Physical Fitness and Maternal Psychosocial Status in Children With Autism Attending a Regular Physical Activity Program

Abstract

The aim of this study was to compare physical fitness-related parameters in Turkish children with mild to moderate autism and their typically developing (TD) peers to determine maternal anxiety level and quality of life. Children with autism had significantly worse scores for all Munich Fitness Test (MFT) parameters except step test heart rate and had lower physical activity levels compared to the TD children (p < .05). There was no difference between groups in terms of postural deviations or maternal anxiety scores (p > .05). The MFT total score was associated with higher maternal quality of life scores (r = .605, p = .006). This study showed that despite participating in a regular physical activity program, children with mild to moderate autism have lower physical fitness and activity levels compared to their TD peers, whereas better physical fitness in children with autism has a positive effect on their mothers’ quality of life.

Keywords

autism physical fitness physical activity posture maternal anxiety level maternal quality of life

According to American Psychiatric Association (APA) criteria, autism spectrum disorder (ASD) is described as a condition characterized by deficits in communication and social interaction and restricted, repetitive patterns of behaviors, interests, and activities (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5; APA, 2013]). Although the most obvious impairments in people with ASD are those related to social interaction, these individuals also exhibit delays in motor skill development and reduced motor performance (Görgün & Melekoğlu, 2016; Pan, 2014). Twenty percent of children with ASD were found to have impairments in gross motor skills, especially those requiring coordination (Pusponegoro etal., 2016). Children with ASD have impairments with balance, coordination, or walking activities due to sensory deficits (vestibular, visual, and proprioception) and motor planning disorder, which is defined as difficulty in planning, sequencing, and performing skills appropriate for the individual’s age in a correct and coordinated manner (Doumas etal., 2016; Downey & Rapport, 2012; Dufek etal., 2017; Eggleston etal., 2018). In addition, current evidence shows that individuals with ASD are more likely to be bullied than their typically developing (TD) peers, with a very high reported rate (94%) (Humphrey & Hebron, 2015). The sensory, motor, and social deficiencies and behavioral problems associated with ASD (lack of interest, perseverance, aggression, hypersensitivity), cognitive deficits, and especially unpredictable behaviors cause individuals with ASD to have low physical activity (PA) levels and time spent in PA and prevent them from participating in sports programs (Görgün & Melekoğlu, 2016; Jones etal., 2017; Nichols etal., 2019; Tyler etal., 2014). Although there are conflicting reports about the physical fitness of individuals with ASD (Borremans etal., 2010; Pan etal., 2016; Tyler etal., 2014), Pan et al. (2016) found that children and adolescents with ASD had lower physical fitness levels compared to TD peers and that muscle strength and aerobic endurance were weakly positively correlated with PA level in ASD.

Another issue in ASD is postural control impairments and related postural deviations (Lim etal., 2018; Memari etal., 2014). Impaired postural control has been reported to be associated with problems in somatosensory inputs (Lim etal., 2018). Several studies have shown that individuals with ASD have larger body sway displacement, larger surface area of the center of pressure, and faster sway velocity compared to their TD peers (Lim etal., 2018). Moreover, it has been reported that children with ASD exhibit various postural impairments from early childhood, including postural developmental delays, atypical posture, asymmetrical sitting positions, and asymmetrical weight distribution (Memari etal., 2014; Nickel etal., 2013).

As summarized above, individuals with ASD differ from TD children in many ways. These issues affect not only the child with ASD (Hayes & Watson, 2013; Wang etal., 2018) but also their parents, especially in terms of psychosocial status and quality of life. Previous studies reported that the parents of children and adolescents with ASD have more psychiatric problems and stress and lower quality of life compared to parents of TD children (Hayes & Watson, 2013; Kuru & Piyal, 2018; Wang etal., 2018; Yirmiya & Shaked, 2005). ASD-related symptoms can increase parents’ stress and apprehension about the future, the economic burden on the family, and problems between parents, thereby leading to negative parental emotional states such as depression and anxiety (Chan etal., 2018; Hayes & Watson, 2013). It is known that parental stress is strongly associated with ASD symptom severity; in other words, more severe ASD symptoms lead to more stress in the parents (Hayes & Watson, 2013). Regular PA participation can provide a wide range of physical and mental health benefits for children with ASD (Brown etal., 2020), thus having a positive effect on the psychosocial status of their parents (Hayes & Watson, 2013; Mello etal., 2019). Although family encouragement of PA has been shown to play an important role in determining the activity level of children with autism, the parents of these children often face various psychosocial barriers that negatively affect their PA promotion and support behaviors (Brown etal., 2020).

Jones et al. (2017) emphasized the importance of avoiding a sedentary lifestyle for children with autism and reported that participation in PA has positive effects on cardio-metabolic, psychosocial, and cognitive outcomes in these individuals. However, it is known that individuals with autism have a more sedentary lifestyle compared to TD peers (Tyler etal., 2014).

In this study, Turkish children with mild to moderate autism who participated in a regular PA program were compared with their TD peers in order to determine whether participation in a PA program closes the gap in PA level between children with autism and TD children. In addition, we compared anxiety levels and quality of life between the mothers of children with autism and TD children. In a study conducted in China, it was reported that the quality of life was affected more among the mothers of children with ASD than the fathers, due to the fact that the burden of childcare falls mainly on mothers (Wang etal., 2018). Likewise, mothers assume a greater share of childcare in Turkish culture, so only mothers were included in this study. The primary aims of the study were (1) to compare postural deviations, physical fitness, and PA levels of children with autism to those of TD children, (2) to compare anxiety levels between the mothers of children with autism and those of TD children, and (3) to determine the relationship between children’s physical fitness levels and their mothers’ quality of life in the autism group.

Research Question 1: Are children with autism who participate in regular PA similar to TD peers in terms of postural deviations, physical fitness, and PA level?

Research Question 2: Do mothers of children with autism have higher anxiety levels than mothers of TD children?

Research Question 3: Is the physical fitness level of a child with autism correlated with maternal quality of life?

Method

Study Design

Data for this cross-sectional study were collected between December 2019 and April 2020. The study was approved by the Hacettepe University Ethics Committee (number: GO18/905-04) and all families signed an informed consent form for their child’s participation. The study is registered with ClinicalTrials.gov (identifier: NCT04199507).

Participants and Procedure

This study was conducted at the Aydın Autism Sports Center in Aydin, Turkey, and included 22 children with autism and 13 TD children between 7 and 15 years of age. The children with autism were attending a PA program that combines games with strength and aerobic exercises for 40 min/day, 2 days/week. The PA program consisted of a treadmill, a bicycle ergometer, and an elliptical bike. The games consisted of activities played with a ball, such as throwing the ball into a basketball hoop, hitting cones with the ball, and throwing and catching the ball. All children in the autism group were diagnosed as having mild to moderate autism according to the Childhood Autism Rating Scale (CARS). Other inclusion criteria applicable to both groups were having no systemic chronic disease or neurological disorders (other than autism in the autism group), having no medical history that may affect physical fitness (e.g., fractures and surgery), being sufficiently cooperative to follow the instructions given during evaluations, and volunteering to participate in the study.

Outcome Measures

The assessments were performed by two physiotherapists (one a specialist in cardiopulmonary rehabilitation and the other with 13 years of experience in autism) and two pediatric psychiatrists. The pediatric psychiatrists determined the severity of autism using the CARS, and all of the other assessments in the study were done by physiotherapists.

Sociodemographic characteristics of all participants were recorded (gender, age, height, body mass, and body mass index [BMI]). Reference values for Turkish children determined by Neyzi et al. (2008) were used to calculate BMI percentile values, height, weight, and BMI z-scores. Detailed history, age at diagnosis, and duration of participation in the PA program were also recorded for the children with autism (see Table 1).

Table 1.

Physical Characteristics of Children in Turkish Physical Activity Study.

Characteristics	Children with autism^a		Typically developing children^b		p
Characteristics	Mean ± SD	Min–max	Mean ± SD	Min–max	p
Age (yrs)	10.60 ± 2.25	7–15	12.07 ± 2.17	8–15	.072
Height (cm)	152.30 ± 15.58	125–184	151.92 ± 14.79	134–183	.945
Height z score	1.60 ± 1.28	−0.60–3.95	0.10 ± 1.61	−3.96–2.04	.006*
Body mass (kg)	47.15 ± 15.99	24–77	49.92 ± 15.27	28–70	.624
Body mass z score	1.07 ± 1.33	−1.40–2.99	0.48 ± 1.38	−2.34–2.58	.236
BMI (kg/m²)	19.86 ± 4.31	12.55–28.44	21.22 ± 4.14	13.91–27.99	.374
BMI z score	0.41 ± 1.57	−2.91–2.60	0.49 ± 1.26	−2.30–2.22	.839
Gender (girls/boys)	2/18		1/12		.662

Note. BMI = body mass index.

n = 20. ^bn = 13.

p < .05, student t test.

Determination of autism severity

The Turkish version of the CARS (Özgür etal., 2017) was used by a pediatric psychiatrist to diagnose and determine the severity of autism. This valid and reliable scale is commonly used in the screening and diagnosis of pervasive developmental disorders and is based on both caregiver reports and clinician observation. The scale consists of 15 items addressing areas such as relationships with people, imitation, body use, object use, adaptation to environmental changes, visual responses, verbal communication, and nonverbal communication (Özgür etal., 2017). Each item is scored between 1 and 4, with higher scores indicating a more severe condition. Total scores range from 15 to 60; scores below 30 are interpreted as not autism, scores between 30 and 36.5 as mild to moderate autism, and scores of 37 to 60 as severe autism.

Physical fitness level

The Munich Fitness Test (MFT) was used to evaluate the children’s physical fitness level. This 6-part test consists of balancing and bouncing, accurate throwing, trunk flexibility, standing, vertical jumping, hanging, and step tests. Raw scores in the separate tasks are converted to objective scores according to normative data for the participant’s age and gender. According to MFT score, physical fitness level is classified as deficient (≤ 35), normal (36–45), satisfactory (46–55), good (56–65), and very good (≥66) (Rusch etal., 1994).

PA level

The Godin Leisure-Time Exercise Questionnaire (GLTEQ) was used to evaluate total leisure time activity level. This scale evaluates the frequency of leisure-time PA (activity periods lasting longer than 15 minutes) per week, with exercise intensity classified as mild, moderate, or strenuous. Based on the total score, the individual’s PA level is described as active (≥24 score), moderately active (14–23 score), or insufficiently active/sedentary (≤ 13 score) (Çırak etal., 2013).

Posture analysis

The New York Posture Rating chart (NYPR) was used for posture assessment. According to this chart, possible posture changes in 13 different parts of the body are inspected and scored. The total score ranges from 13 to 65, and posture is classified according to this score as very good (≥ 45), good (40–44), intermediate (30–39), weak (20–29), or poor (≤13) (McRoberts etal., 2013).

Maternal anxiety level

The State-Trait Anxiety Inventory (STAI) was used to evaluate the mothers’ anxiety levels for both groups. State anxiety reflects feelings of fear and tension related to stressful situations, while trait anxiety is relatively constant and occurs independently of any specific situation or time. The total score obtained from both scales varies between 20 and 80, with higher scores indicating higher anxiety levels (Öner & LeCompte, 1985).

Maternal quality of life assessment

The Quality of Life in Autism Questionnaire–Parent Version (QoLA) was used to evaluate the quality of life of the mothers in the autism group. The assessment is specific to parents of children with autism and can be used to evaluate the effect of treatments and interventions on parental quality of life (Özgür etal., 2017). Section A of the scale contains a total of 28 items about the parent’s feelings and perceived quality of life; Section B consists of 20 items related to how the child’s autism-related difficulties are problematic for the parents. Higher scores indicate a better quality of life (Özgür etal., 2017).

Data Analysis

The statistical evaluation was performed using IBM SPSS for Windows version 23.0 (IBM Corp., Armonk, NY, USA). Variables were descriptively expressed as mean ± standard deviation, median (minimum–maximum), frequency, and percentage. Normal distribution was evaluated using Shapiro–Wilk test and histograms. Continuous variables were compared using Student’s t test when the data were normally distributed and Mann–Whitney U-test if non-normally distributed. Discrete variables were compared using the chi-square test. Relationships between the children’s PA and physical fitness levels and maternal anxiety/quality of life were assessed using Pearson or Spearman rank correlation coefficients for normally and non-normally distributed variables, respectively. Correlation coefficients were interpreted as negligible (0–0.25), weak (0.26–0.49), moderate (0.50–0.69), strong (0.70–0.89), and very strong (0.90–1.00). For all tests, the level of significance was p < .05 (Munro, 2005). According to post-hoc power analyses (G*Power, version 3.1., Heinrich Heine University Düsseldorf, Düsseldorf, Germany), the power of the study (1−β) was 99% according to the difference in standing vertical jumping distance (cm) of the two groups.

Results

Two children with severe autism, according to the CARS score, were excluded from the study. Therefore, 20 children with autism and 13 TD children were analyzed. The groups were similar in terms of gender, age, z-scores for body weight, and BMI (p > .05, Table 1). Only the z-scores for height were significantly higher in the children with autism than in the TD children (p < .05, Table 1).

All MFT parameters except step test heart rate score were significantly lower in the autism group compared to the TD group (p < .05, Table 2). According to the total MFT score, fitness level was deficient in 42.1% and normal in 57.9% of the autism group, while in the TD children’s group the distribution was 8.3% deficient, 75% normal, and 16.7% satisfactory fitness (see Figure 1).

Table 2.

Comparison of Physical Fitness, Physical Activity, Posture Analyses Scores Between Children With Autism and Typically Developing Peers.

Parameters	Children with autism^a		Typically developing children^b		p
Parameters	Mean ± SD	Min–max	Mean ± SD	Min–max	p
Munich Fitness Test
Bouncing a ball (n)	15.10 ± 8.61	0–26	34.83 ± 5.37	26–43	<.005*
Bouncing a ball score	31.89 ± 5.91	30–53	32.83 ± 4.38	30–45	.005 †
Throwing sandbag (total)	5.00 ± 0.00	5–5	6.89 ± 2.42	4–13	.003 †
Accurate throw score	30.00 ± 0.00	30–30	41.78 ± 12.17	30–66	.000 †
Trunk flexibility (cm)	−14.89 ± 13.99	−40 to 6	−4.25 ± 15.98	−40 to 10	.035 †
Trunk flexibility score	37.05 ± 10.85	30–59	48.75 ± 14.49	30–66	.014 †
Hanging (s)	0.05 ± 0.22	0–1	7.25 ± 6.36	0–20	.000 †
Hanging score	30.00 ± 0	30–30	38.33 ± 7.87	30–54	.004*
Standing vertical jumping (cm)	7.47 ± 6.51	3–31	34.25 ± 14.29	20–70	.000 †
Standing vertical jumping score	30.78 ± 3.44	30–45	48.08 ± 11.28	31–70	<.000 †
Step test ∆HR (beats/min)	12.73 ± 10.22	1–40	11.83 ± 9.89	0–29	.903
Step test HR score	47.84 ± 6.38	30–56	48.66 ± 4.90	39–58	.968
Total score	36.68 ± 3.16	32–44	41.16 ± 4.58	32–48	.003*
Godin Leisure-Time Total Score	22.40 ± 17.87	3–70	36.61 ± 30.10	15–119	.058
NYPR chart total score	65 ± 0	65–65	64.38 ± 1.50	61–65	.075

Note. MFT = Munich Fitness Test; HR = Heart Rate; NYPR = New York Posture Rating Chart.

p < .05, student t test. †p < .05, Mann–Whitney U-test.

n = 20. ^bn = 13.

Bold values represents statistically significant of p values.

The mean duration of participation in the PA program for children with autism was 31.50 months (SD = 16.15; range: 6–72). According to the GLTEQ, 7 (35%) of the children with autism were active, 5 (25%) were moderately active, and 8 (40%) were insufficiently active/sedentary; in the TD group, 8 children (61.5%) were active, and 5 (38.5%) were moderately active (Figure 2). Although the mean total GLTEQ score was similar between the groups (p > .05, Table 2), there was a statistically significant difference in the distribution of PA levels (p = .035). No significant difference was detected between the groups in terms of postural deviation in the NYPR; all children in both groups were evaluated as having good posture (p > .05, see Table 2).

The education and economic/income levels of the parents were similar in both groups (p > .05, see Table 3). In addition, both the state and trait anxiety levels of the mothers in the groups were similar according to STAI values (p > .05, Table 3). Correlation analyses revealed a moderate positive correlation between maternal education level and total GLTEQ score (r = .523, p = .018). The MFT total score was also moderately correlated with the QoLA subscale A score (r = .605, p = .006).

Table 3.

Comparison of Parent Education, Economic/Income, and Anxiety Levels.

Parameters	Children with autism^a n (%)		Typically developing children^b n (%)		p
Education of mothers					.461
Less than high school	7 (35)		2 (15.4)
High school	4 (20)		4 (30.8)
Bachelor’s degree	6 (30)		2 (15.4)
Master’s degree/doctorate	3 (15)		5 (38.4)
Education of fathers					.159
Less than high school	7 (35)		1 (7.7)
High school	5 (25)		2 (15.4)
Bachelor’s degree	6 (30)		4 (30.8)
Master’s degree/doctorate	2 (10)		6 (46.1)
Total income					.118
<1,500 ₺	1 (5)		0
1,500–2,000 ₺	2 (10)		0
2,000–2,500 ₺	5 (25)		0
2,500–3,000 ₺	2 (10)		1 (7.7)
More than 3,000 ₺	10 (50)		12 (92.3)
	Mean ± SD	Min–max	Mean ± SD	Min–max	p
State anxiety score (STAI)	41.55 ± 9.31	18–62	43.92 ± 7.06	31–54	.440
Trait anxiety score (STAI)	44.70 ± 6.17	30–54	44.07 ± 5.70	34–55	.773

Note. STAI = State-Trait Anxiety Inventory; (Öner & LeCompte, 1985); ₺ = Turkish Lira.

n = 20. ^bn = 13.

Discussion

This study demonstrated that compared to TD peers, children with mild to moderate autism had lower levels of physical fitness (based on parameters of speed, coordination, endurance, strength, flexibility, and power) and lower PA levels despite attending a PA program. However, the children with autism and TD children had comparable posture and their mothers reported similar levels of anxiety. This study also showed that higher maternal education levels were correlated with higher PA levels in children with autism. In addition, higher physical fitness scores in children with autism were moderately correlated with better maternal quality of life.

Pan et al. (2016) stated in their study that male students with ASD had similar body composition but significantly lower scores for cardiovascular endurance, strength and endurance of the upper body and abdominal muscles, and lower body flexibility when compared with TD peers. In addition, daily time spent doing moderate-to-vigorous PA was shown to be lower among individuals with ASD than their counterparts, and there was a significant association between PA and physical fitness components for the ASD group (especially abdominal muscular strength and endurance). According to the results of another study in school-age children (mean age: 12.6 years), participants with ASD had lower muscle strength than their TD counterparts but showed similar flexibility, body composition, and aerobic endurance. In the same study, it was shown that the fitness level of children with ASD was not related to income, maternal education, or ethnic origin (Tyler etal., 2014). Previous research indicates that children and/or adolescents with mild to moderate autism have lower fitness parameters (speed, coordination, flexibility, strength, and power) and lower PA levels compared with their TD peers (Bricout etal., 2018; Bricout etal., 2019; Pan etal., 2016; Tyler etal., 2014).

In our study, we used the MFT to evaluate physical fitness and the GLTEQ to assess PA levels. The children with autism still had lower physical fitness than their TD peers, and the proportion of inactive children was higher in the autism group despite regular participation in a PA program. Although a higher proportion of children in the ASD group were inactive, the similar total GLTEQ score between the groups may be attributed to the small sample size and the subjective nature of the questionnaire. We also demonstrated that maternal education level was moderately associated with the PA level of children with autism. Nearly half of the mothers had bachelor’s, master’s, or doctoral degrees. We think this may have positively affected the supportive position of the mothers, because according to the results of this study, 60% of children with autism were still active (Figure 2).

Proper posture is important for children’s development because abnormal posture can hinder learning abilities and perceptual-motor skills in children, which may further contribute to social interaction and communication problems in children with ASD (Memari etal., 2014; Travers etal., 2013). Although postural deviations are an important parameter to consider, previous studies and reviews have mostly focused on motor development (Downey & Rapport, 2012; Travers etal., 2013). In our study, we used the NYPR to evaluate the postural alignment of children with autism and TD peers from lateral and posterior views. According to our results, the total NYPR score of the two groups was comparable, with all children showing good posture. Some studies on children with overweight/obesity have observed that physical exercise has a positive effect on body posture in both the sagittal and frontal planes (Molina-Garcia etal., 2020; Schwanke etal., 2016). A meta-analysis of 16 studies in ASD also confirmed that exercise has beneficial effects on motor performance, in addition to social and communication skills (Sowa & Meulenbroek, 2012). Furthermore, Memari et al. (2013) reported that autism severity is associated with postural misalignments. One of the reasons for the comparable posture scores of the two groups in our study is that we included children with mild to moderate autism, and another reason is that these children were participating in a PA program twice a week. We believe these exercises might have promoted optimal posture by improving their motor, social, and communication abilities.

Durukan et al. (2018) stated that increased symptom severity in children with neurodevelopmental disorders was associated with more severe parental anxiety and depression. In particular, mothers of children with ASD were reported to have significantly higher levels of anxiety and depression than fathers. In another study of 102 parents of children with autism, the prevalence of anxiety was 33.7%, and more severe behavioral problems in children were associated with a higher risk of severe depression and anxiety in the parents. The study also showed that if the father lives with the family, the risk of severe anxiety and depression declines by 95.2% (Machado Junior etal., 2016). In a recently published study, parents of children with developmental disabilities exhibited higher anxiety about the future, especially in the areas of health and wellbeing, the meaning of life, pessimism, social relations, and helplessness, than parents of TD children. In addition, higher anxiety was associated with having a lower education level and having male or older children with developmental disabilities (Bujnowska etal., 2019). The similar anxiety levels of parents of children with autism and TD children in our study may be due to the comparable education and economic levels of the parents. In addition, all parents in the autism group were living together except for one couple, and the severity of disability in the autism group was mild to moderate according to the CARS classification. Therefore, our results are consistent with those of previous research indicating that multiple factors can affect the anxiety level of parents of children with developmental disabilities (Bonis, 2016; Bujnowska etal., 2019).

Increasing the quality of life of patients and/or caregivers is also among the main goals in the treatment of autism (Özgür etal., 2017). Recent research reported that families of children with ASD are most satisfied with their physical and financial state but least satisfied with their family interactions. In addition, the child’s age child’s functional level, and total number of children are also associated with a family’s quality of life (Mello etal., 2019). Another study from Turkey stated that higher social support levels lead to a higher quality of life in parents of children with autism (Kuru & Piyal, 2018). Parents’ stress level directly affects their quality of life (Hsiao etal., 2017). We found that as the children’s physical fitness level increased, maternal quality of life improved. This result strongly suggests that rehabilitation professionals should focus on increasing the fitness level of children/adolescents with ASD in order to improve their level of independence and functional status and thereby improve their caregivers’ quality of life.

Study Limitations

The relatively small sample size, the inclusion of only mild to moderate autism cases, and the inability to assess PA with objective monitors are the main limitations of our study. Another limitation was the gender distribution. The incidence of ASD is higher in boys, and as a result, the number of girls in our study was low. These factors limit the generalizability of our findings. The last limitation was that we only evaluated the emotional state and quality of life of mothers of children with autism rather than both parents, which may limit the usefulness of our findings for both parents.

Conclusion

This study confirmed that the PA and fitness levels of children and adolescents with autism, even those who attend a regular PA program, are lower compared to their TD peers. The anxiety levels of mothers of children with mild to moderate autism are comparable to those of mothers of TD children. According to this study, higher fitness scores in children/adolescents with autism lead to a better quality of life for their mothers. Therefore, we recommend that rehabilitation professionals include physical fitness and PA assessments in comprehensive rehabilitation assessments of children with autism. Rehabilitation interventions or community-based physical education programs or other PA opportunities may help children with autism maintain or improve activity level and physical fitness in addition to having potential psychosocial benefits (Toscano etal., 2018; Zhao & Chen, 2018). Better functional status and health of children can positively affect their parents’ quality of life (Mello etal., 2019). Finally, considering the amount of time children spend at school, we would like to emphasize the importance of physical educators in promoting PA and improving physical fitness in children/adolescents with autism (Kwon etal., 2019). We also want to emphasize the importance of physical educators in modifying physical education lessons according to the needs of children with autism and individualizing the instructions in order to meet the needs of all children (Zhang & Griffin, 2007). Rehabilitation professionals or physical education teachers of children with autism should especially focus on the speed, coordination, flexibility, strength, endurance, and power dimensions of physical fitness and teach activities responsive to age-appropriate motor skills. There is a need for new research investigating the effects of different exercise interventions on major health outcomes in children with autism and their families.

Footnotes

Authors’ Note

None of the parts of this original research article has had prior or duplicate publication or submission elsewhere.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Ayse Kubra Sahan

Nazan Ozturk

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Bonis

(2016). Stress and parents of children with autism: A review of literature. Issues in Mental Health Nursing, 37(3), 153–163. https://doi.org/10.3109/01612840.2015.1116030

Borremans

Rintala

McCubbin

J. A.

(2010). Physical fitness and physical activity in adolescents with Asperger syndrome: A comparative study. Adapted Physical Activity Quarterly, 27(4), 308–320. https://doi.org/10.1123/apaq.27.4.308

Bricout

V. A.

Pace

Dumortier

Baillieul

Favre-Juvin

Guinot

(2018). Reduced cardiorespiratory capacity in children with autism spectrum disorders. Journal of Clinical Medicine, 7(10), 361. https://doi.org/10.3390/jcm7100361

Bricout

V. A.

Pace

Dumortier

Miganeh

Mahistre

Guinot

(2019). Motor capacities in boys with high functioning autism: Which evaluations to choose? Journal of Clinical Medicine, 8(10), 1521. https://doi.org/10.3390/jcm8101521

Brown

D. M.

Arbour-Nicitopoulos

K. P.

Martin Ginis

K. A.

Latimer-Cheung

A. E.

Bassett-Gunter

R. L.

(2020). Examining the relationship between parent physical activity support behaviour and physical activity among children and youth with autism spectrum disorder. Autism, 24(7), 1783–1794. https://doi.org/10.1177/1362361320922658

Bujnowska

A. M.

Rodríguez

García

Areces

Marsh

N. V.

(2019). Parenting and future anxiety: The impact of having a child with developmental disabilities. International Journal of Environmental Research and Public Health, 16(4), 668. https://doi.org/10.3390/ijerph16040668

Çırak

Savcı

Yılmaz

G. D.

Demir

Y. P.

Dalkılınç

(2013). Sağlıklı yetişkinlerde godin boş zaman-fiziksel aktivite anketinin geçerliği ve güvenirliği. 4. Ulusal Fizyoterapi ve Rehabilitasyon Kongresi. 9-11 Mayıs; Denizli. Turkish Journal of Physiotherapy and Rehabilitation, 24(2), 68. https://dergipark.org.tr/tr/pub/tfrd/issue/12952

Chan

K. K. S.

Lam

C. B.

Law

N. C. W.

Cheung

R. Y. M.

(2018). From child autistic symptoms to parental affective symptoms: A family process model. Research in Developmental Disabilities, 75, 22–31. https://doi.org/10.1016/j.ridd.2018.02.005

10.

Doumas

McKenna

Murphy

(2016). Postural control deficits in autism spectrum disorder: The role of sensory integration. Journal of Autism and Developmental Disorders, 46(3), 853–861. https://doi.org/10.1007/s10803-015-2621-4

11.

Downey

Rapport

M. J. K.

(2012). Motor activity in children with autism: A review of current literature. Pediatric Physical Therapy, 24(1), 2–20. https://doi.org/10.1097/PEP.0b013e31823db95f

12.

Dufek

J. S.

Eggleston

J. D.

Harry

J. R.

Hickman

R. A.

(2017). A comparative evaluation of gait between children with autism and typically developing matched controls. Medical Sciences, 5(1), 1. https://doi.org/10.3390/medsci5010001

13.

Durukan

Kara

Almbaideen

Karaman

Gül

(2018). Alexithymia, depression and anxiety in parents of children with neurodevelopmental disorder: Comparative study of autistic disorder, pervasive developmental disorder not otherwise specified and attention deficit-hyperactivity disorder. Pediatrics International, 60(3), 247–253. https://doi.org/10.1111/ped.13510

14.

Eggleston

J. D.

Landers

M. R.

Bates

B. T.

Nagelhout

Dufek

J. S.

(2018). Weighted walking influences lower extremity coordination in children on the autism spectrum. Perceptual and Motor Skills, 125(6), 1103–1122. https://doi.org/10.1177/0031512518803178

15.

Görgün

Melekoğlu

(2016). Review of studies on physical activities of individuals with autism spectrum disorders (ASD). Ankara University Faculty of Educational Sciences Journal of Special Education, 17(3), 347–376. https://doi.org/10.21565/ozelegitimdergisi.268559

16.

Hayes

S. A.

Watson

S. L.

(2013). The impact of parenting stress: A meta-analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder. Journal of Autism and Dvelopmental Disorders, 43(3), 629–642. https://doi.org/10.1007/s10803-012-1604-y

17.

Hsiao

Y. J.

Higgins

Pierce

Whitby

P. J. S.

Tandy

R. D.

(2017). Parental stress, family quality of life, and family teacher partnerships: Families of children with autism spectrum disorder. Research in Developmental Disabilities, 70, 152–162. https://doi.org/10.1016/j.ridd.2017.08.013

18.

Humphrey

Hebron

(2015). Bullying of children and adolescents with autism spectrum conditions: A “state of the field” review. International Journal of Inclusive Education, 19(8), 845–862. https://doi.org/10.1080/13603116.2014.981602

19.

Jones

R. A.

Downing

Rinehart

N. J.

Barnett

L. M.

May

McGillivray

J. A.

Papadopoulos

N. V.

Skouteris

Timperio

Hinkley

(2017). Physical activity, sedentary behavior and their correlates in children with autism spectrum disorder: A systematic review. PLOS ONE, 12(2), Article e0172482. https://doi.org/10.1371/journal.pone.0172482

20.

Kuru

Piyal

(2018). Perceived social support and quality of life of parents of children with Autism. Nigerian Journal of Clinical Practice, 21(9), 1182–1189. https://doi.org/10.4103/njcp.njcp_13_18

21.

Kwon

J. Y.

Kulinna

P. H.

Van Der Mars

Amrein-Beardsley

Koro-Ljungberg

(2019). Comprehensive school physical activity programs preparation in physical education teacher education programs. Journal of Teaching in Physical Education, 38(3), 271–276. https://doi.org/10.1123/jtpe.2018-0110

22.

Lim

Y. H.

Lee

H. C.

Falkmer

Allison

G. T.

Tan

Lee

W. L.

Morris

S. L.

(2018). Effect of visual information on postural control in adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 49(12), 4731–4739. https://doi.org/10.1007/s10803-018-3634-6

23.

Machado Junior

S. B.

Celestino

M. I. O.

Serra

J. P. C.

Caron

Pondé

M. P

. (2016). Risk and protective factors for symptoms of anxiety and depression in parents of children with autism spectrum disorder. Developmental Neurorehabilitation, 19(3), 146–153. https://doi.org/10.3109/17518423.2014.925519

24.

McRoberts

L. B.

Cloud

R. M.

Black

C. M.

(2013). Evaluation of the New York Posture Rating Chart for assessing changes in postural alignment in a garment study. Clothing and Textiles Research Journal, 31(2), 81–96. https://doi.org/10.1177/0887302X13480558

25.

Mello

Rivard

Terroux

Mercier

(2019). Quality of life in families of young children with autism spectrum disorder. American Journal on Intellectual and Developmental Disabilities, 124(6), 535–548. https://doi.org/10.1352/1944-7558-124.6.535

26.

Memari

A. H.

Ghanouni

Gharibzadeh

Eghlidi

Ziaee

Moshayedi

(2013). Postural sway patterns in children with autism spectrum disorder compared with typically developing children. Research in Autism Spectrum Disorders, 7(2), 325–332. https://doi.org/10.1016/j.rasd.2012.09.010

27.

Memari

A. H.

Ghanouni

Shayestehfar

Ghaheri

(2014). Postural control impairments in individuals with autism spectrum disorder: A critical review of current literature. Asian Journal of Sports Medicine, 5(3), e22963. https://doi.org/10.5812/asjsm.22963

28.

Molina-Garcia

Mora-Gonzalez

Migueles

J. H.

Rodriguez-Ayllon

Esteban-Cornejo

Cadenas-Sanchez

Plaza-Florido

Gil-Cosano

J. J.

Pelaez-Perez

M. A.

Garcia-Delgado

Vanrenterghem

Ortega

F. B.

(2020). Effects of exercise on body posture, functional movement, and physical fitness in children with overweight/obesity. The Journal of Strength & Conditioning Research, 34(8), 2146–2155. https://doi.org/10.1519/JSC.0000000000003655

29.

Munro

B. H.

(2005). Statistical methods for health care research (5th ed.). Lippincott Williams & Wilkins.

30.

Neyzi

Günöz

Furman

Bundak

Gökçay

Darendeliler

(2008). Türk çocuklarında vücut ağırlığı, boy uzunluğu, baş çevresi ve vücut kitle indeksi referans değerleri [Weight, height, head circumference and body mass index references for Turkish children]. Çocuk Sağlığı ve Hastalıkları Dergisi, 51(1), 1–14. https://doi.org/10.1519/JSC.0000000000003655

31.

Nichols

Block

M. E.

Bishop

J. C.

McIntire

(2019). Physical activity in young adults with autism spectrum disorder: Parental perceptions of barriers and facilitators. Autism, 23(6), 1398–1407. https://doi.org/10.1177/1362361318810221

32.

Nickel

L. R.

Thatcher

A. R.

Keller

Wozniak

R. H.

Iverson

J. M.

(2013). Posture development in infants at heightened versus low risk for autism spectrum disorders. Infancy, 18(5), 639–661. https://doi.org/10.1111/infa.12025

33.

Öner

LeCompte

W. A.

(1985). Durumluk-Sürekli Kaygı Envanteri El Kitabı. Boğaziçi Üniversitesi Yayınları.

34.

Özgür

B. G.

Aksu

Eser

(2017). Turkish validity and reliability of quality of life in autism questionnaire-parent version. Anatolian Journal of Psychiatry, 18(4), 344–352. https://doi.org/10.5455/apd.249390

35.

Pan

C. Y.

(2014). Motor proficiency and physical fitness in adolescent males with and without autism spectrum disorders. Autism, 18(2), 156–165. https://doi.org/10.1177/1362361312458597

36.

Pan

C. Y.

Tsai

C. L.

Chu

C. H.

Sung

M. C.

W. Y.

Huang

C. Y.

(2016). Objectively measured physical activity and health-related physical fitness in secondary school-aged male students with autism spectrum disorders. Physical Therapy, 96(4), 511–520. https://doi.org/10.2522/ptj.20140353

37.

Pusponegoro

H. D.

Efar

Soebadi

Firmansyah

Chen

H. J.

Hung

K. L.

(2016). Gross motor profile and its association with socialization skills in children with autism spectrum disorders. Pediatrics & Neonatology, 57(6), 501–507. https://doi.org/10.1016/j.pedneo.2016.02.004

38.

Rusch

Bradfisch

Irrgang

(1994). Auswahltest Sportförderunterricht [Selection test for remedial physical education]. Haltung und Bewegung, 14(1), 4–17.

39.

Schwanke

N. L.

Pohl

H. H.

Reuter

C. P.

Borges

T. S.

de Souza

Burgos

M. S.

(2016). Differences in body posture, strength and flexibility in schoolchildren with overweight and obesity: A quasi-experimental study. Manual Therapy, 22, 138–144. https://doi.org/10.1016/j.math.2015.11.004

40.

Sowa

Meulenbroek

(2012). Effects of physical exercise on autism spectrum disorders: A meta-analysis. Research in Autism Spectrum Disorders, 6(1), 46–57. https://doi.org/10.1016/j.rasd.2011.09.001

41.

Toscano

C. V.

Carvalho

H. M.

Ferreira

J. P.

(2018). Exercise effects for children with autism spectrum disorder: Metabolic health, autistic traits, and quality of life. Perceptual and Motor Skills, 125(1), 126–146. https://doi.org/10.1177/0031512517743823

42.

Travers

B. G.

Powell

P. S.

Klinger

L. G.

Klinger

M. R.

(2013). Motor difficulties in autism spectrum disorder: Linking symptom severity and postural stability. Journal of Autism and Developmental Disorders, 43(7), 1568–1583. https://doi.org/10.1007/s10803-012-1702-x

43.

Tyler

MacDonald

Menear

(2014). Physical activity and physical fitness of school-aged children and youth with autism spectrum disorders. Autism Research and Treatment, 2014, Article 312163. https://doi.org/10.1155/2014/312163

44.

Wang

Xiao

Chen

R. S.

Chen

Xun

G. L.

X. Z.

Shen

Y. D.

R. R.

Xia

Zhao

J. P.

J. J.

(2018). Social impairment of children with autism spectrum disorder affects parental quality of life in different ways. Psychiatry Research, 266, 168–174. https://doi.org/10.1016/j.psychres.2018.05.057

45.

Yirmiya

Shaked

(2005). Psychiatric disorders in parents of children with autism: A meta-analysis. Journal of Child Psychology and Psychiatry, 46(1), 69–83. https://doi.org/10.1111/j.1469-7610.2004.00334.x

46.

Zhang

Griffin

A. J.

(2007). Including children with autism in general physical education: Eight possible solutions. Journal of Physical Education, Recreation & Dance, 78(3), 33–50. https://doi.org/10.1080/07303084.2007.10597987

47.

Zhao

Chen

(2018). The effects of structured physical activity program on social interaction and communication for children with autism. Biomed Research International, 2018, 1825046. https://doi.org/10.1155/2018/1825046