International Journal of

Environmental Research
and Public Health

Review
Meta-Analysis on Intervention Effects of Physical
Activities on Children and Adolescents with Autism
Jinfeng Huang 1,† , Chunjie Du 2,† , Jianjin Liu 3, * and Guangxin Tan 1, *
1 School of Physical Education, South China Normal University, Guangzhou 510631, China;
2019020923@m.scnu.edu.cn
2 College of Vocational and Technical Education, South China Normal University, Nanhai 528000, China;
duchunjie@m.scnu.edu.cn
3 Department of Physical Education, Guangzhou College of Commerce, Guangzhou 511363, China
* Correspondence: 20061015@xs.gzcc.cn (J.L.); tgx33@163.com or tanguangxin@m.scnu.edu.cn (G.T.);
Tel.: +86-139-2648-2306 (J.L.); +86-158-0000-8353 (G.T.)
† These authors equally contributed to this work.




Received: 19 February 2020; Accepted: 14 March 2020; Published: 17 March 2020


Abstract: This paper aimed to discuss the intervention effects of physical activities on children and
adolescents with autism with a meta-analysis so as to serve as a reference to further relevant research
on the same topic. As for research methods, by searching in CNKI (China National Knowledge
Infrastructure), WanFang data, VIP Database for Chinese Technical Periodicals, PubMed, Scopus,
Web of Science, and other databases, this study collected randomized controlled trials (RCTs) on the
intervention of physical activities on children and adolescents with autism and used Review Manager
5.3 software to process and analyze the outcome indicators of the literature. As for the result, a total of
12 papers and 492 research targets were selected. The results of the meta-analysis show that physical
activity had a significant positive impact on social interaction ability, communication ability, motor
skills, and autism degree of autistic children as well as the social skills and communication skills of
autistic adolescents. On the other hand, physical activity had no significant effect on the stereotyped
behavior of autistic children and adolescents. In conclusion, physical activity intervention is beneficial
to children and adolescents with autism, and continuous physical activity intervention can produce
greater intervention effect.

Keywords: physical activities; autism; children; adolescents; meta-analysis

1. Introduction
Autism is a common developmental disorder characterized by difficulties with speech and
behaviors, such as lack of social abilities, repetitive behaviors, communication disorders, activity and
interest disorders with limitations [1]. The disease mainly occurs in children and adolescents, but the
explicit age limits of children and adolescents haven’t been decided. Based on the degree of individual
cognition and socialization, Zhang Wenxin divides the kids under 12 years old into children and kids
between 13 and 22 years old into adolescence [2]. According to the latest data from the Centers for
Disease Control and Prevention, the prevalence rate of autistic children is 1/59. And the data from
Asia, Europe and North America reports an average prevalence of 1–2% [3]. According to the report
on the development of Chinese autistic children released by China on 17 October 2014, the prevalence
of autism in China is similar to that in other countries in the world, with about 1%. It can be seen that
autism has become a public health problem that seriously affects the health of children and adolescents.
In addition to the core symptoms of social interaction, communication, and stereotyped behavior,
the motor skills of autistic patients are usually stunted [4]. At present, many researches on the

Int. J. Environ. Res. Public Health 2020, 17, 1950; doi:10.3390/ijerph17061950 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 1950 2 of 11

intervention of physical activity on children and adolescents with autism have been conducted.
Physical activity refers to all kinds of physical actions that consume energy due to skeletal muscle
contraction, including physical exercise, work, housework, entertainment and other activities [5].
However, due to social and behavioral defects, autistic patients usually show a decline in physical
activity level. Fewer opportunities for physical activity are more likely to affect their behavior [6], and
cause some chronic diseases, such as obesity, which is very common in autistic patients [7]. It has been
reported that physical activity has a good intervention effect on autistic patients [8], and the physical
and mental health of autistic patients contains the improvement of core symptoms [9]. Some studies
have shown that after the intervention of physical activity, all of the social interaction ability [10–12],
communication ability [11,13–15], stereotyped behavior [11,16] and sports skills [11,17–19] of children
and adolescents with autism have been improved, which can reduce the degree of autism [14,15,20,21].
These studies show that physical activity is very effective in intervention of children and adolescents
with autism.
Although a large number of studies have shown that physical activity is effective in the intervention
of children and adolescents with autism, the results of individual studies may still be uncertain due to
the great differences in sample size, intervention means, intervention time, intervention frequency and
measurement results in various studies. Therefore, this meta-analysis was carried out on studies of
the intervention of physical activity on children and adolescents with autism of the in the latest 10
years to objectively evaluate the intervention effect of physical activity on social interaction ability,
communication ability, stereotyped behavior, sports skills and autism degree of children and adolescents
with autism so as to provide the basis for clinical application of physical activity intervention in the
operation of children and adolescents with autism.

2. Materials and Methods

2.1. Selection and Exclusion Criteria of Literature

Literature including all of these criteria were selected: (1) the research type was experimental,
particularly randomized control experiments; (2) the research target were children and adolescents
with autism; (3) the test group had obvious physical activity intervention, while the control group
did not carry out any physical activities; (4) the outcome indicators were either autism rating scales
or motor skills rating scale. Literature including any of these criteria were excluded: (1) they were
non-randomized controlled trials; (2) subjects were neither children nor adolescents with autism;
(3) they are repetitive published literature; (4) intervention means were non-physical activities; (5) the
literature results showed no outcome index data; (6) they were reviews; (7) the control group had
physical activity intervention.

2.2. Searching Strategies

Literature searching was conducted in CNKI, WanFang Data, VIP Database for Chinese Technical
Periodicals, PubMed, Scopus, Web of Science, and other databases with “free words + subject words”,
including Chinese and English journals, conference papers, and dissertations. Key words both in
English and Chinese, such as physical activities, physical exercise, sports, and autism, were used. The
literature searching period was from January 2010 to December 2019.

2.3. Data Extraction and Quality Evaluation

2.3.1. Data Extraction and Processing

Data on authors, publication time, physical activity contents, test groups, and control groups
(sample sizes, measurement tools for autistic patients, means and standard deviations before and after
intervention) were extracted. When different scales were used in each experiment, standardized mean,
difference, SMD (standardized mean difference), and 95% confidence intervals (CIs) were selected as
 Int. J. Environ. Res. Public Health 2020, 17, 1950 3 of 11

Int. J. Environ. Res. Public Health 2020, 17, x 3 of 12

the combined statistics. When the same scales were used in each experiment, weighted mean difference
(WMD) and 95%
heterogeneity CIsresults,
in the were selected as theeffect
the random combined
modelstatistics.
was used If there was heterogeneity
to analyze in the
the data; if not, theresults,
fixed
the random
effect effect
model was model
used. was usedthe
I represents
2 to analyze the data;
heterogeneity if not, the
of various effect model was used. I2
fixed[22].
studies
represents the heterogeneity of various studies [22].
2.3.2. Literature Quality Evaluation
2.3.2. Literature Quality Evaluation
We evaluated the quality of the literature according to the Jadad scale [23]. The evaluation
We three
included evaluated therandom
aspects: qualityand
of the literature
its hidden according
program, to thewithdrawal,
blinding, Jadad scaleand [23].loss
The evaluation
to follow up.
included three aspects: random and its hidden program, blinding, withdrawal,
The scale was from 0–5; a 0–2 score was considered low-quality research, and a 3–5 score and loss to follow
was
up. The scale
considered was fromresearch.
high-quality 0–5; a 0–2 score was considered low-quality research, and a 3–5 score was
considered high-quality research.
3. Results
3. Results
3.1. General Results of Selected Research Literature
3.1. General Results of Selected Research Literature
Figure 1 depicts the detailed literature search process. A total of 1357 primary literature were
Figure 1 depicts the detailed literature search process. A total of 1357 primary literature were
obtained by using literature searching strategy. After the selection of reading topics and abstracts,
obtained by using literature searching strategy. After the selection of reading topics and abstracts,
240 papers were analyzed. In the second round, the following conditions were excluded: 1) the
240 papers were analyzed. In the second round, the following conditions were excluded: (1) the
intervention means were not physical activities; 2) the research type was not an RCT experimental
intervention means were not physical activities; (2) the research type was not an RCT experimental
study; 3) there was no outcome index data; 4) the control group was physical activity; 5) they were
study; (3) there was no outcome index data; (4) the control group was physical activity; (5) they were
reviews; 6) subjects were not children nor adolescents with autism. Finally, 12 articles were included
reviews; (6) subjects were not children nor adolescents with autism. Finally, 12 articles were included
in the meta-analysis.
in the meta-analysis.

Figure 1. Literature selection process.

Figure 1. Literature selection process.

3.2. General Features of Selected Research Literature

Int. J. Environ. Res. Public Health 2020, 17, 1950 4 of 11

3.2. General Features of Selected Research Literature

3.2.1. General Information of Each Study

Through comprehensive search of relevant literature and strict selection according to the inclusion
and exclusion criteria, 12 randomized controlled trials finally met the inclusion criteria for systematic
evaluation (see Table 1). All of the 12 papers were published within the past decade. A total of 492
children and adolescents with autism were included in 12 articles, including 253 in the experimental
group and 239 in the control group.

3.2.2. Interventions of Physical Activities

The relevant literature included in this study all used physical activities as intervention
means, including sports games, water sports, football, aerobics, karate, horse riding, and other
physical activities.

3.2.3. Frequency of Physical Activity Intervention

In seven papers [10,12–16,20], the frequency of physical activity intervention was more than
3 times per week; in four papers [17–19,21], the frequency of physical activity intervention was 3 times
or less; and in one paper [11], the frequency of intervention was not reported.

3.2.4. Duration of Each Physical Activity Intervention

Among 12 selected papers, 11 [10–19,21] mentioned the duration of each physical activity
intervention (between 45 and 90 min).

3.2.5. Physical Activity Intervention Cycle

The intervention cycle of physical activity ranged from 4 weeks to 24 weeks. There were
5 papers [11,15,18,19,21] with an intervention period less than 12 weeks (including 12 weeks), and
7 papers [10,12–14,16,17,20] with an intervention period more than 12 weeks.

3.3. Results

3.3.1. Quality Evaluation of Selected Literature

Among the 12 papers included in meta-analysis, four [14,15,20,21] were Chinese and
eight [10–13,16–19] were English. All papers had a clear autism behavior score scale or motor
skills score scale. Among the 12 literatures, 11 [10–20] mentioned randomness. Two of them [11,19]
mentioned randomization and described the correct randomization method. None of the 12 papers
mentioned the implementation of a blind method, and no one quit the intervention process. According
to the Jadad quality rating scale, these papers were evaluated from three aspects: random, blinding,
loss to follow up or withdrawal. Nine [10,12–18,20] were scored 1, 1 [21] was scored 0, and 2 [11,19]
were scored 2. In this case, papers selected by this method had poor qualities.

3.3.2. Impacts of Physical Activities on Social Interaction Ability of Autistic Children and Adolescents
In a meta-analysis of three studies (n = 197), physical activity significantly improved the social
interaction ability of autistic children and adolescents (SMD = −0.58, 95% CI: −0.87 to −0.29, I2 = 3%,
z = 3.95, p < 0.0001, Figure 2).
Int. J. Environ. Res. Public Health 2020, 17, 1950 5 of 11

Table 1. General features of selected research literature.

Participants Physical Activity Intervention

Study Intervention Program Measuring Tools
Sample Age Frequency Duration
Time (min)
Size (n) (years) (weekly) (week)
Movahedi, Bahrami, et al. EG: Kata techniques 30 (week 1 to week 8) Social Communication
30 5–16 4 14
(2013) [10] CG: No exercise intervention 90 (week 9 to week 14) subscale of GARS-2
EG: Therapeutic horseback
BOT-2; PPVT-4; SALT;
Gabriels, Pan, et al. (2015) [11] 116 6–16 intervention NR 45 10
SRS; VABS-II
CG: Completed a brief artistic project
EG: Outdoor activities
Zachor, Vardi, et al. (2017) [12] 51 3–7 13 30 13 SRS
CG: No exercise intervention
Bahrami, Movahedi, et al. EG: Karate training 30 (week 1 to week 8) Communication
30 5–16 4 14
(2015) [13] CG: No exercise intervention 90 (week 9 to week 14) subscale of GARS-2
EG: Sports game
Yang, Yang, et al. (2016) [14] 80 3–10 6 90 24 CARS Scale; ATEC
CG: Regular education
EG: Water sports training
Wu (2017) [15] 14 4–10 5 90 4 ABC
CG: No exercise intervention
Bahrami, Movahedi, et al. EG: Karate training 30 (week 1 to week 8) Stereotypy subscale of
30 5–16 4 14
(2012) [16] CG: No exercise intervention 90 (week 9 to week 14) GARS-2
EG: Trampoline training
Lourenço (2015) [17] 16 4–10 6 90 24 BOT-2
CG: No exercise intervention
EG: Table tennis
Pan, Chu, et al. (2016) [18] 22 6–12 2 70 12 BOT-2; WCST
CG: No intervention
Sarabzadeh, Azari, et al. EG: Tai Chi
18 6–12 3 60 6 MABC-2
(2019) [19] CG: No exercise intervention
EG: Sports game
Zhang, Yang, et al. (2017) [20] 60 3–11 7 NR 24 CARS Scale; CBS
CG: No exercise intervention
EG: Sports activities
Jiang, Xu, et al. (2018) [21] 25 12–18 3 62 12 ABC
CG: No exercise intervention
EG = experimental group; CG = control group; CARS Scale = Child Autism Rating Scale; ATEC = Autism Treatment Evaluation Checklist; CBS = Clancy Behavior Scale; ABC = autism
behavior checklist; GARS-2 = Gilliam Autism Rating Scale-Second Edition; BOT-2 = Bruininks–Oseretsky Test, 2nd Ed; PPVT-4 = Peabody Picture Vocabulary Test, 4th Ed; SALT =
Systematic Analysis of Language Transcripts; SRS = Social Responsiveness Scale; VABS-II = Vineland Adaptive Behavior Scales-II; WCST= Wisconsin Card Sorting Test; BASC = Behavior
Assessment System for Children; MABC-2 = Movement Assessment Battery for Children-Second Edition; NR = not reported.
3.3.2. Impacts of Physical Activities on Social Interaction Ability of Autistic Children and
Adolescents
In a meta-analysis of three studies (n = 197), physical activity significantly improved the social
interaction ability of autistic children and adolescents (SMD = −0.58, 95% CI:−0.87 to −0.29, I2 = 3%, z
Int. J. Environ. Res. Public Health 2020, 17, 1950 6 of 11
= 3.95, p < 0.0001, Figure 2).

Figure 2. Forest plot of meta-analysis on impacts of physical activities on social interaction ability of
Figure 2.
Int. J. Environ.
autistic Forest
Res. Publicplot
children of 2020,
Health
and meta-analysis
17, x
adolescents. on impacts of physical activities on social interaction ability of7 of 12
autistic children and adolescents.
Int. J. Environ.
3.3.3. Impacts Res.of
Public Health 2020,
Physical 17, x
Activities
on=Communication Abilitysignificantly
of Autistic Children 7 of 12
In a meta-analysis of 4 studies (n 240), physical activity improvedand Adolescents
communication
3.3.3. Impacts
ability of Physical
in children Activitieswith
and adolescents on Communication Ability
autism (SMD = −0.29, of Autistic
95%CI: −0.55 Children
to −0.04, Iand
2 = 35%, z = 2.25,
In a meta-analysis of 4 studies (n ==240),
240),physical
physicalactivity
activitysignificantly
significantly improved
improved communication
communication
Adolescents
p = 0.02 < 0.05, Figure 3).
ability in children and adolescents with autism (SMD = −0.29, 95% CI: −0.55 to −0.04, I 22 = 35%, z = 2.25,
children and adolescents with autism (SMD = −0.29, 95%CI: −0.55 to −0.04, = 35%, = 2.25,
p= 0.02 <<0.05,
= 0.02 0.05,Figure
Figure3).
3).

Figure 3. Forest plot of meta-analysis on impacts of physical activities on communication ability of

autistic children and adolescents.
Figure 3.
Figure Forest plot
3. Forest plot of
of meta-analysis on impacts
meta-analysis on impacts of
of physical
physical activities on communication
activities on ability of
communication ability of
autistic children and adolescents.
autistic children and adolescents.
3.3.4. Impacts of Physical Activities on Stereotyped Behaviors of Autistic Children and Adolescents
3.3.4. Impacts of Physical Activities on Stereotyped Behaviors of Autistic Children and Adolescents
3.3.4.Among
Impacts the 12 papers
of Physical included,
Activities two [11,16] Behaviors
on Stereotyped (n = 146) of compared the scores
Autistic Children andofAdolescents
stereotyped
behaviors
Among between the control
the 12 papers group
included, twoand the (n
[11,16] = 146) compared
experimental group.
theThrough
scores of the heterogeneity
stereotyped test
behaviors
Among the 12 papers included, two [11,16] (n = 146) compared the scores of stereotyped 2 = 1.82,
(Chi2 = 1.82,
between df = 1(p
the control = 0.18),
group and Ithe
2 = experimental
45%). Since pgroup.> 0.1, Through
I2 < 50%,theaccording to Cochrane
heterogeneity test (ChiManual,
behaviors between2 the control group and 2the experimental group. Through the heterogeneity test
df = 1 (p = 0.18),
heterogeneity I = 45%). Since
is acceptable, p > 0.1, I the
and therefore < 50%,
fixedaccording
effect model was usedManual,
to Cochrane for analysis. The results
heterogeneity is
(Chi2 = 1.82, df = 1(p = 0.18), I2 = 45%). Since p > 0.1, I2 < 50%, according to Cochrane Manual,
showed thatand
acceptable, thetherefore
horizontal theline andeffect
fixed the diamond,
model was after
usedcombining the two
for analysis. Thestudies, intersected
results showed thatwith
the
heterogeneity is acceptable, and therefore the fixed effect model was used for analysis. The results
the invalidline
horizontal line,and
indicating that the
the diamond, combination
after combiningstatistics of multiple
the two studies, studies were
intersected not invalid
with the statistically
line,
showed that the horizontal line and the diamond, after combining the two studies, intersected with
significantthat
indicating (SMD the=combination
−0.13, 95%CI:statistics
−0.46 toof 0.20, I2 = 45%,
multiple z = 0.78,
studies werep not
= 0.43 > 0.05, Figure
statistically 4). That
significant =
is, the
(SMD
the invalid line, indicating that the combination statistics of multiple studies were not statistically
influence
−0.13, 95%ofCI:
physical 0.20, I2 =on
−0.46 toactivities 45%, = 0.78, p =2 0.43
thez stereotyped > 0.05, Figure
behaviors of children and
4). That is,adolescents
the influencewith autism
of physical
significant (SMD = −0.13, 95%CI: −0.46 to 0.20, I = 45%, z = 0.78, p = 0.43 > 0.05, Figure 4). That is, the
was not significant.
activities on the stereotyped behaviors of children and adolescents with autism was not significant.
influence of physical activities on the stereotyped behaviors of children and adolescents with autism
was not significant.

Figure
Figure 4.4. Forest
Forest plot
plot of
of meta-analysis
meta-analysis on
on impacts
impacts of
of physical
physical activities
activities on
on stereotyped
stereotyped behaviors
behaviors of
of
autistic children and adolescents.
autistic children and adolescents.
Figure 4. Forest plot of meta-analysis on impacts of physical activities on stereotyped behaviors of
3.3.5.autistic
Impacts of Physical
children Activities on Motor Skills of Autistic Children and Adolescents
and adolescents.
3.3.5. Impacts of Physical Activities on Motor Skills of Autistic Children and Adolescents
In the four selected papers [11,17–19] (n = 172), the total sample size of the experimental group
3.3.5.In the four
Impacts selected papers [11,17 19] (n Skills
= 172), the total sample size of Adolescents
the experimental group
was 86, and theoftotal
Physical
sample Activities on—
size of the Motor
control groupofwasAutistic Children
86. There and
was heterogeneity among the four
was 86, and the total sample size of the control group was 86. There was heterogeneity among the
2 = 89%);
research
In the four selected papers [11,17—19] (n = 172), the total sample size of the experimentalshowed
results (I thus, the random effect model was used for analysis. The results group
four research results (I2 = 89%); thus, the random effect model was used for analysis. The results
was 86, combined
that the statistics
and the total sample of size
multiple
of thestudies
controlwere not was
group statistically
86. Theresignificant (SMD = −0.17,
was heterogeneity 95%the
among CI:
showed that the combined statistics of multiple studies were not statistically significant (SMD = −0.17,
−1.46research
four
2 = 89%,(I2z == 89%);
to 1.11, Iresults = 0.79the
0.26, pthus, > 0.05,
randomFigure 5). model was used for analysis. The results
effect
95%CI: −1.46 to 1.11, I2 = 89%, z = 0.26, p = 0.79 > 0.05, Figure 5).
showed that the combined statistics of multiple studies were not statistically significant (SMD = −0.17,
95%CI: −1.46 to 1.11, I2 = 89%, z = 0.26, p = 0.79 > 0.05, Figure 5).
3.3.5. Impacts of Physical Activities on Motor Skills of Autistic Children and Adolescents
In the four selected papers [11,17—19] (n = 172), the total sample size of the experimental group
was 86, and the total sample size of the control group was 86. There was heterogeneity among the
four research results (I2 = 89%); thus, the random effect model was used for analysis. The results
showed thatRes.
Int. J. Environ. thePublic
combined statistics
Health 2020, of multiple studies were not statistically significant (SMD = −0.17,
17, 1950 7 of 11
95%CI: −1.46 to 1.11, I2 = 89%, z = 0.26, p = 0.79 > 0.05, Figure 5).

Figure 5.
Figure Forest plot
5. Forest plot of
of meta-analysis
meta-analysis on
on impacts
impacts of
of physical
physical activities
activities on
on motor
motor skills
skills of
of autistic
autistic
Int. J. Environ. Res. Public Health 2020, 17, x 8 of 12
children
Int. J. children and
Environ. Res.
and adolescents.
Public Health 2020, 17, x
adolescents. 8 of 12

The
The data
data in
The data in Figure
Figure555show
inFigure show
show high
high
high heterogeneity
heterogeneity
heterogeneity (I2 =(I
22= 89% > 50%). Therefore, sensitivity analysis is
(I89%= 89%
> 50%).> 50%).
Therefore,Therefore, sensitivity
sensitivity analysisanalysis
is
needed
is needed
needed to
to todetermine
determine
determine the
the the heterogeneity
heterogeneity
heterogeneity sources of of
sources
sources ofphysical
physical
physical activities
activities
activities on
on motor
on motor skillsskills
motor skills of autistic
of autistic
of autistic
children
children and adolescents.
and
children and adolescents.Firstly,
adolescents. Firstly,
Firstly,wewe
we removed
removed
removed Reference
Reference
Reference [19][19]
withwith
[19] with aa biggest
a biggestbiggest difference
difference
difference from
from from others
othersothers
but
but found
but found differences
found differences
differencesstill still existed.
stillexisted. Then,
existed.Then,
Then, the
thethe method
method
method of reducing
of reducing
of reducing one
one one
study study at
at a time
study a time
was used
at a time was
was toused to test
testto
used test
whether
whether each
whether each study
each study
studyhad had a significant
hadaasignificant
significant impact
impact
impact on
onon the
thethe combined
combined
combined effecteffect of
of motor
effect motor skills
skillsskills
of motor of
of autistic autistic children
children
of autistic children
and
and adolescents.
adolescents. The
The sensitivity
sensitivity analysis
analysis showed
showed thatthat
the the heterogeneity
heterogeneity
and adolescents. The sensitivity analysis showed that the heterogeneity dropped to 0 after deleting dropped
dropped to 0 to
after0 after deleting
deleting
References [11]
References
References [11] and
and
[11,19] [19]
[19]which
which which
had ahadhada asignificant
significantsignificant
impact impact
impact
on onresults
the the
on theresults of concomitant
ofresults
the the
of concomitant
the concomitant effect.
effect. effect.
Another
Another
Another of analysis
analysis of References
of References [11] and
[11] and [19] showed that the research objects of study [11] were
analysis References [11,19] showed that[19]theshowed
researchthat the research
objects of study objects
[11] were of autistic
study [11] were
children
autistic children
autistic children andand adolescents
adolescents aged
aged fromfrom 6 to16,
6 while
to16, those
while of References
those of References[17] and[17] [18]
and were
[18] were
and adolescents aged from 6 to16, while those of References [17,18] were children aged from 4 to 12.
children aged
children aged from 44toto12. Therefore, the difference may be caused by different research objects.
Therefore, the from
difference 12. may Therefore,
be causedthe bydifference may
different research be objects.
caused by different
Reference research
[19] had a objects.
shorter
Reference
Reference [19]
[19] had
had aashorter
shorter intervention
intervention period
period(6 weeks).
(6 weeks).To sum
To up,
sum long-term
up, long-termphysical activity
physical activity
intervention period (6 weeks). To sum up, long-term physical activity intervention may not have a
intervention may not have a significant impact on the motor skills of autistic adolescents but has a
intervention
significant may not
impact onthe have
the a significant
motor skills impact adolescents
on the motor skills has aofsignificant
autistic adolescents butmotor
has a
significant impact on motor skills ofof autistic
autistic children. In the but meta-analysis impact (n
of two studies on= the
38),
significant
skills impact
of autistic on the motor skills of autistic children. In the meta-analysis
(n = 38), of two studies (n = 38),
physical activity children.
significantly In improved
the meta-analysis
motor skills of two studies
of autistic children physical
(SMD = 1.02,activity
95% CI: significantly
0.33 to
physical activity significantly improved motor skills of autistic children (SMD = 1.02, 95% CI: 0.33 to
6). = 1.02, 95% CI: 0.33 to 1.71, I = 0%, z = 2.91, p = 0.004
improved motor skills 2
1.71, I2 = 0%, z = 2.91, p of autistic
= 0.004 children
< 0.05, Figure(SMD
1.71, I2 = 0%, z = 2.91, p = 0.004 < 0.05, Figure 6).
< 0.05, Figure 6).

Figure 6. Forest plot of meta-analysis on impacts of physical activities on motor skills of autistic
Figure 6. Forest plot of meta-analysis on impacts of physical activities on motor skills of autistic children.
children.6. Forest plot of meta-analysis on impacts of physical activities on motor skills of autistic
Figure
3.3.6.children.
Impacts of Physical Activities on Levels of Autism of Children and Adolescents
3.3.6. Impacts of Physical Activities on Levels of Autism of Children and Adolescents
A meta-analysis was conducted on 4 papers [14,15,20,21] on the level of autism in children and
3.3.6.AImpacts of Physical
meta-analysis Activities on
was conducted on4Levels
papersof[14,15,20,21]
Autism of onChildren and
the level Adolescents
of autism in children and
adolescents. According to the results of heterogeneity test (chi2 = 19.75, df = 3 (p = 0.0002), I2 = 85%
adolescents. According to the results of heterogeneity test (chi2 = 19.75, df = 3 (p = 0.0002), I2 = 85% (I2
>A
(I>250%) meta-analysis
50%) which
which indicated
was conducted
indicated that there
that there
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papers [14,15,20,21]
was significant
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heterogeneity inlevel
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literatures.
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7). 7). adopted for analysis, and the results showed that the combined statistics
of multiple studies had no statistical significance (SMD = -1.14, 95% CI: −2.02 to −0.25, z = 2.52, p =
0.01 < 0.05, Figure 7).

Figure Forestplot
7. Forest
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significant impact on
intervention
Int. J. Environ. Res. Public Health 2020, 17, 1950 8 of 11

The data in Figure 7 show high heterogeneity (I2 = 85% > 50%). Therefore, in order to find the
sources of heterogeneity, sensitivity analysis should be carried out, and the method of reducing one
document at a time should be adopted to check whether each document has a significant impact on
the results of merger effect. Sensitivity analysis shows: The deletion of Jiang Feng’s [21] study had a
significant effect on the results of merger effect. Another analysis on Jiang Feng [21] showed that the
subjects
Int. of this
J. Environ. Res. study were2020,
Public Health autistic
17, xadolescents aged from 12 to18 years old. The intervention frequency 9 of 12
of physical activity was three times a week. Its difference from the other three studies [14,15,20] is the
difference may be and
age of the subjects caused
the by the age of frequency
intervention the subjects
ofor the intervention
physical frequency
activity. So, of physical
the difference may beactivity.
caused
In
by the
the meta-analysis
age of the subjectsof theorthree studies (n = frequency
the intervention 154), physical activityactivity.
of physical significantly
In thedecreases the autism
meta-analysis of the
level
three in autistic
studies = 154), physical
(nchildren (SMD = −0.61, 95%CI:
activity −0.94 todecreases
significantly −0.29, I2 = the
0%, autism
z = 3.72,level
p = 0.0002< 0.05,
in autistic Figure
children
8).
(SMD = −0.61, 95% CI: −0.94 to −0.29, I2 = 0%, z = 3.72, p = 0.0002 < 0.05, Figure 8).

Figure 8. Forest
Figure plot plot
8. Forest of meta-analysis on impacts
of meta-analysis of physical
on impacts activities
of physical on levels
activities of autism
on levels of children.
of autism of
4. Discussion children.

This paper is a systematic review of quantitative data analysis on the physical activity effects
4. Discussion
of children and adolescents with autism. All eligible randomized controlled trials were published
This paper is a systematic review of quantitative data analysis on the physical activity effects of
between 2010 and 2019. The results showed that physical activity can significantly improve the social
children and adolescents with autism. All eligible randomized controlled trials were published
interaction ability and communication ability of children and adolescents with autism, improve the
between 2010 and 2019. The results showed that physical activity can significantly improve the social
motor skills, and reduce the degree of autism of children with autism.
interaction ability and communication ability of children and adolescents with autism, improve the
The social and communication defects in individuals with autism make them less likely to
motor skills, and reduce the degree of autism of children with autism.
participate in sports activities and get along with people [6], which may lead to the sedentary lifestyle
The social and communication defects in individuals with autism make them less likely to
of autistic patients. Not only does it affect the overall health of autistic patients, but it also further
participate in sports activities and get along with people [6], which may lead to the sedentary lifestyle
deprives them of social adaptability. Studies have shown that physical activity is beneficial to the
of autistic patients. Not only does it affect the overall health of autistic patients, but it also further
health of autistic patients [24]. Through organized physical activities, people with autism have the
deprives them of social adaptability. Studies have shown that physical activity is beneficial to the
opportunity to communicate with others. In the six [10–15] articles about the influence of physical
health of autistic patients [24]. Through organized physical activities, people with autism have the
activity on the social interaction ability and communication ability of children and adolescents with
opportunity to communicate with others. In the six [10—15] articles about the influence of physical
autism, all the researchers mentioned the way of guiding the patients to play games. Autistic children
activity on the social interaction ability and communication ability of children and adolescents with
have a lower quality of games experience than non-autistic children of the same intellectual age [25].
autism, all the researchers mentioned the way of guiding the patients to play games. Autistic children
Perhaps for children and adolescents with autism, these physical activities are games they are playing.
have a lower quality of games experience than non-autistic children of the same intellectual age [25].
In the case that children cannot use language to express completely and clearly, playing games is a
Perhaps for children and adolescents with autism, these physical activities are games they are
good communication method [26].
playing. In the case that children cannot use language to express completely and clearly, playing
Stereotyped behavior is one of the core defects of autistic patients, which is a series of repetitive,
games is a good communication method [26].
aimless and meaningless behaviors [27]. The physical activity on the reduction of stereotyped behavior
Stereotyped behavior is one of the core defects of autistic patients, which is a series of repetitive,
of autistic patients may be explained by the fact that the stimulation obtained by physical activities of
aimless and meaningless behaviors [27]. The physical activity on the reduction of stereotyped
autistic patients has similar internal mechanism of action with the stimulation produced by stereotyped
behavior of autistic patients may be explained by the fact that the stimulation obtained by physical
behavior, which can bring comfortable sensory stimulation to autistic patients, so that they can achieve
activities of autistic patients has similar internal mechanism of action with the stimulation produced
appropriate level of excitation through sensory stimulation and adjustment [28]. However, the results
by stereotyped behavior, which can bring comfortable sensory stimulation to autistic patients, so that
of this review show that physical activity has no significant effect on the stereotyped behavior of
they can achieve appropriate level of excitation through sensory stimulation and adjustment [28].
children and adolescents with autism. Through a careful analysis of the two articles [11,16], it can be
However, the results of this review show that physical activity has no significant effect on the
seen that Reference [16] refers to the intervention of physical activity combined with conventional
stereotyped behavior of children and adolescents with autism. Through a careful analysis of the two
treatment on children and adolescents with autism, while Reference [11] does not. Therefore, the
articles [11,16], it can be seen that Reference [16] refers to the intervention of physical activity
statistical difference may be caused by different interventions. Physical activity, a single intervention,
combined with conventional treatment on children and adolescents with autism, while Reference [11]
may be combined with conventional therapy to intervene in children and adolescents with autism, and
does not. Therefore, the statistical difference may be caused by different interventions. Physical
activity, a single intervention, may be combined with conventional therapy to intervene in children
and adolescents with autism, and the effects of these two interventions on children and adolescents
with autism should be considered in future studies.
Heterogeneity of results has been found in the analysis of four articles [11,17—19] on the
influence of physical activity on motor skills of autistic children and adolescents, but it disappears
Int. J. Environ. Res. Public Health 2020, 17, 1950 9 of 11

the effects of these two interventions on children and adolescents with autism should be considered in
future studies.
Heterogeneity of results has been found in the analysis of four articles [11,17–19] on the influence
of physical activity on motor skills of autistic children and adolescents, but it disappears when two
articles [11,19] are excluded. Through the analysis of two articles with significant effects [17,18], the
intervention cycle of physical activity is 12–32 weeks, with each intervention lasting 45–75 min and
1–2 times per week. Furthermore, the subjects of intervention are all children with autism aged from 4
to 12. It can be concluded that physical activity intervention can improve the sports skills of children
with autism, while exerting little effect on the sports skills of adolescents with autism.
Eventually, among the effects of physical activity on the degree of autism of children and
adolescents, the positive effect of physical activity on the degree of autism of children is significant,
excluding the article [21] of the research object including adolescents. Therefore, physical activity can
be considered effective in reducing the degree of autism in children, but it may have little effect on the
degree of autism in adolescents.
According to the results of this meta-analysis, physical activity in the cycle of 4–24 weeks, 4–13
times a week, 30–90 min each time is conducive to the improvement of social interaction ability and
communication ability in children and adolescents with autism, and physical activity in the cycle
of 4–24 weeks, 5–7 times a week, 90 min each time is conducive to the decrease of degree of autism
in children. However, the improvement of sports skills of children by physical activities requires
long-term intervention, at least 12 weeks, 45–75 min each time, 1–2 times a week. In conclusion,
continuous physical activity intervention is beneficial to children and adolescents with autism.

5. Limitations of Current Research

There are some limitations and shortcomings in this meta-analysis. First and foremost, there are
relatively few RCTS on physical activity intervention in individuals with autism, and consequently
the number of articles included was small. Furthermore, most of the random methods in the study
were not clear, and all the articles do not mention the allocation concealment and blinding, which
may have a certain negative impact on the evaluation results of the system. Last but not least, among
the 12 articles included, 4 of them [14,16,18,20] have mentioned that physical activity combined with
routine rehabilitation treatment is used to intervene the patients, while the rest 8 [10–13,15,17,19,21] do
not describe whether there is routine rehabilitation treatment for the patients during the intervention
period, while routine treatment during the intervention period may affect the intervention effect of
physical activity on children and adolescents with autism. Therefore, in order to confirm the positive
effect of physical activity children and adolescents with autism, physical activity can be adopted alone
to intervene patients in the future research.

6. Conclusions
The results of this meta-analysis show that after physical activity intervention, the social interaction
ability and communication ability of children and adolescents with autism have been improved, and the
motor skills of children with autism have been improved as well, while the degree of autism of children
has been reduced. In conclusion, physical activity intervention is beneficial to children and adolescents
with autism, and continuous physical activity intervention can produce greater intervention effect.
In addition, in the future research, children and adolescents with autism can be intervened with other
physical activities, which may also be a reference for improving other symptoms of children and
adolescents with autism through physical activities in the future.

Author Contributions: Conceptualization, J.H., C.D., and G.T.; methodology, J.H., C.D. and G.T.; Data curation,
J.H. and J.L. Writing–the original draft, J.H. and C.D.; Writing–reviewing and editing, J.H., C.D., J.L., and G.T.
All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Int. J. Environ. Res. Public Health 2020, 17, 1950 10 of 11

Acknowledgments: The authors are grateful to all the participants who were involved in this study.
Conflicts of Interest: The authors declare no conflict of interest.

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