Effects of Creative Movement, General Movement, or Seated Play Interventions on Motor Performance in Children with Autism Spectrum Disorder: A Pilot Randomized Controlled Trial

Abstract

Background:

Children with ASD experience significant gross motor challenges that could be addressed using motor interventions. However, contemporary ASD interventions that are sedentary in nature often target communication and fine motor skills and not children’s gross motor difficulties.

Methods:

In the current pilot RCT, we evaluated changes in various motor outcomes (i.e., gross/fine motor coordination, locomotor skills, functional endurance, and praxis/imitation performance) following two types of whole-body motor interventions (Creative Movement (CM) or General Movement (GM)) and compared them to a Sedentary Play (SP) intervention focused on improving fine motor skills in children with ASD. Forty-five children with ASD (Mean Age ±SE: 8.7 ± 0.3, 38 males) were randomly assigned to the CM, GM, or SP groups and received 8 weeks of group-specific training.

Results:

Both CM and GM interventions led to medium-to-large improvements in gross motor performance, including improved body coordination, strength/agility, locomotor skills, and walking endurance. Children in the CM group additionally showed medium-to-large-sized improvements in praxis performance, while children in the SP group showed improvements in fine motor performance. These training-related improvements were supported by improvements reported via parental questionnaires.

Conclusions:

Researchers and clinicians should incorporate whole-body interventions targeting gross motor skills in the plan of care for children with ASD.

Graphical abstract

1. Introduction

Autism Spectrum Disorder (ASD) is one of the most prevalent neurodevelopmental disorders, affecting 1 in 36 children in the US (Maenner et al., 2023). The hallmarks of ASD include challenges in social communication skills such as poor use of verbal and nonverbal communication during social interactions as well as the presence of repetitive behaviors such as motor stereotypies (e.g., arm flapping, body rocking) and restricted interests such as fascination with certain topics and objects (American Psychiatric Association, 2013). Besides these core symptoms, children with ASD often encounter concurrent motor difficulties, such as poor body coordination, balance, strength, agility, locomotor skills, functional endurance, as well as impaired praxis/imitation skills (Bhat et al., 2011, Bhat 2020, 2021; Bhat, 2023a, 2023b, Bhat et al., 2023c; Kaur et al., 2018; Fournier et al., 2010). Recent findings from the nationwide SPARK study indicate that 87–88% of children with ASD were at risk for motor impairment. However, despite the high prevalence of motor difficulties, only 32% of children with ASD receive physical therapies and only 13% receive recreational therapies (Bhat, 2020, 2021, 2023a). In contrast, 85% of children with ASD receive speech or occupational therapies that often target communication and fine motor skill performance, respectively (Bhat, 2023a). With greater motor impairment, one would expect greater proportion of services, however, the receipt of physical or recreational therapy services remained low compared to the high proportions of speech and occupational therapy services (Bhat, 2023a). This discrepancy in service access underscores the urgent need for robust evidence to support the use of gross motor interventions (i.e., physical and recreational therapy) for children with ASD (Bhat, 2023a). There is a growing body of evidence for whole-body, creative movement therapies (e.g., yoga, music, dance, martial arts), physical activity, and general exercise/games to improve motor performance in children with ASD (Ruggeri et al., 2020; Amonkar et al., 2021). However, the precise training effects of these movement-related interventions compared to standard of care, as well as the differential effects of various types of movement interventions remain poorly understood. Therefore, in the current pilot Randomized Controlled Trial (RCT), we compared the effects of a synchrony-based Creative Movement intervention (CM, incorporating music, dance, and yoga activities), physical activity-based General Movement intervention (GM, using exercise/physical activity and locomotor games), and standard of care, Sedentary Play intervention (SP, focusing on reading and fine motor skills) on the motor performance of children with ASD including changes in gross and fine motor coordination, locomotor skills, functional endurance, and praxis/imitation performance.

Children with ASD often encounter a range of gross and fine motor challenges, including motor incoordination, reduced functional strength and endurance, atypical gait/locomotor skills, as well as impaired fine motor dexterity compared to their Typically Developing (TD) peers (Bhat et al., 2011; Bhat, 2020; Kangarani-Farahani et al, 2023; Kushki et al., 2011; Wang et al., 2022). For example, a comprehensive systematic review comprising 114 studies revealed substantial ASD-related disparities in object control and balance/posture proficiency (Kangarani-Farahani et al., 2023). Similarly, a review on fine motor skills also suggested slower and less proficient handwriting, potentially influencing the academic performance of children with ASD compared to their TD peers (Kushki et al., 2011). Remarkably, the motor challenges displayed by children with ASD extend beyond controlled environments, manifesting within social contexts, such as when imitating and synchronizing movements with others (Edwards, 2014; Kaur et al., 2018; Su et al., 2021). Kaur et al. (2018) reported impaired praxis performance and diminished interpersonal synchrony among children with ASD during joint marching and clapping with an adult partner. These motor difficulties in children with ASD are linked to their social communication and cognitive abilities, and autistic severity, highlighting the multisystem nature of the disorder and how interconnected motor skills are to a child’s social communication and cognitive performance (O’hara et al., 2019; Bhat, 2021; Bhat et al., 2022; Bhat, 2023b). Motor difficulties in children with ASD are said to contribute to reduced social engagement and participation, further hindering opportunities for social interactions with peers and caregivers (Oliveira et al., 2021).

Despite the widespread prevalence of motor difficulties in children with ASD and its direct influence on children’s social performance, promoting gross motor skills and physical activity remains a low priority within contemporary ASD intervention approaches. Using principles from approaches such as Applied Behavior Analysis (ABA; Lovaas, 1987), Picture Exchange Communication System (PECS; Bondy & Frost, 2001, 2003), and Teaching and Education of Autistic and Related Communication Handicapped Children (TEACHH; Mesibov et al., 2004), contemporary interventions provide repeated practice and reinforcement of desired social communication skills such as joint attention, verbal and gestural communication, and positive behaviors/compliance within daily/educational activities. While these contemporary approaches have been found to benefit receptive and expressive language acquisition, reduce negative behaviors, and improve adaptive functioning (Reichow et al., 2018), the majority of these interventions are conducted while the child is seated/sedentary, and place limited emphasis on gross motor skills training, whole-body coordinated movement, or exercise. In the current pilot RCT, we compared the training effects of SP interventions against two whole-body movement interventions focused on gross motor skills: (i) Creative Movement (CM, utilizing music, dance, and yoga-based activities) and (ii) General Movement (GM, using exercise and indoor sports/games) against (iii) a Sedentary Play (SP) control group intervention emphasizing fine motor skill development through seated play using building and art-crafts to mimic occupational therapies (i.e., the current standard of care) for children with ASD. Our past work has found improvements in gross motor skills following creative movement interventions (i.e., yoga and musical/rhythm training) (Kaur & Bhat, 2019; Srinivasan et al., 2015). However, it is unclear whether the socially synchronous nature of the training or the physical exercise/movement training aspects led to motor improvements. Thus, in the current pilot RCT, we compared the motor effects across three intervention groups: (i) a CM intervention using socially synchronous musical, dance, and yoga activities, (ii) a GM intervention based on exercise games that were done in an individual/turn taking fashion in the absence of music and (iii) a standard of care, SP intervention focused on fine motor skills training in children with ASD including changes in various aspects of motor coordination, functional endurance, and praxis skills.

In light of the growing focus on motor challenges faced by children with ASD (Bhat, 2020, 2021, 2023; Bhat et al., 2022; Miller et al., 2024), it is encouraging that CM interventions could address the multisystem impairments of children with ASD including their motor, social communication, and cognitive challenges (Amonkar et al., 2021). Using yoga and musical/rhythmic whole-body movement activities, our previous pilot RCT suggested training-related improvements in gross motor performance, and imitation/praxis skills in children with ASD (Kaur & Bhat, 2019; Srinivasan et al., 2015). In a comprehensive systematic review spanning various CM modalities (e.g., music, dance, yoga, theater, and martial arts), we observed small-to-large-sized improvements in social communication after music/rhythm-based and martial arts-based therapies, and medium-to-large-sized improvements in motor and cognitive domains after yoga and martial arts training (Amonkar et al., 2021). Despite the diverse types/contexts of CM interventions, they all provide an enjoyable environment that naturally encourages social communication, imitation/interpersonal synchrony, and learning/practice of gross motor skills (Srinivasan & Bhat, 2013). However, whether the socially synchronous or the physical exercise/movement training aspects of the CM intervention lead to the motor improvements remains unclear. Therefore, in the current RCT, we combined rhythm-based music, dance, and yoga activities and developed a socially synchronous CM intervention that is less specific to certain activity types, while being equally enjoyable for children with ASD. We compared the CM intervention to a general motor exercise/game-based GM intervention to control for pure motor training effects. Our aim was to create two motor interventions that can be readily incorporated by clinicians, educators, and parents during daily services provided to children with ASD.

Regular exercise/physical activity, active play, and sports participation are known to improve the gross motor skills of children with ASD (Ruggeri et al., 2020; Pan et al., 2017; Rafiei Milajerdi et al., 2021; Healy et al., 2018; Ji et al., 2023). For example, Rafiei Milajerdi et al. (2021) reported notable improvements in motor skill proficiency and executive functioning in children with ASD after 12 weeks of physical activity intervention. A recent meta-analysis of 13 RCTs, encompassing over 500 children with ASD, also found improved locomotor, object control, and postural/balance skills after exercise interventions (Ji et al., 2023). Interestingly, while studies involving creative movement and general movement interventions have both demonstrated positive effects on motor performance in children with ASD, the intervention approaches have not been compared within the same study to understand their precise effects on motor performance. Creative movement fosters social engagement and naturally encourages social awareness, imitation practice, and interpersonal synchrony with partners which conventional exercise/activity might not offer (Srinivasan & Bhat, 2013; Srinivasan et al., 2014). Thus, in the current pilot RCT, we compared the effects of a CM intervention using socially synchronous musical, dance, and yoga activities to a GM intervention based on exercise games that were done in an individual/turn-taking fashion, and a standard of care, SP intervention focused on fine motor skills training on overall motor performance of children with ASD including changes in various aspects motor coordination, functional endurance, and praxis skills. We hypothesized that the two movement interventions (CM and GM) would lead to improvements in gross motor coordination skills compared to the standard of care, SP intervention. Conversely, we expected that the SP group would exhibit greater improvements in fine motor performance compared to CM and GM interventions. Lastly, we hypothesized that the CM intervention would lead to greater improvements in praxis skills compared to both GM and SP interventions, due to its socially synchronous nature.

2. Methods

2.1. Participants

Forty-six children with ASD aged between 5 and 14 years (mean age ± SE: 8.77 ± 0.42; 40 Males and 6 Females) participated in this study. The sample size was determined using G power, based on effect sizes from previous studies that examined training-related improvements in motor and praxis performance following whole-body movement interventions (Srinivasan et al., 2015; Kaur & Bhat, 2019). For standardized motor assessments (BOT-2 BC scores), the effect size was 0.83 (Srinivasan et al., 2015), with a significance criterion (α) of 0.05 and a power of 0.80, the minimum required sample size was 14. Consequently, we recruited 15 participants per group for the current study (Figure 1).

Figure 1:

CONSORT flow chart of the current RCT.

Upon confirming eligibility, the children were matched on age bands and the level of support required (more vs. less support) and then randomly assigned to the CM, GM, or SP groups (Figure 1). Recruitment involved online and onsite distribution of fliers to local schools, ASD services, advocacy groups, and through the Simons Powering Autism Research (SPARK) participant research match service (https://www.sfari.org/resource/spark/). Interested families were screened to confirm eligibility for study participation. During the screening process, parents completed the Social Communication Questionnaire (SCQ; Rutter et al., 2003) to confirm social communication delays and provided a school/medical record confirming their child’s ASD diagnosis (e.g., a school psychologist record confirming an ASD diagnosis and/or an Individualized Education Plan for ASD-related services or a medical or neuropsychological record from a psychiatrist or clinical psychologist using the Autism Diagnostic Observation Schedule (ADOS) and/or Autism Diagnostic Interview-Revised (ADI-R) measures). Children who did not exhibit social communication delays on the SCQ or whose parents failed to provide a medical record were excluded from participation. Additionally, parents completed the Vineland Adaptive Behavioral Scales-2nd edition (VABS; Sparrow et al., 2005) and the Social Responsive Scale questionnaire (SRS; Constantino et al., 2000) to assess their child’s adaptive functions and social responsiveness respectively (Table 1). Based on SRS T scores, 25 children were in the severe range, 13 children were in the moderate range, and 7 children were in the mild range (Table 1 lists group-specific data). There were no significant between-group differences in age, sex, race, ethnicity, SCQ, VABS, and SRS scores (p > 0.05, Table 1). One child from the GM group dropped out after receiving 5 intervention sessions due to family issues (Figure 1). This study was a multisite collaboration between the the University of Delaware and the University of Connecticut. The study procedures were conducted in accordance with the Declaration of Helsinki and were approved by the University of Delaware Institutional Review Board (UD IRB, Study Approval #1539736). Parents provided written informed consent for study participation and consent to use their child’s picture for this publication. Children also provided written or verbal assent for study participation.

Table 1.

Demographic information for children assigned to the CM, GM, and SP groups.

Characteristics	CM group (n = 15) Mean ± Standard error (SE)	GM group (n = 15) Mean ± SE	SP group (n = 15) Mean ± SE
Age in years	9.1 ± 0.6	8.8 ± 0.6	8.4 ± 0.6
Sex	12M, 3F	14M, 1F	13M, 2F
Race	11C, 3AAC, 1A	6C, 5A, 1AA, 3MR	8C, 4AA, 1AAC, 2A
Ethnicity	1H, 14NH	1H, 14NH	3H, 12NH
Delivery Method (F2F, TH)	7 F2F, 8 TH	6 F2F, 9TH	7 F2F, 8 TH
SCQ scores	18.2 ± 1.8	13.3 ± 1.6	13.1 ± 0.9
VABS-II (SS)	70.4 ± 2.9	77.1 ± 3.0	75.5 ± 2.9
Communication (SS)	73.6 ± 3.0	81.6 ± 3.3	80.1 ± 4.0
Daily living (SS)	72.1 ± 3.5	81.4 ± 3.5	79.3 ± 2.7
Socialization (SS)	68.9 ± 3.2	74.9 ± 3.5	74.1 ± 3.6
SRS (T scores)	78.4 ± 2.9	74.1 ± 1.4	74.1 ± 1.5
SRS Severity Level	10 severe, 4 moderate, 1 mild	7 severe, 5 moderate, 3 mild	8 severe, 4 moderate, 3 mild
DCD-Q total score	41.3 ± 2.7	44.2 ± 2.6	41.5 ± 1.9

SCQ = Social Communication Questionnaire; VABS-II = Vineland Adaptive Behavior Scale - 2nd Edition; SRS = Social Responsiveness Scale; DCD-Q = Developmental Coordination Disorder Questionnaire; SS = Standard Score; M = Male; F = Female; C = Caucasian; A = Asian; AA = African American; AAC= African American-Caucasian; MR = More than one race; H = Hispanic; NH = Not Hispanic; F2F = Face to Face; TH = Telehealth. No significant group differences were found for the listed baseline measures.

2.2. Experimental Procedures

The current pilot RCT spanned 10 weeks, during which 16 training sessions were provided over an 8-week period at the frequency of 2 sessions per week. Pretests and posttests were conducted before and after the training sessions (Figure 1). Before the training period, a parent orientation was conducted in person or through Zoom to introduce the training activities. Each training session had a duration of approximately 60–90 minutes (Training time (mean ± SE): CM: 78.6 ± 3.9; GM: 73.1 ± 5.4; SP: 71.3 ± 3.3; no significant differences between groups). The study was carried out during the COVID-19 pandemic from 2020 and 2022. Due to the early lockdowns and later social restrictions on participation, we incorporated a hybrid model and gave the families the option to choose between face-to-face (F2F) or Telehealth (TH) training delivery based on their comfort level of engaging in social interactions during the pandemic (Bhat et al., 2021; Su et al., 2021; Srinivasan et al., 2021). Out of the total 45 participants who completed the entire training protocol, 20 children completed the sessions in a F2F manner, while the remaining 25 children opted for TH sessions (participants were evenly distributed between the two formats in all groups, p > 0.05; Table 1). The F2F training sessions were conducted in the lab or at the child’s home, while the TH sessions were conducted using Zoom video conferencing while the child was at home and interacting with the trainer through their computer screens. Parents in both subgroups were encouraged to participate in the intervention. To address the technological challenges associated with TH, we met with the parents in advance to - assist with setting up the videoconferencing technology/software, inform them of training goals, identify the training materials, session activities, and convey their role within the training sessions. Additionally, we communicated the training goals and provided parents with the training materials to ensure a smooth session. Note that we have compared the magnitude, variability, and change in outcome measures between the TH and F2F subgroups for each of the 3 groups and outcomes were similar across the 2 delivery methods for each of the 3 intervention groups – CM, GM, and SP (Su et al., 2023, 2024a, 2024b). Hence, we have pooled the data across the TH and F2F subgroups for each of the 3 intervention groups.

2.3. Training Protocol

The CM group engaged in rhythmic musical, dance, and yoga-based activities focused on improving whole-body coordination, praxis, and interpersonal synchrony. The GM group, on the other hand, employed exercise and locomotor games to target coordination, strength, and endurance. The SP group engaged in seated/sedentary play modeled around standard of care and involved reading, building, and art-craft activities to enhance communication and fine motor performance. All three interventions used strategies from the approaches of Applied Behavior Analysis (ABA), Picture Exchange Communication System (PECS), Treatment and Education of Autistic and related Communications Handicapped Children (TEACCH), and motor learning to provide structure, repetition, reinforcement, and opportunities for improvisation and free exploration. During the intervention, visual, verbal, and manual prompts/assistance were provided as required by the child along with positive reinforcement using verbal and gestural reinforcers or favorite activities. Children were encouraged to choose from a range of suggested actions and could improvise to include their own movements. A picture schedule was used to inform the child of the activity plan and provide structure to each session.

Each session included an expert trainer (i.e., a physical therapist or a developmental expert with experience working with children), a model (i.e., an undergraduate student or the parent of the child), and the participating child. The expert trainer guided the child through specific activities, while the model/parent acted as a buddy, providing visual models and assistance to the children. For the F2F intervention delivery format, a trained undergraduate student acted as the model, while for the TH format, the parent was pre-trained to assist their child during the intervention. To ensure consistency, two one-hour meetings were conducted in-person or via Zoom with the undergraduate student and parent to explain the training goals, intervention principles, and the main training activities depending on the intervention type. To ensure the fidelity of training, a student coder randomly selected and coded one early (sessions 1–5) and one late session (sessions 12–16) for each child, using a fidelity checklist to assess the trainer’s delivery of activities (Supplementary information, Table S2–S4). The training fidelity scores were consistently above 90% for all three groups (CM: 91.7 ± 0.7; GM: 91.7 ± 0.7; SP: 91.0 ± 0.9). In the following sections, the specific training activities offered to the CM, GM, and SP groups will be explained.

2.3.1. Creative Movement (CM) Intervention (Figure S1):

Children in the CM group received a synchrony-based intervention across different contexts, including (A) Hello game: the trainer and the child greeted each other, sang the hello song, and moved together; (B) Action game: the child gestured to the music and played hand-clapping games with the trainer/model; (C) Warm-up: the trainer and the child stretched, breathed, and moved together with music to warm up their bodies; (D) Music Time: the child played a variety of percussion instruments (drums, tambourines, etc.) together with the trainer/model in a synchrony/imitation format; (E) Moving game: the child performed whole-body rhythmic actions and locomotor skills during dance activities; (F) Yoga and breath: the child held yoga poses described in a song, a story, or game while practicing different breathing patterns and relaxation techniques; (G) Farewell song: the child reflected on the session, shared favorite activities, sang a farewell song, and said goodbye to partners (Supplementary Table S1; Supplementary Figure S1).

2.3.2. General Movement (GM) intervention (Figure S2):

Children in the GM group participated in exercise and games in a turn-taking manner in the absence of music/rhythm across 7 conditions: (A) Hello game: the child engaged in icebreaker games involving back-and-forth communications; (B) Warm-up: the child performed a series of dynamic stretches to prepare for the subsequent activities; (C) Grow strong: the child performed upper and lower body exercises targeting functional muscle strength; (D) Speed up: the child played ball games and navigated obstacle courses to challenge their physical endurance and locomotor skills; (E) Cool down: the child performed static stretches to relax their body and increase flexibility; (F) Breathing: the child practiced different breathing patterns with or without props; (G) Goodbye: the child reflected on the training activities by engaging in back-and-forth communication with the trainer/model (Supplementary Table S1; Supplementary Figure S2). Note that this group differs from the CM group due to a lack of music/rhythms and the use of synchronous actions.

2.3.3. Sedentary Play (SP) intervention (Figure S3):

Children in the SP group participated in sedentary/fine motor activities across various contexts, including (A) Hello: the child greeted the trainer/model and played icebreaker games that involved natural conversations; (B) Reading: the child read or listened to a picture book, answered questions, and engaged in back-and-forth conversations with the trainer/model through the use of words or picture-based options to listen and respond; (C) Warm-up: the child engaged in manual dexterity activities, such as peg boarding and beading, to warm up finger/hand muscles; (D) Building: the child built LEGO or Playdoh creations according to visual instructions; (E) Free Build: the child built creations of their choice or added more details to the creations made during the Building activity; (F) Art-Craft: the child made art-craft creations involving coloring, cutting, gluing, and folding materials, (G) Farewell: the child reflected on the session activities, cleaned up the supplies, and said bye to all partners (Supplementary Table S1; Supplementary Figure S3).

2.4. Testing protocol

We evaluated training-related changes in motor and praxis performance using standardized motor assessments, functional tests, as well as parent questionnaires before and after the intervention.

2.4.1. Bruininks-Oseretsky Test of Motor Proficiency (BOT-2; Bruininks & Bruininks, 2005):

The BOT-2 is a reliable and valid assessment that targets 4 motor area composites with 8 subscales, namely (A) Body Coordination (BC), consisting of Bilateral Coordination and Balance Subscales; (B) Strength and Agility (SA), consisting of Running Speed and Agility and Strength subscales; (C) Manual Coordination (MC), consisting of Manual Dexterity and Upper-limb Coordination subscales; and (D) Fine Manual Control (FMC), consisting of Fine Motor Precision, Fine Motor Integration subscales. The standard scores from these four motor composites were used to evaluate training-related differences in motor performance from pretest to posttest.

2.4.2. Locomotor Subtest of the Test of Gross Motor Development-Second Edition (TGMD-2; Ulrich, 2000):

We used the locomotor subtest of the TGMD-2 to assess the child’s proficiency in locomotor skills, including running, galloping, hopping, leaping, jumping, and sliding. For example, the galloping form was evaluated based on the child’s arm position (whether arms were bent and lifted at take-off), leg position (whether there was a brief period when both feet were off the ground), and the fluidity of the movement (whether the child could maintain the pattern for 4 continuous cycles). The raw scores for each locomotor skill and the standard score for the entire locomotor subtest were used to assess differences in locomotor performance between the posttest and the pretest.

2.4.3. The Bimanual Coordination and Postural Praxis Subtests of Sensory Integration and Praxis Tests (SIPT-BMC and SIPT-PP; Ayres, 1988):

The SIPT is a comprehensive assessment tool for evaluating praxis and sensory integration in children aged between 4 and 8 years. We used the SIPT-PP and SIPT-BMC subtests to evaluate changes in praxis performance during imitation when children emulated novel hand/feet rhythmic actions (SIPT-BMC) and when they acquired novel whole-body postures (SIPT-PP). During the SIPT-BMC test, the tester sat across from the children and performed 22 rhythmic action sequences involving bilateral hand or foot motions. The children were asked to repeat the movement sequences back to the tester. An error was counted if the child paused in between the sequences, did not follow the tester’s rhythm, moved too fast or too slow, or failed to perform movement sequences correctly. Similarly, during the SIPT-PP, the tester sat across from the children and performed 17 novel postures involving finger and upper/lower limb movements. An error was recorded if the children posed with insufficient/exaggerated joint angles, incorrect joint and hand orientation, or used the wrong side of the body. The total number of errors made by the children during the SIPT-PP and SIPT-BMC tests were used to monitor the training-related changes in praxis performance.

2.4.4. Two-Minute Walk Test (2MWT; Bohannon et al., 2018):

The 2MWT is a standardized measure of functional walking endurance. The child was asked to walk as fast as they could (without running) around 2 cones placed 50 feet apart for 2 minutes. We calculated the total distance covered in the 2-minute period and used it to assess improvements in functional endurance between the posttest and the pretest.

2.5. Parent Survey and Questionnaire

In addition to assessing motor and praxis performance, parents completed the Developmental Coordination Disorder Questionnaire (DCD-Q; Schoemaker et al., 2006) before and after the intervention to screen for children’s comorbid coordination difficulties and to evaluate the change in children’s motor coordination from parent’s perspective. Based on the DCD-Q cut-off, 38 of the 45 children with ASD who participated in the study are at-risk of having co-occurring DCD. Furthermore, parental feedback was gathered through a custom-designed, post-intervention survey to assess change in outcomes following the intervention.

2.5.1. Developmental Coordination Disorder Questionnaire (DCD-Q; Schoemaker et al., 2006):

The DCD-Q is a parent questionnaire used to screen for developmental coordination disorder in school-age children between 5 and 15 years. It comprises 3 subscales which sum to a total score: (A) Control During Movement (CDM): Assesses motor coordination while the child is moving or the target object is in motion, such as catching and throwing; (B) Fine Motor/Handwriting (FMH): Assesses fine motor skills, including writing fast and legibly; (C) General Coordination (GC): Assesses general motor skills such as engaging in sports, learning new skills, being quick and competent, etc.

2.5.2. Parental Feedback on the Intervention:

Following the intervention, parents were invited to complete a survey focusing on their satisfaction with, appropriateness of, and perceived benefits from the intervention. Satisfaction with the study was assessed by the question: “Please rate your overall satisfaction with the intervention your child received. The appropriateness of the intervention was evaluated with the question: “Was the intervention appropriate for your child?” Lastly, parents were asked to rate the perceived benefit to their child with the statement: “My child benefited from the intervention he/she received.” Responses to each query were recorded on a 5-point Likert scale, with scores of 1 or 2 classified as low/worst ratings, 3 as medium/neutral, and 4 or 5 as highly positive/excellent ratings.

2.6. Statistical Analyses

At baseline, we employed one-way ANOVAs to compare all variables at the pretest between the 3 groups. To assess training-related differences, repeated-measures ANOVAs were conducted with age, sex, and training delivery method (TH vs F2F) included as covariates. Specifically, for BOT-2 and DCD-Q measures, we conducted a Group (CM, GM, SP) x Time (pretest, posttest) x Motor Subtest (BOT-2: BC, SA, MC, FMC; DCD-Q: CDM, FMH, GC) 3-way repeated measures ANOVAs. For all other measures (TGMD, SIPT-BMC, SIPT-PP, 2MWT), a Group x Time 2-way repeated measures ANOVA was performed. We tested the normal distribution and sphericity using Kolmogorov-Smirnov and Mauchly’s tests, respectively. Most of the variables were normally distributed and did not violate the sphericity test. In cases where the sphericity assumption was violated, Greenhouse–Geisser corrections were applied. For post-hoc analyses, we conducted t-tests to explore the training-related differences in motor performance across all three groups (Group x Time interaction). Effect sizes are reported using the Hedge’s g method (Hedge, 1981). All statistical analyses were conducted using SPSS (SPSS, Inc., Chicago, IL).

3. Results

3.1. Baseline comparisons

The One way ANOVA comparing pretest scores revealed no significant group differences in BOT-2 standard scores (BOT-2, BC: F (2, 42) = 0.028, p > 0.05; BOT-2, SA: F (2, 42) = 1.345, p > 0.05; BOT-2, MC: F (2, 42) = 2.284, p > 0.05; BOT-2, FMC: F (2, 42) = 0.896, p > 0.05), TGMD-2 standard locomotor scores (F (2, 42) = 0.005, p > 0.05), number of errors during the SIPT-BMC test (F (2, 42) = 3.067, p > 0.05) and SIPT-PP test (F (2, 42) = 2.751, p > 0.05), distance covered during the 2-minute walk task (F (2, 42) = 1.102, p > 0.05), as well as the DCD-Q scores (DCD-Q CDM: F (2, 42) = 0.185, p > 0.05; DCD-Q FMH: F (2, 42) = 2.825, p = 0.07; DCD-Q GC: F (2, 42) = 0.232, p > 0.05; DCD-Q total: F (2, 42) = 0.458, p > 0.05). These results suggest comparable motor and praxis performance among the groups at baseline. Detailed t-statistics for baseline analyses are provided in Supplementary Table S5.

3.2. Training-Related Improvements in Standardized Motor Assessments

3.2.1. Bruininks-Oseretsky Test of Motor Proficiency–2nd Edition (BOT-2)

The ANOVA revealed a significant Group (CM, GM, SP) x Time (pretest, posttest) x Subtest type (BC, SA, MC, FMC) interaction for the BOT-2 standard scores (F (4.9, 95.2) = 5.079, p < 0.01). No other significant main effects, two-way interactions, or interactions with covariates (e.g., age, gender, delivery method) were observed (ps > 0.05). Post-hoc analyses indicated a large-sized training-related improvement in BOT-2 BC and a medium-sized improvement in BOT-2 SA scores in the CM group (ps < 0.05; Hedge’s g = −0.745 and −0.539 respectively; % child showed improvement: 73% and 80% respectively; Figure 2A). The GM groups showed large-sized training-related improvements in both BOT-2 BC and SA scores (ps < 0.05; Hedges’s g = −0.862 to −1.578; % child showed improvement: 60% and 93% respectively; Figure 2B). Conversely, the SP group demonstrated a large-sized training-related improvement in BOT-FMC score only (p < 0.05, Hedges’s g = −0.897; % child showed improvement: 93%; Figure 2C). No other significant training-related improvements in BOT-2 scores were observed (ps > 0.05). Detailed t-statistics and effect sizes for training-related differences are reported in Supplementary Table S6.

Figure 2:

Training-related changes in Bruininks-Oseretsky Test of Motor Proficiency–2nd Edition (BOT-2) scores. BC = Bilateral Coordination, SA = Strength and Agility, MC = Manual Coordination, FMC = Fine Manual Control.

3.2.2. Test of Gross Motor Development-Second Edition (TGMD-2), Locomotor Subtest

A borderline significant Group x Time interaction was found in the TGMD-2 standard scores (F (2, 39) = 2.645, p = 0.084), with no significant main effects or interactions with covariates (e.g., age, gender, delivery method) found (ps > 0.05). Post-hoc analyses revealed a medium-sized training-related improvements in the CM and GM groups (ps < 0.05; Hedges’s g = −0.644 and −0.773 respectively; % child showed improvement: 67% and 60% respectively; Figures 3A and 3B). However, no significant training-related differences were seen in the SP group (p > 0.05; Figure 3C). Specifically, children in the CM group demonstrated enhanced galloping, leaping, and horizontal jumping performance (ps < 0.05, Figure 3D), whereas children in the GM group showed improved running skills (p < 0.05, Figure 3E). On the other hand, children in the SP group did not show significant training-related improvements in locomotor skills (ps > 0.05; Figure 3F). Detailed t-statistics and effect sizes for training-related differences are reported in Supplementary Table S6.

Figure 3:

Training-related changes in Test of Gross Motor Development-Second Edition (TGMD-2), Locomotor Subtest Scores.

3.2.3. Sensory Integration and Praxis Tests, Bimanual Coordination and Postural Praxis Subtests (SIPT-BMC, SIPT-PP)

Significant Group x Time interactions were observed in SIPT-BMC (F (2, 38) = 11.456, p < 0.001) and SIPT-PP error scores (F (2, 33) = 5.145, p < 0.05). Post-hoc analyses revealed a medium to large-sized reduction in SIPT-BMC and SIPT-PP error scores in the CM group only (p = 0.001; Hedges’s g = 1.006 and 0.767 respectively; % child showed improvement: 80% and 67% respectively; Figure 4A). However, no significant training-related differences were noted in the GM and SP groups (ps > 0.05; Figure 4B and 4D). Detailed t-statistics and effect sizes for training-related differences can be found in Supplementary Table S6.

Figure 4:

Training-related changes in Sensory Integration and Praxis Tests, Bimanual Coordination and Postural Praxis Subtests (SIPT-BMC, SIPT-PP) Scores.

3.3. Training-Related Improvements in Functional Assessment

For the functional assessment using the 2MWT, a significant Group x Time interaction was observed in the 2 MWT (F (2, 39) = 2.357, p = 0.108). Post-hoc analyses revealed medium-sized training-related increases in walking distances over a 2-minute period for CM and GM groups (ps < 0.05; Hedges’s g = −0.714 and −0.790; % child showed improvement: 73% and 87% respectively), but no significant training-related differences were found in the SP group (p > 0.05). Detailed t-statistics and effect sizes for training-related differences can be found in Supplementary Table S6.

3.4. Parent Reported Training-Related Improvements

For training-related improvements on the DCD-Q, the Group (CM, GM, SP) x Time (Pretest, posttest) x Domain (CDM, FMH, GC) ANOVA yielded a significant main effect of domain (F (2,76) = 3.166, p < 0.05) and a significant three-way interaction of Group x Time x Domain (F (4, 76) = 9.708, p < 0.05). No other significant main effects, two-way interactions, or interactions with covariates were found. Post-hoc analysis revealed medium-sized training-related improvements in DCD-Q total scores in the CM and GM groups (ps < 0.05; Hedges’s g = −0.664 and −0.561; Figure 5A and 5B). However, no significant training-related DCD-Q differences were found in the SP group (p > 0.05; Figure 5D). Specifically, the CM group showed a significant improvement in the GC score (p < 0.05, Hedges’s g = −0.540; Figure 5D), whereas the GM group showed a significant improvement in the CDM score (p < 0.05, Hedges’s g = −0.694; Figure 5E). On the other hand, the SP group showed significant improvement in the FMH score (p < 0.05, Hedges’s g = −0.678; Figure 5F). Detailed t-statistics and effect sizes for parent-reported DCD-Q improvements can be found in Supplementary Table S6.

Figure 5:

Parent-reported differences in Developmental Coordination Disorder Questionnaire (DCD-Q) scores. CDM = Control During Movement, FMH = Fine Motor/Handwriting, GC = General Coordination

3.5. Parent Feedback

Parents reported high levels of satisfaction, perceived appropriateness, and significant benefits across all three interventions, with over 80% of parents providing highly positive ratings (Figure 6). Chi-square analysis revealed no significant differences on feedback ratings between the three intervention groups for all questions (p > 0.05).

Figure 6:

Parent feedback on training satisfaction, appropriateness, and benefit.

4. Discussion and Implications

Children with Autism Spectrum Disorder (ASD) display primary challenges in social communication and repetitive behaviors, accompanied by concurrent difficulties in gross and fine motor skills (American Psychiatric Association, 2013; Bhat et al., 2011; Bhat, 2020, 2021). These motor difficulties can have a cascading effect on various developmental domains, further restricting social participation in children with ASD (Oliveira et al., 2021). The current pilot RCT compared the training effects of 2 types of whole-body interventions, a synchrony-based CM and a physical activity-based GM intervention, to that of a standard-of-care, sedentary play (SP) intervention. Both CM and GM interventions yielded medium-to-large-sized improvements in gross motor skills, including body coordination, strength, agility, locomotor skills, as well as functional walking endurance. Between the two whole-body movement groups (CM vs. GM), children in the CM group additionally showed medium-to-large-sized improvement in praxis performance, which was not seen in the GM group; while children in the GM group showed larger effects for strength and agility improvements compared to the CM group. The standard of care, SP intervention, on the other hand, led to fine motor improvements only. These training-related improvements were confirmed by parent-reported questionnaires. Parents of children in the CM group reported improved general coordination subtest scores, parents in the GM group reporting improved control during movement subtest scores, and parents in the SP group reporting improved fine motor subtest scores. In short, the findings of the current pilot RCT supported the use of (a) a synchrony-based CM intervention to address gross motor (balance, coordination, strength/agility, and endurance) and praxis difficulties, (b) a physical activity-based, GM intervention to address gross motor impairments (balance, coordination, strength/agility, and endurance), and (c) a standard of care, SP intervention in improving the fine motor performance in children with ASD. This study highlights the importance for researchers and clinicians to recognize the motor as a co-occurring condition in children with ASD and emphasizes the inclusion of whole-body movement interventions tailored to the needs of each child and family within the care of children with ASD.

4.1. Movement Interventions Led to Improved Body Coordination, Strength, Agility, Locomotor Skills, and Functional Endurance in Children with ASD

Using standardized motor assessments, the current pilot RCT found notable medium-to-large-sized improvements in body coordination, strength, agility, locomotor skills, and functional endurance in children with ASD following both types of motor interventions (CM and GM). Additionally, we observed medium-sized improvements in parent-reported DCD-Q scores for both the CM and GM interventions. This underscores the notion that activities involving whole body movements inherently facilitate advancements in gross motor skills, regardless of the incorporation of creative and synchronous elements. Additionally, given the high prevalence of co-occurring DCD among our participants (38 of the 45 children were at-risk for DCD), the training-related improvements in DCD-Q scores underscore the potential of the current movement interventions to address coordination difficulties in autistic children with co-occurring DCD. Our findings align with previous studies utilizing creative movement and physical activity-based movement interventions, which both effectively enhance gross motor performance in children with and without ASD (Amonkar et al., 2021; Birdee et al., 2009; Srinivasan et al., 2015; Kaur & Bhat, 2019; Ji et al., 2023). For example, a systematic review focusing on CM interventions reported medium-to-large-sized improvements in motor skills following yoga and martial arts training (Amonkar et al., 2021). Likewise, another systematic review and meta-analysis highlighted enhanced fundamental motor skills, such as locomotion, object control, and balance, after physical activity/exercise interventions (Ji et al., 2023). Throughout the current CM and GM interventions, we focused on practicing dual- and multi-limb movements (constituting over 90% of the training time), with locomotor skills, strength, and endurance targeted in various training activities. In the CM group, complex movement sequences were embedded in Music Time/Action Game conditions, with singing, dancing, and drum circle activities used to facilitate coordination. Strength, endurance, and balance were practiced in Yoga games, during which children were asked to hold the strengthening (e.g., bridge and downward-facing dog) and balancing poses (e.g., tree and dancer poses). Agility and locomotor skills were targeted during Moving games as children were encouraged to move freely in space using complex locomotor skills such as galloping, skipping, and hopping. Similarly, in the GM group, upper and lower limb coordination, strength, and flexibility were facilitated during Warm-up (e.g., alternative punching), Grow Strong (e.g., squatting), and Cool-Down (e.g., crossed leg stretching) conditions. Fundamental movement skills (e.g., jumping, hopping, frog jumping) and functional endurance were targeted through locomotor games/obstacle courses during the Speed Up condition. Moreover, in both motor interventions, we employed motor learning principles, including part-whole practice, gradual increase in task difficulty, and provision of visual demonstrations, instant feedback, as well as visual/verbal/physical assistance according to the child’s needs. The extensive practice of motor skills coupled with the use of motor learning principles might have contributed to improved motor performance by children with ASD following the 8-week training program.

4.2. Creative Component of Movement Intervention (CM) Additionally Facilitate Praxis/Imitation Skills in Children with ASD

Among the two movement groups, only children in the CM group showed improved praxis/imitation after the intervention, suggesting that “creative synchrony” is key to facilitating motor skills within a social context. Our findings are consistent with previous studies using imitation-based rhythm and yoga interventions (Srinivasan et al., 2015; Kaur & Bhat, 2019). It has been suggested that creative synchrony that involves children moving to music and trying to match their movements to the rhythm of the music and/or movements of their partner naturally facilitates imitation/interpersonal synchrony, back-and-forth social communication, and motor planning/coordination (Srinivasan & Bhat, 2013). Similarly, imitation-based contexts, such as partner yoga provide multisystem experiences to enhance motor (i.e., strength, flexibility, balance), perceptual (i.e., joint proprioception, kinesthesia), cardiorespiratory (i.e., heart rate variability, breathing strategies), behavioral (i.e., attention, anxiety), and communication skills of children (Galantino et al., 2008; Beauchemin et al., 2008; Mohanty et al., 2014), which might further facilitate social interactions. In the current CM intervention, we created a triadic context for the trainer, model, and the child to move in synchrony. For example, during Music Time, the trainer, model and the child formed a drum circle to play music together; during the Moving Game, all participants moved synchronously with each other and with the music; and during Yoga/ breathing, the participants synchronized their poses and breathing patterns to each other and to calming music/songs. During these activities, children needed to constantly monitor and match movements to their partner’s movements. In short, the group-based nature of these activities and the repeated showing, observing, and copying of movement patterns might have contributed to improved praxis/imitation performance in the CM group. Additionally, we found that such improvements are not limited to a certain creative movement type (e.g., music making, yoga poses, or dance moves); in fact, creative activities that incorporate key ingredients of interpersonal synchrony, multilimbed coordination, and imitation can promote praxis, bilateral coordination, and social-motor synchrony in children with ASD.

4.3. Physical Activity-based Intervention (GM) Led to Greater Improvements in Strength and Agility

Despite the numerous benefits related to Creative Movement, it is imperative to acknowledge that general physical activity-based interventions have their own distinct advantages. Compared to the CM intervention, the GM intervention led to larger training-related improvements in Strength and Agility in children with ASD (CM: Hedges’s g = −0.539 vs GM: Hedges’s g = −1.578). This difference could potentially be attributed to the dedicated, repetitive practice of simple dual limb movement patterns (e.g., punching, throwing, catching, running, etc.) and a focus on functional strength training involving core and major upper and lower body muscles (e.g., squats, lunges, bridging, sit-ups etc.) in this group. While the CM intervention required children to continuously monitor their partners, synchronize their movements in spatial and temporal domains with them, and was generally confined by the duration of the accompanying music, the GM group activities were conducted in a turn-taking manner and allowed children more freedom and time to move in different ways. This is consistent with other studies using physical activity/exercise reporting enhanced motor skills in children with ASD (Ruggeri et al., 2020; Pan et al., 2017; Rafiei Milajerdi et al., 2021; Healy et al., 2018; Ji et al., 2023). Moreover, a study comparing the effects of an aerobic/physical activity-based intervention with a coordination-based intervention found greater improvement in shuttle run performance after aerobic vs. coordination-based intervention (Ludyga et al., 2019). Similarly, we also found improved running skills after GM intervention, whereas the CM group improved complex locomotor skills, such as galloping, leaping, and horizontal jumping. Taken together, compared to the CM intervention, which focused on more complex motor skills in synchrony-based contexts, GM interventions mainly focused on simpler locomotor skills, allowed more repetition and isolated practice, leading to greater improvements in strength and agility.

4.4. Traditional Sedentary Play Intervention (SP) Led to Fine Motor Improvements

Children in the SP group showed large-sized improvements in fine motor performance using the fine motor subtests of the BOT-2. The parents of children in the SP group additionally reported improvements in handwriting skills using the DCD-Q questionnaire. The observed surge in fine motor skills following the SP intervention is in line with expectations, given that the SP training protocol was intentionally structured to mirror school-based, occupational therapy approaches which emphasize crucial aspects of handwriting quality (e.g., legibility, optimal pace), fine motor proficiencies (e.g., scissor usage, folding, coloring, manipulation of small objects), and organizational skills pertaining to tabletop supplies (e.g., sorting supplies and art-craft creations) (McHale & Cermak, 1992; Reid et al., 2006). For example, during Building games, children actively engaged with assembling and dis-assembling LEGO and ZOOB pieces, adopted diverse hand pincer/grip strategies, such as pinching, rolling, and pressing, to sculpt Playdoh creations. During Art -Craft activities, children practiced writing, coloring, folding, and mastering the use of scissors to make art creations. Our findings are consistent with previous studies using seated play and tabletop interventions effectively to foster fine motor and visuomotor skills in children with fine motor difficulties (Case-Smith, 2002; Dankert et al., 2003; Hirschmann et al., 2023). Taken together, this collective evidence substantiates that conventional sedentary tabletop activities are effective in enhancing fine motor performance in children with ASD.

4.5. Limitations and Future Directions

The current study had a relatively small sample size with a relatively broad range in age, adaptive functioning, and autistic severity. To understand how these factors might influence intervention outcomes, we conducted correlations between demographic variables and training-related improvements and found no significant associations. This suggests that the interventions are broadly applicable to autistic children with wide-ranging ages and impairments. Future studies should consider using larger sample sizes and study which subgroups most benefit from these different movement interventions. Moreover, due to the constraints imposed by the COVID-19 pandemic, a hybrid intervention delivery approach was employed (Face-to-Face or Telehealth). We have conducted comparative analyses between the F2F and TH subgroups for each intervention group and found no statistically significant differences in training outcomes between the two delivery formats for all three intervention groups (Su et al., 2023, 2024a, 2024b). We found that parents and trainers reported greater technological issues during the TH delivery format; however, they also reported greater parental involvement (seen as beneficial) during TH delivery. To address these differences we controlled for delivery method as a covariate within our statistical analyses. Lastly, we did not control for other interventions or prevent children from receiving standard interventions.

Future studies involving large sample sizes must compare different intervention delivery methods for various motor interventions and examine the underlying neural mechanisms of behavior change. For example, researchers have also found training-related changes in neural activity associated with behavioral improvements (Su et al., 2022). Future studies could incorporate objective, neuroimaging measures to unravel the underlying mechanisms of change following behavioral interventions. Furthermore, in the current study, we observed comparable improvements in body coordination, strength, agility, locomotor skills, and functional endurance following both the CM and GM interventions. Future research should further investigate the differences between the two interventions in other developmental outcomes such as social interactions, cognitive performance, and repetitive behaviors. Given our findings that CM and GM interventions were both beneficial future studies could examine the additive effects of the 2 types of movement interventions.

4.6. Clinical Implication and Conclusions

Our findings support the use of CM and GM interventions in addressing motor challenges in children with ASD. The CM and GM interventions grounded in whole-body movements promote whole-body coordination, strength, and agility. Moreover, the synchronous and creative components of CM interventions are also effective in enhancing praxis/imitation performance in children with ASD. During therapy sessions, clinicians should consider combining or prioritizing CM and/or GM interventions based on the child’s preferences. Given the high prevalence of co-occurring DCD among our participants, the positive motor findings emphasize the importance of CM and GM interventions to address coordination difficulties in autistic children with co-occurring DCD. Conversely, traditional, seated play interventions hold promise for facilitating fine motor performance in children with ASD. In light of these findings, clinicians and scientists should advocate for incorporating movement / physical activity interventions in addressing motor difficulties, improving physical health, and promoting cascading effects on the mental and social well-being of autistic individuals. Clinicians should tailor creative or general movement intervention activities per children’s age, ability levels, and child/family preferences.

Highlights.

• Engaging in whole-body physical activity (creative or general movement) led to significant improvement in body coordination, strength, agility, locomotor skills, and functional walking endurance of children with Autism Spectrum Disorder (ASD).

• Incorporating creative movement into gross motor interventions showed improvement in praxis performance of children with ASD.

• Conversely, participation in sedentary fine motor activities showed improvements in fine motor skills of children with ASD.

• It is important for movement clinicians to incorporate interventions targeting gross motor skills into the plans of care for children with ASD including those with co-occurring DCD.

Data Sharing Statement

Individual subject electronic data can be made available upon reasonable request by researchers.