Motor Intervention and Assessment Instruments in Autism Spectrum Disorders ()
1. Introduction
Autism spectrum disorder (ASD) is a neurological disorder that is characterized by impairments in communication and social skills, and is associated with repetitive behavior and stereotypical movements (Dillon, Adams, Goudy, Bittner, & McNamara, 2017) . Many children with ASD motor and sensory difficulties are observed (Baranek, 2002) . Several studies have also reported changes in the motor development profile of these children contributing to a lower physical fitness (Loh et al., 2007; Ozonoff, Young, Goldring, Hess, Herrera, & Steele, 2008; Pan et al., 2009; Fournier, Hass, Naik, Lodha, & Cauraugh, 2010) . The strategies for the treatment of ASD are focused mainly on cognitive stimulation, social and language development and the elimination of stereotyped movements ( Koenig et al., 2010 in Sowa & Meulenbroek, 2012 ).
Research suggests that exercise is beneficial for improving children with ASD motor coordination, balance, and flexibility. It also reduces their stereotypical behavior and has positive effects on socialization, and communication (Bremer, Crozier, & Lloyd, 2016; Lang, Liu, & Ledbetter-Cho, 2018; Sam, Chow, & Tong, 2015) .
Therefore, motor intervention programs have been increasingly used for the development of children with ASD, both at the motor level and at the social level. Motor deficits are a hallmark of autism spectrum disorders and the treatment of this pathology should consider interventions to improve these deficits, including motor performance involved with motor coordination (gait, balance, arm functions and movement planning) (Fournier, Hass, Naik, Lodha, & Cauraugh, 2010) or even associate activity or physical exercise with the development of communication and socialization.
In order to evaluate the effects of motor intervention programs, assessment instruments (test batteries, questionnaires) are commonly used. There are many instruments of motor evaluation, however, neither is perfect nor encompasses all aspects of development (Neto, 2007) .
Considering the variety of motor programs used in children with ASD presented in literature, it is important, for those intending to make a practical motor intervention, to synthesize the different existing programs, the population in which they are applied and the improvements that each.
In this sense, the present work seeks to review the motor interventions used in children with ASD, as well as the evaluation methods used, so that it becomes clear what the options are for motor work with this population.
2. Methods
Research Procedures
This research was carried using a narrative revision comprehending three databases: Web of Science, SCOPUS and Google Scholar. The key words used were autism spectrum disorders, motor program. The research was carried out based on articles published since 2013 until now. The main reason for this methodological decision was the existence of two systematic reviews on the subject, date 2012.
According to the objective of the work, we considered as inclusion criteria: 1) the participants—children or adolescents with the diagnosis of ASD; 2) the motor intervention programs used based on physical activity. As exclusion criteria we considered all interventions that only focused fine motor control, or interventions that were not described in the research (Figure 1).
Of the 15 studies presented, all participants had diagnosed ASD and were children or youth/adolescents. The ages range from 4 to 16 years old. All studies performed between 2013 and 2018, which resulted from motor intervention programs performed in children or young people with ASD.
3. Results and Discussion
Table 1 synthetized the essential information of articles retrieved. For each study the first author and year of publication are presented, the type of intervention performed and duration, the total number and age of the participants, evaluation instruments used to evaluate the variables under study and the main results.
The results of the motor programs were presented between 2013 and 2018, having been studied with different activities in children with ASD. These activities range from: dance, trampolines, assisted cycling, equine or more specific activities with the aid of training or core development.
The impact of different intervention programs on the social and motor dimensions was studied.
As for the evaluation instruments, it was verified that a practical evaluation was carried out through different instruments: Korperkoordinations test für Kinder (KTK) (Kiphard & Schilling, 1974) , Movement Evaluation Battery for Children-2 (MABC-2), Bruininkse Oseretsky Motor Proficiency Test
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Figure 1. Fluxogram of article selection.
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Table 1. Motor intervention programs performed with children with ASD.
(BOTMP), Gross Motor Development Test (TGMD-2). Eurofit, a Bertec strength plate (strain gage type, 40 - 60) and the Stork test were also used to evaluate the static balance.
In order to evaluate the social dimension, we used Gilliam Autism Rating Scale-second edition (GARS-2), Vineland Adaptive Behavior Scale (VABS, Sparrow et al., 1984 ), Social Skills Improvement System (SSIS, Gresham and N. Elliott), Pediatric Quality of Life 4.0 Generic Core Scales (PedsQL) and Child Health Questionnaire (CHQ).
4. Conclusion
The studies presented are quite diverse, with intervention programs whose activities, in some cases, are uncommon. However, all had as objective to prove the benefits of physical activity in the different domains, namely at the motor and social level of children with ASD.
The type of intervention performed varies between Kata techniques and trampoline training, dance, assisted cycling therapy, equine activities, balance and “core” training, exercise-gaming, different basic skills and exercises using Wii console.
When analyzing the results obtained in the different studies, the improvements found in the study population after several weeks of intervention are notorious.
With respect to the sample used in the various studies, it is possible to verify that, in general, the sample consisted of a minimum of 7 and a maximum of 50 children/adolescents with ASD.
In analyzing Table 1, we verified the existence of different proposals of physical activity, such as training of trampolines (Lourenço, Esteves, Corredeira, & Seabra, 2015a, 2015b) or dance (Krüger, Garcias, Hax, & Marques, 2018) . To improve motor skills, it may improve the motor skills of children with ASD, in a program whose aim was to work the fundamental motor skills (Bremer, Balogh, & Lloyd, 2014) . Also, Dickinson & Place (2014) verified the existence of significant improvements in all parameters evaluated after an exercise program using the Wii.
In a dance program (Arzoglou, Tsimaras, Kotsikas, Fotiadou, Sidiropoulou, Proios, & Bassa, 2013) significant improvements in neuro-muscular coordination were recorded.
Currently, different motor intervention programs are used to develop socialization. Equine therapy activities contributed to the improvement of social function (Borgi, Loliva, Cerino, Chiarotti, Venerosi, Bramini, & Cirulli, 2016) and improvements in physical, emotional and social functioning and behavior (Lanning, Baier, Ivey-Hatz, Krenek, & Tubbs, 2014) .
Ringenbach, Lichtsinn & Holzapfel (2015) have proven that an Assisted Cycling Therapy program has contributed to improving in cognitive planning.
On the other hand, in only 36 sessions of SPARK improved balance (static and dynamic), bilateral coordination and social interaction (Najafabadi, Sheikh, Hemayattalab, Memari, Aderyani, & Hafizi, 2018) .
Likewise, the neuromuscular coordination (Arzoglou et al., 2013) and the static and dynamic balance (Golsefidi, Younesi, & Golsefidi, 2013) showed significant improvements, following physical activity charts, respectively, of training of traditional Greek dance and “core” stabilization training.
According to the literature we consulted, we verified that motor intervention programs in children with ASD seem to be a very pertinent aspect, providing benefits in the different domains, being significant the influence of exercise in this population, both in the improvement of the their physical condition, or in the improvement of cognitive and sensorial capacities.
Since motor deficits are a characteristic of the PEA and the treatment of this pathology should consider interventions to improve these deficits, including motor performance along with motor coordination (gait, balance, arm functions and movement planning) (Fournier et al., 2010) . Thus, the use of physical exercise as an instrument for the development of children with autism has been increasingly used, requiring theoretical research that supports this use, giving it greater scientific robustness.
After the research and construction of this article, we concluded that regardless of the type of physical activity, number of sessions or duration of the training program, the results were very positive.