A scoping review of adapted physical activity interventions for children and youth with disabilities using international classification of functioning, disability and health: children and youth version as a reference

Abstract

Purpose: Adapted physical activity (APA) provides children and youth with disabilities more opportunities to be physically active. Nevertheless, it is not well known how APA implementation in different services has benefited them. This study reviews the existing literature on APA interventions to identify characteristics and program descriptions, and to primarily synthesize information relating to the goals, for children and youth with disabilities.

Methods: A literature search was performed using (1) electronic databases Scopus and EBSCO ALL and (2) manual and individual scrutinization of the four major APA journals. The characteristics and program were summarized narratively, and outcome items were extracted using the established International Classification of Functioning, Disability and Health: Children and Youth version (ICF-CY) linking rules.

Results: Thirty-five APA intervention studies published between 1987 and 2020 (with the majority in North America, since 2000) were included. Children with autism are the largest target group. Rich and diverse programs implemented were proved to be effective. Among the 184 outcome items coded within the categories of ICF-CY, 48% focused on Body Functions while 52% focused on Activities and Participation.

Conclusions: This scoping review provides APA professionals and non-professionals (e.g. guardians) a broader and systematic overview on existing APA interventions for children and youth with disabilities.

Background

Physical activity in the children and youth with disabilities

Physical activity (hereafter abbreviated as PA) is associated with improved health, psychological benefits, and social development among children and youth (with or without disabilities) (Murphy et al. 2008, Poitras et al. 2016). According to the Global Matrix 2.0 and 3.0 (Aubert et al. 2018, Tremblay et al. 2016), there is ‘new evidence showing that the situation regarding the PA of children and youth is a concern worldwide’. By looking at the WHO guidelines and recommendations (World Health Organization 2010), which provide details for children and youth aged 5–17 years (with and without disabilities) on how much PA is indispensable for good health, no difference was found among children and youth with and without disabilities. However, compared to their typically developing peers, children and youth with disabilities are at a higher risk of obesity (Collins and Staples 2017, Hinckson et al. 2013), and do not achieve the recommended level of daily PA (Lobenius-Palmér et al. 2018). It is already alarming that children and youth worldwide are not engaging in PA as recommended. Furthermore, it is especially hard to notice that the situation is more severe for children and youth with disabilities. In fact, children and youth with disabilities experience significant restrictions in participating in PA (McGarty and Melville 2018, Tonkin et al. 2014), mainly related to individual, familial, and wider environmental concerns and factors (King et al. 2003). Due to the complexity of barriers (ranging from individual child’s level of functioning to the person–environment contextual factors) (McGarty and Melville 2018, Shields et al. 2012) impeding overall PA participation, interventions seeking to implement PA for children and youth with disabilities can be especially difficult.

Adapted physical activity has the interventional potential for children and youth with disabilities as a cross-disciplinary body of knowledge

In recent decades, research has revealed the potential of interventions based on adapted physical activity (hereafter abbreviated as APA) dealing with individual difference, and the children and youth with disabilities are no exceptions (Steadward et al. 2003). According to the International Federation of APA, ‘APA is defined as a cross-disciplinary body of knowledge directed toward the identification and solution of individual differences in PA. It is a service delivery profession and an academic field of study that supports an attitude of acceptance of individual differences, advocates access to active lifestyles and sport, and promotes innovation and cooperative service delivery programs and empowerment systems. APA includes, but is not limited to, physical education, sport, recreation, dance and creative arts, nutrition, medicine, and rehabilitation’ (IFAPA 2014). It has also been widely acknowledged that intervention and services for children and youth with disabilities operate on an interdisciplinary basis (Björck-Åkesson et al. 2010). APA professionals from various disciplines are likely to be able to provide children and youth with disabilities a diversity of experiences in PA participation, whereas the definition of APA and the meaningfulness of implementing APA across individual differences lack specificity. It is too conceptual to understand or capture a clear picture as to how APA has been implemented among children and youth with disabilities to support their needs. In type usage, ‘adapt’ means ‘to adjust’ or ‘to fit’, and the meaning of adapt in APA’s working definition is consistent with this understanding by including modifications to meet the needs of children and youth with disabilities (Winnick 2010). What can be grasped from the APA definition is that APA can be a service delivery that uses modifications of PAs to cater to the children and youth with disabilities needs and support an attitude of acceptance of individual differences and to advocate access to active lifestyles and sport. Because of the wide range of disciplines, goals and target groups involved in APA, a systematic overview of APA interventions implemented for children and youth with disabilities is not yet available. To the best of our knowledge, existing reviews attempting to clarify the PA interventions for children and youth with disabilities either narrow the focus to a single type of disability (Howells et al. 2019, Kilgour et al. 2022) or focuses on a particular setting; for example, in an out-of-school context (Arbour-Nicitopoulos et al. 2018, Orr et al. 2021), or in a school-based context (Wilhelmsen and Sørensen 2017). Only one review discussed a similar topic excluding therapeutic interventions, but this is a review of a review (Lai et al. 2020).

A common framework used to synthesize information relating to the multidisciplinary APA interventions’ goals

To better understand how APA has been implemented in different services across countries in relation to children and youth with different kinds of disabilities, especially in terms of the intervention goals, there is a requirement for a common language between professionals and a shared framework for intervention goals (outcome items). The International Classification of Functioning, Disability and Health for Children and Youth (hereafter abbreviated as ICF-CY), derived from the International Classification of Functioning, Disability and Health (ICF) (World Health Organization 2001), may serve as the common framework that can be applied across disciplines as well as national boundaries to: (1) facilitate the documentation of health and disability in children and youth, and, (2) advance services and research on behalf of children and youth (World Health Organization 2007). It is a biopsychosocial model by facilitating to understand human functioning with three interrelated components; namely, body functions and body structures and activities and participation. This model also includes contextual (personal and environmental) factors that interact with the three components of human functioning. Within the ICF-CY, children’s functioning and disability are viewed as being a dynamic interaction between health conditions and contextual factors. APA is a production of the evolving concepts from ‘corrective therapy’ to ‘adapted physical education’ and then ‘adapted physical activity’ (shifting the emphasis from correcting personal functioning impairments to focusing on solving problems on overall interaction of person–environmental context) (Steadward et al. 2003). The fundamental concept of APA accords with how the ICF-CY model recognizes children’s functioning and disability. In addition, the ICF-CY model has been useful for identifying potential points of interventions for children, including those with disabilities (Hwang et al. 2014, Tantilipikorn et al. 2012, World Health Organization 2007, Yildiz Kabak et al. 2021). Practically, the ICF-CY model can help define areas of intervention after understanding the child’s need (McDougall and Wright 2009). It is unlikely that all APA professionals from distinct disciplines refer to ICF-CY to set up the intervention plan and advance their services. Conversely, it is possible to use ICF-CY systematically to document the current existing literature on the various intervention goals of APA and this has been conducted by evaluating goals for children (Rainey et al. 2014).

This study aims to identify and review characteristics (study and participant characteristics) and program descriptions, and primarily synthesizes information relating to the goals of current APA interventional studies for children and youth with disabilities. To achieve the study aims, the following research questions will be addressed:

1. What are the characteristics (in terms of study characteristics and participant characteristics) of current APA interventional studies for children and youth with disabilities?

2. What are the program descriptions of current APA interventional studies for children and youth with disabilities?

3. What kinds of abilities and behaviors do the current APA interventional studies for children and youth with disabilities focus on (using ICF-CY)?

4. To what extent are current APA interventional studies for children and youth with disabilities reported as beneficial or effective?

Methods

Search strategy

A literature search was performed using two procedures. In Procedure 1 (Figure 1), electronic databases Scopus and EBSCO ALL (with overall 70 databases) were used on June 4, 2020. The search strategy was probing within the abstract of articles containing ‘Adapted Physical Activity’ and ‘disabled or disability or disabilities or impaired or impairment’ and ‘youth or young or teenager or child or children or adolescent’. It was also crucial to review four journals listed on the International Federation of Adapted Physical Activity (IFAPA) official website. Despite these being included in the electronic databases Scopus and EBSCO ALL, data describing the year of publication is limited and not always complete. Procedure 2 was carried out to ensure that intervention studies from the four mainstream APA journals listed on the official website of IFAPA during the time the search was performed are not missing from the search. In Procedure 2 (Figure 2), the manual-search method was applied to and performed on two APA journals: Adapted Physical Activity Quarterly and European Journal of Adapted Physical Activity. A keyword search was used for the online databases of the other two APA journals; namely, Palaestra and Therapeutic Recreation Journal. The keywords ‘intervention/interventions’ and ‘children, youth, or children’ and PUBID (32045) were searched in the Palaestra (accessed electronically via ProQuest Central from 1997 to 2019). Therapeutic Recreation Journal was accessed electronically via ProQuest Central from 1998 to the latest issue Third Quarter 2020, 54(3). The search strategy was changed to use keywords (‘intervention or interventions’ and PUBID (5997)) and ‘children with disabilities or youth with disabilities’ and ‘adapted physical activity’.

Figure 1.

A summary of the screening process for procedure 1.

Figure 2.

A summary of the screening process for procedure 2.

Inclusion and exclusion criteria

Criteria for study selection are as follows: (1) A considered article must be in English; (2) The article must be an intervention or service delivery research and the study design has to be an experimental study; (3) The intervention/service delivery recipients must be children or youth aged 5–18 with disabilities and not their parents or teachers (such that the outcome variables are measured from the children/youth); and, (4) The article must have been peer-reviewed. Included and excluded criteria are mentioned in Table 1.

Table 1.

The included and excluded criteria.

	Included criteria	Excluded criteria
Population	• Children and youth, 5–18 years of age with disabilities	• Pre-school populations of children (4 years of age and younger), and parents and teachers
Intervention	• Single or multicomponent interventions in any settings	• N/A
Study design	• An experimental study	• N/A
Publication type	• Peer reviewed journal article	• Conference abstract, study protocol, report, dissertation, book
Publication year	• Till 2020 June	• N/A
Language	• English	• All other languages

Study selection

Following the four stages (identification, screening of title and abstracts, eligibility, and inclusion) of the PRISMA guidelines on the selection process, authors identified a certain number of papers by searching the databases at the first stage. In the second stage, three authors screened all titles and abstracts from the above, removing duplicates. The relevance of the studies was further examined at the third stage, where the same three authors read the full text of each article obtained from the previous stage. As a result, 35 studies were included.

Data synthesis strategy

The studies that met the inclusion criteria are summarized in Table 2, and provide a systematic overview of our current findings. The combination of included studies was reorganized and analyzed in relation to the research questions. A summary of each study is presented in Table 2, with reference to the following aspects: column 1: study origin and characteristics, such as author(s), year of publication, country, and study design; column 2: participant characteristics: the number, age of the participants; the original wording of the type of disabilities was maintained; (column 1 and column 2 contribute to the answers to the first research question relating to the characteristics); column 3: physical activities: organized at the individual level or group level, the type of PAs has been used in the study and adaptations were made for the intervention (since all information were summarized in the table, common adaptions for the same type of PA will be highlighted in the result only); column 4: program details: information for settings and schedule of the program were extracted; (column 3 and column 4 contribute to the answers to the second research question relating to the program descriptions); and, column 5: targeted abilities and behaviors, which centered on the goals of the included studies. The goals were coded with reference to each available items in the measurement tools based on the existing ICF linking rules (Cieza et al. 2005). Four main domains, namely, body functions, body structure, activities and participation, and environmental factors are classified in ICF-CY. Practically, the ICF-CY is used in intervention studies by researchers focusing on children and youth with disabilities (Cronin et al. 2020, Pan et al. 2019). While summarizing APA interventions from an international perspective, a study (Hutzler and Sherrill 2007) mentioned that the use of WHO terminology may facilitate a common language among APA professionals who cooperate across service delivery programs. To show how the ICF-CY linking rules are applied, an example of the coding process used in this study is described and presented in Table 3. Four steps were undertaken to complete the ICF-CY coding procedure. Two authors (occupational therapists) firstly identified target abilities and behaviors, and then each assessment tool contents were noted down with specific items in accordance with the target abilities and behaviors. Under the ICF-CY coding process column (6 and 7), each specific item of the tool was mapped to the ICF-CY codes one by one (Cieza et al. 2005). Any disagreements were discussed, and consensus was achieved. The final summary step was done to list the included code in order of the smaller to larger code, and to ensure that overlapping codes are removed; (column 5, 6 and 7 contributes to the answer to the third main research questions relating to the intervention goals and ICF codes) and, the answers toward the fourth research question relating to the reported effectiveness of APA interventions were marked in column 5: the two authors simply marked positive target abilities and behaviors with a plus mark(+) and negative ones or those without any change with a minus mark (−) in Table 2.

Table 2.

An overview of the studies on research questions included in the review.

Characteristics		Program Descriptions		Abilities and Behaviors in Focus (using ICF-CY linking rules)
Authors, Study Design, Year, Country	Participant Characteristics (n, age)	Physical Activities; (which part is adapted)	Settings; Length, Frequency, Duration;	Target Abilities and Behaviors (＋,−)	ICF-CY Code Summary (b Body Functions)	ICF-CY Code Summary (d Activities and Participation) (e Environmental Factors)
1. Schleien et al., Other design, 1987, USA (Schleien et al. 1987)	Two severely handicapped autistic children (aged 8 years, 5 months and 11 years, 2 months) and 67 non handicapped children (aged 7–12)	Individual and group; cooperative, competitive, individualistic play and games (・ Modifications of traditional sports such as volleyball, badminton, soccer, and floor hockey and fundamental movement, gymnastic, and aquatic skills)	Various locations at the university campus; 40-min cooperative sports and game, swimming and gymnastics and 30-min open recreation session once a week, for three weeks	Orientation toward peers and objects (−), Appropriate and inappropriate play behavior (+), Individual target behavior patterns (−)	b11421 Orientation to others, b1143 Orientation to objects, b1521 Regulation of emotion, b7653 Stereotypies and motor perseveration	d720 Complex interpersonal interactions
2. Porretta, Randomized controlled trial, 1988, USA (Porretta 1988)	Forty-Eight mildly mentally handicapped children (ages 8–12)	Group; bean bag tossing (・ Greater or smaller contextual interference of four weighted bean bags (85,128,142,184 g))	A typical physical activity setting; each participant had 3 blocks of trials (48 practice trials, 4 transfer trails on the same day and another 4 retention trail after 2 days)	Immediate transfer of tossing skills (+), 2 day retention of tossing skills (+), (Greater contextual interference’s leads to better transfer and retention)	b1442 Retrieval of memory	d4454 Throwing
3. Revie and Larkin, Randomized controlled trial, 1993, Australia (Revie and Larkin 1993)	Twenty-four children (ages 5 - 9) with poor coordination	Group and individual; overarm distance throw, a hop, target kicking, ball bounce and catch (・ The teaching strategies used with logical development of chosen skills, ・ Presentation of the skill involved auditory, visual, and tactile modes, ・ Feedback and opportunity for practice of efficient movement patterns)	No information for the settings; 1 h,1) a 10-min group warm-up, 2) 20-min specific task teaching (10 min for each task: overarm distance throw, a hop, target kicking, ball bounce and catch, 3) 20-min other movement experiences (e.g. running, skipping),4) 10-min group games and movement to music; once or twice a week, over 9 weeks	Motor skill: An overarm throw for distance (+), A distance hop (−), Target kicking (+), A bounce-and-catch task (+)		d4351 Kicking, d4454 Throwing, d4455 Catching, d4553 Jumping
4. Silliman and French, Single-subject design, 1993, USA (Silliman and French 1993)	Fifteen youths (ages 10–17) with profound mental retardation	Individual; a kicking task (・ Use of Reinforcement: The verbal reinforcement was specific (e.g. "Great, [subject’s name], for kicking the ball through the cones"); Music was played when the ball was kicked through the cones)	A residential facility; 15-min each time, three times a day, overall 30 sessions	A gross motor skill: kicking (+)		d4351 Kicking
5. Bar-Eli et al., Randomized controlled trial, 1994, Israel (Bar-Eli et al. 1994)	Eighty adolescents (age approximately 15 years) with behavior disorders	Individual; sit-up trials (・ Each subject was given a goal; Long-term goals: each subject was given a goal of 40% higher than his or her previous baseline sit-up score. Long- plus short-term goals: to set short-term goals, an 8% improvement was calculated for each subject. In addition, long-term goals were set for the subjects)	Two "special education"boarding schools; five sit-up trials, twice a week, over the course of 10-week training period	Physical performance (+)	b740 Muscle endurance functions
6. Valentini and Rudisill, Randomized controlled trial, 2004, Brazil (Valentini and Rudisill 2004)	One hundred and four students (ages 5.9 − 10.9) with and without disabilities: 36 having disabilities resulting in a motor delay and 68 as not having disabilities but demonstrating motor delay	Group; fundamental motor skills (FMS) activity: (・ FMS activity stations (having multiple levels of task and difficulty),・ A variety of ways (e.g. goal driven activities including independent and small group games, movement exploration through trial and error, cooperative and self-competition games)to practice at stations, ・ An inclusive mastery climate is consisted of a variety of activities as well as chances to choose tasks, establish rules, share decisions, work with partners and/or small groups, participate in a private evaluation of progress and effort, and self-manage the time and pace of the activities)	A classroom setting; 60 min: (1) 10-min intro, (2) 45-min fundamental motor skills (FMS) activity; skill instruction and practice, and (3) 5-min closure, twice a week, 24 sessions during a 12-week	Motor skill performance (+)		d4351 Kicking, d445 Hand and arm use, d4454 Throwing, d4455 Catching, d4552 Running, d4553 Jumping
7. Yılmaz et al., Single-subject design, 2005, Turkey (Yılmaz et al. 2005)	Four boys (ages 7–9) with autism	Individual; fun water activities and instructions for aquatic play skills of kangaroo, snake, and cycling (・ A constant time delay (0 s and 4 s delay) procedure was used to teach)	At university indoor swimming pool; one day session only	Aquatic play skills (+)	b176 Mental functions of sequencing complex movements	d455 Moving around
8. Reid and Campbell, Randomized controlled trial, 2006, Canada (Reid and Campbell 2006)	Thirty-one children (ages 8–10) with cerebral palsy	Individual; virtual reality(sport applications like soccer and volleyball; music programs like drums; game-like programs like sharks or juggler) (・ Participants could choose the applications to be played)	In a lab; each session lasted for 1.5 h, one session a week for 8 weeks	Upper-extremity movement skills (−), Self-efficacy (−), Self-concept (−)	b1266 Confidence, b1801 Body image, b7600 Control of simple voluntary movements	d140 Learning to read, d145 Learning to write, d150 Learning to calculate, d210 Undertaking a single task, d250 Managing one’s own behavior, d4401 Grasping, d7500 Informal relationships with friends, d9200 Play d9201 Sports
9. Borremans et al., Quasi-experimental nonequivalent-control-group design, 2009, Finland (Borremans et al. 2009)	Twenty adolescents (mean age 16.8) diagnosed with Asperger syndrome	Group; “Move your body & Stretch your mind” consisted of three main parts: 1) an extra-curricular physical exercise program (activities and games that can be easily transferred towards leisure time (e.g. floor ball, soccer, badminton.) 2) an exercise program with stations focusing on core and stretching (warm-up, core workout and stretching ) 3) an aerobic physical activity of choice(e.g. biking, swimming, running, nordic walking, aerobics), (・ All activities are easily available to the student, and explained in simple text with pictures, ・ The participants received weekly reminders about their training diaries, ・ Teachers and guardians were encouraged to contact the primary investigator）	A sports center (the first part), home (the second part), their own community setting (the third part); 1 h, 3 days a week, 12 weeks	Motor competence (+), Physical fitness (+)	b1470 Psychomotor control, b2351 Vestibular function of balance, b4551 Aerobic capacity, b7101 Mobility of several joints, b7300 Power of isolated muscles and muscle groups, b7354 Tone of muscles of all limbs, b740 Muscle endurance functions, b755 Involuntary movement reaction functions	d4402 Manipulating, d4454 Throwing, d4455 Catching, d4552 Running, d4553 Jumping
10. Kelly and Legg, Single-subject design, 2009, Canada (Kelly and Legg 2009)	Six children (ages 8–12) with ambulatory cerebral palsy	Group; aerobic (stationary bicycles, arm ergometers, steppers, treadmills, and elliptical trainers) and strength training activity (knee extension exercises, hip abduction exercises, toe raises, half squats, step ups), Sports (swimming, cycling, wrestling, rock climbing), (・ A list of appropriate pieces of up to four pieces of equipment was made for each child based on the size and ability for children to manage independently for aerobic activity)	A community recreation center; one hour, three times per week (twice a week children performed an aerobic and PRE workout (a 7-10 min warm-up, a 30 min aerobic activity set, a 20 min PRE circuit, and a 10 min stretch/cool down) and once a week children played in a sport context), for 10 weeks;	Energy expenditure (+), Muscle strength for plantar flexion, knee extension and hip extension (−), Perceived satisfaction and perceived performance of a functional motor goal (+)	b455 Exercise tolerance functions, b7303 Power of muscles in lower half of the body	d2102 Undertaking a single task independently
11. Mazzoni et al., Wait-list control design, 2009, Canada (Mazzoni et al. 2009)	Forty-six children(ages 6-12)with physical, developmental,and or emotional/behavioral challenges	Individual; indoor wall climbing (・ The goals were individualized based on the first attempt at climbing, ・ The climber to belayer ratio allowed the goals for each child to be specific to their needs, ・ Physical assistance with hand-over-hand guidance and verbal cueing, verbal guidance, encouragement to persist with the task were provided)	A commercial indoor climbing facility; one hour, once a week, for six weeks	Self-perception (−), Self-efficacy (+)	b1266 Confidence, b1141 Orientation to place, d4451 Climbing	d9200 Play, d9201 Sports, d7500 Informal social relationships
12. Devine and Dawson, Quasi-experimental pretest-posttest design, 2010, USA (Devine and Dawson 2010)	Thirty-one children (ages 9-18) and adolescents with Craniofacial Differences (CD)	Group; a residential summer camp(team building exercises, non-competitive team-oriented activities and a group challenge day and typical camp activities: horseback riding, archery, camp outs, creative arts, nature activities, canoeing and boating) (・ A supportive environment and atmosphere, ・ Camp staff were trained to use personal first language, empower campers to be independent, use empathy and engage campers socially)	Located at a university based outdoor center; 5 days	Self-esteem (+), Social acceptance (+).	b1266 Confidence	e425 Individual attitudes of acquaintances, peers, colleagues, neighbors and community members
13. Honkavaara and Rintala, Single-subject design, 2010, Finland (Honkavaara and Rintala 2010)	Two boys (ages 12 and 13) with spastic diplegia and one girl (age 14) with athetoid cerebral palsy	Individual; short term intensive hippotherapy （・ Rode without a saddle to maximize the therapeutic effects for the rider ・ Held a safety belt that was attached around the horse’s trunk ・ Balance activities (releasing grip and holding arms upward, outward) added gradually)	No info for the setting; 25 mins to 40 mins, three times a week, three weeks	Gait functions: Velocity (+), Stride length (+), Cadence (+) (−).	b770 Gait pattern functions
14. Todd et al., Single-subject design, 2010, Canada (Todd et al. 2010)	Three adolescents(ages 15–17) with severe autism	Individual; cycling (・ a self-regulation instructional strategy on sustained cycling which included self-monitoring, goal setting, and self-reinforcement ・ The participants selected the adapted bicycle or adult tricycle they preferred to ride)	Thirty-one sessions were completed:12 sessions were held indoors and 19 outside; 30 min, three days per week, 12-week	Sustained physical activity (two of the participants +)		d920 Recreation and leisure, d9201 Sports
15. Wuang et al., Wait-list control design, 2010, Taiwan (Wuang et al. 2010)	Sixty children (ages 6–8) with autism	Group; a Simulated Developmental Horse-Riding Program (SDHRP) using Joba®, consisted of three sessions:1)simple limb movements and mat exercises,2)mounted exercises,3)a game offered while riding on the Joba® (・ A treatment plan was especially designed for each child that incorporated SDHRP activities compatible with the child’s interest and current motor function)	The pediatric therapy unit at a university-affiliated medical center; 1 h, 2 sessions per week, 20-week	Motor proficiency (+) Sensory integrative functions (+)		d4402 Manipulating, d4552 Running, d4553 Jumping
16. Casey and Emes, Randomized controlled trial, 2011, Canada (Casey and Emes 2011)	Twenty-eight adolescents (mean age 14.6) with Down syndrome	Group; swim training (be taught only one-stroke, front-crawl, and focused on breathing by emphasizing “1-2-3 Breathe” techniques), (・ Motivational strategies(verbal reinforcement and physical praise) used, ・ Provided a visual image of an on-going sports training environment, ・ Flutter-boards were provided for assistance, ・ The load of RMT(respiratory muscle training ) involved in learning to breathe was raised incrementally as the study progressed)	A competitive-size, indoor pool; one-hour, three times per week, 12 weeks	Speech Respiratory Variables (SRV), Maximum phonation duration (MPD) (+), Initiation Volume (−), Expired Mean Airflow (−)	b3100 Production of voice, b4402 Depth of respiration
17. Sangster Jokić et al., Other design, 2013, Canada (Sangster Jokić et al. 2013)	Ten children(ages 7–9) with developmental coordination disorder (DCD)	Group; self-selected motor activity skills (・ The Cognitive Orientation to Daily Occupational Performance (CO-OP), an intervention approach, used to teach, ・ Traditional session length was shortened, ・ Self-selection tasks on cards depicting childhood motor activities (such as handwriting, bike riding, or tying a shoelace) according to the child’s perceived skill and participation level)	Quiet therapy or study rooms in schools; each session in this study were limited to 30 min, on a twice-weekly basis, overall 10 COOP intervention sessions	Self-regulatory (SR) skills as a mediator to acquire motor skills (+)		d155 Acquiring skills
18. Hawkins et al., Single-subject design, 2014, USA (Hawkins et al. 2014)	Two children (7 years old and 11 years old) with autism spectrum disorder (ASD)	Individual; a mid-size equine-assisted therapy program(warm-up and stretching, riding goals and therapeutic interactions) (・ Used an English saddle to provide more challenge. ・ Cued by horse handler and side walkers)	At the university’s equine center; 30 min per riding session, three times a week, for 5 weeks	Gross motor skills (+), Body coordination (+), Strength and agility (+)	b2351 Vestibular function of balance, b730 Muscle power functions, b755 Involuntary movement reaction functions, b760 Control of voluntary movement functions	d4552 Running, d4553 Jumping
19. Salaun et al., Quasi-experimental pretest-posttest design, 2014, France (Salaun et al. 2014 )	Twenty-three adolescents with mild intellectual disabilities and obesity (with a mean age of 15.13 years (+-1.10 years)	Individual; adapted physical activity program (predominantly aerobic) (・ The working loads were individualized, gradually increase the duration and intensity of physical activity sessions)	In four specialized school;duration varies 30mins, 50mins to 1 h, at least twice a week, a 9-month program	Self-perception (+), Anthropometric measurements and body composition (−)	b1266 Confidence, b1300 Energy level, b1801 Body Image, b530 Weight maintenance functions, b5403 Fat metabolism
20. Armitano et al., Quasi-experimental pretest-posttest design, 2015, USA (Armitano et al. 2015)	Sixteen children(ages 5–18)with disabilities(included intellectual and learning disabilities, down syndrome, several autism spectrum disorders, microcephaly, global developmental delays, dandy-walker syndrome, heart defects, and hypothyroidism)	Individual; a surfing program(1) paddling; 2) balancing on a surf-board while sitting; laying, kneeling, or standing; catching a wave and riding it into shore in the prone, sitting, kneeling, or standing position; and 4) how to paddle back out through the wave unassisted) (・ The progression through the skills were based on each child’s individual pace of learning and the goals set by the surf instructors)	On a beach; a one-hour session, twice a week, for eight weeks	Physiological outcomes: Balance(−), Strength and endurance (+), Flexibility (+), Cardiorespiratory endurance (+)	b2351 Vestibular function of balance, b755 Involuntary movement reaction functions, b730 Muscle power functions, b740 Muscle endurance functions, b7101 Mobility of several joints, b7354 Tone of muscles of all limbs, b4551 Aerobic capacity
21. Choi and Cheung, Quasi-experimental pretest-posttest design, 2016, Hong Kong (Choi and Cheung 2016)	Thirty Grade 2 children (ages 7–8) with mild Intellectual Disabilities	Group; 12 physical activities:1) hop-leap-jump,2) catch a cuppa ball,3) wonder whacker, 4) simple simon said, 5) pushing for distance, 6)beanbag sorting,7) delivery express,8) copycat,9) Ball on ring,10) passing the basi,11) crossing obstacles,12) cone stacking (・ Therapeutic recreation accountability model (TRAM) approach reinforces ‘activity analysis, selection, and modification’, ・ Specific cues and prompts, with encouragement. ・ Activities needed to be further broken down, ・ Equipment needed to be adapted to aid skill acquisition)	A designated covered area and was delivered after all formal classes were completed at a school; each session was 1 h (warm-up, intervention activities, and cool down), 3 times per week for 8 weeks	Emotional self-control (+), Social interaction (−)	b1520 Appropriateness of emotion, b1521 Regulation of emotion	d2401 Handling stress, d250 Managing one’s own behavior, d2501 Responding to demands, d7100 Respect and warmth in relationships, d7103 Criticism in relationships, d7202 Regulating behaviors within interactions, d7203 Interacting according to social rules
22. Hayward et al., Quasi-experimental pretest-posttest design, 2016, USA (Hayward et al. 2016)	Eighteen children (a mean age of 9.77 (SD = 2.15) )with autism spectrum disorder(ASD) and buddies were comprised of 20 local high school volunteers and five Doctor of physical therapy (DPT) students	Individual and group; soccer program:soccer bowling; kicking soccer balls into a regulation size goal; 15-yard dribbling agility; tunnel soccer; a 30-yard dash; and passing (・ Using tokens and picture exchange communication systems (PECS), ・ Verbal praise for reinforcement, ignoring negative behaviors, ・ Water breaks after completion of a designed task/skill. ・ Use of simple and direct verbal commands)	In a community; the outdoor soccer program ran for 90 min (a 5-minute check in, 10-minute warm-up (game of tag, dynamic stretching), 35 min of soccer drills in the form of six stations, 20 min of 3-on-3 soccer games, two 5-minute water breaks, and 10 min of parachute activities to conclude with a fun, socially interactive, group activity;) each session, meeting once weekly for overall six sessions	Basic soccer skills: A 30-yard run (−), A 15-yard agility run (+), Kicking accuracy (+)		d9201 Sports, d4552 Running, d4351 Kicking
23. Henderson et al., Quasi-experimental pretest-posttest design, 2016, USA (Henderson et al. 2016)	Thirty-seven children (ages 5-12) with autism spectrum disorder (ASD)	Group; TGMD-2 motor skills teaching and practice (・ The didactic teaching style was augmented with many demonstrations, repetition of cues, and verbal, manual, and physical prompting to elicit performance)	In the gymnasium at a center for children with ASD; 40-minute physical education (warm-up activities, skill development activities) class provided twice a week for six months	The locomotor skills (+), The object control skills (+)		d4552 Running, d4553 Jumping, d445 Hand and arm use, d4455 Catching, d4454 Throwing, d4351 Kicking
24. Lee and Porretta, Single-subject design, 2016, USA (Lee and Porretta 2016)	Two boys (ages 8)with autism spectrum disorder (ASD)	Individual; gymnasium (running, throwing, catching, kicking) and pool (bobbing, blowing bubbles, kicking, back floating, and playing with a ball) (・ Verbal and physical prompts)	At a university(in a multipurpose room and in a swimming pool); each session lasted 13 to 15 min, one session per day, two to three sessions a week	Stereotypic behaviors (+)	b7653 Stereotypies and motor perseveration
25. Yu et al., Quasi-experimental design, 2016, Hong Kong (Yu et al. 2016)	Thirty-eight children (ages 7–10) with developmental coordination disorders (DCD) and Forty-six children with TD	Group; group-based multi skill fundamental movement skills (FMS) training; Participants in the experimental groups were instructed to practice five skills (i.e. running, jumping, catching, kicking, and throwing) underpinned by error-reduced learning paradigm (・ FMS tasks were designed to initially be very easy with the difficulty progressively increasing over time, ・ To control the task difficulty, either the distance was increased (running, jumping, and catching) or the target area was progressively narrowed (kicking and throwing))	PE classes; 35 min, twice per week, a total of nine sessions over 6 weeks	FMS proficiency (+), Self-perceived physical competence (+), Physical activity (−), Sleep disturbance(+)	b11420 Orientation to self, b1266 Confidence, b134 Sleep functions, b1801 Body image, b7101 Mobility of several joints, b730 Muscle power functions, b7354 Tone of muscles of all limbs, b7602 Coordination of voluntary movements	d4 Mobility, d4351 Kicking, d4552 Running, d4553 Jumping, d4454 Throwing, d4455 Catching, d570 Looking after one’s health, d5702, Maintaining one’s health, d920 Recreation and leisure, d9201 Sports
26. Dieringer et al., Single-subject design, 2017, USA (Dieringer et al. 2017)	Five preschool children (ages 5–6) diagnosed with autism spectrum disorder (ASD)	Individual; locomotor and manipulative skills (e.g. running, hopping, crawling, galloping, placing bean bag on specific body part) were taught with three songs chosen from “Greg and Steve’s Kids in Motion,” a musical group commonly used in movement setting (・ A positive and effective learning environment in which instruction was explicit, ・ The activities were presented via the lyrics of the music or spoken instruction with or without verbal prompts)	The lunchroom at a preschool; four 10-minute sessions, per week at the same time each day, at least ten, but no more than thirteen, weeks of sessions	On-task behaviors (+)		d155 Acquiring skills, d161 Directing attention, d2501 Responding to demands, d3101 Comprehending simple spoken messages
27. Guest et al., Quasi-experimental pretest-posttest design, 2017, Canada (Guest et al. 2017)	Thirteen girls with Autism Spectrum Disorder (ages 8–11)	Group; multi-sport camp (active group games, track and field, basketball, soccer) (・ Motor skills were incorporated into active group games, ・ The skills taught progressed in difficulty throughout the week and were implemented into translational sport settings)	At a local school gymnasium with indoor and outdoor activity space; a five full-day camp	Motor skills (+), Physical activity level (−), Physical self-perceptions (+), Adaptive behavior (−), Social skills (+)	b1252 Activity level, b1255 Approachability, b1266 Confidence, b4550 General physical endurance, b730 Muscle power functions	d4552 Running, d4553 Jumping, d445 Hand and arm use, d4351 Kicking, d4455 Catching, d4454 Throwing, d710 Basic interpersonal interactions, d720 Complex interpersonal interactions, d729 General interpersonal interactions, other specified and unspecified, d920 Recreation and leisure, d9201 Sports
28. Hauck et al., Quasi-experimental pretest-posttest design, 2017, USA (Hauck et al. 2017)	Twenty-five adolescents (aged 9-18)with down syndrome(DS) and autism spectrum disorder (ASD); cycle	Individual and group; ride a bicycle (・ Encouraging words and stickers as well as by facilitating short water breaks ・ Specially-designed bicycles and standard two-wheeled bicycles were used)	A large indoor space where participants rode the specially-designed bicycles (with non-marking tires) and a large outdoor space (parking lot) where participants transitioned once they graduated to the standard two-wheeled; 75 min each day for five consecutive days	Physiological outcomes: Leg strength (+), Balance (+), Body mass index (−)	b730 Muscle power functions, b2351 Vestibular function of balance, b755 Involuntary movement reaction functions, b530 Weight maintenance functions
29. Mische Lawson and Little, Quasi-experimental pretest-posttest design, 2017, USA (Mische Lawson and Little 2017)	Ten children with Autism Spectrum Disorder (aged 5–12)	Individual; sensory enhanced aquatics (・ Sensory support (visual and sensory supports, communication strategies, physical supports, modeling), ・ Social opportunities (e.g. songs and games) at the beginning and end of each lesson)	No info for the setting; 30-minute, eight weekly swimming lessons	Sleep behaviors (+)	b134 Sleep functions
30. Bittner et al., Single-subject design, 2018, USA (Bittner et al. 2018)	Six children (mean age= 7 years,7 months (SD = ± 1.39)with autism spectrum disorders(ASD)	Individual; the participant selected a skill from TGMD-3 and an instructional protocol (i.e. PTC, EB App,  combination) and be taught the selected skill in the selected method (・ Verbal instruction with a PTC visual, ・ Verbal instructions were used and the demonstration consisted of viewing the video modeling skill in the EB App)	A gym; the instructional methods trials were conducted for 15 min per session(one trail for 5 min and overall 3 trails), 3 days a week, for 4 consecutive weeks	Gross motor skills: Horizontal Jump (−), Kick a stationary ball (−), Overhand Throw (−), Dribble (+), Strike off Tee (+), Catch (+), Run (−)		d4553 Jumping, d4351 Kicking, d4454 Throwing, d445 Hand and arm use, d4455 Catching, d4552 Running
31. Kokaridas et al., Single-subject design, 2018, Greece (Kokaridas et al. 2018)	Three male children(aged 9)with autism spectrum disorder(ASD) and three without ASD	Individual; climbing program(a 5 min warm up, a 30 min indoor climbing at a traverse and a top-rope route,a 5 min cool-down), (・ Specific colored tapes that corresponded to specific separate routes of different difficulty level, served as a conditional stimulus that allowed individuals with ASD to discriminate stimulus for the behavior of reaching up and grasping)	A regular rock-climbing gym setting, leisure activity facilitates; 40 min each session at a frequency of two sessions per week, for 12 weeks	Handgrip strength (+), Traverse speed (+)	b7300 Power of isolated muscles and muscle groups	d4551 Climbing
32. Pritchard Orr et al., Wait-list control design, 2018, Canada (Pritchard Orr et al. 2018)	Thirty children (ages 7–14) with a diagnosis under the (Fetal Alcohol Spectrum Disorder)FASD umbrella	Individual; the FAST Club program(children rotated through a subset of six motor skill stations that were based on the subtests of the motor domains of the BOT-2), (・ An individualized PA program based on each child’s PA strengths and personalized activity choices)	An elementary school gymnasium; 1.5 h per session, 2 sessions per week, 8 weeks	Executive function (+)	b164 Higher-level cognitive functions
33. Ekins et al., Quasi-experimental pretest-posttest design, 2019, Germany (Ekins et al. 2019)	Fifteen children diagnosed with an intellectual disabilities or related developmental disability such as autism spectrum disorder(aged 13.9 ± 2.7)	Group; drumming,the IG conducted two Drums Alive® (the original and researched based brain and body drumming fitness and wellness program applies a multi-disciplinary approach (dance, movement,music, rhythm, modeling and patte) and additionally two conventional physical exercise (PE) classes per week, (・ IG combines cognitive experiences with simple dynamic movements and drumming on a fitness (stability) ball, and reinforces rhythm exploration)	In a special school; twice a week for 7 weeks	Cognitive, social and practical competencies (−), Behavior and emotions (−), Motor skills: 20m sprint (−), Sit-ups (+), Standing long jump (+), Forward bend (−), Jumping side-to-side (+), Balancing backwards (+), Medicine ball shots (−), 6 min run (−)	b152 Emotional functions, b140 Attention functions, b152 Emotional functions, b2351 Vestibular function of balance, b4550 General physical endurance, b7306 Power of all muscles of the body, b7355 Tone of muscles of trunk, b755 Involuntary movement reaction functions	d155 Acquiring skills, d3 Communication, d4552 Running, d4103 Sitting, d4553 Jumping, b7101 Mobility of several joints, d740 Formal relationships, d750 Informal social relationships
34. Mohanty et al., Wait-list control design, 2019, India (Mohanty et al. 2019)	Eighty-three children (ages 9-16) with visual impairment	Group; yoga practices:1) breathing practices,2) loosening practices,3) yoga asanas (postures), 4) pranayama (regulation of breath),and 5) relaxation; (・ Audio cassettes with detailed instructions of all practices were also provided)	Residential school; 1 h, 5 days/week, 16 weeks	Muscle strength (+), Flexibility (+), Endurance (+), Coordination (+), Respiratory health (+)	b4402 Depth of respiration, b7101 Mobility of several joints, b7300 Power of isolated muscles and muscle groups, b7354 Tone of muscles of all limbs, b740 Muscle endurance functions, b7602 Coordination of voluntary movements
35. Trocki-Ables et al., Single-subject research, 2020, USA (Trocki-Ables et al. 2020)	Five boys (aged 8–11) with autism spectrum disorders(ASD)	Individual; participant completes as many correct 90° push-ups as possible in 1 min, demonstrating correct form, and under three different treatment conditions (・ Watched a video of a cross-aged peer performing pushing-up, ・ Primary reinforcer was given to the participant on completion of the push-ups if the participant matched or improved his previous number of push-ups from his last primary reinforcer session)	In the home setting; 3 baseline trails, 24 randomly assigned treatments, and 1 generalization phase	Upper body strength: Endurance push-up performance (+)	b740 Muscle endurance functions

Table 3.

An example of the ICF-CY coding procedure.

Abilities and behaviors in focus (using ICF-CY linking rules)
Target abilities and behaviors (+, –)	Measurement tools	ICF-CY coding process	ICF-CY code summary
Fundamental motor skills (FMS) proficiency (＋)	TGMD-2 (＋)	(d4552 Running, d4553 Jumping, d4455 Catching, d4351 Kicking, d4454 Throwing)	b11420 Orientation to self
	locomotor skills (running, jumping)		b1266 Confidence
	object controls kills (catching, kicking, overarm throwing)		b134 sleep functions
			b1801 Body image
			b7101 Mobility of several joints
Self-perceived physical competence (＋)	The Physical Self-Descriptive Questionnaire (PSDQ) (＋)	(d5702 Maintaining one’s health, b7602 Coordination of voluntary movements, b1801 Body image, d9201 Sports, b11420 Orientation to self, b1801 Body image, b730 Muscle power functions, b7101 Mobility of several joints, b7354 Tone of muscles of all limbs, d570 Looking after one’s health, d920 Recreation and leisure, b1266 Confidence)	b730 Muscle power functions
			b7354 Tone of muscles of all limbs
	physical health, physical coordination, body fat, sporting ability, physical self-concept, physical appearance, physical strength, physical flexibility, physical fitness, and global self-esteem		b7602 Coordination of voluntary movements
			d4 Mobility
			d4351 Kicking
Physical activity (–)	GT3× + accelerometers (−)	(d4 Mobility)	d4 Mobility
Sleep disturbance (＋)	The Children’s Sleep Habits Questionnaire—Chinese version (CSHQ-C) (＋)	(b134 Sleep functions)	d4454 Throwing
			d4455 Catching
	bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnias, sleep-disordered breathing, daytime sleepiness		d570 Looking after one’s health
			d5702 Maintaining one’s health
			d920 Recreation and leisure
			d9201 Sports

Results

Characteristics

Study characteristics

Thirty-five included intervention studies were published between 1987 and 2020. The majority (85.71%) were published since 2000. Most (14 studies, 40%) were conducted in the United States, followed by Canada (8 studies, 22.84%); two studies (5.71%) were conducted in China (Hong Kong) and Finland and one study each (2.86%) was conducted in the following countries or regions: Australia, Brazil, France, Germany, Greece, India, Israel, Taiwan and Turkey. Regarding the study design, the largest number of studies consisted of a quasi-experimental design (12 studies, 34.3%) followed by a single-subject study design (11 studies, 31.4%). The number of the randomized controlled trial design (6 studies,17.2%) ranked third. The wait-list control design (4 studies, 11.4%) and other designs (2 studies, 5.7%) contributed to the rest of studies.

Participant characteristics

Sample sizes across the 35 studies varied from 2 to 104 participants. Regarding the type of disability (Graph 1), the number of studies examining autism spectrum disorders (hereafter abbreviated as ASD) was the highest (15 studies, 42.9%). Particularly, 2 among the 15 studies included both ASD and their typically developing peers. The second most numerous types are composed of those including a group of participants with various disabilities and those with multiple disabilities, consisting of 5 (14.3%) of 35 articles. Three (8.6%) studies examining cerebral palsy and developmental coordination disorders (with 1 among 3 including both developmental coordination disorder (DCD) and their typically developing peers), contributed the third largest share. The number of studies focusing on other disabilities was the fewest, consisting of intellectual disabilities (2 studies, 5.7%), emotional disorders (2 studies, 5.7%), visual impairment (1 study, 2.9%), Down’s syndrome (1 study, 2.9%), fetal alcohol spectrum disorder (1 study, 2.9%), craniofacial differences (1 study, 2.9%) and behavior disorders (1 study, 2.9%).

Program descriptions

Types and adaptations of PA

PA in 17 studies (48.6%) was organized at individual levels, while PA in 14 studies (40%) was organized at group levels. The rest of the studies (4 studies, 11.4%) included a combination of both individual and group level PA. Regarding the types of PA, 9 studies (25.7%) used simple motor activities. Simple motor activities, such as a single (bean bag tossing, a kicking task) or a few or a whole set (TGMD-2 and TGMD-3), were used to incorporate motor skills practice/training. The adaptations of simple motor activities were mainly established for: (1) teaching strategies (used with logical development of skills and difficulty increasing over time); (2) providing verbal, musical, visual, tactile reinforcement/prompts; (3) giving children a goal and chance to have autonomy. Seven studies (20%) used a variety of PAs. All wide-ranging PA program details can be found in the Table 2 and two examples are listed here: one study included gymnastics and pool activities and the other included aerobic and strength training and organized sports. No common adaptations were found among them. The number of studies applying equine-assisted therapy (8.6%) and aquatics (8.6%) contributed to 3 of 35 studies. One of the equine-assisted therapy used a horse-riding exercise machine (Joba) instead of real horses. Adaptations for equine-assisted therapy were mostly relevant to the saddle, offering cues by horse handler and side walker, and incorporating balance activities on the horseback. Aquatic programs consisted of basic stroke and breathing training sessions, sensory-enhanced aquatics, and fun water activities with aquatic play skills. Verbal and visual, sensory reinforcement, and modeling, were used for aquatic programs adaptation. Simple tasks (sit-up trails, push-up trails) (5.7%) with adaptations on goal setting, video modeling and personal reinforcement; indoor wall climbing (5.7%) with adaptations on physical assistance and verbal cueing); biking (5.7%) with adaptations on specially designed bikes, and camping (5.7%) with adaptations on creating supportive environment were used in 2 studies each. The remainder of the studies used yoga (1 study, 2.9%), surfing (1 study, 2.9%), soccer programs (1 study, 2.9%), drumming (1 study, 2.9%), and virtual reality PA (1 study, 2.9%).

Settings

Among the 35 studies, the largest number of studies (19 studies, 54.3%) were conducted in community and recreational settings, which varied from campsites, swimming pools, equine centers, gym/fitness centers, beaches, cycling courses and indoor and climbing facilities. This was followed by those conducted in school settings (11 studies, 31.4%). However, it is important to mention that even though some interventions were held at schools or universities, the intervention itself was not part of a school-sanctioned activity. These activities were neither part of the school curriculum nor were they conducted in a school classroom. For example, one activity was held in the school after the formal class ended as part of an after-school activity. Alternatively, in the original articles, the setting was described as ‘in quiet therapy or study rooms in schools,’ or ‘in the lunchroom’. Overall, four studies were conducted in similar situations. Nevertheless, school settings play an essential role. There were two articles (5.7%) which fell under the “no information” category, which was the third largest, followed by other settings (2 studies, 5.7%) and clinic (1 study, 2.9%). The other settings included settings in a laboratory or at home.

Program length, frequency and duration

Program length ranged from one trial (without specific length mentioned) or a minimum of 10 min to a maximum of 90 min. The most common length is 1 h (9 studies, 25.7%). Program frequency ranged from only one main trial to 5 days a week. The most common frequency is twice a week (10 studies, 28.6%), followed by three times a week (9 studies, 25.7%), and once a week (5 studies, 14.3%). Program duration ranged from 1 day to 9 months. Twenty studies’ (57.1%) duration fell within the range of 5 weeks to 12 weeks.

Abilities and behaviors the studies focus on and reported effectiveness

Due to the prevalence of a large variety of research designs, an article could have more than one research purpose. Among the 35 articles, 184 outcomes were identified (Graph 2). Of these, 88 (around 48%) aimed at improving body functions, while only 1 outcome (0%) was focused on the environmental factors. The largest number (95), accounting for 52% of the overall outcomes, fell under the ‘activities and participation’ category. Apparently, the only category not mentioned in the ICF-CY is body structures.

The first conclusion this study can draw is that changing or improving body structures is not one of the main outcomes associated with services to children and youth with disabilities. In the category of body functions (Graph 3), most body functions aimed at improvement were neuromusculoskeletal and movement-related functions, followed by mental functions, and then, sensory functions and pain. It is clear that: (1) Muscle power functions were the main focus among the neuromusculoskeletal and movement-related functions, and it reinforces functions related to the force generated by the contraction of a muscle or muscle groups. The mobility of joint functions, muscle endurance functions, involuntary movement reaction functions, control of voluntary movement functions also played important roles; (2) Confidence building, orientation functions, emotional functions, body image were the highlights among the ‘mental functions’; and, (3) Vestibular function of balance was the most significant goal in the category of ‘sensory functions and pain’.

Graph 1.

The number of studies by disability category.

The authors further discussed the components contributing to mobility, interpersonal interactions and relationships and community, social, and civic life under the category of ‘activities and participation’ (Graph 4). Mobility had the largest number of components. Improving the skills of kicking, hand, and arm use (throwing, catching), moving around (running, and jumping) are the main outcomes. When it came to interpersonal interactions and relationships, the results showed that most APA articles examined the basic, complex, and general interpersonal interactions, formal and informal relationships. In regards to the community, social, and civic life, only recreation and leisure (play and sports) have been included within the 35 APA articles.

Graph 2.

A summary of key outcomes by linking to the ICF-CY category.

Graph 3.

A summary of key outcomes under the body function category.

Graph 4.

A summary of key outcomes under the activities and participation category.

Only 1 outcome item was related to environmental factors. In the category of environmental factors, the outcome was to change attitudes (individual attitudes of acquaintances, peers, colleagues, neighbors and community members).

Overall, the main outcomes associated with APA services to children and youth with disabilities were improving body functions, especially mental functions (confidence, orientation functions, emotional functions, body image), sensory functions and pain (vestibular function of balance), movement functions (control of voluntary movement functions, involuntary movement reaction functions) and muscle functions (muscle power and endurance functions). These also aim to improve the gross and fine motor skills of kicking, hand and arm use (throwing and catching), running, jumping and building informal social relationships, and taking part in recreation and leisure activities (play and sports).

Regarding the reported effectiveness, a large majority (19 studies, 54.3%) of the studies reported positive benefits or effectiveness of APA interventions (Table 2). In another 42.9% (15) of the studies, partial effectiveness was found (e.g. in some behaviors and/or abilities in some participants). One study (2.9%) reported that the virtual reality of sport applications, music programs and game-like programs are no more effective than regular physical therapy or occupational therapy intervention for children with cerebral palsy. As a result, all but one study showed effectiveness or partial effectiveness of APA on improving the abilities and behaviors for children and youth with disabilities.

Discussion

The aim of this scoping review was to identify and review the current existing literature on APA interventions (characteristics, program descriptions, and goals), and to understand how APA has been implemented in different services in relation to 5–18 years old children and youth with disabilities (excluding pre-schoolers). Peer-reviewed journal articles describing interventional programs with an experimental study design written in English were screened. A narrative synthesis was undertaken to answer the research questions on characteristics, program descriptions and goals of APA interventions (abilities and behaviors the studies focus on and reported effectiveness). The ICF-CY linking rules were applied to synthesize the goals.

Characteristics (study characteristics)

Thirty-five articles were found that met the inclusion criteria between the years of 1987 and 2020. Similar with previous studies in out-of-school contexts (Arbour-Nicitopoulos et al. 2018, Orr et al. 2021), a majority of the included studies were published since 2000. The research comes from different countries and continents, with a big concentration in the United States and Canada. APA started in the United States with its first implementation at the Perkins School for The Blind in Boston in 1838 (Winnick 2010). Three mainstream journals included in our search are based in the United States. It is thus not surprisingly to see that a majority of the studies have been conducted in North America. In 1984, it was suggested that the individualized nature of instructional programs for the mentally handicapped often makes group designs inappropriate in PA research (Watkinson and Watson 1984). It is still the case in the 21st century as our search identified a big portion of single-subject study which thinks highly of individualization in the included studies. As per our findings, even in controlled trails, the PA offered to all children or youth with disabilities in the intervention group can still be provided in an individual context rather than in a group-based format.

Characteristics (participant characteristics)

Children and youth with ASD contributed to the largest target group in the existing APA interventions literature. Expanded diagnostic criteria, more awareness of ASD, and diagnosis occurring at earlier ages led to the prevalence of ASD as a categorical diagnostic condition (Matson and Kozlowski 2011). It was indicated that, within the last two decades, interest in the potentially beneficial effects of PA has grown for children with ASD, even though PA is usually not regarded as a standard treatment/intervention (Sowa and Meulenbroek 2012). Fifteen studies focusing on ASD proved to have an overall/partial positive effectives on various outcomes, but this study cannot simply draw a conclusion that APA is more beneficial to children with ASD than the other subgroups. This topic needs further examination. However, this study attests to the fact that researchers in recent decades have realized the potential benefit that PA might bring to children and youth with ASD. Different types of disabilities and children and youth with multiple disabilities contributed to the second largest target group. As discussed with respect to the study design, APA reinforces individualized nature of instructional programs. ASD and different types of disabilities or multiple disabilities, which indicate more complex conditions than other types of disabilities, are more likely to be dealt with individually in the field of APA.

Program descriptions

In terms of the types of PA, this study tried to identify whether the program is organized at an individual level or as group-based level, and the PAs which have been used for the intervention. Not surprisingly, the number of individual-level PAs is bigger than group-level activities. It is understandable that special needs can be better fulfilled in individual programs. A previous meta-analysis for children with ASD study provided proof for that (Sowa and Meulenbroek 2012). However, it is worthy to consider how APA could be organized in a group format to include a larger sample size and still be effective (Lai et al. 2020). The current review covered a wide range of APA intervention studies by implementing rich and diverse adaptive PA programs. Simple motor activities and a variety of PAs were priority selections. In accordance with previous finding (Lai et al. 2020, Orr et al. 2021) on modifications of PA, the descriptions in our findings are also very limited. With adequate modifications information, more PA evidence-based strategies for a certain type of disability (Knight et al. 2015) can be developed. Therefore, a call for more transparent program descriptions regarding modifications in APA is needed. Concerning settings, studies conducted both in-and-out of the school settings and even school-based ones are not school-sanctioned but community-embedded activities (Lai et al. 2020). Regarding the program dose, the average duration of the program is shown to be similar (5 weeks to 12 weeks) as the previous reviews for children with physical disabilities and children with impairments in social skills and cognition (Arbour-Nicitopoulos et al. 2018; Orr et al. 2021).

Abilities and behaviors the studies focus on and reported effectiveness

Using ICF-CY linking rules to synthesize outcome items allows: (1) content comparison of outcome items used in APA with details in a systematic way and (2) guidance on selecting the most appropriate intervention goals.

Content comparison of outcome items used in APA with details in a systematic way

One of the previous reviews for children and youth with physical disabilities simply listed discovered outcomes, which were mainly related to social skills, physical skill development, psychological well-being, and participation in PA (Arbour-Nicitopoulos et al. 2018). Another for children and youth with impairments in social skills and cognition included (Orr et al. 2021) anthropometrics and fitness, motor, and sport skills, psychological well-being, and socialization. The above outcome areas were derived from reviewers’ categorization of the associated findings. Without a framework, it is difficult for the readers to capture which specific aspects of the mentioned outcome areas were examined and the portion and the level of importance of the specific aspects compared to others. However, mapping these factors to ICF-CY codes give an obvious outline to our findings. Regarding the overlapping outcome areas (social aspects, physical skill development, and psychological well-being) of the two previous studies, the new findings of our review can be explained by differentiating the focus of outcome areas. First, the previous studies mostly covered social skills/relationships. Key findings (Arbour-Nicitopoulos et al. 2018) included studies on peer relationships between the typical developing peers of children and youth with disabilities in terms of increasing social acceptance and disability awareness from the perspective of developing peers. Extra reinforcements were put in place for familial interactions from the viewpoint of parents. As per this review, social skills/relationships are not the most significant outcomes that APA scholars are keen to examine. We discovered that social skills/relationship studies focused not on a particular type of disability. Due to the various types of disabilities, social skills are evaluated by all forms of methodology, ranging from standardized social skills instruments filled by teachers or participants themselves to trained observations either from in-person interaction or recorded videotapes. These focus more on the social skills of the children and youth with disabilities themselves on a particular occasion instead of typical developing peers’ opinions, and developing peers are not frequently involved. We coded these mostly in d7 interpersonal interactions and relationships, which reinforces improving interaction skills in a contextually and socially appropriate manner with a goal of being involved in the activities and participation. Second, while fewer studies examined physical skill development (improvements in locomotion, object control, and activity-specific skills) in previous studies, this contributed to the biggest outcome areas (hand and arm use, kicking, jumping, and running, which are necessary for mobility, muscle, and movement functions under the neuromusculoskeletal and movement-related functions) with a mixed focus on both body function and activities and participation in our review. Third, psychological well-being was studied, particularly in the form of self-perceptions (e.g. self-efficacy, autonomy, self-concept, and self-esteem) in the previous review (Arbour-Nicitopoulos et al. 2018). In this review, mental functions consisting of orientation functions, temperament and personality functions, emotional functions and body image played the third most important role in the outcome areas. ‘Confidence’ was the most frequently counted outcome category. Self-esteem and self-perception were the two main forms of tracing back to the original texts.

Although another review had included systematic reviews, our current scoping review included intervention studies, sharing similarities in the wider coverage of the outcome areas with another review in terms of its outcome areas (Lai et al. 2020). These include indicators of fitness (aerobic capacity and muscular strength), physical and cognitive function, body weight and composition, physical development, social skills and relationships and psychological well-being. The first reason for the similarity could be because both these reviews consider the same group of study participants: children and youth with disabilities. Even though our studies did not exclude therapy-based interventions as per the eligibility criteria, we did not end up including many therapy-based interventions. This result is in accordance with the previous review, which excluded all therapeutic studies. We assume this is the second reason behind the similarity. Moreover, compared with results from direct derivation of associated findings without a unified ‘language’, graphs with various ICF-CY levels of codes are easier to refer to.

Guidance on selecting the most appropriate intervention goals

This review identifies the fact that current APA interventional literature providing children and youth with disabilities services works toward a pragmatic direction of supporting children and youth with disabilities to become engaged in PA. Activity is defined as the execution of a task or action by an individual and participation is involvement in a life situation (World Health Organization 2007). To achieve this goal, APA, as a service delivery, has been working mainly toward increasing the mobility. Along with this goal, improving functions of movement and mobility, including functions of joints, bones, reflexes and muscles gains its popularity among APA studies. Other than this, secondary focus of goals on improving social skills on a particular occasion and further encouraging doing sports or being active in play along with mental functions to a lesser extent. Future PA interventions for children and youth with disabilities could be planned based on the current goals (Table 2) to ensure the immediate effectiveness or expanded more on those uncovered or unexplored areas. It is also recommended APA implementers refer to ICF-CY to give intervention descriptions for children and youth with disabilities because we did not find a single study mentioning the use of ICF-CY.

In terms of the reported effectiveness, all but one study considered it beneficial for the abilities and behaviors in question. However, this study simply reviews the result of each included studies without conducting a quantitative analysis. A major concern with the quantitative analysis lies in considerable heterogeneity across the included studies. Without the effect sizes indicating clearer intervention outcomes, the results of this study should be interpreted with caution. At least our discoveries could provide apparent evidence that children and youth with disabilities showed immediate improvements to outcomes because of the intervention (Lai et al. 2020).

Conclusion

Overall, this comprehensive review provides an overview of the characteristics, program descriptions and goals (outcome areas) of APA studies for children and youth with disabilities. In accordance with APA’s holistic definition, this review, with specific characteristics and outcomes, proved that APA started serving one of its target groups—children and youth with disabilities, mainly in North America and from 2000 by working on neuromusculoskeletal and movement-related and mental aspects of body functions mostly and reinforcing the mobility and socialization capacity or participation in everyday activities effectively. The biggest target group involved children and youth with ASD. A majority of the PA interventions were held in recreational and after-school school settings with an average program length of 1 h and frequency of 2 or 3 times a week for duration of 5 to 12 weeks. This review not excluding therapeutic intervention studies or limiting the participants to children and youth with a single type of disability provides APA specialists, researchers and educators a broader overview of interventional studies in the field. Using the ICF-CY linking system also generates systematic insights related to the more specific outcome areas under the three of four major domains: body functions, activities and participation, and environmental factors. This will not only encourage APA practitioners to be more confident when setting a goal for children and youth with disabilities but also provide potential recipients and their parents or families with a more convincing report of wide coverage and precise outcomes of APA services. Finally, professionals across disciplines will develop a better understanding of APA through this review and explore areas for potential cooperation in the future.

Limitation

Like most reviews, eligibility criteria could be a limitation because of the language selection. Selecting studies written in English could be one of the potential reasons for missing important studies in the field.

Disclosure statement

The authors report there are no competing interests to declare.