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Article

Physical Education and Development of Locomotion and Gross Motor Skills of Children with Autism Spectrum Disorder

by
Adriana Kaplánová
1,*,
Nikola Šišková
2,
Tatiana Grznárová
2 and
Marián Vanderka
2
1
Department of Sport Science in Educology and Humanities, Faculty of Physical Education and Sport, Comenius University in Bratislava, 814 99 Bratislava, Slovakia
2
Department of Track and Field, Faculty of Physical Education and Sport, Comenius University in Bratislava, 814 99 Bratislava, Slovakia
*
Author to whom correspondence should be addressed.
Sustainability 2023, 15(1), 28; https://doi.org/10.3390/su15010028
Submission received: 18 October 2022 / Revised: 14 December 2022 / Accepted: 17 December 2022 / Published: 20 December 2022
(This article belongs to the Special Issue Physical Education for Sustainability: Policy and Practice)
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Abstract

:
Movement abnormalities are a common problem in children with autism spectrum disorder (ASD), which affect their fine and gross motor skills, locomotion, and eye movements, along with their ability to conduct more complex movement types. The purpose of this study was to determine whether regular exercises in physical education classes using the Test of Gross Motor Development Second Edition (TGMD-2) improve locomotion, gross motor skills, and overall movement performance in children with ASD and eliminate the occurrence of movement abnormalities. Twenty children aged 5–10 years (M ± SD; 7.51 ± 1.58 years) who were diagnosed with ASD participated in the research. The TGMD-2 training program was applied for a period of 8 weeks with a frequency setting of two times a week and a duration of 30 min under the guidance of a physical education teacher. Group A exercised according to TGMD-2 instructions, while Group B was the control group, then vice versa. The rest period between exercises was 13 weeks. The research results indicate that the use of exercises to develop the motor performance of children with ASD contributed to the significant development of their locomotion and gross motor skills. In both groups A and B, we noted an improvement in locomotion (p < 0.01) and gross motor skills (p < 0.01). The results demonstrated a significant improvement in gains between the control and experimental periods in groups A (p < 0.001) and B (p < 0.001). During the 13-week rest period between exercises, we found a decrease in the level of motor performance in both groups of children with ASD (p < 0.01). In group A, we found a decrease in motor performance (p < 0.01), locomotion (p < 0.01), and gross motor skills (p < 0.01), and in group B, a significant deterioration of motor performance in terms of the total TGMD-2 score (p < 0.05). Regular movement intervention is very important for children with ASD; otherwise, their level of motor performance can drop significantly. Therefore, we recommend implementing TGMD-2 exercises as part of the physical education of children with ASD and supporting the routine and healthy habits of children.

1. Introduction

Children with autism spectrum disorder (ASD) suffer from neurodevelopmental disorders, which are characterized by certain limitations that manifest in several areas of the children’s development and lives [1]. Deficits appear primarily in verbal and non-verbal communication and interactions, and children with ASD have a reduced ability to adapt and function among peers when there is a general disruption to the social relationships in the classroom [2,3,4,5]. A deficit in social-emotional reciprocity makes it impossible for children with ASD to judge the appropriate contact with peers, meaning there may be abnormal contact establishment or difficulties with sharing emotions [6,7].
ASD is diagnosed in early childhood, usually around the fourth year of a child’s life, and its occurrence was found to be four times as frequent in boys compared to girls [8,9]. It is at this age that movement abnormalities often occur in children with ASD, which have been recorded in the areas of locomotion and motor skills, eye movements, or the ability to conduct more complex movement types [10,11,12,13]. Children with ASD prefer activities characteristic of a lower developmental stage and they create an intense and gratuitous relationship with objects or sequences of certain movements with increasing intensity, which when disturbed lead to mood changes and angry behavior [14,15,16,17,18]. Motor abnormalities are observable in children with ASD in early childhood and they become more significant with increasing age [19,20,21,22]. The most frequent movement abnormalities of school-aged children with ASD include clumsy handling of objects and a ball and an inability to catch the ball, dribble, throw it in the right direction, or roll the ball. Children with ASD have difficulties in controlling their legs when kicking a ball, in locomotion skills that include jumping related to the incorrect procedure when bending the knees, as well as difficulties in balancing [23]. Therefore, many experts emphasize the importance of training children with ASD in basic movement skills and adapting their physical education to suit their needs [24,25,26].
According to experts, early movement interventions can improve the manipulation of objects and increase the motor skills of children with ASD [27,28], and can also contribute to enhancing locomotion and ball handling [29]. Individual exercise therapies are proving to be a suitable adjunct to other targeted interventions as part of a comprehensive treatment model [30]. Their advantage is in taking an individual approach that protects children with ASD from having negative thoughts resulting from a misunderstanding of interactions and communications between children [31].
Possibilities for developing the socialization of children with ASD have not yet been sufficiently explored, but experts are investigating the benefits of group activities [32,33]. If the communication or social skills of children with ASD are reduced, there is a risk of isolating these children from the group [34]. It is proven that sports or organized regular physical activities provide a suitable environment for the development of a relationship with peers. Physical education classes can thus become a suitable environment for helping children with ASD to create a natural relationship with sports, build a healthy lifestyle routine, and learn to socialize in society [35].
In addition, regular exercise with the use of TGMD-2 in physical education classes can have a positive effect on children’s engagement in terms of performing individual movement exercises since routine and immutability are among the main addictions of children with ASD. Furthermore, a consistent environment and carrying out activities among a group of children they know can deepen their sense of safety and security and have a significant impact on their physical and mental health. Plus, the implementation of proven series of physical education exercises among a stable group of peers can increase the interest of children with ASD in their development of physical capabilities. Since there is little research in Slovakia focused on physical activity and the elimination of movement abnormalities of children with ASD in the area of locomotion or motor skills, the Faculty of Physical Education and Sports of Comenius University in Bratislava, in cooperation with the Academic Center for Autism Research, conducted research aimed at monitoring the development of children with ASD’s motor performance. We assumes that when implementing regular exercises using TGMD-2, we would note improvements in locomotion, gross motor skills, and overall movement performance among children with ASD and eliminate the occurrence of movement abnormalities.

2. Materials and Methods

2.1. Participants

The research group consisted of 20 participants aged 5–10 years (M ± SD; 7.51 ± 1.58 years), made up of 17 boys and 3 girls, who were diagnosed with ASD at the Academic Center for Autism Research (ACVA) in Bratislava, Slovakia. Children completed a standardized examination using the ADOS-2 Autism Diagnostic Observation Schedule scale [36]. The examination lasted 40–60 min and consisted of a series of precisely defined activities and conversations, during which the psychologist purposefully elicited specific types of reactions from the child. Based on monitoring the child’s expressions in interactions with the parent, deficits were evaluated in five main areas: language and communication skills, mutual social interaction, play and creativity, stereotypical expressions, and narrowly defined interests. With the aim of gaining a more detailed picture of the children’s development and current behavior, a structured interview was conducted with the parents or primary guardians using the ADI-R Autism Diagnostic Interview, lasting 90–150 min. The diagnosis covered three areas of problems: quality of communication, quality of reciprocal social interactions, and limited, repetitive, and stereotypical patterns of behavior in children with ASD. A thorough evaluation of the developmental history, relevant information for differential diagnosis, and possible comorbidities was also part of the diagnosis [37].
All parents or primary guardians of the subjects gave their informed consent for a child’s inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the Faculty of Physical Education and Sports of Comenius University in Bratislava, Slovakia (code 3/2019). The children were divided into two groups (A and B) based on the average motor performance score achieved during the initial measurements. There were nine boys and one girl in group A (6.78 ± 1.34 years) and eight boys and two girls (8.25 ± 1.44 years) in group B. Group A, as an experimental group, exercised for eight weeks with a frequency setting of two times a week and a duration of 30 min according to the TGMD-2 instructions, while group B was the control group, then vice versa (crossover study). The parents or primary guardians of the children were informed about and gave consent for these conditions, that the children involved in our research did not perform any other regular physical activity in their free time.

2.2. TGMD-2 Training Program

TGMD-2 is a training program that serves to identify children who are significantly behind in terms of their motor skills compared to their peers. It contains 12 exercises focused on changes in the level of motor performance, which are performed under the guidance of a physical education teacher [38]. Movement skills are assessed based on 3–5 performance criteria. A child with ASD receives a rating of 0 if they do not perform the requirements correctly, or 1 if they do. The highest achieved score for one sample group in each exercise, taken from one or the other of the subtests, is shown in Table 1. We could use the results of this assessment to monitor the children’s progress, evaluate the treatment, and conduct further research on their locomotion and gross motor development. A more detailed description of the exercise program is given in Table 2.

2.3. Statistical Analyses

The statistical program 2IBM® SPSS® Statistics, version 26.0, for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. The normality of the distribution of the data was ascertained using the Shapiro–Wilk test. The differences between input and output measurements in both experimental periods and in the rest period were evaluated by Wilcoxon’s T-test. Increases during the entire experimental period were evaluated by Friedman’s test. Differences between control and experimental groups were assessed using Wilcoxon’s rank-sum test. The effect size was determined using Cohen’s r: large effect—Cohen’s r ≥ 0.50, medium effect—0.30 ≤ Cohen’s r < 0.50, and small effect—0.10 ≤ Cohen’s r < 0.30 [39].

3. Results

In Table 3, we present our evaluation of the motor performance of children with ASD during the first period of exercise using the TGMD-2 training program at a frequency setting of two times a week and a duration of 30 min for the experimental group A, and the same evaluations of motor performance for control group B, where children with ASD did not perform any physical leisure activity, nor regular physical activity. The maximum number of points that children with ASD could obtain for individual exercises was 960, of which 480 was for the locomotion subtest and 480 was for the gross motor subtest. From the results, it is clear that in the first experimental group A, there were significant improvements in the locomotion subtest (p < 0.01), in the gross motor subtest (p < 0.01), and in the overall motor performance of children with ASD (p < 0.01).
In the second experimental period (October/November), group B performed exercises using TGMD-2 instructions, and group A became the control group, without regular physical activity. The results show that in the locomotion subtest (p < 0.01) and in the gross motor subtest (p < 0.01), as well as in the total motor activity (p < 0.01), the experimental B group of children with ASD improved significantly (Table 4).
Between the first experimental period (May/June) and the second (October/November), there was a 13-week rest period in implementing the exercises. During the rest period, in experimental group A, the motor performance of children with ASD decreased by 15.52%, which points to the importance of developing the physical activity of children with ASD. Meanwhile, in control group B, children with ASD’s motor performance improved by 5.63%, which was caused naturally since these children with ASD were in their period of greatest motor development.
Friedman’s test showed that the gains in the motor performance of children with ASD during the period from May to November in both groups A and B were significant (p < 0.001). In group A, we noted significant differences in the motor performance gains for children with ASD between the experimental (May/June) and the control (October/November) periods (p < 0.001), in the locomotion subtest (p < 0.001), and in the gross motor skills subtest (p < 0.001) (see Figure 1). The average increase in the motor performance of children with ASD in the experimental period was 30.7 ± 7.59 based on the total score, and in the control period, the average decrease was −2 ± 6.31. In the experimental period, the average increase in the locomotion subtest was 15.9 167 ± 6.55, and in the control period, it was 1.3 ± 4.88. In the experimental period, the gross motor skills score increased by 14.8 ± 6.10, and in the control period, the average decrease was −3.3 ± 3.72.
In group B, we noted significant differences in the motor performance gains of children with ASD between the experimental (May–June) and control (October-November) periods (p < 0.001), as well as in the locomotion subtest (p < 0.001) and the gross motor skills subtest (p < 0.001) (see Figure 1 and Figure 2). The average increases in motor performance of children with ASD in terms of the total score were 30.8 ± 7.47 in the experimental period and 4.3 ± 3.72 in the control period. For the locomotion subtest, they were 15.1 ± 6.88 in the experimental period and 0.3 ± 4.63 in the control period, and for the gross motor skills subtest, they were 15.7 ± 2.76 in the experimental period and 3.8 ± 3.92 in the control period.
Overall, movement intervention in the form of an 8-week program of TGMD-2 exercises with a frequency of 30 min twice a week significantly increased the locomotion, gross motor skills, and overall motor performance of children with ASD.

4. Discussion

This study presents findings on the implementation of 12 exercises through TGMD-2 in children with ASD under the guidance of a trained physical education teacher. The results show a significant improvement in motor performance, specifically locomotion and gross motor skills, in children with ASD between the ages of 5 and 10 in both experimental periods, which is in line with the research findings of other experts [27,28,29]. Children with ASD improved in their ball and object handling, learned to dribble, caught the ball, threw the ball in the right direction, and also rolled it. After the implementation of exercises according to TGMD-2, children’s leg control improved when kicking a ball. We also noted improvements in their jumping, and difficulties with balancing decreased, which is in line with the findings of previous authors to have used TGMD-2 for the development of locomotion and gross motor skills [22,40]. Physical activity can stimulate the cerebral cortex of children with ASD, and at the same time, contribute to an increased supply of oxygen and nutrients, which helps to maintain or restore the normal functioning of the nervous system. Movement interventions to combat mental health problems, such as autism, have been shown to have a positive impact, but it is important to set certain standards so that physical activity for children with ASD is consistently effective [41].
Leading children with ASD in the performance of regular physical activity—with a frequency set of two times a week for 30 min each time over eight weeks—appears to be effective, which is consistent with the findings of another study (n = 60) that showed a relationship between physical exercise and improving symptoms or reducing deficits caused by comorbidities associated with ASD [42]. Our findings are also consistent with another study to have focused on the application of exercise programs using TGMD-2 in children with ASD, lasting for 30 min three times a week, in which 14 training sessions were applied (less than in our battery of exercises) with similar findings in favor of the motor development of children with ASD [43]. Similarly, another study aimed at evaluating the effects of creative yoga over the same period of eight weeks (n = 24), which also demonstrated improvements in gross motor skills in children with ASD, as well as reduced errors when carrying out training-specific yoga exercises [44]. The same training mesocycle in the form of swimming training (technical and game) resulted in improvements in gross motor skills, as well as improvements in stereotypical autistic behavior and emotion regulation in children with ASD [45].
There is also growing evidence of the positive effect of interventions using music, dance, theater, and martial arts for addressing multisystem disorders in autism. Improvements in social communication skills have been demonstrated after the implementation of music and moderate to large improvements in children’s motor skills and cognition after martial arts therapy [46]. Even virtual training and physical exercises, when implemented for nine weeks, have the potential to effectively strengthen executive functions and the self-regulation of children with ASD [47]. In addition, we showed that movement load improves motor skills even in healthy children (p = 0.012). Healthy children had a 35.15% higher total score in the exit measurements than at the beginning of the experiment, which is a similar result to that in our research with autistic children [48].
The motor skills of children with ASD and their imitation skills are interconnected and related to early social communication skills at the preschool age [49]. This evidence suggests that motor skills and intellect are highly interconnected in children with ASD. In addition, basic movement skills are part of the developmental process of children with ASD and form the basis for more advanced movement patterns, which appear to be effective to developing, especially when at school, and can eliminate delays in the development of locomotion and gross motor skills [22,40]. Furthermore, it is beneficial, in general, for us to increase children’s interest in physical activities and sports and to build their natural relationship with a healthy lifestyle [40]. Our findings should support educators’, psychologists’, therapists’, doctors’ and other professionals’ interest in the issue and fuel their efforts to eliminate movement delays. Systematic assessment of basic movement skills can also provide a basis for developing a diagnosis of movement delay in children with ASD [23,40]. Moreover, it can provide valuable information for the development of movement elements suitable for implementation in physical education classes for children with ASD, which proves to be helpful in terms of peer group stability and the development of socialization and communication skills among such children with ASD.

5. Limitations

A limitation of this study was the size of the research sample compared to research from other countries, as Slovakia is a country with a small population. Furthermore, it was limited by the varying severity of the children’s autism and mental disability, along with gender imbalances in the individual groups. Plus, the findings may not be generalizable to other countries, especially considering that physical education classes vary in their nature and scope internationally. Moreover, although the parents or primary guardians of the children with ASD were informed that children should not perform other physical activity, even during the rest period, this factor was not monitored or verified by research tools. In the future, it would be interesting to conduct similar studies with different movement loads, volumes, and times of use for children, with a better division into individual groups. It would also be interesting to compare the progress of the development of locomotion and gross motor skills in children with ASD in individual developmental periods, i.e., preschool age and infant school age, during which motor development is the most intensive.

6. Conclusions

Our findings suggest that a training intervention using TGMD-2 may have a positive effect on the improvement of the locomotion, gross motor skills, and motor performance of children with ASD. Such a regular exercise program may offer a suitable tool for improving the motor level of children with ASD after the eighth week of its implementation at a frequency of two times per week for 30 min each time. Moreover, after a 13-week rest period, in the case of experimental group A, we recorded a significant decrease in the motor performance of children with ASD. This result indicates that regular movement intervention is very important for children with ASD; otherwise, their level of motor performance drops significantly. Therefore, we recommend implementing regular exercises according to the TGMD-2 instructions as part of the physical education for children with ASD and supporting their routine and healthy habits.

Author Contributions

Conceptualization, A.K., N.Š. and M.V.; methodology, A.K., N.Š. and M.V.; software, T.G.; validation, T.G.; formal analysis, A.K. and N.Š.; investigation, N.Š.; resources, A.K.; data curation, A.K.; writing—original draft preparation, A.K.; writing—review and editing, A.K.; visualization, A.K. and T.G.; supervision, M.V.; project administration, N.Š. and T.G.; funding acquisition, M.V. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by [The Scientific Grant Agency of the Ministry of Education, Science, Research and Sport of the Slovak Republic (VEGA)] grant number [1/0608/20 with the title “The influence of movement activities on the cognitive, social and motor skills of children with autism"].

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of the Ethics Commission of the Faculty of Physical Education and Sport of Comenius University in Bratislava (protocol code 3/2019 and date of approval 15 May 2019).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Acknowledgments

We greatly appreciate the cooperation of the Academic Center for Autism Research (ACVA) in Bratislava in Slovakia.

Conflicts of Interest

The authors declare no conflict of interest.

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Figure 1. Differences in gains in motor performance between the experimental and control periods in group A.
Figure 1. Differences in gains in motor performance between the experimental and control periods in group A.
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Figure 2. Differences in gains in motor performance between the experimental and control periods in group B.
Figure 2. Differences in gains in motor performance between the experimental and control periods in group B.
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Table
Table 1. Description of the TGMD-2 rater training program.
Table 1. Description of the TGMD-2 rater training program.
LocomotionScoreGross Motor Skills Score
1. Run87. Striking a Stationary Ball10
2. Gallop88. Stationary Dribble8
3. Hop109. Catch6
4. Lead810. Kick8
5. Horizontal Jump611. Overhand Throw8
6. Slide812. Underhand Roll8
∑ score48∑ score48
Table
Table 2. Study design and procedure.
Table 2. Study design and procedure.
1–4 weeks of the experimentExercisesTraining time
(min)		Number of series
(n)		Rest interval between exercises
(s)
1/2 daysTGMD–2 (12 exercises)30330
5–8 weeks of the experimentExercisesTraining time
(min)		Number of series
(n)		Rest interval between exercises
(s)
1/2 daysTGMD–2 (12 exercises)30520
Table
Table 3. Evaluation of the motor performance of children with ASD during the first period of exercise using the TGMD-2 training program.
Table 3. Evaluation of the motor performance of children with ASD during the first period of exercise using the TGMD-2 training program.
Group Score (n)MSDDifference
(%)		pZCohen’s r
TGMD-2 totalAInput37037.0021.5731.980.005
**		−2.8070.888
Output67767.7021.25
BInput32132.1017.734.480.007
**		−2.6890.851
Output36436.4018.11
Locomotion subtestAInput18218.2010.6833.130.005
**		−2.8030.887
Output34134.1011.32
BInput17017.0010.970.630.439
n.s.		−0.7740.245
Output17317.308.65
Gross motor skills subtestAInput18818.8011.8730.830.005
**		−2.8070.888
Output33633.6010.74
BInput15315.308.137.920.025
*		−2.2450.710
Output19119.1011.29
Notes: A—experimental group, B—control group, * p < 0.05, ** p < 0.01.
Table
Table 4. Evaluation of the motor performance of children with ASD during the second period of exercise using the TGMD-2 training program.
Table 4. Evaluation of the motor performance of children with ASD during the second period of exercise using the TGMD-2 training program.
Group Score (n)MSDDifference
(%)		pZCohen’s r
TGMD-2 totalBInput31031.0019.6132.080.005
**		−2.8210.892
Output61861.8023.91
AInput52852.8018.74−2.080.444
n.s.		−0.7660.242
Output50850.8017.22
Locomotion subtestBInput16116.1010.4031.460.005
**		−2.8050.887
Output31231.2013.12
AInput25825.808.772.710.261
n.s.		−1.1230.355
Output27127.108.22
Gross motor skills subtestBInput14914.9010.2932.710.005
**		−2.8140.891
Output30630.6011.52
AInput27027.008.77−6.860.011
*		−2.5360.802
Output23723.709.90
Notes: A—experimental group, B—control group, * p < 0.05, ** p < 0.01.
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Kaplánová, A.; Šišková, N.; Grznárová, T.; Vanderka, M. Physical Education and Development of Locomotion and Gross Motor Skills of Children with Autism Spectrum Disorder. Sustainability 2023, 15, 28. https://doi.org/10.3390/su15010028

AMA Style

Kaplánová A, Šišková N, Grznárová T, Vanderka M. Physical Education and Development of Locomotion and Gross Motor Skills of Children with Autism Spectrum Disorder. Sustainability. 2023; 15(1):28. https://doi.org/10.3390/su15010028

Chicago/Turabian Style

Kaplánová, Adriana, Nikola Šišková, Tatiana Grznárová, and Marián Vanderka. 2023. "Physical Education and Development of Locomotion and Gross Motor Skills of Children with Autism Spectrum Disorder" Sustainability 15, no. 1: 28. https://doi.org/10.3390/su15010028

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