Exercise Effects for Children With Autism Spectrum Disorder: Metabolic Health, Autistic Traits, and Quality of Life
Abstract
This study examined the effects of a 48-week exercise-based intervention on the metabolic profile, autism traits, and perceived quality of life in children with autism spectrum disorder (ASD). We randomly allocated 64 children with ASD (aged 6–12 years) to experimental (n = 46) and control groups (n = 18) and used multilevel regression modeling to examine responses to receiving or not receiving the intervention. The experimental group showed beneficial effects on metabolic indicators (high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and total cholesterol), autism traits, and parent-perceived quality of life. Our results provide support for exercise and physical activity, including basic coordination and strength exercises, as important therapeutic interventions for children with ASD.
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References
American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: Author.
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: Author.
Atkinson G., Batterham A. M. (2015) True and false interindividual differences in the physiological response to an intervention. Experimental Physiology 100(6): 577–588. doi: 10.1113/EP085070.
Barnhill K., Tami A., Schutte C., Hewitson L., Olive M. L. (2016) Targeted nutritional and behavioral feeding intervention for a child with autism spectrum disorder. Case Reports in Psychiatry. 2016, 1420549. doi: 10.1155/2016/1420549.
Bastiaansen D., Koot H. M., Bongers I. L., Varni J. W., Verhulst F. C. (2004) Measuring quality of life in children referred for psychiatric problems: Psychometric properties of the PedsQL 4.0 generic core scales. Quality of Life Research 13(2): 489–495. doi: 10.1023/B:QURE.0000018483.01526.ab.
Batey C. A., Missiuna C. A., Timmons B. W., Hay J. A., Faught B. E., Cairney J. (2014) Self-efficacy toward physical activity and the physical activity behavior of children with and without Developmental Coordination Disorder. Human Movement Science 36: 258–271. doi: 10.1016/j.humov.2013.10.003.
Berntsson L. T., Kohler L. (2001) Long-term illness and psychosomatic complaints in children aged 2–17 years in the five Nordic countries. Comparison between 1984 and 1996. European Journal of Public Health 11(1): 35–42.
Bremer E., Crozier M., Lloyd M. (2016) A systematic review of the behavioural outcomes following exercise interventions for children and youth with autism spectrum disorder. Autism 20(8): 899–915. doi: 10.1177/1362361315616002.
Broder-Fingert S., Brazauskas K., Lindgren K., Iannuzzi D., Van Cleave J. (2014) Prevalence of overweight and obesity in a large clinical sample of children with autism. Academic Pediatrics 14(4): 408–414. doi: 10.1016/j.acap.2014.04.004.
Celiberti D. A., Bobo H. E., Kelly K. S., Harris S. L., Handleman J. S. (1997) The differential and temporal effects of antecedent exercise on the self-stimulatory behavior of a child with autism. Research in Developmental Disabilities 18(2): 139–150.
Cheng N., Rho J. M., Masino S. A. (2017) Metabolic dysfunction underlying autism spectrum disorder and potential treatment approaches. Frontiers in Molecular Neuroscience 10: 34. doi: 10.3389/fnmol.2017.00034.
Cole T. J., Bellizzi M. C., Flegal K. M., Dietz W. H. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320(7244): 1240–1243.
Cole T. J., Flegal K. M., Nicholls D., Jackson A. A. (2007) Body mass index cut offs to define thinness in children and adolescents: International survey. BMJ 335(7612): 194. doi: 10.1136/bmj.39238.399444.55.
Conde W. L., Monteiro C. A. (2006) Body mass index cutoff points for evaluation of nutritional status in Brazilian children and adolescents. Jornal de Pediatria (Rio de Janeiro) 82(4): 266–272. doi:10.2223/JPED.1502.
Cooper M., Martin J., Langley K., Hamshere M., Thapar A. (2014) Autistic traits in children with ADHD index clinical and cognitive problems. European Child & Adolescent Psychiatry 23(1): 23–34. doi: 10.1007/s00787-013-0398-6.
Correr C. J., Pontarolo R., Melchiors A. C., Rossignoli P., Fernandez-Llimos F., Radominski R. B. (2008) [Translation to portuguese and validation of the Diabetes Quality Of Life Measure (DQOL-Brazil)]. Arquivos Brasileiros de Endocrinololia e Metabologia 52(3): 515–522.
Curtin C., Jojic M., Bandini L. G. (2014) Obesity in children with autism spectrum disorder. Harvard Review of Psychiatry 22(2): 93–103. doi: 10.1097/HRP.0000000000000031.
de Vries M., Geurts H. (2015) Influence of autism traits and executive functioning on quality of life in children with an autism spectrum disorder. Journal of Autism and Developmental Disorders 45(9): 2734–2743. doi: 10.1007/s10803-015-2438-1.
Dickinson K., Place M. (2014) A randomised control trial of the impact of a computer-based activity programme upon the fitness of children with autism. Autism Reseach and Treatement. 2014, 419653. doi: 10.1155/2014/419653.
Dumville J. C., Hahn S., Miles J. N. V., Torgerson D. J. (2006) The use of unequal randomisation ratios in clinical trials: A review. Contemporary Clinical Trials 27(1): 1–12. doi: 10.1016/j.cct.2005.08.003.
Duvekot, J., van der Ende, J., Verhulst, F. C., Slappendel, G., van Daalen, E., Maras, A., & Greaves-Lord, K. (2016). Factors influencing the probability of a diagnosis of autism spectrum disorder in girls versus boys. Autism, 21(6), 646–658. doi: 10.1177/1362361316672178.
Dziobek I., Gold S. M., Wolf O. T., Convit A. (2007) Hypercholesterolemia in Asperger syndrome: Independence from lifestyle, obsessive–compulsive behavior, and social anxiety. Psychiatry Research 149(1–3): 321–324. doi: 10.1016/j.psychres.2006.02.003.
Felce D., Perry J. (1995) Quality of life: Its definition and measurement. Research in Developmental Disabilities 16(1): 51–74.
Fragala-Pinkham M., Haley S. M., O’Neil M. E. (2008) Group aquatic aerobic exercise for children with disabilities. Developmental Medicine and Child Neurology 50(11): 822–827. doi: 10.1111/j.1469-8749.2008.03086.x.
Friedewald W. T., Levy R. I., Fredrickson D. S. (1972) Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clinical Chemistry 18(6): 499–502.
Goldstein H. (2011) Multilevel statistical models, 4th ed. Chichester, England: Wiley.
Green J. L., Rinehart N., Anderson V., Efron D., Nicholson J. M., Jongeling B., Sciberras E. (2016) Association between autism symptoms and family functioning in children with attention-deficit/hyperactivity disorder: A community-based study. European Child & Adolescent Psychiatry 25(12): 1307–1318. doi: 10.1007/s00787-016-0861-2.
Grether J. K., Anderson M. C., Croen L. A., Smith D., Windham G. C. (2009) Risk of autism and increasing maternal and paternal age in a large North American population. American Journal of Epidemiology 170(9): 1118–1126. doi: 10.1093/aje/kwp247.
Kahn H. S., Imperatore G., Cheng Y. J. (2005) A population-based comparison of BMI percentiles and waist-to-height ratio for identifying cardiovascular risk in youth. The Journal of Pediatrics 146(4): 482–488. doi: 10.1016/j.jpeds.2004.12.028.
Kern L., Koegel R. L., Dunlap G. (1984) The influence of vigorous versus mild exercise on autistic stereotyped behaviors. Journal of Autism and Developmental Disorders 14(1): 57–67.
Kheir N., Ghoneim O., Sandridge A. L., Al-Ismail M., Hayder S., Al-Rawi F. (2012) Quality of life of caregivers of children with autism in Qatar. Autism 16(3): 293–298. doi: 10.1177/1362361311433648.
Kim E.-K., Neggers Y. H., Shin C.-S., Kim E., Kim E. M. (2010) Alterations in lipid profile of autistic boys: a case control study. Nutrition Research 30(4): 255–260. doi: 10.1016/j.nutres.2010.04.002.
Kingsbury S. J., Fayek M., Trufasiu D., Zada J., Simpson G. M. (2001) The apparent effects of ziprasidone on plasma lipids and glucose. The Journal of Clinical Psychiatry 62(5): 347–349.
Kuczmarski R. J., Ogden C. L., Grummer-Strawn L. M., Flegal K. M., Guo S. S., Wei R., Johnson C. L. (2000) CDC growth charts: United States. Advance Data. 314, 1–27.
Lohman T. G., Roche A. F., Martorell R. (1988) Anthropometric standardization reference manual, Champaign, IL: Human Kinetics.
Malone R. P., Delaney M. A., Hyman S. B., Cater J. R. (2007) Ziprasidone in adolescents with autism: An open-label pilot study. Journal of Children and Adolescent Psychopharmacology 17(6): 779–790. doi: 10.1089/cap.2006.0126.
McCormack S. E., McCarthy M. A., Harrington S. G., Farilla L., Hrovat M. I., Systrom D. M., Fleischman A. (2014) Effects of exercise and lifestyle modification on fitness, insulin resistance, skeletal muscle oxidative phosphorylation and intramyocellular lipid content in obese children and adolescents. Pediatric Obesity 9(4): 281–291. doi: 10.1111/j.2047-6310.2013.00180.x.
Mokha, J. S., Srinivasan, S. R., DasMahapatra, P., Fernandez, C., Chen, W., Xu, J., & Berenson, G. S. (2010). Utility of waist-to-height ratio in assessing the status of central obesity and related cardiometabolic risk profile among normal weight and overweight/obese children: The Bogalusa Heart Study. BMC Pediatrics, 10(1), 73. doi: 10.1186/1471-2431-10-73.
Moses, L., Katz, N., & Weizman, A. (2014). Metabolic profiles in adults with autism spectrum disorder and intellectual disabilities. European Psychiatry, 29(7), 397–401. doi: 10.1016/j.eurpsy.2013.05.005.
Moulton E., Bradbury K., Barton M., Fein D. (2016) Factor analysis of the childhood autism rating scale in a sample of two year olds with an autism spectrum disorder. Journal of Autism and Developmental Disorders. 1–14. doi: 10.1007/s10803-016-2936-9.
Must A., Curtin C., Hubbard K., Sikich L., Bedford J., Bandini L. (2014) Obesity prevention for children with developmental disabilities. Current Obesity Reports 3(2): 156–170. doi: 10.1007/s13679-014-0098-7.
Nambiar S., Hughes I., Davies P. S. W. (2010) Developing waist-to-height ratio cut-offs to define overweight and obesity in children and adolescents. Public Health Nutrition 13(10): 1566–1574. doi: 10.1017/s1368980009993053.
Neely L., Rispoli M., Gerow S., Ninci J. (2015) Effects of antecedent exercise on academic engagement and stereotypy during instruction. Behavior Modification 39(1): 98–116. doi: 10.1177/0145445514552891.
Obrusnikova I., Miccinello D. L. (2012) Parent perceptions of factors influencing after-school physical activity of children with autism spectrum disorders. Adapted Physical Activity Quarterly 29(1): 63–80. doi: 10.1123/apaq.29.1.63.
Oriel K. N., George C. L., Peckus R., Semon A. (2011) The effects of aerobic exercise on academic engagement in young children with autism spectrum disorder. Pediatric Physical Therapy 23(2): 187–193. doi: 10.1097/PEP.0b013e318218f149.
Pereira A., Riesgo R. S., Wagner M. B. (2008) Childhood autism: Translation and validation of the Childhood Autism Rating Scale for use in Brazil. Jornal de Pediatria (Rio de Janeiro) 84(6): 487–494. doi: 10.2223/JPED.1828.
Pinheiro J. C., Bates D. M. (2000) Mixed-effects models with Sand and S-plus, New York, NY: Springer.
Raat H., Bonsel G. J., Essink-Bot M. L., Landgraf J. M., Gemke R. J. (2002) Reliability and validity of comprehensive health status measures in children: The Child Health Questionnaire in relation to the Health Utilities Index. Journal of Clinical Epidemiology 55(1): 67–76.
Rossignol, D. A., & Frye, R. E. (2012). A review of research trends in physiological abnormalities in autism spectrum disorders: immune dysregulation, inflammation, oxidative stress, mitochondrial dysfunction and environmental toxicant exposures. Molecular Psychiatry, 17(4), 389–401. doi: 10.1038/mp.2011.165.
Santosh P. J., Singh J. (2016) Drug treatment of autism spectrum disorder and its comorbidities in children and adolescents. BJPsych Advances 22(3): 151.
Schopler E., Reichler R. J., Renner B. R. (2002) Western Psychological Services. The childhood autism rating scale (CARS), Los Angeles, CA: Western Psychological Services.
Schopler E., Reichler R. J., DeVellis R. F., Daly K. (1980) Toward objective classification of childhood autism: Childhood Autism Rating Scale (CARS). Journal of Autism and Developmental Disorders 10(1): 91–103.
Shedlock K., Susi A., Gorman G. H., Hisle-Gorman E., Erdie-Lalena C. R., Nylund C. M. (2016) Autism spectrum disorders and metabolic complications of obesity. The Journal of Pediatrics 178: 183–187.e1. doi: 10.1016/j.jpeds.2016.07.055.
Sowa M., Meulenbroek R. (2012) Effects of physical exercise on Autism Spectrum Disorders: A meta-analysis. Research in Autism Spectrum Disorders 6(1): 46–57. doi: 10.1016/j.rasd.2011.09.001.
Srinivasan S. M., Pescatello L. S., Bhat A. N. (2014) Current perspectives on physical activity and exercise recommendations for children and adolescents with autism spectrum disorders. Physical Therapy 94(6): 875–889. doi: 10.2522/ptj.20130157.
Srinivasan S. R., Wang R., Chen W., Wei C. Y., Xu J., Berenson G. S. (2009) Utility of waist-to-height ratio in detecting central obesity and related adverse cardiovascular risk profile among normal weight younger adults (from the Bogalusa Heart Study). American Journal of Cardiology 104. doi: 10.1016/j.amjcard.2009.04.037.
Tan B. W., Pooley J. A., Speelman C. P. (2016) A meta-analytic review of the efficacy of physical exercise interventions on cognition in individuals with autism spectrum disorder and ADHD. Journal of Autism and Developmental Disorders 46(9): 3126–3143. doi: 10.1007/s10803-016-2854-x.
Telford, R. D., Cunningham, R. B., Waring, P., Telford, R. M., Potter, J. M., Hickman, P. E., & Abhayaratna, W. P. (2015). Sensitivity of blood lipids to changes in adiposity, exercise, and diet in children. Medicine & Science in Sports & Exercise, 47(5), 974–982. doi: 10.1249/mss.0000000000000493.
Tilford J. M., Payakachat N., Kovacs E., Pyne J. M., Brouwer W., Nick T. G., Kuhlthau K. A. (2012) Preference-based health-related quality-of-life outcomes in children with autism spectrum disorders. PharmacoEconomics 30(8): 661–679. doi: 10.2165/11597200-000000000-00000.
Tymms P. (2004) Effect sizes in multilevel models. In: Schagen I., Elliot K. (eds) But what does it mean? The use of effect sizes in educational research, Slough, England: National Foundation for Educational Research, pp. 55–66.
Väistö J., Eloranta A.-M., Viitasalo A., Tompuri T., Lintu N., Karjalainen P., Lakka T. A. (2014) Physical activity and sedentary behaviour in relation to cardiometabolic risk in children: Cross-sectional findings from the Physical Activity and Nutrition in Children (PANIC) Study. International Journal of Behavioral Nutrition and Physical Activity 11(1): 55. doi: 10.1186/1479-5868-11-55.
van der Meer, J. M. J., Oerlemans, A. M., van Steijn, D. J., Lappenschaar, M. G. A., de Sonneville, L. M. J., Buitelaar, J. K., & Rommelse, N. N. J. (2012). Are autism spectrum disorder and attention-deficit/hyperactivity disorder different manifestations of one overarching disorder? Cognitive and symptom evidence from a clinical and population-based sample. Journal of the American Academy of Child & Adolescent Psychiatry, 51(11), 1160–1172.e1163. doi: 10.1016/j.jaac.2012.08.024.
Wachob D., Lorenzi D. G. (2015) Brief report: Influence of physical activity on sleep quality in children with autism. Journal of Autism and Developmental Disorders 45(8): 2641–2646. doi: 10.1007/s10803-015-2424-7.
Watters R. G., Watters W. E. (1980) Decreasing self-stimulatory behavior with physical exercise in a group of autistic boys. Journal of Autism and Developmental Disorders 10(4): 379–387.
Williams B., Hornig M., Buie T., Bauman M., Cho Paik M., Wick I., Lipkin I. (2011) Impaired carbohydrate digestion and transport and mucosal dysbiosis in the intestines of children with autism and gastrointestinal disturbances. PLoS One 6(9): e24585. doi: 10.1371/journal.pone.0024585.
Xia W., Zhou Y., Sun C., Wang J., Wu L. (2010) A preliminary study on nutritional status and intake in Chinese children with autism. European Journal of Pediatrics 169(10): 1201–1206. doi: 10.1007/s00431-010-1203-x.
Xiong N., Ji C., Li Y., He Z., Bo H., Zhao Y. (2009) The physical status of children with autism in China. Research in Developmental Disabiitiesl 30(1): 70–76. doi: 10.1016/j.ridd.2007.11.001.
Zuckerman K. E., Hill A. P., Guion K., Voltolina L., Fombonne E. (2014) Overweight and obesity: Prevalence and correlates in a large clinical sample of children with autism spectrum disorder. Journal of Autism and Developmental Disorders 44(7): 1708–1719. doi: 10.1007/s10803-014-2050-9.
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