables Gender, % (n) Male Socioeconomic status, % (n)
Race/ethnicity, % (n)
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Child body mass index (BMI) Child BMI, kg/m2 (SD)
16.10 (1.16) 15.32 (0.76) 16.89 (0.95)
Child BMI-Z (SD)
0.30 (0.78) –0.12 (0.65)
0.71 (0.70)
Child weight status, % (n) Healthy weight
83.3 (10)
Overweight/obese
16.7 (2)
Parent BMI, kg/m2 (SD)
25.01 (6.07)
100.0 (6)
66.7 (4)
0.00 (0)
33.3 (2)
26.91 (7.02) 23.11 (4.81)
Parent weight status, % (n) Normal
58.3 (7)
50.0 (3)
66.7 (4)
Overweight/obese
41.7 (5)
50.0 (3)
33.3 (2)
Abbreviations: NT, neurotypical; ASD, Autism spectrum disorder.
Care Needs.17 Questions regarding the child included: the age and birth date of the child who was enrolled in the summer camp, the child’s race/ethnicity, whether the child had been diagnosed with ASD by a physician or other health care provider, the specific diagnosis of ASD (Autism, Asperger’s Disorder, pervasive developmental disorder, or other ASD), and the age at which the child first began receiving ASD-related services. Additional questions included sex, parent race/ethnicity, marital status, parent education, socioeconomic status (eligibility for free or reduced lunch), and self-reported height and weight for the parent and children living at home (see Table 1). Body Mass Index (BMI). Research assistants assessed participants’ weight to the nearest 0.1 kg using a high precision digital scale (Seca Corp, Model 770, Hamburg, Germany) and height to the nearest millimeter with shoes removed using a Seca Corp (Model 214, Hamburg, Germany) portable stadiometer. Raw BMI scores were determined for each child using the average values of the 2 closest measurements for height and weight. These scores were converted to percentile ranks and z-scores utilizing norm reference standards from the Centers for Disease Control and Prevention.18 Children were classified as healthy weight (greater than 5th percentile and less than 85th percentile) or overweight/obese (greater than 85th percentile). See Table 1 for participants’ BMI data. The Observational System for Recording Activity of Children— Preschool Version (OSRAC-P) was used to assess PA and to provide contextual information about the social environments during which children engaged in PA.19 PA codes used in OSRAC-P came from the Children’s Activity Rating Scale (CARS), an observational system which ranks PA on a scale of 1 to 5.20 In a previous study,20
PA levels (1, stationary; 2, stationary with limb movement; 3, sloweasy movement; 4, moderate movement; 5, vigorous activity) were calibrated with energy expenditure measures (heart rate and VO2) of children aged 3 to 6 years, and results indicated significant differences between levels for both heart rate and VO2 comparisons. Further, initial field tests of CARS on 3 to 6 year old children yielded 84.1% agreement between observers.20 In the current study, all OSRAC-P categories were assessed, but the focus was on setting (free play, organized) and social group composition (solitary, one-on-one with a peer, one-on-one with an adult, peer group, group with an adult) while simultaneously coding PA levels.19 Consistent with previous research,19 PA codes were aggregated to create a variable for sedentary activity (codes 1 and 2), LMVPA (codes of 3, 4 and 5), and MVPA (codes of 4 and 5). Children were observed for 15 min twice in each setting (free play and organized) using the OSRAC-P momentary time sampling protocol.19 Sessions comprised 30-s coding intervals (5 s observe, 25 s record), yielding a total of 1,440 intervals across 4 sessions. Children within matched pairs were coded simultaneously for each of the 4 observations. To control for observer effects, each child was observed once by each research assistant in free play (2 sessions) and organized activity (2 sessions). Research assistants wore headphones and were prompted by individual audio devices. The lead author trained research assistants on the OSRAC-P via group discussions, reviews, and training videos. Research assistants completed in situ training at the summer camp 1 week before the study began. When an agreement of 80% or more on all variables was reached, observers were allowed to begin the study.19 During the observation period, 8 field-based interobserver agreement (IOA) checks were conducted. Two observers independently coded the same child in a PA session while listening to the audio recording prompts through split headphones. Overall, IOA [#agreements/ (#agreements + #disagreements) × 100] by session ranged from 94.6% to 100%, which were deemed acceptable.19
Analysis The influence of group social composition (solitary, one-on-one with adult, one-on-one peer, group with adult, group without adult) by diagnosis (ASD, NT) by setting (free play, organized) on frequency of LMVPA or MVPA was analyzed using generalized mixed models (Proc GLIMMIX, SAS 9.2) with observer (research assistant), session, matched pair, and child as random effects. Hypothesis 1 was evaluated by the diagnosis main effect on the 2 outcome variables (LMVPA, MPVA). Hypothesis 2 was evaluated by the setting main effect. Hypothesis 3 was evaluated by planned comparisons that compared the difference between each group composition type on proportion (percent) of time spent in LMVPA and MVPA within diagnosis (ASD, NT) and setting (free play, organized). Alpha level was set at P ≤ .05.
Results Overall, all children (NT and ASD) spent 40.2% of session time performing LMVPA and 13.2% in MVPA across organized and free play sessions. During these sessions, children were among a group of peers 59.9% of the time, with (12.2%) or without (47.7%) an adult present, in a one-on-one social setting 29.3% of the time with either a peer (11.0%) or an adult (18.3%) present, or solitary for 10.8% of the time. Children with ASD spent the majority of time among a group of peers with (45.3%) or without (14.3%) an adult present, and only 8.8% of the time alone with a peer. When children with ASD were solitary, they participated in LMVPA 70.3% of the time (see Table 2).
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638 Schenkelberg et al
Table 2 Physical Activity Intensity of Children With ASD and NT by Group Composition Across All Settings Intervals (n)
Time (%)
LMVPA (%)
MVPA (%)
Solitary
91
12.6
70.3
24.2
1:1 Adult
137
19.0
37.2
12.4
1:1 Peer
63
8.8
33.3
4.8
Group (adult present)
326
45.3
34.7
9.8
Group (peers)
103
14.3
19.4
8.7
Total
719
37.4
11.5
Category/code ASD Group composition
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Group composition Solitary
64
9.0
70.3
18.8
1:1 Adult
125
17.6
44.8
18.4
1:1 Peer
94
13.2
39.4
10.6
Group (adult present)
356
50.1
39.0
14.0
Group (peers)
71
10.0
39.4
14.1
Total
710
43.0
14.8
Abbreviations: NT, neurotypical; ASD, Autism spectrum disorder; LMVPA, light and moderate-to-vigorous physical activity; MVPA, moderate-to-vigorous physical activity.
There were no significant main effects on LMVPA for diagnosis [F(1, 5) = 0.0, P = .99], setting [F(1, 14) = 0.0, P = .99], or group composition [F(4, 117) = 0.24, P = .06]. There were also no significant main effects on MVPA for diagnosis [F(1, 5) = 0.0, P = .99], setting [F(1, 14) = 0.0, P = .99], or group composition [F(4, 117) = 0.41, P = .80]. Therefore children with ASD did not appear to have lower levels of PA compared with NT peers, PA levels for all children (NT and ASD) did not appear to be different based on setting (free play, organized), and there were no significant differences between PA for all children in different group composition settings. Further, we found no significant 2- and 3-way interaction effects: LMVPA [Setting × Diagnosis = F(1,14) = 0.0, P = .99; Group Composition × Diagnosis = F(4, 117) = 0.44, P = .78; P = 1.50, P = .21; Group Composition × Setting × Diagnosis = F(4, 117) = 0.53, P = .71], MVPA [Setting × Diagnosis = F(1,14) = 0.0, P = .99; Group Composition × Diagnosis = F(4, 117) = 0.13, P = .97; Group Composition × Setting = F(4, 117) = 2.12, P = .08; Group Composition × Setting × Diagnosis = F(4, 117) = 0.77, P = .55]. Planned comparison analyses, however, showed that during free play, children with ASD spent significantly more time in LMVPA while in a solitary social context (68.2%) compared with one-on-one with an adult (25.8%, P = .00), one-on-one with a peer (34.8%, P = .01), or with a peer group (28.2%, P = .00) (see Figure 1). In the free play setting, children with ASD spent significantly more time in MVPA while in a group of peers (11.5%) as opposed to one-on-one with a peer (1.2%, P = .05) (see Figure 2). In addition, significantly more time in MVPA was observed when the child with ASD was solitary (13.2%) as compared with one-on-one with a peer (1.2%, P = .04). In the organized setting, PA intensities of children with ASD were not significantly different by group composition (see Figure 3 and Figure 4).
Figure 1 — Comparing percentage of time spent in light and moderate-to-vigorous physical activity (LMVPA) across group compositions during free play. * Significant from 1:1 Adult (P = .00; SEM = 0.63), 1:1 Peer (P = .01; SEM = 0.55), Group Peer (P = .00; SEM = 0.52). ** Significant from 1:1 Adult (P = .03; SEM = 0.51), 1:1 Peer (P = .03; SEM = 0.54). JPAH Vol. 12, No. 5, 2015
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Figure 2 — Comparing percentage of time spent in moderate-to-vigorous physical activity (MVPA) across group compositions during free play. * Significant from 1:1 Peer (P = .04; SEM = 1.21). ** Significant from 1:1 Peer (P = .05; SEM = 1.20).
Figure 3 — Comparing percentage of time spent in light and moderate-to-vigorous physical activity (LMVPA) across group compositions during organized activity. * Significant from Group Adult (P = .04; SEM = 0.79).
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640 Schenkelberg et al
Figure 4 — Comparing percentage of time spent in MVPA across group compositions during organized activity.
Discussion This study compared setting and social group composition influences on PA behaviors of children with ASD during a summer camp. Results indicated that children with ASD did not have lower overall LMVPA and MVPA compared with NT children, and children were not more active in free play compared with organized settings. Although these findings parallel some studies,21,22 others have found lower PA levels among children with ASD compared with NT. Pan13 found that children with ASD (aged 7 to 12 years) were significantly less active than NT peers in an inclusive recess free play setting. Another study suggested that youth with ASD have less PA overall compared with NT children.6 The conflicting findings between the literature and the current study may be due to environmental variables interacting with characteristics of ASD to influence PA. Specifically, in the current study there was evidence that PA of children with ASD differs depending on the setting (free play, organized) and social group composition within that setting. Consistent with our final hypothesis, during free play, children with ASD had greater LMVPA when they were solitary compared with other social contexts, and they also had greater MVPA when solitary compared with alone with a peer. These results were similar to 2 studies on NT preschoolers which found that a solitary social context was associated with more time spent in MVPA, compared with a peer group context.23,24 MVPA was 3.55 times more likely when children were solitary compared with when engaged in activities with an adult present.24 Compared with a peer group setting, children were 1.6 and 1.3 times more likely to engage in MVPA when solitary and alone with a peer, respectively.23 It is unclear whether the processes underlying the solitary social situation are the same for children with ASD and NT children. Social
interactions with unfamiliar individuals have been shown to elevate stress for children with ASD25 and marked social impairments associated with ASD8 may contribute to difficulties engaging with peers when activities are not organized. It may be that children with ASD are more engaged in the PA task when they are solitary in the free play setting because it meets their need for less social interaction, however additional research is necessary before accepting this conclusion. This study has several limitations. Our sample was highly selective as participants represented a small number of children enrolled in the summer camp and consisted of males aged 5 to 6 years. Further, because we had a small sample of children with little variability in parent-reported ASD diagnosis we did not assess the severity of ASD beyond parental report of diagnosis. Five children were reportedly diagnosed with autism, and 1 child was diagnosed with PDD-NOS. Thus, the potential to generalize results to older children, females, and children with varying degrees of ASD is reduced. Next, group composition was coded based on the number of individuals who were engaged with or in proximity (within 5 feet) of the focal child19 and was not dependent on explicit social interaction or engagement. Children may have been coded with a peer group yet they may not have interacted, but rather existed in proximity of the group. Given the limited literature surrounding social interaction and engagement of children with ASD, it would be meaningful to further explore this area. Finally, another factor that may influence PA is the environment in which the PA setting takes place. All free play settings took place outdoors, whereas organized PA took place both indoors and outdoors. Instructors were volunteers who had little to no prior experience leading organized PA, particularly for children with ASD. A challenge in the current study was a lack of events in the peer group context for children with ASD in organized activity (see Figures 3
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and 4). The proportion of time spent in LMVPA and MVPA may not be representative of what would be found if this event were to occur more frequently with a larger sample size. While limitations must be considered, this pilot study had several strengths. First, we selected an observational measure that used validated PA codes to explore the influence of the social environment on PA levels of children. Second, participants were matched on age and diagnosis, ensuring that children with and without ASD were observed simultaneously in the same setting. In addition, the mixed model used in our analyses accounted for random effects including the observer, matched pair, session, and child. Finally, research assistants were required to complete thorough training sessions before the study which resulted in high IOA across all variables. To our knowledge, the current study is the first to explore the influence of the social environment on PA behaviors of children with ASD. Results warrant further exploration of social environmental influences, specifically social engagement and interaction, on PA behaviors of children with ASD. An understanding of how characteristics of ASD and environmental variables interact may better inform interventions, and ultimately enhance opportunities for PA participation among this population. Acknowledgments The authors would like to thank the camp directors for assisting with coordinating the study and all the teachers, parents, and children for their participation. Special thanks to Paige Johnson, Tiffany Johnson, and Kelly Polin for assistance with data collection, and Dr. Katie Heinrich for reviewing earlier drafts.
References 1. Department of Health and Human Service. Physical Activity Guidelines for Americans. 2008. Available at: www.health.gov/paguidelines/ guidelines/chapter7.aspx. Accessed March 15, 2013. 2. Pate R, O’Neill J. Physical activity guidelines for young children: an emerging consensus. Arch Pediatr Adolesc Med. 2012;166:1095–1096. PubMed doi:10.1001/archpediatrics.2012.1458 3. Troiano R, Berrigan D, Dodd K, Mâsse L, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc. 2008;40:181–188. PubMed doi:10.1249/ mss.0b013e31815a51b3 4. Hinkley T, Salmon J, Okely AD, et al. Preschoolers’ physical activity, screen time, and compliance with recommendations. Med Sci Sports Exerc. 2012;44:458–465. PubMed doi:10.1249/ MSS.0b013e318233763b 5. Pan C, Tsai C, Chu C, Hsieh K. Physical activity and self-determined motivation of adolescents with and without autism spectrum disorders in inclusive physical education. Res Autism Spectr Disord. 2011;5:733–741. doi:10.1016/j.rasd.2010.08.007 6. Pan C, Frey G. Physical activity patterns in youth with autism spectrum disorders. J Autism Dev Disord. 2006;36:597–606. PubMed doi:10.1007/s10803-006-0101-6 7. Centers for Disease Control and Prevention. Prevalence of Autism Spectrum Disorders—Autism and Developmental Disabilities Monitoring Network, United States, 2008. MMWR Morb Mortal Wkly Rep. 2012;6:1–19. 8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (text revision). 4th ed. Washington, DC: American Psychiatric Association; 2000.
9. Trost S, Pate R, Sallis J, et al. Age and gender differences in objectively measured physical activity in youth. Med Sci Sports Exerc. 2002;34:350–355. PubMed doi:10.1097/00005768-20020200000025 10. Obrusnikova I, Cavalier A. Perceived barriers and facilitators of participation in after-school physical activity by children with autism spectrum disorders. J Dev Phys Disabil. 2011;23:195–211. doi:10.1007/ s10882-010-9215-z 11. Obrusnikova I, Miccinello D. Parent perceptions of factors influencing after-school physical activity of children with autism spectrum disorders. Adap Phys Act Q. 2012;29:63–80. PubMed 12. Obrusnikova I, Dillon S. Challenging situations when teaching children with autism spectrum disorders in general physical education. Adap Phys Act Q. 2011;28:113–131. PubMed 13. Pan C. Objectively measured physical activity between children with autism spectrum disorders and children without disabilities during inclusive recess settings in Taiwan. J Autism Dev Disord. 2008;38:1292–1301. PubMed doi:10.1007/s10803-007-0518-6 14. Pan C, Tsai C, Hsieh K. Physical activity correlates for children with autism spectrum disorders in middle school physical education. Res Q Exerc Sport. 2011;82:491–498. PubMed doi:10.1080/02701367.2 011.10599782 15. Memari AH, Ghaheri B, Ziaee V, Kordi R, Hafizi S, Moshayedi P. Physical activity in children and adolescents with autism assessed by triaxial accelerometry. Pediatr Obes. 2012;8:150–158. PubMed doi:10.1111/j.2047-6310.2012.00101.x 16. Behavioral Risk Factor Surveillance System. Available at: http://www. cdc.gov/brfss/annual_data/pdf-ques/2011brfss.pdf. Accessed April 25, 2013. 17. Centers for Disease Control and Prevention. 2009-2010 National Survey of Children with Special Health Care Needs. Available at: http:// www.cdc.gov/nchs/data/slaits/NS_CSHCN_Questionnaire_09_10. pdf. Accessed April 25,2013. 18. Kuczmarski, RJ, Ogden, CL, Grummer Strawn, LM, Flegal, et al. CDC growth charts: United States. Vital Health Stat 11. 2002;246:1–190. PubMed 19. Brown W, Pfeiffer K, Mclver K, Dowda M, Almeida MJCA, Pate R. Assessing preschool children’s physical activity: the observational system for recording physical activity in children-preschool version. Res Q Exerc Sport. 2006;77:167–176. PubMed 20. Puhl J, Greaves K, Hoyt M, Baranowski T. Children’s activity rating scale (CARS): description and calibration. Res Q Exerc Sport. 1990;61:459–477. PubMed doi:10.1080/02701367.1990.10607475 21. Bandini L, Gleason J, Curtin C, et al. Comparison of physical activity between children with autism spectrum disorders and typically developing children. Autism. 2012;17:44–54. PubMed doi:10.1177/1362361312437416 22. Rosser-Sandt DD, Frey GC. Comparison of physical activity levels between children with and without autistic spectrum disorders. Adap Phys Act Q. 2005;22:146–159. 23. Nicaise V, Kahan D, Sallis J. Correlates of moderate-to-vigorous physical activity among preschoolers during unstructured outdoor play periods. Prev Med. 2011;53:309–315. PubMed doi:10.1016/j. ypmed.2011.08.018 24. Brown W, Pfeiffer K, McIver K, Dowda M, Addy C, Pate R. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Dev. 2009;80:45–58. PubMed doi:10.1111/ j.1467-8624.2008.01245.x 25. Lopata C, Volker M, Putnam S, Thomeer M, Nida R. Effect of social familiarity on salivary cortisol and self-reports of social anxiety and stress in children with high functioning autism spectrum disorders. J Autism Dev Disord. 2008;38:1866–1877. PubMed doi:10.1007/ s10803-008-0575-5
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ORIGINAL RESEARCH
Social Environmental Influences on Physical Activity of Children With Autism Spectrum Disorders Michaela A. Schenkelberg, Richard R. Rosenkranz, George A. Milliken, and David A. Dzewaltowski Background: Children with Autism Spectrum Disorders (ASD) may be at greater risk for not meeting physical activity (PA) guidelines than neurotypical children (NT). The purpose of this study was to explore setting (free play versus organized) and social group composition influences on PA of children with ASD during summer camp. Methods: Data were collected on 6 ASD and 6 NT boys (aged 5 to 6 years) attending an inclusive summer camp. During free play and organized activity, research assistants observed the camp’s social environment and children’s PA using a modified version of the Observational System for Recording Physical Activity of Children—Preschool version. Results: In free play, children with ASD spent significantly less time in Moderate-Vigorous PA (MVPA) while with a peer (1.2%), compared with a peer group (11.5%) or alone (13.2%). They demonstrated significantly more Light-Moderate-Vigorous PA (LMVPA) while in a solitary social context (68.2%) compared with alone with an adult (25.8%), alone with a peer (34.8%), or with a peer group (28.2%). No significant differences were noted during organized activity. Conclusion: Features of the social environment may influence PA levels of children with ASD. Specifically, certain social group contexts may be more PA-promoting than others depending on the setting. Keywords: developmental disability, free play, organized play
U.S. public health recommendations state that children aged 6 to 17 years should engage in at least 60 minutes of moderate-tovigorous physical activity (MVPA) daily.1 Preschoolers (aged 3 to 5 years) should engage in light and MVPA (LMVPA) for 15 minutes per waking hour for 12 waking hours, which corresponds to 3 hours of PA per day.2 Less than 50% of children aged 6 to 11 meet guidelines3 and many preschoolers are not achieving adequate amounts of PA.4 One population that may be at greater risk for not meeting PA guidelines is children with Autism Spectrum Disorder (ASD).5,6 ASD affects 1 in 88 children in the U.S.,7 and is characterized by deficits in communication, social interactions, and restricted, repetitive behaviors and interests.8 Some studies suggest children with ASD are less physically active overall than NT peers.6,9 Low levels of participation in PA may be due to environmental variables, such as lack of developmentally appropriate programs, lack of resources, and inadequate staff training,10,11 or individual ASD characteristics, such as a desire for sameness, a focus on narrow interests, a lack of motivation, and preference for sedentary activities,8,10–12 independently influencing PA. However, environmental variables may interact with ASD characteristics to influence PA. For example, children with ASD have been found to demonstrate less PA in settings such as recess13,14 but more PA in afterschool settings.6,15 Understanding the environments, both social and physical, that are PA-promoting for children with ASD may provide useful information for developing or improving PA interventions for this population. Summer camp is one setting that has not been studied in the PA and ASD literature. This setting affords various opportunities for free play and organized activity as well as interaction within several social environmental contexts. The purpose of this study was to compare setting (free play versus organized) and
social group composition influences on PA (LMVPA, MVPA) of young children with ASD during an inclusive summer camp. We hypothesized that children with ASD would have lower LMVPA and MVPA than NT children in both settings, children with ASD and NT children would have greater LMVPA and MVPA in the free play setting compared with organized setting, and in both settings, children with ASD would have less LMVPA and MVPA in social group environments compared with solitary contexts.
Schenkelberg ([email protected]) and Dzewaltowski are with the Dept of Kinesiology, Kansas State University, Manhattan, KS. Rosenkranz is with the Dept of Human Nutrition, Kansas State University, Manhattan, KS. Milliken is with the Dept of Statistics, Kansas State University, Manhattan, KS.
Measures
636
Methods This exploratory pilot study used a factorial cross-sectional design to examine social environmental influences on PA of young children. This design allowed for further examination of whether associations were moderated by diagnosis (ASD, NT) and setting (free play, organized) during which PA took place. The study was approved by Kansas State University’s Institutional Review Board (IRB).
Participants and Setting Young children (aged 5 to 6 years) attending an inclusion-based summer camp located in Kansas were eligible for participation. Parental consent was received for all children attending the camp (aged 5 to 12 years; n = 58), however only 18 children (ASD = 6, NT = 12) met our age requirement and were selected for participation. Children with ASD (autism, n = 5; pervasive developmental disorder, not otherwise specified (PDD-NOS), n = 1) were matched on age and male gender with NT children (n = 6), and the remaining children (NT) were excluded. Demographic information for the 12 participants (mean age = 5.4, SD = 0.52 years) after exclusion is illustrated in Table 1.
Parent Survey. A parent survey used demographic questions from
the Behavioral Risk Factor Surveillance System (BRFSS)16 and the 2009–2011 National Survey of Children’s Health with Special Health
Physical Activity and Autism 637
Table 1 Descriptive Characteristics of Study Participants ALL (n = 12)
NT (n = 6)
ASD (n = 6)
100 (12)
100 (6)
100 (6)
Not eligible
66.7 (8)
66.7 (4)
66.7 (4)
Free/Reduced
33.3 (4)
33.3 (2)
33.3 (2)
Non-Hispanic Caucasian
75.0 (9)
83.3 (5)
66.7 (4)
Racial/ethnic minority
25.0 (3)
16.7 (1)
33.3 (2)
Age, years (SD)
5.5 (.52)
5.3 (.52)
5.7 (.52)
Demographic variables Gender, % (n) Male Socioeconomic status, % (n)
Race/ethnicity, % (n)
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Child body mass index (BMI) Child BMI, kg/m2 (SD)
16.10 (1.16) 15.32 (0.76) 16.89 (0.95)
Child BMI-Z (SD)
0.30 (0.78) –0.12 (0.65)
0.71 (0.70)
Child weight status, % (n) Healthy weight
83.3 (10)
Overweight/obese
16.7 (2)
Parent BMI, kg/m2 (SD)
25.01 (6.07)
100.0 (6)
66.7 (4)
0.00 (0)
33.3 (2)
26.91 (7.02) 23.11 (4.81)
Parent weight status, % (n) Normal
58.3 (7)
50.0 (3)
66.7 (4)
Overweight/obese
41.7 (5)
50.0 (3)
33.3 (2)
Abbreviations: NT, neurotypical; ASD, Autism spectrum disorder.
Care Needs.17 Questions regarding the child included: the age and birth date of the child who was enrolled in the summer camp, the child’s race/ethnicity, whether the child had been diagnosed with ASD by a physician or other health care provider, the specific diagnosis of ASD (Autism, Asperger’s Disorder, pervasive developmental disorder, or other ASD), and the age at which the child first began receiving ASD-related services. Additional questions included sex, parent race/ethnicity, marital status, parent education, socioeconomic status (eligibility for free or reduced lunch), and self-reported height and weight for the parent and children living at home (see Table 1). Body Mass Index (BMI). Research assistants assessed participants’ weight to the nearest 0.1 kg using a high precision digital scale (Seca Corp, Model 770, Hamburg, Germany) and height to the nearest millimeter with shoes removed using a Seca Corp (Model 214, Hamburg, Germany) portable stadiometer. Raw BMI scores were determined for each child using the average values of the 2 closest measurements for height and weight. These scores were converted to percentile ranks and z-scores utilizing norm reference standards from the Centers for Disease Control and Prevention.18 Children were classified as healthy weight (greater than 5th percentile and less than 85th percentile) or overweight/obese (greater than 85th percentile). See Table 1 for participants’ BMI data. The Observational System for Recording Activity of Children— Preschool Version (OSRAC-P) was used to assess PA and to provide contextual information about the social environments during which children engaged in PA.19 PA codes used in OSRAC-P came from the Children’s Activity Rating Scale (CARS), an observational system which ranks PA on a scale of 1 to 5.20 In a previous study,20
PA levels (1, stationary; 2, stationary with limb movement; 3, sloweasy movement; 4, moderate movement; 5, vigorous activity) were calibrated with energy expenditure measures (heart rate and VO2) of children aged 3 to 6 years, and results indicated significant differences between levels for both heart rate and VO2 comparisons. Further, initial field tests of CARS on 3 to 6 year old children yielded 84.1% agreement between observers.20 In the current study, all OSRAC-P categories were assessed, but the focus was on setting (free play, organized) and social group composition (solitary, one-on-one with a peer, one-on-one with an adult, peer group, group with an adult) while simultaneously coding PA levels.19 Consistent with previous research,19 PA codes were aggregated to create a variable for sedentary activity (codes 1 and 2), LMVPA (codes of 3, 4 and 5), and MVPA (codes of 4 and 5). Children were observed for 15 min twice in each setting (free play and organized) using the OSRAC-P momentary time sampling protocol.19 Sessions comprised 30-s coding intervals (5 s observe, 25 s record), yielding a total of 1,440 intervals across 4 sessions. Children within matched pairs were coded simultaneously for each of the 4 observations. To control for observer effects, each child was observed once by each research assistant in free play (2 sessions) and organized activity (2 sessions). Research assistants wore headphones and were prompted by individual audio devices. The lead author trained research assistants on the OSRAC-P via group discussions, reviews, and training videos. Research assistants completed in situ training at the summer camp 1 week before the study began. When an agreement of 80% or more on all variables was reached, observers were allowed to begin the study.19 During the observation period, 8 field-based interobserver agreement (IOA) checks were conducted. Two observers independently coded the same child in a PA session while listening to the audio recording prompts through split headphones. Overall, IOA [#agreements/ (#agreements + #disagreements) × 100] by session ranged from 94.6% to 100%, which were deemed acceptable.19
Analysis The influence of group social composition (solitary, one-on-one with adult, one-on-one peer, group with adult, group without adult) by diagnosis (ASD, NT) by setting (free play, organized) on frequency of LMVPA or MVPA was analyzed using generalized mixed models (Proc GLIMMIX, SAS 9.2) with observer (research assistant), session, matched pair, and child as random effects. Hypothesis 1 was evaluated by the diagnosis main effect on the 2 outcome variables (LMVPA, MPVA). Hypothesis 2 was evaluated by the setting main effect. Hypothesis 3 was evaluated by planned comparisons that compared the difference between each group composition type on proportion (percent) of time spent in LMVPA and MVPA within diagnosis (ASD, NT) and setting (free play, organized). Alpha level was set at P ≤ .05.
Results Overall, all children (NT and ASD) spent 40.2% of session time performing LMVPA and 13.2% in MVPA across organized and free play sessions. During these sessions, children were among a group of peers 59.9% of the time, with (12.2%) or without (47.7%) an adult present, in a one-on-one social setting 29.3% of the time with either a peer (11.0%) or an adult (18.3%) present, or solitary for 10.8% of the time. Children with ASD spent the majority of time among a group of peers with (45.3%) or without (14.3%) an adult present, and only 8.8% of the time alone with a peer. When children with ASD were solitary, they participated in LMVPA 70.3% of the time (see Table 2).
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Table 2 Physical Activity Intensity of Children With ASD and NT by Group Composition Across All Settings Intervals (n)
Time (%)
LMVPA (%)
MVPA (%)
Solitary
91
12.6
70.3
24.2
1:1 Adult
137
19.0
37.2
12.4
1:1 Peer
63
8.8
33.3
4.8
Group (adult present)
326
45.3
34.7
9.8
Group (peers)
103
14.3
19.4
8.7
Total
719
37.4
11.5
Category/code ASD Group composition
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Group composition Solitary
64
9.0
70.3
18.8
1:1 Adult
125
17.6
44.8
18.4
1:1 Peer
94
13.2
39.4
10.6
Group (adult present)
356
50.1
39.0
14.0
Group (peers)
71
10.0
39.4
14.1
Total
710
43.0
14.8
Abbreviations: NT, neurotypical; ASD, Autism spectrum disorder; LMVPA, light and moderate-to-vigorous physical activity; MVPA, moderate-to-vigorous physical activity.
There were no significant main effects on LMVPA for diagnosis [F(1, 5) = 0.0, P = .99], setting [F(1, 14) = 0.0, P = .99], or group composition [F(4, 117) = 0.24, P = .06]. There were also no significant main effects on MVPA for diagnosis [F(1, 5) = 0.0, P = .99], setting [F(1, 14) = 0.0, P = .99], or group composition [F(4, 117) = 0.41, P = .80]. Therefore children with ASD did not appear to have lower levels of PA compared with NT peers, PA levels for all children (NT and ASD) did not appear to be different based on setting (free play, organized), and there were no significant differences between PA for all children in different group composition settings. Further, we found no significant 2- and 3-way interaction effects: LMVPA [Setting × Diagnosis = F(1,14) = 0.0, P = .99; Group Composition × Diagnosis = F(4, 117) = 0.44, P = .78; P = 1.50, P = .21; Group Composition × Setting × Diagnosis = F(4, 117) = 0.53, P = .71], MVPA [Setting × Diagnosis = F(1,14) = 0.0, P = .99; Group Composition × Diagnosis = F(4, 117) = 0.13, P = .97; Group Composition × Setting = F(4, 117) = 2.12, P = .08; Group Composition × Setting × Diagnosis = F(4, 117) = 0.77, P = .55]. Planned comparison analyses, however, showed that during free play, children with ASD spent significantly more time in LMVPA while in a solitary social context (68.2%) compared with one-on-one with an adult (25.8%, P = .00), one-on-one with a peer (34.8%, P = .01), or with a peer group (28.2%, P = .00) (see Figure 1). In the free play setting, children with ASD spent significantly more time in MVPA while in a group of peers (11.5%) as opposed to one-on-one with a peer (1.2%, P = .05) (see Figure 2). In addition, significantly more time in MVPA was observed when the child with ASD was solitary (13.2%) as compared with one-on-one with a peer (1.2%, P = .04). In the organized setting, PA intensities of children with ASD were not significantly different by group composition (see Figure 3 and Figure 4).
Figure 1 — Comparing percentage of time spent in light and moderate-to-vigorous physical activity (LMVPA) across group compositions during free play. * Significant from 1:1 Adult (P = .00; SEM = 0.63), 1:1 Peer (P = .01; SEM = 0.55), Group Peer (P = .00; SEM = 0.52). ** Significant from 1:1 Adult (P = .03; SEM = 0.51), 1:1 Peer (P = .03; SEM = 0.54). JPAH Vol. 12, No. 5, 2015
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Figure 2 — Comparing percentage of time spent in moderate-to-vigorous physical activity (MVPA) across group compositions during free play. * Significant from 1:1 Peer (P = .04; SEM = 1.21). ** Significant from 1:1 Peer (P = .05; SEM = 1.20).
Figure 3 — Comparing percentage of time spent in light and moderate-to-vigorous physical activity (LMVPA) across group compositions during organized activity. * Significant from Group Adult (P = .04; SEM = 0.79).
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640 Schenkelberg et al
Figure 4 — Comparing percentage of time spent in MVPA across group compositions during organized activity.
Discussion This study compared setting and social group composition influences on PA behaviors of children with ASD during a summer camp. Results indicated that children with ASD did not have lower overall LMVPA and MVPA compared with NT children, and children were not more active in free play compared with organized settings. Although these findings parallel some studies,21,22 others have found lower PA levels among children with ASD compared with NT. Pan13 found that children with ASD (aged 7 to 12 years) were significantly less active than NT peers in an inclusive recess free play setting. Another study suggested that youth with ASD have less PA overall compared with NT children.6 The conflicting findings between the literature and the current study may be due to environmental variables interacting with characteristics of ASD to influence PA. Specifically, in the current study there was evidence that PA of children with ASD differs depending on the setting (free play, organized) and social group composition within that setting. Consistent with our final hypothesis, during free play, children with ASD had greater LMVPA when they were solitary compared with other social contexts, and they also had greater MVPA when solitary compared with alone with a peer. These results were similar to 2 studies on NT preschoolers which found that a solitary social context was associated with more time spent in MVPA, compared with a peer group context.23,24 MVPA was 3.55 times more likely when children were solitary compared with when engaged in activities with an adult present.24 Compared with a peer group setting, children were 1.6 and 1.3 times more likely to engage in MVPA when solitary and alone with a peer, respectively.23 It is unclear whether the processes underlying the solitary social situation are the same for children with ASD and NT children. Social
interactions with unfamiliar individuals have been shown to elevate stress for children with ASD25 and marked social impairments associated with ASD8 may contribute to difficulties engaging with peers when activities are not organized. It may be that children with ASD are more engaged in the PA task when they are solitary in the free play setting because it meets their need for less social interaction, however additional research is necessary before accepting this conclusion. This study has several limitations. Our sample was highly selective as participants represented a small number of children enrolled in the summer camp and consisted of males aged 5 to 6 years. Further, because we had a small sample of children with little variability in parent-reported ASD diagnosis we did not assess the severity of ASD beyond parental report of diagnosis. Five children were reportedly diagnosed with autism, and 1 child was diagnosed with PDD-NOS. Thus, the potential to generalize results to older children, females, and children with varying degrees of ASD is reduced. Next, group composition was coded based on the number of individuals who were engaged with or in proximity (within 5 feet) of the focal child19 and was not dependent on explicit social interaction or engagement. Children may have been coded with a peer group yet they may not have interacted, but rather existed in proximity of the group. Given the limited literature surrounding social interaction and engagement of children with ASD, it would be meaningful to further explore this area. Finally, another factor that may influence PA is the environment in which the PA setting takes place. All free play settings took place outdoors, whereas organized PA took place both indoors and outdoors. Instructors were volunteers who had little to no prior experience leading organized PA, particularly for children with ASD. A challenge in the current study was a lack of events in the peer group context for children with ASD in organized activity (see Figures 3
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and 4). The proportion of time spent in LMVPA and MVPA may not be representative of what would be found if this event were to occur more frequently with a larger sample size. While limitations must be considered, this pilot study had several strengths. First, we selected an observational measure that used validated PA codes to explore the influence of the social environment on PA levels of children. Second, participants were matched on age and diagnosis, ensuring that children with and without ASD were observed simultaneously in the same setting. In addition, the mixed model used in our analyses accounted for random effects including the observer, matched pair, session, and child. Finally, research assistants were required to complete thorough training sessions before the study which resulted in high IOA across all variables. To our knowledge, the current study is the first to explore the influence of the social environment on PA behaviors of children with ASD. Results warrant further exploration of social environmental influences, specifically social engagement and interaction, on PA behaviors of children with ASD. An understanding of how characteristics of ASD and environmental variables interact may better inform interventions, and ultimately enhance opportunities for PA participation among this population. Acknowledgments The authors would like to thank the camp directors for assisting with coordinating the study and all the teachers, parents, and children for their participation. Special thanks to Paige Johnson, Tiffany Johnson, and Kelly Polin for assistance with data collection, and Dr. Katie Heinrich for reviewing earlier drafts.
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