The Problem of Evaluating the Effectiveness of Physical Development Programs for Children with ASD. An Example of the Implementation of the Intensive Motor Training Program “Out Fitness”

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Abstract

Objectives. Motor disorders can be one of the early predictors of autism, and also reduce the potential for developing social interaction skills. This makes the problem of diagnosing motor development in children with ASD relevant and necessitates taking into account the difficulties specific to children of this category that affect the interpretation of test results, which was the purpose of the study.

Methods. The study of the effectiveness of the implementation of the program of intensive motor training “Aut Fitness” was carried out by the method of case analysis for a child 5 years 10 months with a diagnosis of autism and severe motor disorders. Motor impairment may be an early predictor of autism and also reduces the potential for developing social interaction skills. The article discusses the problem of diagnosing motor development in children with ASD and the need to take into account difficulties specific to children in this category that affect the interpretation of test results. The intervention was planned based on the results of a comprehensive diagnosis using the author’s “FizRas” algorithm, which included motor tests adapted for children with developmental disorders and assessment of the development of everyday motor skills (questioning of parents). The goals of the program: development of muscle strength in the main parts of the body, development of coordination abilities and correction of behavior during training.

Results. Diagnostics of motor development indicators after the training revealed an increase in independence when performing motor tests, as well as an improvement in speed and strength qualities, coordination and endurance.

Conclusions. Аchieving the goals of the program for physical development and behavior correction contributed to the improvement of motor activity in everyday life, as well as the sensitivity of the developed diagnostic algorithm “FizRas” to changes in the parameters of the child’s motor activity even with short-term intervention.

General Information

Keywords: spectrum disorders (ASD); adaptive physical education; diagnostics of motor skills; the “Aut Fit- ness” technology; correctional program for motor functions development; behavioral disorders

Journal rubric: Interventions for ASD: Evidence-Based Approach

Article type: scientific article

DOI: https://doi.org/10.17759/autdd.2023210402

Received: 13.11.2023

Accepted:

For citation: Soloveva M.V., Davydov D.V., Movchan A.A., Zhang Ji. The Problem of Evaluating the Effectiveness of Physical Development Programs for Children with ASD. An Example of the Implementation of the Intensive Motor Training Program “Out Fitness”. Autizm i narusheniya razvitiya = Autism and Developmental Disorders, 2023. Vol. 21, no. 4, pp. 15–25. DOI: 10.17759/autdd.2023210402. (In Russ., аbstr. in Engl.)

Full text

Introduction
Methods for Assessing Motor Skills in Children with ASD
Autism spectrum disorder (ASD) is a developmental disorder characterized by difficulties in social interaction and communication, as well as the presence of repetitive and restricted behavior. Despite the fact that movement disorders are not included in the diagnostic criteria of the most common classifications (ICD-10, DSM-5), studies in recent decades have shown that 86.9% of children and adolescents with autism spectrum disorders (ASD) have some kind of motor development and coordination problems [11]. Motor difficulties in ASD occur in the first years of life, even preceding signs of communication deficits, and tend to increase with age, reducing the potential for social interaction [25]. The frequency of early motor impairments in children with ASD suggests the need to include motor examination in basic diagnostic protocols [19]. Motor development and social development have been shown to be mutually related, especially at a younger age, as poor motor skills limit a child’s ability to participate in play and cooperative activities, and difficulties in engaging in active play, in turn, hinder the creation of favorable conditions for the development of motor functions [23]. Thus, the development of motor skills is necessary, among other things, to enhance the activity of children with ASD, to ensure participation in activities [14]. Interest in the study of motor activity indicators of children with ASD is also due to the recent findings that motor features can serve as early predictors of ASD [21].
In a review of current research on the effectiveness of various programs for basic motor skills development published by Healy S. et al. [17], it was shown that in most cases there is a positive dynamics of motor activity indicators, but the level of evidence of these studies cannot be called sufficient due to small sample sizes, not very clear description of intervention parameters, lack of data on the degree of severity of ASD. At the same time, most studies used standardized methods of diagnosing motor skills or their separate subtests, which allows us to compare the effectiveness of different interventions.
Here is a brief description of the most common foreign methods of assessing motor skills.
At present, there is a great variety of methods that allow estimating a set of parameters of motor activity and physical development of children of different ages, but the problem of determining normative criteria taking into account constitutional features remains unsolved. At the same time, individual features of physical development in some periods of ontogenesis can determine the biomechanical features of movements and, consequently, the motor capabilities of a child with normotypic development, which can be assessed, for example, using the method of indices [9]. The diagnosis of physical and motor development parameters in children with disabilities, in particular, with autism spectrum disorders, often characterized by developmental dyssynchrony and asynchrony and various motor disorders, seems to be more difficult. The problem of organizing adaptive physical education classes for children with ASD has two important aspects: on the one hand, technologies aimed at physical development require adaptation taking into account socio-communicative and sensory features, on the other hand, sports and recreational activities, as it has been shown [27; 28], can be effective in relation to behavioral disorders characteristic of ASD. In this regard, the problem of selecting diagnostic tools that are applicable not only for assessing the parameters of motor activity in children with ASD, taking into account the peculiarities of social interaction, but also allow us to assess the therapeutic effect of activities to reduce the severity of undesirable behavior and improve the skills of social interaction comes to the forefront.
One of the most popular is the Test of gross motor development (TGMD-2) [20], which is used to identify children who are significantly behind their peers in the development of basic motor skills and need special educational conditions. The test includes two subtests: the assessment of locomotor functions (running, jumping) and the ability to control an object (ball exercises), with 6 samples each. A more detailed assessment of motor activity indicators is provided by using the Bruininks-Oseretsky Test of Motor Proficiency, second edition (BOT-2) skills [13], the first version of which was developed by N.I. Ozeretsky in 1923 [4]. The standardized modification of the test evaluates aspects of motor activity that characterize the degree of differentiation of the motor apparatus: static and dynamic coordination, speed, strength, synkinesia, balance retention, and others. The test consists of 53 observation items and is designed for school-age children and young adults (4 years to 21 years of age). The Movement Assessment Battery for Children (M-ABC) [18] is most commonly used in clinical studies of motor skills in children, in particular, to detect coordination disorders. It is designed for diagnosing children from 3 to 16 years of age and includes 8 subtests grouped into three subscales: manual dexterity, aiming and catching, and balance. A modification of the M-ABC-2 [18] also includes an additional checklist to be completed by a parent or a person familiar with the child's behavior. For younger children, the Peabody Developmental Motor Scales (PDMS-2) [24], developed to assess large and fine motor skills in children from birth to 5 years of age, includes six subtests: reflexes, stability (body control and balance), locomotion, object manipulation, grasping, and hand-eye integration. Having undoubted advantages in the form of shortness of the diagnostic procedure and the presence of age equivalents of indicators on the scales, this test allows to detect motor disorders reliably enough, but it is not sensitive enough to control the dynamics of changes in motor activity indicators [22].
In the domestic practice of correction of motor development disorders and motor skills development, a large number of diagnostic methods are also used, many of which are based on the works of N.I. Ozeretsky and M.O. Gurevich [4]. The initial version of the scale allows us to study various components of psychomotor skills: static and dynamic coordination of body and hand movements, speed and simultaneity of movements, clarity of their performance and the presence of synkinesias. A total of 78 test tasks of different motor structure and complexity were presented in the scale. Despite the widespread use of elements of this technique, a standardized diagnostic tool with modern normative criteria for the Russian sample has not been developed, which significantly complicates the comparison of the results of different studies. N.P. Vaisman [2] proposed to use N.A. Bernstein's level theory of movement construction to study the psychomotor skills of mentally retarded children. He drew up a scheme of motor skills examination consisting of 12 tests, each of which is aimed at studying the participation of one or another cerebral level of movement control in a given motor act. According to the results of these tests, it is possible to judge simultaneously about the components and level of movement organization, as well as about motor qualities. When interpreting the data, the level theory of movement construction is applied with an emphasis on analyzing the afferent component of any motor act. This methodology makes it possible to identify qualitative violations of the psychomotor skills of children with developmental delays. The most developed in terms of standardization of the testing procedure can be considered the technique of motor examination of young children [6], which is designed to examine the motor development of children from birth to 3 years of age, to identify and assess the level of formation of motor functions by age periods, to draw a conclusion about the state of the motor sphere and to develop the necessary recommendations for its correction. The scale of motor development is represented by three blocks according to the types of motor skills: general (gross) motor skills, fine (fine) hand motor skills and speech (articulation-mimic) motor skills. The age range of the children studied by this method from birth to 3 years of age is divided into periods characterized by certain patterns of psychomotor development. The tasks for each age period are grouped according to three motor components: general motor skills, fine motor skills, speech (articulation) and mimic motor skills. The method allows to calculate the "motor development coefficient" (MDC) on a 100-point scale, accurately and quickly identify deficiencies in the motor development of the child and differentiate children with motor development deviations from their peers with normally developing motor skills.
The technique of examining children's skills related to physical movements is presented in the manual by Yu.F. Garkusha "Pedagogical examination of preschool children" [3]. [3]. In addition to the examination of motor functions, the manual also contains a system of tasks to test the skills related to the development of elementary mathematical concepts, visualization and construction of children with speech pathology. To test motor skills, the author offers a system of tasks selected in accordance with the program requirements for the upbringing and education of children in kindergarten. Normative indicators of the fulfillment of these tasks are presented by the author in Appendix 7. The system of tasks proposed in the method is aimed at studying the basic types of movements in children aged 4-7: walking, running, crawling and climbing, jumping, throwing, catching and throwing. The methodology includes six tasks, five of which are aimed at studying various movements, and one task - to determine the degree of formation of the child's sense of balance as a necessary component of basic movements. The content of each task is differentiated taking into account the program requirements depending on the age of children. To perform some tasks it is necessary to have small sports equipment. The method of examining motor functions in preschoolers, compiled by G.V. Babina and colleagues [1], is aimed at studying the state of motor functions in preschoolers with dysarthria, but can be used for other categories of children with disabilities. This method includes the most complete range of tasks to study all aspects of the motor sphere, since the motor tasks presented in it from various author's methods are grouped into blocks with respect to different motor components.
 
The Problem of Evaluating the Effectiveness of Physical Development Programs for Children with ASD
Despite the availability of a large number of techniques for diagnosing motor development parameters, their direct application in work with children with ASD causes certain difficulties due to the predominant lack of normative evaluation criteria.
The results of the application of the above tests cannot always be unambiguously interpreted due to the difficulties of interaction with children with ASD.
An attempt to identify specific features of motor impairments characteristic of people with ASD and ADHD [26] showed the need for a more differentiated diagnostic approach, possibly taking into account the individual peculiarities of perception and communication inherent in children with ASD.
According to an analysis of forty-one studies [24], additional factors, such as the quality of trial performance, the program adaptations used, and the amount of intervention, must be considered to make an informed conclusion about the effectiveness of a particular intervention for motor development in children with ASD.
 
Methods
Based on the available approaches and taking into account the behavioral characteristics of children with ASD, a special diagnostic algorithm for the technology of adaptive physical culture "Out Fitness" was developed. This technology, developed in the Federal Resource Center for the organization of comprehensive support for children with ASD [5; 8], provides for the development of a plan of adaptive physical education sessions, taking into account the peculiarities of behavior, including undesirable behavior, as well as taking into account the indicators of motor development, communication and social interaction skills. Intervention planning is carried out based on the results of complex diagnostics according to the author's algorithm "FizRas". The diagnostic algorithm includes motor tests adapted to the specificity of disorders of children with ASD and assessment of the formation of everyday motor skills also using the results of parental questionnaires. When adapting the exercises, the peculiarities of communication, sensorics, and speech characteristic of children with ASD were taken into account [7; 10]. The results of test performance are evaluated quantitatively in appropriate units (centimeters, number of times, time of performance in seconds) and qualitatively with the assignment of points depending on the need for support (0 - does not perform, 1 - performs with full support, 2 - performs with partial support, 3 - performs independently). The regulations for conducting the diagnostics provide for the use of visual demonstration and verbal explanation with the use of short and clear instructions and additional visual cues to explain the exercises. When performing the diagnostics, encouragement for the child may be needed, as well as a countdown timer, visual timetable, tokens, additional equipment (hoops or traces to guide where the child should stand/where to jump, etc.).
Results
An Example of the Implementation of an Intensive Movement Program "Out Fitness"
Child: Ilya B., 5 years 10 months, diagnosed with EIA.
The family sought help in developing independent movement and strengthening the muscular system.
Request from parents, "We hope that exercising the body will develop a desire to do things on your own."
Prior to the intensive course, a parent survey and initial consultation in an online format was conducted, which is a prerequisite for starting the pre-program.
The consultation provided the information needed to design an individualized program:
Communication: no speech (boy uses PECS alternative communication system, gestures).
Medication: neuroleptics (no sleep without them), nootropics.
Encouragements used: social praise, a toy, candy.
Autostimulation: bounces and screams when happy.
Playground preferences: swinging on swings, spinning.
Recommendations from orthopedist, neurologist: adaptive physical training (APT).
Medical contraindications for APT classes: none
Physical activity experience: a 10-day course of classes with a neuropsychologist.
After the consultation, the form and frequency of classes were determined: individual sessions lasting 60 minutes, of which 50 minutes - work with the child and 10 minutes - counseling parents on the results of the session; course duration - 8 days, frequency of classes - daily.
Diagnostic Results
Diagnostics was carried out after the child's initial adaptation to the conditions of classes. The results showed (Tables 1-2) that the child needs full or partial physical prompting in learning most of the skills, the formation of which directly depends on the level of development of muscle groups and physical qualities, which determines success in solving everyday motor tasks. The boy was found to have deficits in the development of strength, the ability to maintain balance, in the coordination of movements, including visual-motor movements, in the formation of motor planning of motor actions.
The Child’s Pedagogical Characterization (Based on Observation Results)
The pedagogical characterization included data from visual assessment using the observation method:
  1. Gym preferences: touching the fitball with hands, jumping briefly on the bosu, rubbing belly on the bosu, touching 3-5 seconds on prickly surfaces and new objects, running chaotically around the gym.
  2. Condition of the musculoskeletal apparatus: increase in lumbar lordosis; shoulders are often raised, neck muscles are tense, does not keep the back straight in sitting position; walks on socks, non-rhythmic walking and chaotic running with autostimulation is observed, does not coordinate the work of hands and feet, lack of imitation.
  3. Peculiarities of behavior and communication: field behavior, does not sit and does not stand still, protests, refusals to perform any exercise, lack of understanding of verbal constructions, lack of speech, frequent self-stimulation: bouncing, circling around, waving hands and clapping, vocalizations, twirling objects near the eyes. Lack of motivation and interest in exercises and in interaction with an adult. The proposed tasks at the first session could perform no more than 5-10 seconds.
Pedagogical conclusion: Non-compliance with age norms of physical and motor development. The child has not formed basic motor skills, imitation skills, reduced development of muscle strength of the shoulder girdle, trunk, legs, underdeveloped coordination abilities, poorly developed agility, flexibility, endurance, motor planning of actions, difficulties in controlling the feet and hands, head, poorly developed proprioreceptive system, pronounced hypersensitivity of the tactile, vestibular, visual systems. The child's sensory search is noticeable, which indicates the need for special sensory integration classes.
Based on the results of the diagnostics and conversation with parents, an individual program of classes aimed at behavioral correction and comprehensive physical development was drawn up.
Individual Program Goals
  1. Behavior correction
  2. At the beginning of the class: stimulation of sensory systems using favorite activities and exercises - rocking on a fitball, full body massage with sensory rollers, deep kneading of hands, feet, passive gymnastics.
  3. Lining up and clearly following the order "Exercise first - then favorite activity".
  4. Gradual increase in dosing of load: from 10 seconds at the initial stage to 30 seconds of work in the exercise by the end of the course.
Following these rules allowed the child to easily adapt to the lessons, get used to the learning process and follow the instructor's instructions.
  1. Physical development
  2. Strengthening of arm muscles, back muscles, abdominal muscles, legs.
Means: crawling on all fours, crawling, carrying a ball weighing 1 kg, lifting a ball weighing 1 kg, pulling up on the bench, climbing the gymnastic wall (gradually, starting with climbing only one bar, then two, three, etc.),
  1. 2. Interaction with balls of different sizes.
Means: pushing, rolling a fitball, catching a basketball, holding and carrying tennis and weighted balls of 300 g., placing small balls on a landmark.
  1. 3. Development of static and dynamic equilibrium.
Means: standing on a balancer and sensory bumps, walking on soft modules, on a bench, on a sensory path, stepping over objects, stepping on a step platform.
  1. 4. Development of motor planning of motor actions, interhemispheric connections.
Means: obstacle courses of 2-3 tasks known exercises from the exercises listed in the program.
Schemes for building coordination routines: incorporating mid-body crossing tasks, strength + balance; attention + coordination, palm grip development.
For example: get in a hoop → pick up a tennis ball → step over 5 obstacles → hoop → put the ball on the cone → bench press → repeat the circle.
III. Structure of the class
  1. Preparatory part: greeting ritual, sensory warm-up.
  2. Main part: isolated exercises for the development of physical qualities, passing the obstacle course.
  3. Final part: ball games, massage, free time for favorite games. Cleaning of the equipment. Farewell.
After each session, a conversation was held with the child's father, describing in detail what had been done during the session, what tasks had been accomplished, and what the plan was for tomorrow. The parent was also sent video recordings of the sessions with tasks to be done at home to consolidate skills.
At the end of the corrective training program, a control diagnostics was conducted at the last session. The results are presented in comparison with the initial indicators in Tables 1-2.
 
Table 1
Results of diagnostics of Ilya's motor abilities according to the algorithm "FizRas" before and after an intensive course of adaptive physical training
 
 

 

 

Motor skills

 

Motor test

Test scores before/.

after

Need for before/after support (points)

1

Speed qualities

running on the spot for 10 seconds - (number of times)

 

0/0

0/0

 

2

Speed and strength qualities

long jump (cm)

 

0/5

0/1

throwing a 1 kg ball with two hands from behind the head while standing (cm)

0/25

0/2

throwing a tennis ball at a target (number of times)

left - 0/2

right - 0/2

 

0/2

3

Static endurance

Plank (straight arms lying on a gymnastics bench) (sec)

0/6

0/2

4

Coordination skills

 

 

 

Static equilibrium

one-leg stand (sec)

 

0/2

0/1

Dynamic balance, coordination

walking on a log (number of times)

 

0/6

0/2

stepping over 5 objects (number of times)

0/5

1/3

crawling on all fours 5 m (sec)

13/9

3/3

Agility and coordination

zig-zag with touching 3 cones (number of times)

0/1

0/1

catching the ball with two hands (number of times)

0/2

0/3

Coordination, strength

climbing the gymnastics wall (sec)

0/18

0/3

5

Flexibility

forward bend from sitting position (cm)

0/0

0/0

           
 
Table 2
Formation of everyday motor skills before and after the course of classes (based on the results of parents' questionnaires)

 

Name of motor skill

before

after

1

Brushes his teeth

1

2

2

Opens the doors

1

2

3

Changing clothes

1

2

4

Shifting

3

3

5

Riding a scooter

0

0

6

Riding a bicycle

0

0

7

Wipes his hands with a towel

0

0

8

Holds household items (comb, fork, spoon, etc.) firmly point

1

2

9

Goes up and down stairs without support

1

2

10

Jumps over obstacles (puddles, curbs, etc.)

2

3

 
Note: In points: 0 - does not perform, 1 - performs with full support, 2 - performs with partial support, 3 - performs independently.
 
After the course, parents provided a video of the boy performing everyday tasks: eating independently, changing clothes with partial physical prompting, stepping over objects in the street independently, showing interest in the playground. Parents also noted that the child has developed the skill of walking hand in hand with his father, he stopped refusing to do joint activities at home (cleaning up after himself, carrying small bags from the store, etc.), which indicates improved communication with parents.
Discussion
Noticeable and confirmed by diagnostic results, positive changes in the formation of the child's motor skills were obtained in a short time, which is generally consistent with the results of other studies of the effectiveness of adaptive physical education [17]. The presence of Ilya's pronounced dynamics in a set of motor activity parameters together with the improvement of social interaction (as observed and assessed by parents) confirms the assumption about the interrelation of these aspects of child behavior in preschool age [23].
The results of single observations have traditionally been viewed with caution in terms of the validity of conclusions about the effectiveness of interventions. However, it should be emphasized that randomization and extraneous influences play a smaller role in short-term, intensive interventions than in long-term programs. At the same time, the problem with short-term interventions is often a decrease in the effect achieved after the sessions are discontinued. In the presented case, the obtained result, according to the parents, contributed to their decision to look for specialists to continue classes, including adaptive physical education.
 
Conclusions
 
The results presented allow us to draw the following conclusions:
  1. The "FizRas" diagnostic algorithm is sensitive enough to assess the dynamics of motor abilities and skills development indicators even with short-term intervention.
  2. As a result of an intensive course of adaptive physical training under the program "Out Fitness", a child with ASD has improved motor skills and expanded the repertoire of motor actions, which is confirmed by the indicators of the following tests: stepping over 5 objects, running zig zag, standing on one leg, walking on a log, catching and throwing a ball with two hands, throwing a tennis ball at a target with the right and left hands, climbing a gymnastic wall, plank.
  3. Achievement of the set goals of the correctional program for physical development and behavior correction contributed to an increase in the volume of motor activity in the child's daily life.
In the future, it is planned to continue research on the effectiveness of the adaptive physical culture program "Out Fitness": conducting studies of quasi-experimental design, improving the diagnostic tool by introducing additional indicators of technical performance of tests, developing evaluation criteria taking into account children’s constitutional characteristics.

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Information About the Authors

Marina V. Soloveva, Physical Culture Teacher, the Federal Resource Center for Organization of Comprehensive Support to Children with ASD, Moscow State University of Psychology & Education, Moscow, Russia, ORCID: https://orcid.org/0000-0003-0896-2477, e-mail: solovevamv@mgppu.ru

Denis V. Davydov, PhD in Biology, Leading Researcher of the Federal Resource Center for Organization of Comprehensive Support to Children with Autism Spectrum Disorders, Moscow State University of Psychology & Education (MSUPE), Moscow, Russia, ORCID: https://orcid.org/0000-0003-0993-3803, e-mail: davydovdv@mgppu.ru

Anna A. Movchan, Junior Researcher, Federal Resource Center for Organization of Comprehensive Support to Children with Autism Spectrum Disorders, Moscow State University of Psychology & Education, Moscow, Russia, ORCID: https://orcid.org/0009-0000-5112-2735, e-mail: movchanaa@mgppu.ru

Jie Zhang, Bachelor’s program “Social sport”, Department of Social Sport , Beijing University of Chemical Technology, Beijing, China, ORCID: https://orcid.org/0009-0009-2519-532X, e-mail: zhang.jaye@outlook.com

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