Double punch to the better than nothing: physical activity participation of adolescents with autism spectrum disorder

Abstract

Participation in physical activity (PA) occurs differently in each individual. Investigating how it comes about in adolescents with autism spectrum disorder (ASD) is seen as an area that does not receive enough attention. In this paper, which was designed to get more information and contribute to the field, the participation of adolescents with ASD in PA was examined in line with the socio-ecological model through the opinions of 17 Turkish parents. Semi-structured interviews well-used to understand the perspective of parents’, and as a main themes constraints and facilitating factors affecting participation of adolescents with ASD in PA were determined. When investigated in terms of intrapersonal factors, which are the first stage of the model, are examined, it is seen that ASD related problems as a constraint and experiences as a facilitator were the foremost themes. Interpersonal constraints were prejudice and family attitude while facilitators were family attitude and attitude of close surroundings. In environmental factors, the main constraints were adapted physical activity (APA) opportunities, while facilitators were neighborhood and facilities. While negative PA approaches of organizations was an institutional constraint, positive PA approach of organizations was a facilitator. In the final stages of the model, in terms of public policy, the constraint was not meeting expectations of current policies and the facilitator was improvements in policies. Consequently, it was understood that adolescents with ASD still participate in PA in some way even though they encounter many constraints when participating in physical activities, the constraints outweigh the facilitating factors.

Introduction

Individuals with autism spectrum disorder (ASD) are observed to be less active compared to individuals with normal development (ND) (Gehricke et al. 2020). It was stated that they are active in the childhood period but adopt a more passive lifestyle with advancing age (Pan 2009). The adolescent period is accepted as a critical period in the development process (Curtin et al. 2010). In the adolescent period, the stage of life extending between childhood and adulthood encompassing biological growth elements and significant social role transitions, there is a severe fall in participation rates in physical activity among individuals with ASD (Sorensen and Zarrett 2014).

Individuals with ASD are stated to experience positive effects like reduced aggressive behavior, risk of depression and prevention of weight gain as a result of participation in physical activity for 30 min per day (Troiano et al. 2008). Regular participation in physical activity is stated to cause a clear reduction in risk of early death and to be effective in reducing the risk of many chronic diseases (Warburton and Bredin 2017). Physical activity is recommended as a result of many studies performed by researchers especially in the adolescent period in terms of reducing negative effects of ASD and improving health (Sorensen and Zarrett 2014, Troiano et al. 2008, Warburton and Bredin 2017).

Though individuals with ASD acquire many positive benefits as a result of participation in physical activity (Menear and Neumeier 2015), there appear to be many negative factors affecting their participation in physical activity (Obrusnikova and Cavalier 2011, Stanish et al. 2015, Menear and Neumeier 2015). The literature shows that individuals with ASD are faced with more constraints to participation in regular activities performed at home or in groups compared to ND individuals (Gürkan and Koçak 2020).

Accordingly, in recent years, in order to understand in depth what factors affect physical activity participation, parents of individuals with ASD have been included in researches (Gregor et al. 2018, Healy et al. 2018, Stavrou et al. 2018). Liang et al. (2020) states that adolescents with ASD have low levels of physical activity and there are many factors that affect their participation in physical activity. There is an urgent need to design effective physical activity interventions for adolescents with ASD that promote the participation of activity in school, family, and community. In the qualitative study of Gregor et al. (2018), one of the leading studies in the field, examining the participation of adolescents with ASD in physical activity from a parent perspective. In the research, it was concluded that the value and prioritization of physical activity according to family, is effective in the participation of the individual with ASD. Top and Akil (2021) also stated that parents play an important role in providing the orientation of their children with special needs to sports. From this perspective, when defining the problems encountered or a making a decision, parents, who are always beside the individuals with ASD, play a very important role. Parents speak for individuals with ASD in situations when they cannot express themselves and are effective in overcoming constraints (Obrusnikova and Miccinello 2012, Arnell et al. 2020).

When the constraints due to the individual with ASD are examined, inadequate social and communication skills of individuals, health problems, lack of time, lack of motivation and lack of interest have a quite important effect as a intrapersonal factor in participation in physical activity (Obrusnikova and Miccinello 2012). It is mandatory to mention interpersonal factors as another factor affecting participation in physical activities as individuals with ASD. A parent without the time or energy to bring the individual with ASD to physical activity, the lack of peers/friends, inadequate friendships of ASD individuals, comparisons with ND children and exclusion can be given as examples of limitations to participation in physical activity according to literature (Gürkan and Koçak 2020, Healy et al. 2013, Sarol and Çimen 2015). In line with structural factors, financial status, transport, accessibility of programs, high costs of activities, lack of facilities, inappropriate design of facilities and adequacy of facilities appear to be structural constraints playing an important role in participation in physical activity (Gürbüz and Henderson 2013, Gürkan and Koçak 2020, Haegele et al. 2018, Must et al. 2015, Prellwitz and Skär 2007).

Acknowledging the factors above, it is quite important to understand the other factors that affect the participation of individuals with ASD in physical activity. Bronfenbrenner (1976) emphasized the necessity of understanding the individual’s environment in order to understand the individual. Also Jachyra et al. (2021) emphasized that their qualitative study based on the perspectives of adolescents with ASD, additionally, participation in physical activity is not only related to the individuals themselves. They stated that there are many social values and norms that affect participation. In research, also emphasized that the process of participation in physical activity in adolescents with ASD is quite complex and it is necessary to consider bio-physical, psycho-behavioral and socio-cultural relations in the conceptualization of the process.

In line with this aspect, the socio-ecological model accepts the interaction between personal and environmental factors and assumes that five headings are effective in shaping the behavior of the individual. These factors are intrapersonal, interpersonal, environmental, institutional and public policies. From this perspective, the socio-ecological model, which is thought to be useful in examining individuals with ASD’s participation in physical activity in depth. Additionally, the model is very useful in classifying the factors that constraining and facilitating in participation in physical activity in individuals with ASD. It appears that ecological models developed by McLeroy et al. (1988) may be applicable to physical activity. There are studies about physical activity and participation constraints included in the literature which take the ‘ecological viewpoint on health developing programs’ developed by McLeroy et al. (1988) as a model (Gyurcsik et al. 2006, Obrusnikova and Cavalier 2011).

To date, there are many studies examining the participation of adolescents with ASD in physical activity, and each of them contributes to the field. However, according to socio-ecological model, there are no studies conducted on parents of adolescent ASD individuals in Turkey. Examining the relevant factors in depth may have positive effects on the participation of adolescents with ASD and their parents in physical activity in terms of awareness, new opportunities and better serve.

In line with this, the aim of this qualitative study was to investigate the factors affecting participation in physical activity of adolescents with ASD. The study explored intrapersonal, interpersonal, environmental, institutional and public policy aspects in order to the socioecological model from parents’ perspective.

Methods

Model of the research

The research is a phenomenological study designed with qualitative and interpretative paradigms. With the interpretative paradigm, individuals attempt to understand the world in which they exist and work. They develop subjective inferences from their experiences. Contrary to a few classifications, these inferences provide the researcher with a diverse perspective. In this context, research with the interpretative paradigm is based on the general viewpoints of participants as much as possible. The aim of the researcher is to understand or interpret the perspectives of participants in relation to the topic (Denzin and Lincoln 2005).

In research, the interpretative perspective on disability is not a constraint but assessed as a dimension due to human differences. During the research process, the differences of disabled individuals are reflected in the questions asked, data collection methods, suitability of communication methods and how data are reported (Creswell 2013).

As an attempt was made to reach the answer to the question of ‘what factors affect participation in physical activity of adolescent individuals with ASD?’ through parental experiences, the most appropriate pattern was considered to be a phenomenological study.

Participants

The study group in the research was chosen with the purposive criteria sampling method. For participants in the study group, the criteria for the research were a) having a child diagnosed with ASD, b) the individual with ASD being 10-19 years, c) the individual with ASD receiving supportive education in a special education center, d) the individual with ASD previously or currently participating in physical activity without regard to the participation level in physical activity, e) the individual with ASD not having any orthopedic disability and f) the family of the individual with ASD living in Turkey, Ankara. The study included 14 women and 3 men who were parents of 17 individuals with ASD. Parents to be included in the study were determined according to the views of educators and administrators in special education centers. Individuals abiding by the criteria listed above were identified in the organization databases and the organization communicated with families. Parents voluntarily participated in the study. Informed consent forms were distributed to parents before the study and the parents were informed about the study. The program for interviews was created on days when individuals with ASD had lessons in the special education center. Sample size calculations were not completed, data collection continued until saturation point was reached. The final form of the collected data was shared with parents and revised in line with opinions they wished to correct. The demographic information for parents and children with ASD can be seen in Table 1 with anonymized names.

Table 1.

Demographic information for participants.

Parents						Adolescents with autism spectrum disorder
Name	Age	Education	Marital status	Occupation	Income ($)	Age	Diagnosis	Number of siblings	Health problems	Weekly PA participation (h)
Eda	48	Associate Degree	Married	Housewife	7,000	19	Autism	3	None	7
Merve	46	Undergraduate degree	Married	Civil servant	14,000	17	Autism	2	None	3
Ayten	42	Undergraduate degree	Married	Housewife	6,000	10	Autism	1	Allergy	5
Banu	41	Undergraduate degree	Married	Housewife	8,000	10	Atypical	2	None	12
Nazan	34	Primary school	Married	Unemployed	5,000	11	Autism	2	None	2
Seher	43	High school	Married	Esthetician	10,000	19	Autism	2	None	4
Hakan	39	Undergraduate degree	Married	Civil Servant	8,000	10	Atypical	3	None	2
Filiz	44	High school	Married	Housewife	7,000	12	Autism	3	Digestive	3
Damla	49	Primary school	Married	Housewife	2,000	19	Autism	1	None	3
Burak	50	Undergraduate degree	Married	Self-employed	14,000	13	Autism	1	Epilepsy	5
Yeliz	49	Undergraduate degree	Married	Housewife	8,000	15	Atypical	3	Digestive	3
Ayşe	38	Undergraduate degree	Married	Teacher	8,000	11	Atypical	1	None	6
Efe	43	Associate Degree	Married	Reporter	7,000	15	Atypical	2	None	8
Berna	34	Undergraduate degree	Married	Teacher	8,000	10	Atypical	2	None	2
Esra	44	High school	Single	Housewife	2,000	19	Atypical	1	None	3
Duygu	40	High school	Married	Housewife	11,000	10	Atypical	1	None	3
Ceyda	35	Undergraduate degree	Married	Programmer	9,000	10	Atypical	2	None	3

Procedures

Necessary permissions were granted by the organization before the research and IRB approval by providing Ankara University Ethics Committee. Parents of children with ASD were met and they were requested not to respond with what they considered the children they represent thought, but to answer in line with their own experiences during the process with their children. Questions were identified by investigating the literature, especially studies by Obrusnikova and Miccinello (2012) and Buchanan et al. (2017). Additionally, in the process of creating questions, opinions were sought from 2 experts in ASD and physical activity fields. A total of 15 questions were asked with examples including ‘what do you think are the personal characteristics preventing your child from participation in physical activity?’, ‘what do you think are the institutional factors facilitating your child’s participation in physical activity?’. Before interviews parents were given an informed consent form and demographic information was obtained. Interviews were held in empty classrooms in the special education center. The researcher took notes. Data in the research were collected by preparing a ‘semi-structured interview form’. Participants were asked about 10 questions. It was ensured that parents communicated their own perspectives. Interviews’ length range between 20 min with the median time being 30 min. Interviews were recorded with a voice recording device.

Data analysis

Content analysis method, which is frequently used in qualitative research, was used in our research. According to Merriam and Tisdell (2015), all qualitative data analysis is content analysis, because at this stage the content of interviews, field notes, documents is analyzed. In this type of analysis, the units of measurement are focused on communication, especially the variety and frequency of messages, and the number of times a certain speech pattern or phrase is used. Qualitative content analysis involves coding data and creating categories at the same time. Altheide (1987) stated that qualitative content analysis is about the insight contained in keywords related to events, places, styles, images, and meaning.

The qualitative content analysis in our research was carried out as follows. The data obtained after the interviews conducted in our research were written in the computer environment and shared with the parents, and they were asked whether they would make corrections in their answers (Holloway and Wheeler 1996). With the consent of the parents, the obtained data were converted into transcripts in the computer environment. The interviews were read several times to understand the whole by authors. A randomly selected document was examined by both authors and pre-coded. In this coding, the five heading factors included in the socio-ecological model were taken into account. After completing their reading independently, the authors identified statements regarding adolescents’ participation in physical activity. The authors associated words or phrases that were related to each other as various units of meaning. Then the units of meaning were coded independently by each author. The authors then got together to compare and combine the codes. Tentative themes were created after both authors completed the coding process for the remaining interview transcripts. In the second phase, all authors met to discuss themes. After these processes, the final version of the themes was reported after the differences of opinion were identified (Graneheim and Lundman 2004). Additionally, while the qualitative analysis was being conducted, the experience of the authors in the research team working with children with ASD also contributed to the quality of the analysis process (Jachyra et al. 2018).

Results

In our study in line with the socioecological model, participation in physical activities by adolescent individuals with autism was investigated under the headings of intrapersonal, interpersonal, environmental, institutional and public policy factors. In line with parent opinions, factors which constrained participation in physical activity by autistic individuals comprised 11 themes and 31 codes. Factors which facilitated participation in physical activity comprised 10 themes and 23 codes in total.

Intrapersonal factors

In the first factor in the findings of intrapersonal factors, parents were asked questions in order to understand the constraints and facilitators due to individual traits affecting participation in physical activity of adolescent children with ASD. In line with parent opinions, the personal constraints and facilitators effective on participation in physical activity of adolescent individuals with ASD were determined (Table 2).

Table 2.

Intrapersonal factors affecting participation of adolescents with ASD in physical activity.

Intrapersonal constraints
Themes	Codes
Constraint 1: Autism related problems	Inadequate social and communication deficiencies Dependence on parents Inadequate motor skills Lack of interest in surroundings Side effects of psychological medications
Constraint 2: Negative attitude	Lack of motivation and interest Anger tantrums Awareness of differences
Constraint 3: Tight schedule	Lack of adequate time
Intrapersonal facilitators
Themes	Codes
Facilitator 1: Experiences	Enjoyment Feeling of success Self-confidence
Facilitator 2: Health promotion	Increased physical health Increased mental health Healthy sleep
Facilitator 3: Development	Development of motor skills Development of social abilities
Facilitator 4: Positive attitude	Acceptance of rules Reduction in unwanted behavior

Intrapersonal constraints

Constraints due to the traits of individuals with ASD are included under the heading of intrapersonal constraints. The negative aspects induced by autism in these individuals affects them from many different aspects. In line with parent opinions, the most emphasized intrapersonal constraints were ‘problems due to autism’, ‘negative attitude’ and ‘tight schedule’.

Constraint 1: autism-related problems

In line with our research, the greatest constraint to individuals with ASD participating in physical activity was related to themselves with parents stating that children did not communicate unless they had to, their children were inadequate in the sense of communication and that children were dependent on their parents for nearly all topics. This inability to socialize and these inadequacies in communication made the general lives of adolescents difficult. Individuals with ASD who live in a world of their own definitely needed someone to help them communicate.

Another intrapersonal factor which restricts individuals with ASD from participating in physical activity was stated to be ‘inadequate motor skills’. This inadequacy is generally experienced as difficulties in being included in activities. Additionally, parents stated their children had their own world, they attempted to bring the children out from that world because they thought it would negatively affect them. They stated they used a variety of psychological medications to reduce this negative situation, pacify the ASD individual and increase focus. These problems, which are thought to be related to autism, negatively affected adolescents’ participation in physical activity.

Constraint 2: negative attitude

It was understood that ASD individuals understand and adjust to daily life as a result of interviews with parents. It appeared that individuals with ASD are ‘aware of their differences’ and this situation has a negative effect as ‘lack of motivation and interest’. Parents stated their children tested those around them and created difficulties, had low confidence in themselves and produced excuses not to participate in physical activity. ‘Temper tantrums’ are thought to have very negative effect on participation in physical activity. The opinions of one of the parents, Ceyda, were as follows:

When my son gets annoyed, he is a child who can hurt others. He’s a child who will hit anyone who catches his eye when he’s annoyed. He’s an aggressive child. I very much want him to be able to start a physical activity program on his own. But I have to be with him constantly. How much can I be with him though? (Ceyda, 35)

Constraint 3: tight schedule

Individuals with ASD are included in a continuous education program. This education has an important place in terms of improving characteristics like creating better communication and meeting special needs of individuals with ASD. The intense academic education of these individuals consumes a large part of the day. While parents acknowledge the importance of physical activity, special education and school covered the whole week days. Many parents planned their weekends for this purpose in order for individuals with ASD to participate in physical activity.

Intrapersonal facilitators

In spite of adolescent individuals with ASD being affected negatively by many aspects of ASD, they benefit from a variety of facilitators to participation in physical activity. In line with the opinions of parents, intrapersonal facilitators affecting participation in physical activity were investigated under the headings of ‘experiences’, ‘health promotion’, ‘development’ and ‘positive attitude’.

Facilitator 1: experiences

For individuals with ASD, experiencing feelings that they have never felt before plays an important role. The most important of these feelings was ‘enjoyment’ as stated by parents. Nearly all parents interviewed stated that their children liked doing physical activity. Apparently, individuals’ ‘self-confidence’ increased through these physical activities, which were designed by considering their abilities. They were glad that ‘feeling of success’ and appreciated by their parents and trainers. Also individuals confidently applied the skills that learned in activities in games with their friends.

Facilitator 2: health promotion

For parents, their children’s participation in physical activity is a necessity for healthy lifestyle. ‘Increased physical and mental health’ and ‘healthier sleep’ which were emphasized the most, were effective in this situation. In addition, individuals with ASD loved to eat and gained weight out of control. Parents were quite happy that their children’s weight is under control due to physical activity.

Facilitator 3: development

Another benefit of participation in physical activity was revealed to be individuals displaying development in different areas. Some of the developments communicated during interviews were ‘motor skill development’. Prior to participation in physical activity, parents acknowledged that their children’s motor skills (e.g. balance, walking, pedaling) were insufficient. However, with regular participation, individuals reached a very good level. Another development was in the ‘social ability development’ aspect. The social environment involved in physical activity encouraged reciprocal relationships. This situation had a positive impact on the daily life of the individual.

Facilitator 4: positive attitude

Physical activity made individuals with ASD more positive and individuals progressed in terms of ‘accepting rules’ and ‘reducing unwanted behavior’. It is thought that the existence of a certain order and discipline in physical activity was effective in these terms. In line with the contributions to individuals with ASD, physical activity should not be forgotten along with academic education.

Interpersonal factors

For the second factor in the findings of interpersonal factors, participating parents were asked questions in order to understand the constraints and facilitators due to interpersonal situations which affected participation in physical activity of adolescent children with ASD (Table 3).

Table 3.

Interpersonal factors affecting participation in physical activity of adolescent individuals with ASD.

Interpersonal constraints
Themes	Codes
Constraint 1: Prejudices	Lack of friends Negative approaches Exclusion
Constraint 2: Family’s attitude	Lack of adequate time or energy of parents Overprotectiveness of parents Having siblings
Interpersonal facilitators
Themes	Codes
Facilitator 1: Family’s attitudes	Perspective on physical activity Decisive and motivated parents Sibling support
Facilitator 2: Attitudes of close surroundings	Conscious friend group Tolerant neighbors

Interpersonal constraints

In line with responses given by parents, the themes of ‘prejudices’ and ‘family attitude’ were determined among interpersonal factors constraining participation in physical activity of individuals with ASD.

Constraint 1: prejudice

The different behavior and approaches of ASD individuals brings them to a different point in society. The society’s perspective towards these different behaviors is effective in the ‘lack of friends’ of individuals with ASD. Attitudes of people towards them plays an important role in the inclusion of ASD individuals in social environments. It seems that there is a general intolerance towards individuals with ASD in the society. This situation causes ‘negative approaches’ towards individuals with ASD. In line with an intolerance of different behaviors and negative approaches of peers, teachers, other parents and many institutions in that society, individuals with ASD face ‘exclusion’.

They have no friends in the neighborhood. They only have a close cousin who is their age (…) Differences begin to form in the games played by an 11-year-old child with autism compared to a child with normal development. As a result, they don’t want them around. Other children grow, but autistic children stay young and we have difficulty finding them friends. (Ayşe, 38)

Constraint 2: family attitude

Families have a significant effect on participation in physical activity by individuals with ASD. The approaches, opinions and general attitude of parents directly affect this situation. The greatest constraint due to parents appears to be ‘lack of adequate time or energy of parents’. Many parents in the study group work at least five days a week and return home late because of their work. This situation affects parents both in terms of time and energy. Another code that emerged was ‘overprotectiveness of parents’. Parents actually have options in terms of participation in physical activity, but they are afraid of other children’s cruel and intolerant approaches. Behavioral problems and negative behaviors of the individual with ASD are another factor that raises concerns. In some situations, the ASD individuals ‘having siblings’ was stated to be a constraint.

Interpersonal facilitators

Among factors facilitating participation of individuals in physical activity, themes of ‘family attitude’ again and ‘attitude of close surroundings’ were encountered.

Facilitator 1: family attitudes

The lives of all individuals with ASD were directed by the amount of time and interest allocated to them by parents. For this reason, parents ‘perspective on physical activity’ was an important factor in terms of participation. The fact that parents have a sports background or participate in physical activity is a situation that also affects their child. It is effective to be more conscious about the benefits and necessity of physical activity. In this context, ‘decisive and motivated parents’ forms another code. Every parent took responsibility for their children, supported their children to the best of their abilities and provided the same support to siblings.

I live for my daughter. I can’t make decisions alone, I can’t go anywhere on my own, it’s not possible to do anything alone. I must always do things with my daughter. My daughter has to do things with me. In other words, I’ve dedicated my life to my daughter. Not everyone is like me. I don’t work and I’ve dedicated my whole life to my daughter. I am my daughter’s chauffeur, her friend, her teacher, her sports coach, her music teacher, her cook, I’m everything. (Burak, 50)

Facilitator 2: attitude of close surroundings

Just as for everyone, the approach toward ASD individuals by people in the family and close surroundings that individuals with ASD interact with during daily life were stated to be an important facilitator. The codes ‘conscious friend group’ and ‘tolerant neighbors’ emerged in this theme.

Environmental factors

Another factor in the findings of environmental factors directed questions to parents about the constraints and facilitators due to the environment which were effective on participation of adolescent children with ASD in physical activity (Table 4).

Table 4.

Environmental factors affecting participation in physical activity of adolescent individuals with ASD.

Environmental constraints
Themes	Codes
Constraint 1: Adapted physical activity opportunities	Lack of adapted physical activity program Lack of competent adapted physical activity coach Prices of adapted physical activity programs
Constraint 2: Physical activity facilities not meeting expectations	Lack of physical activity facilities Distance to physical activity facilities Rules of physical activity facilities
Constraint 3: Safety and facilities	Lack of safety of neighborhood Inadequate areas and equipment
Constraint 4: Climatic conditions	Inadequate socioeconomic conditions Weather conditions
Environmental facilitators
Themes	Codes
Facilitator 1: Neighborhood and facilities	Suitability of environment or equipment Accessible facilities
Facilitator 2: Adapted physical activity opportunities	Accessible adapted physical activity opportunities Competent adapted physical activity coaches

Environmental constraints

In line with the parents’ responses, environmental factors obstructing individuals with ASD from participating in physical activity were determined to have the themes of ‘adapted physical activity (APA) opportunities’, ‘physical activity facilities not meeting expectations’, ‘safety and facilities’ and ‘climate conditions’.

Constraint 1: adapted physical activity opportunities

APA plays an important role in the movement of ASD individuals, allowing them to socialize and be physically active when included in a program. However, nearly all parents had difficulty finding suitable programs for their children. For this reason, they wanted to enroll in the programs that individuals with ND, but every official who heard the word ‘autism’. cancelled the registration. Even if they found one, it is stated that due to the difficulty of working with individuals with ASD, the fees are higher than the courses of individuals with ND. The ‘lack of authorized coach’ in existing programs was another worrying factor according to parents’.

Constraint 2: physical activity facilities not meeting expectations

According to interviews, finding a suitable physical activity facility for individuals with ASD is difficult. ‘Lack of physical activity facilities’ affiliated with state institutions and private enterprises were effective in this situation. In addition, there are parents who spend a total of four hours reaching the physical activity facility and returning home in our study group. In line with this, ‘distance to physical activity facilities’ making it difficult to participate for individuals with ASD. The ‘rules’ that apply throughout the facilities (e.g. separated women’s and men’s days, separated lines) were another factors affecting participation.

Constraint 3: safety and facilities

Most of the parents in the study group live in the city center and close to the main streets. According to this situation, ‘lack of neighborhood safety’ was a constraint to participation in physical activity. The structure of the city was also not suitable for physical activity, and the activity areas were narrow.

In another code of the related title, the majority of parents defined autism as a rich disease and stated they could not ensure physical participation of their children due to ‘inadequate socioeconomic conditions’. In this case, the cost of school expenses, special education center’s tuitions, expensive psychological/pharmacological medications and psychiatrist sessions play an important role.

Constraint 4: climatic conditions

When examined in terms of environmental factors, it was stated that climate conditions were effective on participation in physical activities.

We take him to parks and gardens, they are not close. But we go. Weather is a little effective. If it’s cold you don’t want to go out. (Damla, 49)

Environmental facilitators

In line with the opinions of parents, facilitating themes and codes among environmental factors were ‘neighborhood and facilities’ and ‘APA opportunities’.

Facilitator 1: neighborhood and facilities

Parents stated that the facilities and opportunities of their neighborhoods and surroundings were effective in their children being active. From this aspect, the first code in this theme was ‘suitability of environment or equipment’. As a result of interviews, other codes were determined to be ‘accessible facilities’ and ‘accessibility of APA programs’.

We live in a complex. There are walking areas around us, sports areas too. It’s a suitable place for physical activity. Even in the winter months, we benefit from these areas as much as possible. (Esra, 44)

Facilitator 2: adapted physical activity opportunities

As a result of interviews, it was determined that ‘adequate coaches’ was important in programs for parents who found suitable physical activity programs. Motivating, happy and positive coachs had a significant impact during the participation and even continuation of the programs for individuals with ASD.

Institutional factors

For another factor in the research of institutional factors, participating parents were asked questions to understand the constraints and facilitators affecting participation in physical activity of adolescent children with ASD in relation to institutions where they spend most of their time during the day (Table 5).

Table 5.

Institutional factors affecting participation in physical activity of adolescent individuals with ASD.

Institutional constraints
Themes	Codes
Constraint 1: Negative physical activity approach of institutions	Quality of school physical education lessons Cost of physical activity lessons in special education centers
Institutional facilitators
Themes	Codes
Facilitator 1: Positive physical activity approach of institutions	Real physical education lessons Physical activity lessons in special education centers

Institutional constraints

In line with the responses given by parents, the institutional factors obstructing physical activity participation of individuals with ASD were determined in the theme ‘negative PA approaches of institutions’.

Constraint 1: negative physical activity approach of institutions

In order for individuals with ASD to receive education within the formal system as inclusive students, they receive supportive education in special education centers. For individuals who finish school, education continues in special education centers. The facilities for individuals with special needs in both these environments were very limited for physical activity. The absence of physical education lessons or physical education teachers and the inadequate physical education hours were examples of constraints according to schools. Cost of physical activity lessons in special education centers was also a constraint to participation.

Institutional facilitators

Facilitating themes and codes under the heading ‘positive PA approaches of institutions’ are given by quotations from responses of parents below.

Facilitator 1: positive physical activity approaches in institutions

Individuals with ASD spend the majority of their days in educational institutions for a variety of purposes. These institutions are mainly schools or special education centers. In relation to these institutions, parents stated their opinions in the codes ‘real physical education lessons’ and ‘PA lessons in special education centers’.

My child spends most of his time during the day in school. There are physical education lessons in school. I don’t know the time, but I think they are supportive in the sense of physical activity. Everyday my son waits for the service bus all ready ‘I will go to school, I will play games in school’ he says. I’ve never seen him not want to go. If he could, he’d even go on Sundays. (Damla, 49)

Public policy factors

Another factor in the research of public policy factors directed questions about constraints and facilitators in current policies that affect participation of adolescent individuals with ASD in physical activity to participating parents (Table 6).

Table 6.

Public policy factors affecting physical activity participation of adolescent individuals with ASD.

Public policy constraints
Themes	Codes
Constraint 1: Current policies not meeting expectations	Not informing parents about adapted physical activity programs Not attaching importance to the physical activity needs of autistic individuals Lack of financial support for physical activity to parents Lack of training for coaches for adapted physical activity programs Inadequate socioeconomic conditions
Public policy facilitators
Themes	Codes
Facilitator 1: Improvements to policies	Increased importance given to disabled people Discounts in physical activity facilities for disabled individuals

Public policy constraints

In line with responses given by parents, the public policy factors obstructing participation of individuals with ASD in physical activity were gathered under the theme of ‘current policies not meeting expectations’.

Constraint 1: current policies not meeting expectations

Public policies in relation to any topic may be generally assessed by principles upheld and administrative organs acting in accordance with the state’s legal and corporate traditions. Just as these policies affect every individual, they closely affect individuals with special needs. In the final stage of the socioecological model used to investigate the effects of current policies on participation in physical activity of individuals with ASD, parents first stated that ‘lack of information about APA programs’ and ‘lack of importance given to PA requirements of autistic individuals’ were each constraints.

Parents of children with ASD encounter a variety of economic difficulties when meeting their needs and education. The state provides certain hours of academic educational support each week; however, they stated this was not the case in the sense of physical activity. An extra expense such as physical activity could be difficult for parents who can allocate a certain amount of their remaining salary to their children after compulsory needs. In this context, another code was ‘lack of financial support for parents about PA’. Parents stated that the child can progress in any area to the degree to which they can provide a budget for that area. In addition, ‘lack of training of coaches for APA programs’ were another important issue that needed to be resolved/improved by the parents.

I have a certain amount of salary. However, I have children. I can only allocate a certain budget from my salary for my children. Your child will socialize to the degree to which you can allocate a budget for this. Our state provides educational facilities which we can benefit from free of charge each week for special education. Similarly, we should be offered activities related to physical activity. In this way, children will become better both physically and mentally. But at the moment, the state is limited to certain hours and provides support for special education lessons. Apart from this, there is no support in the sense of physical activity. In our educational center, there is a physical activity classes. But you need to pay for sure. What can we do? It’s better than nothing… (Banu, 41)

Public policy facilitators

Facilitators and codes under the heading ‘improvements in policies’ are given below in line with responses of parents.

Facilitator 1: improvements to policies

Parents communicated that there was development of current policies in line with the increase in numbers and needs of individuals with special needs in our interviews. In line with this, the codes ‘increased importance given to the disabled’ and ‘discounts for disabled individuals in physical activity facilities’ were encountered.

Discussion

The research is an important study in terms of investigating factors affecting participation in physical activity of individuals with ASD in the adolescent period. When the literature is investigated, there are few studies about individuals in this age group which encouraged us to perform this research. In the adolescent period individuals with ASD have more free time compared to their peers, development is observed most clearly and problems increase in line with this, which appear to be very important for participation in physical activity. Interviews with parents representing their children investigated factors affecting participation in physical activity in terms of socioecological factors. The constraints and facilitators revealed by this research using the conceptual framework of the socioecological model (McLeroy et al. 1988) were grouped according to intrapersonal, interpersonal, environmental, institutional and public policy factors.

Constraints to participation in physical activity

According to findings of our research, it appears individuals with ASD face more constraints compared to ND individuals. In studies completed from the perspective of parents (Gyurcsik et al. 2006, Obrusnikova and Miccinello 2012), the most commonly stated constraints were personal and this is compatible with our research in this context. Inadequate social and communication deficiencies, dependence on parents, inadequate motor skills, lack of interest in surroundings and side effects of psychological medications were stated in our findings (Ohara et al. 2019, Pan 2009).

Though individuals with ASD acquire many skills like their peers, it is stated that they acquire these skills later than peers due to deficient interest in their surroundings. Compatible with our research, studies have stated that individuals with ASD are aware of this deficiency (Frith and Happé 1999) and this situation negatively affects participation in physical activity of individuals. In line with the parents’ opinions, individuals with ASD were not interested in their surroundings and experienced attention deficit. Also with lack of interest in surroundings encountered as an intrapersonal constraint to physical activity participation. Additionally, parents stated that individuals with ASD may use a variety of psychological/pharmacological medications in order to be more productive in their activities. Using psychological/pharmacological medications were observed to have a reduction in temper tantrums and aggressive attack numbers; however, side effects like increased appetite, dizziness, increased salivation, lethargy and fatigue were observed individuals (McCracken et al. 2002). These observed side effects, affect participation negatively. In order to prevent or reduce these factors affecting participation, it will be very effective especially for parents to receive support and correct guidance on the issues that their children are lacking. Psychiatrists, special education specialists and physical activity trainers/physical education teachers can play important roles in this orientation. With early interventions, it may be easier for the individual to develop himself in the areas where he is deficient and to resist the constraints he/she encounters.

Another constraint affecting participation in physical activity of individuals with ASD were interpersonal constraints. In terms of findings, individuals with ASD ignore social or physical contact and dismiss other people. Parents communicated that one of the most significant interpersonal constraints to participation in physical activity was lack of friends. One of the most important factors in the inability to make friends appears to be exclusion (Healy et al. 2013). Planning activities where individuals with ASD and ND can be together and have the opportunity to get to know each other is very critical at this point. In addition, parents’ knowledge of disorders such as ASD and informing their children accordingly can be very effective in coping with these and similar constraints.

In line with the findings of our research, parents avoid their children facing similar risks during participation in physical activity and display a more protective attitude and this situation negatively affects participation of individuals with ASD. It seems very necessary to carry out researches in order to examine the reasons behind the over-sensitive and protectiveness of parents with children with ASD. Lack of adequate time or energy of parents appears to be another factor making participation in physical activity more difficult for individuals with ASD (Obrusnikova and Cavalier 2011). According to working parents who have children with ASD to have flexible/less working hours, would be beneficial for them to save time and energy.

Another stage in the socioecological model of constraints encountered in environmental factors were determined in line with participant opinions. In line with the opinions of parents, they stated that the lack of adequate numbers of APA programs was a constraint to their children participating in physical activity (Obrusnikova and Miccinello 2012). For participation in available programs, parent pay a fee to include their children. The cost of APA programs appears to be a constraint for parents because all of our study group had difficulty in terms of inadequate socioeconomic conditions. This situation directly affected participation in physical activity (Russell et al. 2011, Memari et al. 2015). Establishing unpaid APA programs that all individuals with ASD can participate in and providing regular financial support to all parents with children with special needs would play a significant role in this regard.

Due to a variety of inadequacies, they attempted to avail of opportunities present in their neighborhood for their children; however, parents stated that the lack of safety of the environment significantly limited the areas their children could use (Prellwitz and Skär 2007). Low numbers of facilities for physical activity and unsuitable construction were revealed (Menear et al. 2006). Parents stated that they wanted to use physical activity facilities; however, facility design was not suitable for use by disabled individuals and many facilities were not accessible to disabled individuals (French and Hainsworth 2001, Gürkan and Koçak 2020). From this point, by increasing and arranging the physical structures and customer policies of the facilities and making each facility available to individuals with ASD would play a very important role in the participation of individuals in physical activity.

Individuals with ASD spend a large part of their day in a variety of institutions with the aim of receiving education. Most adolescent individuals with ASD in our research group spent at least 5 h a day in school. The same individuals may attend special education centers for the remainder of the day to continue with extra education. In line with parent opinions, physical education lessons in schools appear to be inadequate and physical education teachers have negative attitudes towards individuals with special needs (Block and Obrusnikova 2007). After questioning the proficiency levels of physical education teachers/trainers assigned in institutions, they should be accepted to work. Additionally, for existing teachers/trainers, an inspection system will be effective in order not to encounter existing these kind of constraints again.

In the final stage of the socioecological model affecting participation in physical activity, constraints in terms of public policies were determined. Parents support their adolescent children with ASD to participate in physical activity, but the perceived cooperation support from public services is not sufficient. It is quite difficult for parents to cope with such situations on their own, without support (Arnell et al. 2020). Though parents know the benefit of physical activity, their information about where and how to participate is limited. They need to be informed about this topic by authorized people; however, they stated that this information service does not occur. Parents should be contacted in this regard and necessary guidance should be provided by the authorities. Also it was considered that coaches in APA programs attended by their children were not adequate (Dwyer et al. 2008). Lack of inclusion of more educated and experienced authorized coaches was stated to be another constraint within this factor. Considering the working with people with special needs in a field, theoretical and applied courses in this field should be added or the qualifications of the existing courses should be improved for students in relevant faculties within the bachelor level. From a different perspective, the fact that the coaches had lack of experience in physical activity with individuals with ASD (Cynthia et al. 2019) may have given these parents the impression that these coaches were inadequate.

As one of the most important factors in line with the findings, it appears the prices for participation in physical activity were higher for individuals with ASD (Russell et al. 2011, Memari et al. 2015). Information sessions should be held to ensure families and special education centers are aware of programs created for children with ASD. Additionally, current policies should be reviewed in terms of reducing the fees for participation. The quantity and quality of physical activity and sport activities for individuals with ASD can be improved through such as municipalities allocating more budget, organizing volunteer activities, sponsor support and projects.

Facilitators to participating in physical activity

Physical activity is known to have countless benefits to both physical and mental health of individuals. However, individuals with ASD cannot benefit from these due to a variety of constraints they encounter (Gürkan and Koçak 2020). There are a variety of facilitating factors in overcoming these constraints affecting participation of individuals with ASD in physical activity (Sarol 2017). Just like constraints encountered in line with the socioecological model, facilitating factors were investigated in five headings.

The first stage of the socioecological model is intrapersonal facilitators. In line with the opinions of parents, individuals with ASD enjoyed physical activity, and their confidence in themselves increased as a result of recognition of what they had done and feelings of success. Participation in physical activity was communicated to be an activity enjoyed by individuals with ASD. One of the most important benefits of physical activity is stated to be positive effects on health (Stanish et al. 2015). Physical activity appears to be an important tool to prevent health problems. In line with this, physical activity increased the physical and mental health of individuals. Stating that development had multiple aspects and that people were continuously interacting, Payne and Isaacs (2017) stated that people without full completion of this development including motor development could not fully understand themselves. Participation in physical activity appears to be a facilitating situation for individuals with adequate levels of motor development.

Another socioecological factor effective in participation of individuals in physical activity is interpersonal facilitation. It appears perspective is effective on participation in physical activity of individuals. From this aspect, though not clearly stated by individuals with ASD, parents shared their own observations and ideas in line with their opinions. In our research, the individual with ASD having siblings was stated to be both a constraint and a facilitator. Though parents state that time spend with other children is a constraint, most of the time the individual with ASD having a sibling was stated to be a facilitator for participation in physical activity (Obrusnikova and Miccinello 2012). This is because it supports the individual with ASD and prevents them from being left alone. Also, as understood from the opinions of parents, the individual with ASD having friends is very effective on their participation (Obrusnikova and Cavalier 2011, Buchanan et al. 2017, Gürkan and Koçak 2020). The impression made on individuals during physical activity appears to be important for participation in the future.

Another stage in the socioecological model of factors affecting participation in physical activity is environmental facilitators. Parents stated that a suitable environment or equipment near where they live with their children was a facilitating factor for participation in physical activity (Obrusnikova and Miccinello 2012). However, very few parents stated that they had this opportunity. Additionally, another important finding about facilitation of physical activity participation is the important role of APA programs suitable for individuals with ASD, appealing to them and providing education suitable for their level. For parents with difficulty finding APA programs, accessible APA programs are an important factor facilitating participation (Sarol and Çimen 2015). Authorized APA coaches were encountered as a very important factor for adapting activities to individuals with ASD (Must et al. 2015).

Another heading in our research findings of institutional facilitators was determined in line with parent opinions. When institutional constraints are investigated, it appears the quality of physical education lessons in schools attended by individuals with ASD is inadequate. Most parents shared this view. Only two parents in our study group stated that their children had good physical education lessons and were satisfied. Special education centers, where some individuals spend the majority of their day and others visited after school, providing physical activity lessons was stated to be a facilitator.

The final stage of the socioecological model included public policy facilitators. Parents stated that many disabled sportspeople had obtained sporting success on a global scale in line with current policies and investments. Additionally, nearly all parents were observed to benefit from discounts for municipal council physical activity facilities. Parents with financial difficulties appeared to be very satisfied with this situation. However, what is important for parents is that their children with ASD are physically active. When facilitators effective on participation in physical activity in terms of public policies are examined, it is notable that there were very few opinions about this topic.

Based on all these findings, adolescent individuals with ASD encountered many constraints to participating in physical activity. In conclusion, they participated in physical activity; however, it was understood that facilitating factors were not at adequate levels to overcome constraints. In line with the opinions of parents, there appear to be more constraints to participation in physical activity for adolescent individuals with ASD compared to facilitators. All parents thought physical activity was required for their children and the results of the research revealed that the constraints encountered were greater than the facilitating factors.

Future research should be completed with different age groups. Opinions may be obtained from individuals directly by performing similarly-designed qualitative studies for different disability groups. Additionally, studies may be performed about concepts like coping strategies and motivation among people with disabilities. Quantitative studies may be performed in order to develop model proposals and understand this topic in depth.

Disclosure statement

No potential conflict of interest was reported by the authors.