A Program to Increase Physical Activity for an Adolescent with Autism Spectrum Disorder and Down Syndrome

Introduction:

In “The Effect of Electronic Self-Monitoring on Weight Loss and Dietary Intake: A Randomized Behavioral Weight Loss Trial,” Emily E. Dunn and Jennifer Robertson-Wilson (2018) state that worldwide 3.2 million deaths annually are associated with physical inactivity. Beyond the health implications, leisure and recreation are associated with a higher quality of life providing opportunities for fun, social interactions, friendship, and dignity (Coyne & Fullerton, 2016). However, Coyne and Fullerton reference several studies reporting that children and adolescents with Autism Spectrum Disorder have significantly fewer recreation activities than their typically-developing peers, and the activities they do participate in are often passive. The authors speculate that individuals with Autism Spectrum Disorder may enjoy one or more of a variety of recreation activities is given the opportunity and choices to do so.

The goal of this applied project was to teach an adolescent diagnosed with Autism Spectrum Disorder and Down syndrome to incorporate regular fitness activities into his weekly routines. The program was comprised of two parts run simultaneously. Part One emphasized choice of activity and choice of reinforcer. Part Two involved self-monitoring through electronic tracking of physical activity.

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In a 2005, Rosanne Burton Smith, Michaela Morgan and John Davidson conducted a study to compare the opportunities for daily choice between typically developing individuals and those with intellectual disabilities with a survey of more than 250 participants ranging in age from 11 to 6 to assess what level of control participants had over their routine daily choices.

According to the authors, adults with intellectual disabilities have significantly less choice as decisions are often made for them by family members or professional support staff. The more severe the disability reflected an even greater restriction on choice (Burton Smith, Morgan, & Davidson, 2005). The opportunity to choose activities, tasks, order of activity and reinforcers have all been shown to increase effective behavior and reduce inappropriate behavior (Akerlund Brandt, Dozier, Foster Juanico, Laudont & Mick, 2015). Studies have found that when children with autism are given choice over one or more of these elements, they exhibit fewer occurrences of aggression and self-injurious behavior. A 2010 study assessed the effect of activity and material choice on on-task behavior for four boys, 5 to 8-years old with Autism Spectrum Disorder. The findings supported previous research indicating that choice of activity and materials increases appropriate and on-task behavior (Ulke-Kurkcuoglu & Kircaali-Iftar, 2010). Another study that examined the reinforcing effects of choice-making revealed that not only do most typically developing children identify independent choice as more reinforcing than having an adult make choices for them, the preference for independent choice-making is strengthened through conditioning, while a preference for accepting the options determined by someone else is not (Ackerlund Brandt et al., 2015). Another study involving four individuals, two of whom were diagnosed with pervasive developmental disorder and two with autism, found that for two of the participants, the choice-making opportunity itself functioned as a reinforcer (Sellers et al., 2013).

Electronic fitness trackers incorporate a variety of Behavior Change Techniques. This study will focus on the visual prompting of the pedometer function in the activity tracker. When the subject dons the wrist-worn fitness tracker, the device becomes a tactile and visual stimulus in the environment and serves as a self-monitoring device. (Sullivan, Alycia, Hawkins, J., & Middelweerd, A., 2019). Electronic self-monitoring devices allow that awareness to occur in real-time, something that is difficult to attain through paper journal methods. The study compared adherence to self-monitoring over a six-month period between dieters using a paper

record system and those using an electronic self-monitoring system. The participants in the paper record group were less adherent to self-monitoring. This may have been due to the tedious nature of a paper record requiring handwritten entries, as well as research for nutritional content of foods consumed (Burke, Conroy, Sereika, Elci, Styn, Acharya, Sevick, Ewing, & Glanz, 2011). Dunn and Robertson-Wilson (2011) cite the increase in an individual’s awareness of their behavior and the variables that influence that behavior as the benefits of self-monitoring. Eight- two percent of the participants in their Dunn study reported wearing their activity tracking device seven days a week, all 45 participants used their activity tracker to monitor steps, a widely- recognized quantification of activity, and the average daily step increase during the study was 2000 steps (2018).

Behavior to Increase

The target of this instruction was to increase physical activity as measured in duration (minutes) and total daily steps. Any increase is physical activity would benefit the subject, however, mastery was defined as a 50-percent increase in daily activity duration over five consecutive days and a 50-percent increase in total daily steps over five consecutive days.

Participant

The subject was a 15-year old male diagnosed with Autism Spectrum Disorder and Down syndrome. At age 5 ½ weeks, the subject underwent open-heart surgery for an Atrioventricular Septal Defect repair and PDA ligation. In addition, at age 7-days, he underwent an intestinal “pull-through” surgical procedure to remove an under-developed section of the colon due to Hirshprung Disease. While the subject maintains a healthy weight and diet, excess weight gain in the future could place undue stress on his heart. Furthermore, he experiences occasional constipation from low motility during periods of reduced physical activity. He has been cleared by his primary care physician, cardiologist, and orthopedist to engage in daily fitness activities including strength training, cardiovascular fitness activities, and stretching. He is restricted from contact sports, such as football, horseback riding, and wrestling, due to a risk of atlantoaxial instability. The subject’s parents express concern over the subject’s limited repertoire of physical activities due to recent school closures and requirements to remain in the home setting as a result of the COVID-19 pandemic.

Interventions

This program was implemented during a time when the family was restricted to home and neighborhood-based activities. The subject was following a loose daily schedule incorporating home-school and virtual-school academic programs, ADLs, cooking and household chores, and recreation. For Part One, teaching techniques included choice, self-monitoring, reinforcement, Premack Principle, and modeling. A laminated choice board allowed the learner to select activities and reinforcers for Part One of the program. A most-to-least prompting hierarchy was used wherein the instructor first gave a verbal prompt for the subject to select an activity. If the subject did not select an activity, the instructor presented a visual First and Next prompt. During

Part Two, the subject was prompted to don his fitness tracker in the morning and log the daily steps at the end of the day. The reinforcement schedule for Part One was Fixed Interval: During days 1-7, the student earned three minutes of screen time for each minute of activity. During days 8-14, he earned two minutes of screen time for each minute of activity. During days 15-31 and maintenance, the student earned one minute of screen time for each minute of activity. The reinforcement schedule for Part II was a fixed ratio wherein the student earned 50-cents for every day steps exceeded 2,500 and $1.00 for every day steps exceeded 5,000. For more information on the procedures, see the attached Procedure Manual (Appendix 1).

Data Collection

Data collection for Part One included total daily activity duration, selected activity, a social validity question response to assess if the student enjoyed the chosen activity, and confirmation the reinforcer was delivered by the parent. During Part Two data included total number of daily steps and if the associated reinforcer was earned and delivered.

Results

The subject reached mastery criteria for Part One on Day 15 (5/15/20) and for Part Two on Day 13 (5/13/20). Interestingly, the subject increased his activity duration to compensate for the thinning reinforcement schedule at both Day 9 and Day 16, two days after each respective reinforcement thinning went into effect. On Day 20, activity was significantly lower due to severe inclement weather and a power outage.

DURATION

Figure 1: Daily Activity Duration

Daily Activity Duration

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Future programs could include more choices that do not depend upon technology and allow more indoor and outdoor choices to replace the least selected activities such as Wii Exercise, Yoga, and Dance Video.

SELECTION COUNT

Figure 3: Activity Preference

Yoga

Walk/RunDance Video

Superhero

Workout

ACTIVITY

Weights

Wii Exercise

Example

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Activity Preference Tracking

The subject selected Walk/Run most often which may be associated with his father’s interest in competitive running, as well as his own past experiences with Special Olympics and school-based track events. He and his father have both received medals for these activities that are displayed in the family room, so the subject likely finds walking and running contribute to a high level of happiness beyond the physical effects. Also, the family takes daily walks together which allowed the subject to quickly accumulate pedometer steps each day.

TOAL STEPS

Figure 2: Part Two – Daily Step Total

Daily Steps

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The data graphing does not clearly depict it, but the four days the participant stated he did not enjoy the activity were the four days he chose the Dance Video activity. This activity may have been too structured to be fun or involved too complex of gross motor movements for this participant.

COUNT

Figure 3: Social Validity – Was this fun?

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RESPONSE

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Conclusion

This program was successful in increasing the subject’s daily physical activity. By providing him with a wide selection of activity choices, the program capitalized on the findings of past studies that had proven choice to be effective at increasing participation and on-task behavior and reducing problem behaviors. The subject was included in various self-monitoring activities in the program, such as logging his daily steps and operating the timer for the various fitness activities. Future studies could strive for a higher level of independence in initiating the program steps and creating the field of activity options. Also, because daily activities were tallied for a total daily duration, there is no record of duration for individual activity, which would provide greater insight into the subject’s activity preferences.

References

Ackerlund Brandt, J. A., Dozier, C.L., Foster Juanico, J., Laudon, C. L. & Mick, B. R. (2015). The value of choice as a reinforcer for typically developing children. Journal of Applied Behavior Analysis, 48(2), 344-362.

Bannerman, D.J., Sheldon, J.B., Sherman, J.A., & Harchik, A.E. (1990). Balancing the right to habilitation with the right to personal liberties: The rights of people with developmental disabilities to eat too many doughnuts and take a nap. Journal of Applied Behavior Analysis, 23(1), 79-89.

Burke, L. E., Conroy, M.B., Sereika, S.M., Elci, O.U., Styn, M. A., Acharya, A. D. , Sevick, M.A., Ewing, L. J., & Glanz, K. (2011). The Effects of Electronic Self-Monitoring on Weight Loss and Dietary Intake: A Randomized Behavioral Weight Loss Trial. Obesity Journal, 19(2), 338-344.

Burton Smith, R., Morgan, M. & Davidson, J. (2005). Does the daily choice making of adults with intellectual disabilities meet the normalization principle? Journal of Intellectual and Developmental Disability, 30(4), 226-235.

Coyne, P. & Fullerton, A. (2014). Toward a Balanced Leisure Lifestyle for Adults with Autism Spectrum Disorders. In M. Tincani & A. Bondy. (Eds.), Autism Spectrum Disorders in Adolescents and Adults: Evidence-Based and Promising Interventions. (pp. 208-233). Guilford Press.

Dunn, E. E. & Robertson-Wilson, J. (2018). Behavior change techniques and physical activity using the Fitbit Flex. International Journal of Exercise Science, 11(7), 561-574.

Sellers, T. P., Bloom, S.E., Samaha, A.L., Dayton, E., Lambert, J. M. & Keyl-Austin, A.A.

(2013). Evaluation of some components of choice making. Journal of Applied Behavior Analysis, 46(2), 455-464.

Sullivan, Alycia, Hawkins, J., & Middelweerd, A. (2019). Behavior Change Techniques Incorporated in Fitness Trackers: Content Analysis. JMIR Mhealth Uhealth, 7(7), doi: 10.2196/12768.

Ulke-Kurkcuoglu, B. & Kircaali-Iftar, G. (2010). A comparison of the effects of providing activity and material choice to children with autism spectrum disorders. Journal of Applied Behavior Analysis, 43(4), 717-721.

Appendix 1: Procedure Manual

Procedure Manual

Goal: This two-part program is designed to increase daily fitness activity.

Teaching Techniques include:

· Choice – Learner will select from a variety of activities and reinforcers

· Self-monitoring – Learner will use wipe-off marker on laminated exercise choice board and time to self-monitor and self-report activity.

· Reinforcement – Part 1: Learner will earn preferred screen time activities. Part 2: Learner will earn a generalized conditioned reinforcer.

· Modeling – parents will implement a similar program to earn their tv time.

Part One Materials:

· Superhero Workout – Superhero Workout Visual

· Weights – Free weights and basic weight routine.

· Wii Exercise – Wii exercise discs, gaming system and television

· Yoga – Yoga Cards, yoga mat, strap and blocks

· Walk/Run – Sneakers and weather appropriate clothing

· Dance Video – Television with internet access

· Timer

· Dry-erase marker

· Exercise Choice Board

· First and Then Visual

· Data sheets and graphs

Part Two Materials:

· Electronic fitness tracker

· Data sheets and graphs

· $1.00 bills and coins totaling 50-cent and $1.00 increments

· Designated box for earned money

Reinforcers:

Part One:

· Television with internet access

· Wii or Switch gaming system with games Part Two:

· Money

Procedure Part One:

This program is being implemented during a time when the family is restricted to home and neighborhood-based activities. The subject is presently following a loose daily schedule incorporating home-school and virtual-school academic programs, ADLs, cooking and household chores, and recreation.

Step 1: Once between 8:00 a.m. and noon, and again between noon and 4:00 p.m., the subject will be prompted to use a dry-erase marker to choose an exercise activity from the Exercise choice board. If he refuses to participate, parent will present the First and Then visual incorporating the Premack Principle to prompt a response.

Step 2: The student selects the activity of choice.

Step 3: The student starts a timer and immediately begins that exercise. Parent will model all exercise activities and participate.

Step 4: When student stops activity and time, he writes the total number of minutes he exercised on the exercise choice board.

Step 5: Parent will ask social validity question, “Is this exercise fun?” and log the child’s yes or no response on the data collection sheet.

Step 6: Parent will offer the option of doing another or more of the same activity to earn more screen time. If the student says, “Yes,” repeat steps 2-4. If he says “No,” immediately provide the reinforcer activity for the earned duration and log duration on the data collection sheet.

Repeat this process at least one more time during the day. Note, students must not have access to the reinforcers without earning them through activity.

Fixed Interval Schedule of Reinforcement:

During days 1-7, student will earn three minutes of screen time for each minute of activity. During days 8-14, student will earn two minutes of screen time for each minute of activity.

During days 15-31 and maintenance, student will earn one minute of screen time for each minute of activity.

I did

Exercise

Superhero Workout minutes	Weights minutes	Wii Exercise minutes
Yoga minutes	Walk/Run minutes	Dance Video minutes

I Earned minutes of:

Music Videos

Youtube

Video Games

FirstThen

Screen Time

Exercise

Procedure Part Two:

Step 1: Each morning, as part of his morning ADL routine, the student will don his watch-style, electronic activity tracker/pedometer.

Step 2: Each evening, as part of the bedtime preparation routine, the parent will prompt the child to check the total number of steps walked on the fitness tracker.

Step 3: The student will write the total daily steps on his My Steps log. Parent will log the total steps on the data collection sheet.

Step 4: If the total daily steps exceed 2,500, the parent will give the child 50-cents. If the total steps exceed 5,000, the parent will give the child $1.00.

Step 5: Student will be allowed opportunities to exchange the accumulated money for reinforcer of his choice.

Fixed Ratio Schedule of Reinforcement: Student will earn 50-cents for every day steps exceed 2,500 and $1.00 for every day steps exceed 5,000.

My Steps

Date	Total Steps	How much did I earn today?