Cognitive-Kinesthetic Integration: Using a Novel Multifaceted Model and Exercise to Target Compliance, Challenging Behaviors and Stereotypy in Autism

Background:  Previous studies have demonstrated the positive effect of exercise in reducing stereotypy, maladaptive behavior and increasing on-task responding in children with autism (e.g., Rosenthal-Malek & Mitchell, 1997). 

Objectives:  To evaluate a multifaceted model using exercise to target behavior and cognitive abilities for two young males with autism. 

Methods:  Two males with autism (age 7 and 13) attended an exercise program at a local YMCA. Sessions were structured so that increasingly more complex motor skills, coordination and voluntary behavior (e.g., compliance) were promoted. The model was individualized to each participant’s needs (e.g., motor skills, aerobic capacity, strength) and behavioral concerns (e.g., compliance, stereotypy). Weekly sessions were conducted by a trainer in a community gymnasium. Five conditions were implemented across 12-months within exercise sessions: 1) adaption to setting and engagement with a simple task, 2) gross motor skill development using obstacle courses, 3) reinforcement of expressive and receptive language use during play, 4) reinforcing left-right discriminations, and 5) crossing the midline. Stereotypy was examined across three conditions for one boy who engaged in stereotypic behavior: exercise, exercise in the presence of a distractor (e.g., toys), and exercise with response blocking and relaxation. Participants were observed 1 year after completing the program to determine long-term effects of the intervention.  A parent interview was also completed to assess behavioral outcomes in the home environment. Compliance to instructions, task interaction (capture and return during a ball-toss task), anticipatory (intentional) movements, and stereotypy (physical and verbal) were measured using behavioral observation. Stereotypy was observed across four intervals during a typical session: 1) pre-exercise; 2) during and 3) following aerobic-type exercise; session conclusion). A second independent observer collected stereotypy data to determine the interobserver agreement (IOA) during random sessions. 

Results:  Compliance to instructions and task interaction improved overall by 75% from baseline; correct responding for capture and return of the ball at baseline (M = 20% and M = 0%, respectively) increased by the end of intervention (M = 100%). Compliance increased across 2 months to the end of training (M = 40% to M = 80% correct responding, respectively). Anticipatory movements improved from baseline to the end of intervention regarding body movements (M = 40% to M = 100%, respectively), while eye contact remained constant (M = 90%). Stereotypy decreased across sessions (start of intervention: M = 11.7 responses per minute (RPM); end of intervention: M = 8.5 RPM). When a distractor was incorporated using a Frisbee or Barney toy, stereotypy increased (M= 21.1 RPM and M = 35 RPM, respectively). Stereotypy decreased significantly when response blocking with relaxation was implemented from 53 RPM to 5.7 RPM by the end of intervention (M = 33 RPM overall). Parents reported significant improvements in behavior at the end of intervention that continued at one year follow up. 

Conclusions:  Interventions incorporating exercise and evidence-based strategies to target specific areas of concerns in individuals with autism are needed. This study proposes a novel methodology employing several components that are individualized to target new behaviors within the context of exercise.