Description #

Meet Arthur.

Arthur is a 19 year-old male. He is overweight and has little experience being physically active. He does not appear to be very coordinated when observing his movements and he doesn’t like to be sweaty. Arthur loves pop music and brings his Ipod and headphones everywhere he goes. Arthur is very verbal, however, it can be difficult for Arthur to attend to us and/or talk about things that are not of interest to him. He may want to give up quickly if he is not experiencing success right away.

What do I need to know? #

Autism spectrum disorder (ASD) is a group of developmental disabilities that includes a wide spectrum of symptoms, skills, and disability levels.  ASD is diagnosed by assessment of behavior and development, and can be reliably determined by the age of two years.  While some with ASD may also have ID, many do not have ID as a component of their ASD.

Persons with ASD often demonstrate these characteristics in mild to severe degrees:

• Social problems including difficulty communicating and interacting with others
• Repetitive behaviors
• Limited or overly focused interests and activities
• Limited eye contact and response to verbal attempts to gain attention
• Getting upset with change in routine or new and stimulating settings

Persons with ASD also have many strengths and abilities:

• Above-average intelligence (45%)
• Able to learn things in detail
• Able to remember for long periods of time
• Strong visual and auditory learners
• Excel in math, science, music or art
• Exceptional knowledge about their area of interest

Why Exercise? Why is it important? #

Exercise is important for everyone! For people with autism, the benefits of regular exercise include:

• Fewer visits to doctor with less medical complications
• Improved balance, muscle strength, and quality of life
• Decreased risk of social isolation and improved mental well-being
• Enhanced self-esteem
• Increased ability to attend school, work and other aspects of community life
• Decreased overweight and obesity
• Increased quality of life, including satisfaction, independence, competence and social interaction (Garcia-Villamisar, & Dattilo, 2010)
• Improve physical stamina

Where do I start? Getting to know Someone with Autism #

Given the individual nature of how people experience autism, this section will highlight the importance of the consultation phase. Many staff are nervous about their first meeting and this section will hopefully make them feel a little more comfortable and better prepared to manage this first step.

Communication is a two-way process that involves sharing information between participant and trainer.  The effectiveness of this communication leads to trust and shared understanding, resulting in an appropriate and effective intervention.

Everyone, even those with communication challenges, can communicate in some manner, using language, gesture, pictures or signs, or body language.  It is up to you to find out the most effective ways to understand and communicate with the participant (you don’t have to do this alone! You can ask others for help!).  AND most important, talk to the participant at an age appropriate level; do not talk to everyone as if they were a child.

The Consultation #

Use the consultation as an opportunity to get to know the participant. In addition to gathering medical information and fitness/ physical activity experience, you can also focus on goal setting and learning about participant preferences. In addition to discussing the exercises themselves, ask the participant about how they will get to the fitness centre, and the level of support they need to access the locker room, and prepare for exercise.

Support the participant to be as independent as possible. Depending on the person, this may change over time as they become more familiar with the setting and feel more confident and capable. Some participants may choose to include activities of daily living in their goal setting (e.g., becoming independent in their use of the locker – learning how to open/ close lock without assistance).

When talking about programs, ascertain what the participant likes, and give them choices in what they can do.  Provide easy read documents if needed, with simplified text, larger font (14 at least), and illustrations to reinforce your instructions.  If the participant cannot read, then provide pictures and/or videos to communicate about your program.

When someone with autism comes in for the consultation you may or may not notice the following:

• They might find it hard to process things that you say. You can:
  • use fewer words,
  • repeat key words to reinforce your message,
  • pause between comments to allow time for thinking and processing,
  • don’t ask too many questions (especially all at once!)
  • pay attention to the environment (is there too much sensory stimulation? Is it too loud? Too bright? Are there too many people around? If so, move to a quieter space)
  • use visual supports such as social stories or pictures
• They may find it difficult to answer open ended questions such as ‘what are your goals?’ You can:
  • Keep questions short and structured
  • Offer options if possible and be specific (for example, would you rather work on getting stronger in your arms or legs? Do you prefer to be active in the morning or the afternoon?)

There may be health-related information that the participant may not be aware of that is necessary for you to ensure their safety. For example, if the participant has underlying secondary conditions such as heart disease, diabetes, hypo or hypertonicity, seizures, or is taking any medications, or if the participant has osteoporosis, obesity, or pain, these may require more information. For this reason, it is recommended that you gather information from the participant’s medical practitioner prior to your session to develop the participant’s exercise program.  Begin with a form that you would typically use when screening a new participant for exercise (e.g., PAR Q) and then follow up as needed. You may wish to use the Form for Medical Personnel that has been developed for UFIT Explorer.

Implications for Exercise #

Individual inclusion and participation in society are influenced by personal and environmental factors as well as health concerns and/or impairments. Each participant needs to be viewed as an individual and their fitness programme should be designed accordingly with their input and the input of those who know the individual well (e.g., family or direct support staff).

Considerations for ASD	Recommendations for Exercise Program
Lower maximal heart rate, cardiac output, & peak aerobic capacity secondary to lower activity levels.	Use RPE scale to measure exertion rather than age-predicted maximal heart rate (220-age)
Participants with ASD often demonstrate self-stimulatory behaviors, hyperactivity and aggression	Vigorous exercise (>20 mins of aerobic activity) has been demonstrated to decrease these behaviors.
Those with ASD have poor social skills and communication	Various forms of exercise from yoga to creative dance seem to improve social interactions, attention, and social gaze
Participants with ASD have poorly developed movement skills (e.g., dynamic balance required for hopping and skipping) which may impact their sense of rhythm and timing, motor planning, sequencing, and coordination.	Games that incorporate music and movement improved social engagement and eye contact, and reduced negative behaviors.   Hopefully this will lead to active community participation and greater independence (Azar, McKeen, Carr, Sutherland, & Horton, 2016)
Considerations for ASD	Recommendations for Exercise Program
Those with ASD often do best with routines and calm settings.	Develop routine programs that teach movement skills Keep the environment calm and non-distracting Focus on fun activities that promote motion and coordination.
Individuals with autism are at an increased risk of experiencing mental health issues such as anxiety and depression (Hillier, Murphy, & Ferrara, 2011)	Recommend regular exercise to decrease stress and help individuals to manage symptoms associated with anxiety and depression
Adults with autism tend to be less physically active and are more likely to have poor motor control (Pan, 2014; Sahlander, Mattsson, & Bejerot, 2008)	You may need to provide more frequent, more detailed, or more simplified instructions Pay attention to the individual’s body language- do they need a break? Do they look like they might be getting frustrated with trying to do the new movements? Get to know the participant- this will help you find ways or things that can increase their motivation. For example- do they have a favourite song? You could use it as an incentive to finish a group of exercises. Play it for the 2nd set.
People with autism benefit from a variety of instructional styles	If possible, use video modelling. You can record a video of the participant performing (or attempting to perform) an exercise (use an Ipad or smart phone). You can then watch together and discuss where or how to improve form. Use pictures where possible- you can create your own exercise cards, or use ones developed by others (e.g., Special Olympics)
New environments can create uncertainty in adults with autism	Take the person on a tour of the gym to introduce the new space- this could be done as part of the consultation Show the participant where they will sign in, leave their bag, get changed, fill up their water bottle, and meet you. Where possible, try to maintain consitency in terms of where equipment is located- however, if necessary, remind participant this may not always be possible.
Some people with autism have a difficult time reading social cues.	This can make it more difficult to participate in different social settings, including ones like joining a health club where there are culturally appropriate behaviours (and these can differ from gym to gym!). As you use the gym space, model approriate social behaviour to show the person how to act and introduce proper etiquette within a health club. For example, it’s ok to say hello to someone who is exercising, but they may not be interested in starting a long conversation. Keep it short, yet friendly.

Don’t forget:

Every person is like every other person, like some other person, and like no other person.

Monitoring Exertion & Exercise Intensity #

It’s really important that people who are new to exercise learn how to monitor and describe how they are feeling or their response to exercise. One helpful way to do this is to introduce the Rate of Perceived Exertion (RPE) scale.  The smiley face RPE Scale or the OMNI scale (see below for examples of both) may be more suitable for participants with various disabilities than the age-predicted maximal heart rate (220 – age) (Stanish & Aucoin, 2007).

In the beginning, it is also recommended that participants measure their heart rate (using wearable technology such as a heart rate monitor may make this easier!). This information will help the trainer and participant to work together to learn about how the participant perceives their exertion during exercise and may help to inform programming strategies. For example, a trainer may encourage the participant to work towards a specific level of RPE, which can be complemented with information from the HR monitor to measure exercise intensity. Monitoring HR may also be useful in the event that participants are exercising at a level beyond the recommended intensity, which may happen if the participant is very engaged in the activity or trying to make a positive impression on the trainer

Smiley RPE Scale

Medication & Exercise: What do you need to know? #

Although you will not be administering medication, it’s important that you have a brief conversation with the participant to ensure they are aware of any side effects of their medications that may impact their ability to take part in exercise and/or specific safety considerations.

Individuals with autism may or may not be taking regular medications. Similar to the variability you will find across individuals, you will find that different people are taking different medications to manage different symptoms or secondary conditions (e.g., for anxiety, seizures, etc.). It is recommended that you talk about this during the consultation to see if there are any side effects that you should be aware of. You may also want to check in with them on a regular basis to see if there are any changes or any new information that you should know. It is also important to ensure the individual has the go ahead from their health care provider prior to beginning a new exercise program.

Inclusive TIMES: Tips & Strategies for Individuals with Autism #

The tips and strategies found within the inclusive TIMES section will help you to create an environment that will support your participant’s participation in physical activity as independently as possible. It is important that you involve the participant whenever possible, along the way to ensure the program that you design will meet their needs physically, as well as emotionally and socially. Introducing a few simple strategies such as offering visual images of the participant’s program will help them to be more independent in completing their fitness programme. Ultimately, they will gain confidence and belief in their abilities (increasing self-efficacy) and experience self-determination (sense of control over their own destiny). This is key to establishing healthy habits that will be adopted for the long term.

Time #

• Send a reminder (e.g., text) about appointment or exercise session
• Begin with shorter duration and lower intensity activities, progressing gradually to moderate intensity.
• Introduce regular and consistent exercise routines on the same days/ time each week
• Check in with the participant on a regular basis to see how things are going. They may be less likely to ask for help.

Instruction #

• Be patient and understanding.
• Provide clear, simple instructions in more than one format (e.g., verbal, written, and visual as needed).
• Always use the person’s name at the beginning when speaking so they know you are talking to them
• Make sure the participant is paying attention to you before giving instructions (this might look different for different people. Hint: it might not always involve eye contact!)
• Avoid using sarcasm, irony or exaggerations in your instructions. These comments may be interpreted literally so be prepared to explain their meaning if you do!
• In a respectful way, ask participant to return demonstration of the activities to increase learning.
• It may help to write down the sequence of an activity or have visual cue cards ready.
• Use photos to help with recall. Taking pictures with their cell phones, with permission, is a good way to record steps that they can easily refer back to.
• Encourage the participant to be as independent as possible. With guidance, have him/her practice selecting his/her own free weights or small equipment and input the settings on the cardio machines. Use a chart to tracking progress.
• Participant may need to be encouraged to begin or continue with the exercise session even when he/she thinks he/she does not want to (e.g., thinking he/she is too tired).
• Introduce the RPE Scale and teach participant to learn their body’s response to various intensities. This will help them become aware of what intensity is appropriate for the body on any given day.
• Share the rules of etiquette for using the fitness equipment. For example, ask the participant to wipe down the cardio or weight machines after each use.

Movement #

• Deconditioned participants and those with heart conditions should start with lighter intensities and gradually progress as their fitness level increases.
• Resistance training machines are best suited to beginners and participants that have impaired balance, motor control or hypotonicity (loose ligaments and tendons) as machines guide movement patterns, e.g., use chest press machine instead of doing push-ups.

Environment #

• Create a lanyard with images of each activity. Have this available for the participant to use on their own.
• Tour the facility, and offer a basic map to help the participant remember the location of different areas.
• If the participant uses an alternate form of communication (e.g., picto-charts, communication device, or personalised system known by their family, friends and support staff), familiarize yourself with their system to build rapport and provide a safe environment.
• A quiet environment might suit some individuals if they become easily distracted or have other sensory issues.
• Model appropriate social behviour for the gym setting (for example, you can demonstrate when it’s ok to say hello or initiate a conversation with staff or other members. Should they wait until someone has finished an exercise or speak to them in the middle? What kind of things are ok to talk about at the gym? For example, it may not be a good idea to comment on the way someone looks, but it’s ok to offer a comment about the weather).

Support #

• Use the consultation to clarify the desired level of support.  This is individual and will be unique to each participant. Some may require support staff/family members or use assistive technology/devices, others may not.
• If a participant has behaviour issues, work with him/her and the family/caregivers to recognize triggers and understand their responses. You should co-create a plan with the participant, with input from their caregiver/family to avoid or overcome these triggers. A clear plan for how to address behaviour issues should be developed which is respectful for the participant and maintains their dignity.
• Introduce the participant to people with similar shared interests (e.g., staff or health club members)
• If the participant has shared a special interest, use this to engage them or involve them in the next activity
• If participant has low levels of motivation, consider introducing a healthy reward system. You can record progress on a wallchart to document appropriate behaviour (e.g., check mark for completing exercises or selecting weights on their own) and celebrate success when a participant reaches a specific goal (e.g., offer time for a participant-selected activity such as free- time on an open court, or enjoy a healthy snack after completing the program).
• Recommend a group fitness class (for example, spin, boot camp, yoga) if the participant is interested in meeting people. Before the first class, talk about what to expect (for example, how to find a space on the floor, where to pick up a token for a spin bike). Talk about what to bring (for example, towel, water bottle) and what will happen during the class. This will help them to feel more comfortable. Consider attending a class together or suggest that the individual observe a class first to see what happens and whether they would like to try it
• Social support is vital to promote a healthy lifestyle, especially for people with autism who are less likely to have this support. Some may enjoy group activities and others may need more encouragement to feel accepted and welcome. Always find out the participant’s preference.

References #

• Azar, N. R., McKeen, P., Carr, K., Sutherland, C. A., & Horton, S. (2016). Impact of motor skills training in adults with autism spectrum disorder and intellectual disability. Journal on Developmental Disabilities, 22, 28-38.
• Garcia-Villamisar, D. A., & Dattilo, J. (2010). Effects of a leisure programme on quality of life and stress of individuals with ASD. Journal of Intellectual Disability Research, 54, 611-619.
• Hillier, A., Murphy, D., & Ferrara, C. (2011). A pilot study: Short-term reduction in salivary cortisol following l ow level physical exercise and relaxation among adolescents and young adults on the autism spectrum. Stress & Health: Journal of the International Society for the Investigation of Stress, 27, 395-343.
• Moore, G. E., Durstine, J. L., & Painter, P. L. (2016). ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. Champaign, IL: Human Kinetics.
• Pan, C. Y. (2014). Motor proficiency and physical fitness in adolescent males with and without autism spectrum disorders. Autism: International Journal of Research & Practice, 18, 156-165.
• Sahlander, C., Mattsson, M., & Bejerot, S. (2008). Motor function in adults with Asperger’s disorder: A comparative study. Physiotherapy Theory & Practice, 24, 73-81.
• Stanish, H. I., & Aucoin, M. (2007). Usefulness of a perceived exertion scale for monitoring exercise intensity in adults with intellectual disabilities. Education and Training in Developmental Disabilities, 42, 230-239.
• The National Autistic Society (2017). Communicating and interacting. Retrieved July 15, 2017 from http://www.autism.org.uk/about/communication/communicating.aspx

Further information/ Recommended Resources #

• The National Autistic Society has some great resource for tips for people with autism on developing social skills and communicating
  • http://www.autism.org.uk/socialskills http://www.autism.org.uk/about/communication/communicating.aspx
• Canadian Society for Exercise Physiology (CSEP) (2002). Inclusive Fitness and Lifestyle Services for All disAbilities.
• This is a great video series, however, remember that the focus is on children- some of the ideas may not apply when working with adult participants: http://www.nchpad.org/1399/6252/Autism~and~Exercise
• Exercise is Medicine, ‘Your Prescription for Health Series’, available at: http://exerciseismedicine.org/assets/page_documents/YPH_All.pdf [accessed 6th April 2016]
• Harvard School of Public Health, ‘Healthy Eating Plate & Healthy Eating Pyramid’, available at: https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/ [accessed 9^th May 2016]
• Martin Ginis, K. A., Evans, M. B., Mortenson, W. B., & Noreau,, L. M. (2017). Broadening the conceptualization of ‘participation’ of persons with physical disabilities: A configurative review and recommendations. Archives of Physical Medicine and Rehabilitation, 98(2), 395-402. doi: 10.1016/j.apmr.2016.04.017.
• Pescatello, L., Arena, R., Riebe, D., Thompson, P., eds. (2014), ACSM’s guidelines for exercise testing and prescription, 9^th Edition, Baltimore: Lippincott Williams & Wilkins
• Swain, D., Brawner, C., Chambliss, H., Nagelkirk, P., Paternostro Bayles, M. and Swank, A., eds. (2014), ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 7^th Edition, Baltimore: Lippincott Williams & Wilkins
• WHO Global Action Plan 2013-2020, available at: http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf [accessed 12th July 2016]

 

 

 

 

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