Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-020-04418-2

BRIEF REPORT

Brief Report: Impact of a Physical Exercise Intervention on Emotion

Regulation and Behavioral Functioning in Children with Autism
Spectrum Disorder
Andy C. Y. Tse1 

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Problems with emotion regulation and behavior are often reported in children with autism spectrum disorders (ASD). This
pilot study examined the effect of physical exercise on emotion regulation and behavioral functioning in children with ASD.
Twenty-seven children aged 8–12 years were randomized into either an exercise intervention group (n = 15) or a control
group (n = 12). The intervention group received a 12-week jogging intervention. Children’s parents completed the Emotion
Regulation Checklist and the Child Behavior Checklist pre- and post-intervention. The intervention group demonstrated
significant improvement in emotion regulation and reduction in behavioral problems (ps < .05). Future studies should explore
the mechanisms underlying the effects of physical exercise on emotion regulation and behavior in children with ASD.

Keywords  Emotion regulation · Behavior · Physical exercise · Children · Autism spectrum disorder

Introduction (2016) found that high levels of disruptive behaviors, self-

Autism spectrum disorder (ASD) is a neurodevelopmental
disorder that is evident in early childhood and that has an
increasing prevalence rate. The most recent ASD prevalence
rate reported for Hong Kong is 1 in 68 children and the
rate is expected to increase (Centre for Disease Control and
Prevention, HKSAR 2012). Children with ASD show per-
sistent deficits in social communication and social interac-
tion, along with restricted and repetitive behavior, interests,
or activities (American Psychiatric Association 2016). In
addition to these core symptoms, emotional and behavioral
difficulties such as aggression and temper tantrums are also
frequently reported (e.g., Berkovits et al. 2017; Jahromi et al.
2012; Jahromi et al. 2013; Samson et al. 2015). For exam-
ple, Maskey et al. (2013) reported that some children with
ASD engaged in maladaptive behaviors such as aggressive
and self-injurious behavior when experiencing negative or
overexciting emotions (Maskey et al. 2013). Chandler et al.
* Andy C. Y. Tse
andytcy@eduhk.hk
1 the effects of yoga and jogging on physical fitness, cog-
Department of Health and Physical Education, The
Education University of Hong Kong, Rm D4‑2/F‑07, Block
D4, 10 Lo Ping Road, Tai Po, N.T., Hong Kong, China
absorption, and hyperactivity are associated with emotional
problems in young children with ASD (Chandler et  al.
2016). These emotional and behavioral problems pose sub-
stantial challenges to daily functioning, as they can result in
poor social development (Baker 2008), depression (Mazef-
sky et al. 2014), and anxiety symptoms (Kim et al. 2000;
Mazefsky et al. 2013). Moreover, these problems are closely
associated with higher levels of parenting stress and family
distress in children with ASD (see Yorke et al. 2018 for a
review).
Two types of interventions are used to tackle the prob-
lems of children with ASD: applied behavior analysis
(Mohammadzaheri et  al. 2014) and cognitive–behavio-
ral therapy (Scarpa and Reyes 2011). These interventions
have demonstrated their effectiveness for emotional and
behavioral problems in children with ASD (see Ung et al.
2015 for a review). Meanwhile, previous literature shows
that physical exercise positively affects emotional wellness
and reduces behavioral problems in children with typical
development (TD) (Fox 1999; Ishii et al. 2016; Penedo and
Dahn 2005; Telles et al. 2013). For instance, Telles et al.
(2013) conducted a randomized controlled trial examining
nitive functioning, and emotional well-being in healthy
children. The results revealed that both yoga and jogging

13
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improve physical strength, attention, and self-esteem. Ishii
et al. (2016) conducted a large-scale questionnaire study on
the effects of regular participation in physical exercise on
emotion and behavior in children. The results showed that
regular exercise participation was strongly associated with
improvements in self-efficacy and reduction of emotional
and behavioral problems (Ishii et al. 2016). Considering the
effectiveness of physical exercise in improving emotional
and behavioral functioning in children with TD, it is likely
that children with ASD could benefit from it.
Indeed, several studies have provided empirical evidence
showing that physical exercise may benefit social function-
ing in children with ASD. For example, Levinson and Reid
(1993) investigated the effectiveness of 5-week physical
exercise intervention (15-min walking on day 1 and 15-min
jogging on day 2) on stereotypic behavior of three children
with ASD. Results showed that their stereotypic behaviors
have been significantly decreased after the intervention
(Levinson and Reid 1993). Rosenthal-Malek and Mitchell
(1997a, b) also showed that 10 sessions of 20-min jogging
intervention could significantly reduce self-stimulation
behavior in children with ASD. Moreover, two systematic
reviews (e.g., Bremer, Crozier, & Lloyd, 2016; Petrus et al.,
2008) and one meta-analysis (Sowa & Meulenbroek, 2012)
have been conducted to investigate the impact of physical
exercise on behavioral functioning in children with ASD.
All concluded that physical exercise may be an effective
intervention for improving social behavior functioning in
children with ASD. However, none of the previous study
have directly examined the effect of physical exercise on
emotion functioning in children with ASD.
The aim of the present pilot study was to examine the
impact of a physical exercise intervention (moderate-to-
vigorous intensity jogging) on emotional and behavioral
functioning outcomes in children with ASD. The jogging
intervention was used because it is easy to administer and
does not require expensive resources. More importantly, it
was shown feasible in children with ASD (Levinson and
Reid, 1993; Rosenthal-Malek and Mitchell 1997a, b). Given
the existing evidence for the emotional and behavioral ben-
efits of physical exercise for TD children (Ishii et al. 2016;
Telles et al. 2013), we hypothesized that the physical exer-
cise intervention would positively affect both emotional and
behavioral functioning outcomes in children with ASD.
Methods
Participants
Initially, 84 children with ASD were recruited from local
special schools for intellectual disabilities and the parent’s
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Journal of Autism and Developmental Disorders
social community. The inclusion screening criteria were:
(1) aged 8–12 years; (2) ASD diagnosis from a physician
based on the Diagnostic and Statistical Manual of Men-
tal Disorders, 5th edition, (DSM-5, American Psychiatric
Association 2016); (3) non-verbal IQ over 50 as assessed
by the Wechsler Intelligence Scale for Children (Chinese
revised) (C-WISC; see Gong and Cai 1993 for more infor-
mation); (4) ability to follow instructions with the assis-
tance of the researcher; (5) ability to perform the requested
physical exercise intervention with the assistance of the
researcher; (6) no history of reading disabilities accord-
ing to parents; (7) no participation in any regular physical
exercise training in the past 6 months; and (8) presence of
severe emotional and behavioral problems as indicated by
the Child Behavior Checklist for ages 6–18 years (CBCL,
Achenbach and Rescorla 2000; Achenbach and Rescorla
2001). The exclusion criteria were (1) having other medi-
cal conditions that limited their physical activity capacities
(e.g., asthma, seizure, cardiac disease); (2) having a com-
plex neurologic disorder (e.g., epilepsy, phenylketonuria,
fragile X syndrome, tuberous sclerosis); and (3) visual
and auditory deficits. All diagnoses and screenings were
conducted by a physician and trained research assistants
at different schools before the pre-test. Similar to previous
studies (Pan et al. 2017; Tse and Masters 2019), we did
not use the Autism Diagnostic Interview-Revised (ADI-R,
Lord et al. 1994) or the Autism Diagnostic Observation
Schedule (Lord et al., 2000) owing to the unavailability of
Chinese versions of these scales. After screening, a total
of 30 participants joined the study and they were randomly
assigned to two groups: intervention group and control
group. However, three participants from the control group
dropped out in the mid of the study (one was admitted to
hospital, one dropped out of school and one did not want
to continue in the study). In total, 27 participants (15 in
the intervention group and 12 in the control group) suc-
cessfully completed the study. Participants’ overall scores
on the Total Problem Scale of the CBCL were in the 99th
percentile, and their scores on at least four of the eight
subscales were in the clinical range (i.e., above the 98th
percentile), which suggested these children had very poor
social and emotional regulation problems. In addition,
we collected parent ratings using the traditional Chinese
version of the Social Responsiveness Scale, Second Edi-
tion (SRS-2; Constantino and Gruber 2012), to screen for
autistic traits and autistic behaviors. Medication usage
and records of after-school therapy (e.g., speech therapy,
occupational therapy) during the study period were also
collected from parents using a questionnaire. Table  1
shows demographic data for the groups. Written consent
was obtained from parents/guardians and schools and the
study was approved by the university ethics committee.
Journal of Autism and Developmental Disorders

Table 1  Demographic statistics Intervention group (n = 15) Control group (n = 12) p

of participants of each group
Gender 13 boys and 2 girls 10 boys and 2 girls 0.66
Age (years) 10.07 ± 1.10 9.42 ± 0.90 0.11
Weight (kg) 40.63 ± 10.06 39.87 ± 10.00 0.85
Height (m) 1.38 ± 0.09 1.34 ± 0.13 0.24
BMI (kg/m2) 21.13 ± 3.20 21.90 ± 3.11 0.53
Non-verbal IQ 60.27 ± 5.80 61.42 ± 3.29 0.55
SRS-2 Raw-scores 80.60 ± 6.59 78.00 ± 8.99 0.39
Medication (n)
 Yes 2 5 0.41

Procedure implemented in the hall/gymnasium/outdoor playground

There were two assessments before the intervention (T1:
baseline) and after the intervention (T2: post-intervention),
in which participants’ emotional and behavioral function-
ing were reported by their parents. The study procedure is
shown in Fig. 1.
Intervention Group
A 12-week jogging intervention consisting of 48 ses-
sions (four sessions per week; 30-min per session) was
of each school. Owing to the tight school schedule and the
students’ reluctance to wear a heart rate monitor, we could
only ensure that the exercise was of moderate-to-vigorous
intensity by observing if students had increased breathing
rates and mildly flushed faces (Rosenthal-Malek and Mitch-
ell 1997a, b). Each intervention session was conducted by
a physical education teacher and a trained research assis-
tant assisted by university student helpers. The staff-to-
participant ratio for both groups was 1:2 to 1:1, depend-
ing on attendance. The overall attendance rate was 97.10%.
The format for all intervention sessions was identical, and

Fig. 1  Flow chart of the present study

13

comprised three activities: warm-up (5 min), continuous jog-
ging paced by the staff at moderate-to-vigorous intensity
(20 min), and cool-down (5 min). To motivate participants,
they were positively reinforced verbally with compliments
for their efforts in jogging. Upon completion of each inter-
vention session, a smiley face sticker was put on a visual
graph to indicate each participant’s progress.
Control Group
Participants in the control group received no intervention.
They were required to follow their daily routine without par-
ticipating in any additional formal physical activity program
throughout the study period (T1–T2).
Assessments
The Emotion Regulation Checklist (ERC, Shields and Cic-
chetti 1998) is a 24-item parent report that generates two
subscale scores: an emotion regulation subscale (ERC-ER)
score and a lability/negativity subscale (ERC-LN) score.
The ERC-ER measures children’s overall mood, emotional
expression, and self-awareness; the ERC-LN measures lack
of flexibility, anger dysregulation, and emotional lability
(Shields and Cicchetti 1998). Higher scores on the ERC-ER
indicate higher levels of emotion regulation abilities; higher
scores on the ERC-LN indicate higher levels of emotion
dysregulation.
The CBCL (Leung et al. 2006) is one of the most widely
used and reliable report measures of children’s emotional
and behavioral functioning (Berkovits et  al. 2017). The
CBCL contains 113 items on eight subscales (anxious/
depressed; withdrawn/depressed; somatic complaints; social
complaints; social problems, thought problems; attention
problems; rule-breaking behavior; aggressive behavior
and other problems). Children’s behaviors were measured
through two composites: internal and external behavior. The
Total Problem Scale score was calculated by summing the
internal and external behavior composite scores and scores
on the other four subscales. In the present study, the main
caregiver of each child participant was asked to complete
the ERC and the CBCL.
Data Analysis
All statistical analyses were conducted using SPSS (version
23.0) for Windows (SPSS Inc., Chicago, IL, USA). Since
ERC has not been validated in children with ASD, Cron-
bach’s alpha was computed for both ERC and CBCL for
reliability analysis. Independent-samples t-tests and paired-
samples t-tests were used to compare between-group dif-
ferences in ERC and CBCL measures and to assess within-
group changes in ERC and CBCL measures at the two time
13
Journal of Autism and Developmental Disorders
points. To assess the effectiveness of physical exercise on
emotion regulation and behavioral functioning, follow-
up analyses were conducted via a series of 2 (Block: Pre
vs. Post) × 2 (Group: Intervention vs. Control) analyses of
covariance (ANCOVAs) with repeated measures for each
emotional regulation (i.e., ERC-ER and ERC-LN) and
behavioral functioning outcome (i.e., T-scores of the inter-
nal behavior composite, external behavior composite, and
total problem scale). Cohen’d was calculated to examine the
effect size with d = 0.2 to be considered as a small effect size,
d = 0.5 as medium effect size and d = 0.8 as large effect size.
Demographic variables (e.g., child age, child gender, and
non-verbal IQ) that correlated with a given outcome variable
at p < 0.05 were entered as covariates in all analyses for that
outcome variable. A p value < 0.05 was considered statisti-
cally significant. Results are presented as mean (standard
deviation). We conducted preliminary tests of the assump-
tions for the ANCOVA by examining data normality using
the Shapiro–Wilk test (all p values > 0.05), homogeneity of
variance (Levene’s test: all p values > 0.05), and homogene-
ity of regression slopes (all p values > 0.05). All assumptions
were met.
Results
Reliability Analysis
Cronbach’s alpha showed that the ERC (α = 0.70) and CBCL
(α = 0.76) had reached the good reliability.
Emotion Regulation
At T1, both ERC-ER and ERC-LN scores were comparable
between groups (see Table 2). Repeated-measures ANCO-
VAs were performed separately for each emotion regula-
tion measure to examine the effects of the physical activity
intervention on emotion regulation after controlling for age,
gender, and non-verbal IQ. A significant interaction effect
(F[1, 22] = 6.89, p = 0.02) was found for ERC-ER. However,
no significant interaction effects were found for ERC-LN
(F[1, 22] = 2.30, p = 0.14). Subsequent tests revealed a sig-
nificant increase on ERC-ER between T1 and T2 in the inter-
vention group (t[14] =  − 2.47, p = 0.03; effect size d = 0.15)
but not in the control group (t[12] = 1.48, p = 0.17; effect
size d = 0.10). Comparisons of emotion regulation measures
between groups and within groups at different timeslots are
shown in Table 2.
Behavioral Functioning
As shown in Table 3, all the behavioral functioning meas-
ures were comparable between groups. Repeated-measures
Journal of Autism and Developmental Disorders

Table 2  Comparisons of Emotion regulation measures Intervention group (SD) Control group (SD) p value p value
emotion regulation measures (group (interaction
between groups and within effect) effect)
groups at different timeslots
Emotion regulation s­ ubscalea (ERC-ER) 0.02
 T1 19.87 (3.44) 20.53 (2.88) 0.56
 T2 21.53 (2.88) 20.50 (3.32) 0.89
p value (time effect) 0.03 0.17
a
Emotion ­regulation lability/negativity (ERC-LN) 0.14
 T1 37.33(3.24) 38.33(4.05) 0.48
 T2 33.40(3.58) 36.58(3.92) 0.03
p value (time effect) 0.001 0.15
a
 The analyses were computed after controlling for age, gender and non-verbal IQ

Table 3  Comparisons of Behavioral functioning Intervention group (SD) Control group (SD) p value p value
T-scores of behavioral measures (group effect) (interaction
functioning measures between effect)
groups and within groups at
different timeslots Internal behavior c­ ompositea 0.06
 T1 76.80 (3.32) 77.08 (2.32) 0.08
 T2 73.07 (2.92) 75.42 (3.50) 0.64
p value (time effect)  < 0.001 0.08
External behavior c­ ompositea 0.01
 T1 71.87(2.33) 71.75(3.52) 0.86
 T2 69.53(3.14) 72.42(2.75) 0.74
p value (time effect) 0.001 0.19
Total problem ­scalea 0.02
 T1 77.13 (1.13) 77.58 (0.90) 0.28
 T2 74.27 (1.71) 76.17 (1.80) 0.92
p value (time effect)  < 0.001 0.10
a
 The analyses were computed after controlling for age, gender, and non-verbal IQ

ANCOVAs were performed separately for each behav- Discussion

ioral functioning measure to examine the impact of the
physical activity intervention on behavioral functioning
after controlling for age, gender, and non-verbal IQ. We
found no significant interaction effect (F [1, 22] = 3.90,
p = 0.06) for the internal behavior composite. However,
there were significant interaction effects for the external
behavior composite (F [1, 22] = 12.88, p = 0.007) and total
problem scale (F [1, 22] = 6.67, p = 0.016). Subsequent
tests revealed a significant reduction in external behavior
composite T-scores between T1 and T2 in the interven-
tion group (t [14] =  − 4.47, p = 0.001; effect size d = 0.54)
but not in the control group (t[11] = 1.38, p = 0.19; effect
size d = 0.14). For the total problem T-score, subse-
quent tests revealed a significant reduction in T-scores
between T1 and T2 in the intervention group (t[14] = 7.37,
p < 0.001; effect size d = 0.56) but not in the control group
(t[11] = 2.93, p = 0.10; effect size d = 0.29).
This pilot study examined the effect of a physical exercise
intervention on emotion regulation and behavioral func-
tioning in children with ASD. We hypothesized that the
intervention would benefit both emotion regulation and
behavioral functioning. This hypothesis was supported, as
the intervention was effective in improving emotion regu-
lation and reducing internal, external, and total behavioral
problems.
These findings are in accord with those of previous
studies examining emotion regulation characteristics in
children with ASD. For example, there is evidence that
the ERC-ER scores of children with ASD are stable across
time without any intervention (Berkovits et  al. 2017;
Thomson et al. 2015). In the present study, the ERC-ER
scores of the control group did not differ significantly

13

after 12 weeks. However, the intervention group scores
increased significantly after the jogging intervention,
which suggested that exercise improved overall mood,
emotional expression, and self-awareness. A study con-
ducted by Bernstein and McNally (2017) in adults revealed
similar findings; the results showed that aerobic exercise
(jogging) attenuated negative emotions for people initially
experiencing difficulties in emotion regulation. A possible
explanation for this effect is that the nature of the interven-
tion (i.e., jogging) requires participants to overcome the
negative emotions caused by fatigue and running more
slowly than others. Another possible explanation is that
participants who jogged may have experienced cognitive
enhancement or increased self-efficacy to deploy emo-
tion regulation strategies to cope with interfering emo-
tion (Bernstein and McNally 2017). However, we did not
incorporate any cognitive function measures to examine
the potential mechanisms underlying the effect of physical
exercise on emotion regulation. Future researchers should
consider examining this aspect.
The reduction in behavioral problems (i.e., internal,
external, and total problems) found here supports previ-
ous findings of the behavioral benefits of physical exer-
cise for children with ASD (Bremer et al. 2016). Bremer
et al. (2016) conducted a systematic review of 13 stud-
ies examining the behavioral outcomes of exercise inter-
ventions in children with ASD. The results showed that
exercise interventions can reduce stereotypic behaviors
and improve social functioning (see Bremer et al. 2016
for review). A possible explanation for this effect may lie
with neurophysiological mechanisms, such as the release
and synthesis of neurotrophic factors (Ferris et al. 2007;
Voss et al. 2011) or the release of neurotransmitters (e.g.,
serotonin, norepinephrine, dopamine) (Lee et al. 2015)
induced by physical exercise, which are believed to be
closely associated with the inhibition of internal and exter-
nal behaviors (Bari and Robbins 2013). As we did not con-
duct any neurophysiological measurements, we are unable
to determine whether our findings can be explained by
the effect of neurophysiological mechanisms on behavior.
Future studies should incorporate such measures to further
elucidate this issue.
As a first attempt at examining how physical exercise
affects emotion regulation and behavioral functioning in
children with ASD, this study produced promising results.
We demonstrated that the exercise intervention group
showed a significant improvement in emotion regulation
and a significant reduction in behavioral problems (inter-
nal, external, and total), whereas the control group did not.
Considering such positive results, it is important to further
examine the mechanisms underlying the positive effect of
physical exercise on emotion regulation and behavior in
children with ASD.
13
Journal of Autism and Developmental Disorders
Several limitations that required attention when inter-
preting the results. First, the participants in the present
study were children with high IQ scores and the findings
cannot be generalized to all individuals with ASD. Second,
sample size is a limitation along with no comprehensive
data on ASD severity of the participant, future studies
should consider using diagnostic characterization (such
as ADI-R and ADOS) to provide more comprehensive
data on ASD severity. Third, we did not examine baseline
physical activity level (e.g., daily time spent engaging in
physical exercise). Without this information, it is diffi-
cult to determine treatment effects. Future studies should
include such baseline assessments to address this question.
Forth, considering the fact that parents were not blinded
to the intervention, the parental reported assessments
might be biased. Future studies may include additional
measures such as videotaping and behavioral coding to
provide a more in-depth investigation. Fifth, the change in
outcome in response to the intervention has an unknown
clinical impact. Lastly, the increase in breathing and the
red flush faces were not a valid indicator of intervention
intensity and it is unclear whether the exercise intensity
was moderate-to-vigorous intensity. Future studies may
considering using heart rate monitor to track the heart rate
of participants during the exercise intervention.
Conclusions
The finding that physical exercise had a positive influ-
ence on emotion regulation and behavioral functioning
in children with ASD is in accordance with accumulat-
ing evidence of the emotional and behavioral benefits of
physical exercise for children. Physicians and educators
should consider prescribing physical exercise to children
with ASD to alleviate symptoms of emotion and behavio-
ral problems. The preliminary findings of this pilot study
are important for guiding future researchers to further
examine the neurophysiological or cognitive mechanisms
of exercise–emotion and exercise–behavior relationships
in children with ASD.
Acknowledgments  The author would like to express his gratitude Dr.
Paul H. Lee and to all the children who participated in this study, and to
the participants’ teachers and parents for their support. This project was
financially supported by EduHK departmental seed funding (Ref No.:
04287). The author thanks Diane Williams, PhD, from Edanz Group
(www.edanz​editi​ng.com/ac) for editing a draft of this manuscript.
Author Contributions  ACYT is the sole author of the present work and
he was in charge of experiment design and manuscript preparation.
Funding  This work was supported by EduHK departmental seed fund-
ing (Ref No.: 04287).
Journal of Autism and Developmental Disorders
Compliance with Ethical Standards  Jahromi, L. B., Bryce, C. I., & Swanson, J. (2013). The importance of
Conflict of interests  The author declared no potential conflicts of inter-
est with respect to the research, authorship, and/or publication of this
article.
Ethical Approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed Consent  Informed consent was obtained from all individual
participants included in the study.
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