By Andy Bading - B.Behav. Sc. (Psych), RTB (BACB0, Mental Health First Aid, Registered Behaviour Support Practitioner., 2021.
What is a Meltdown?
A meltdown is an intense emotional reaction to circumstances or situations, when the individual is overwhelmed, causing a loss of control, resulting in verbal and physical behaviour that can be exhibited in different ways, for each given situation. The topography (how the behaviour (Bx) is expressed or looks) of verbal Bx typically resembles yelling, crying, screaming, or swearing. Physical Bx can resemble kicking, biting, spitting and self-injurious Bx (SIB). However, Bx is not typically exhibited in one modality and can be both physical and verbal.
Meltdowns can be cause by many factors; environmental, personal and interpersonal. It is important to understand the reason for the Bx in order to effectively treat the Bx. The key to calming and Autistic Child is to understand not only the function of the Bx but also what has possibly caused or triggered it in the first place.
Some of the causes for melt downs that can be attributed to personal factors in a child with Autism include ADHD, Developmental delay, A lack of skill acquisition for appropriate responding. Anxiety Disorders, and Sensory Processing Disorders.
What is a Tantrum?
Tantrums like meltdowns vary greatly from one child to another, particularly when that child has Autism. Tantrums often present in the form of crying, rigidity and tension in the body, particularly the upper body, screaming whilst tensioning up the arms neck and chest (hulk mode screaming), kicking things, falling and bashing hands on the ground while screaming/crying/talking to self, or they may run away. Sometimes, a child may hold their breath and work themselves up until they are physically ill.
Children with Autism often become aggressive during tantrums and can direct this aggression either at objects or people. Typically developing children will throw tantrums when they don’t get what they want, however, for children with Autism, triggers can be as simple as hunger, thirst, or tiredness. While this can also be the case for typically developing children, those with Autism have more difficulty with frustrations, which results in tantrums much quicker, and often for simpler things.
The Difference Between Meltdown and Tantrum
The difference between a meltdown and a tantrum lies in the motive or function of the Bx, and whilst Autistic Children may be more prone to meltdowns, they are not void of tantrums and may exhibit both. Once again, according to Applied Behaviour Analysis theory, the function of the Bx can determine the difference.
A main point of difference between a tantrum and meltdown can depend on the audience, and its response to the individual or Bx. Tantrums typically cease when ignored or when the individual exhibiting them gets what they want, however, autistic meltdowns can occur without an audience and without a tangible need. This is due to the Bx being a direct response to what we call overstimulation resulting in dysregulation and could happen when a child is alone or in a noisy environment with a crowd and not reliant on a response.
Tantrums are typically generated from frustration and anger regarding social interactions including demands, and access to tangible objects. But autistic meltdowns are generally a reaction to being overwhelmed. Autistic children struggle to, or are unable to control their meltdowns, and strategies that work on tantrums, such as hugs, incentives and distractions, have no effect on meltdowns. It is important to note that not all meltdowns are displayed with outward expression, and in some cases may be demonstrated by a complete withdrawal of the individual from the outside world as a way of coping with the situation. This can also look different for each person from, a complete shutdown, zone out, or blank stare, to repetitive self-stimulatory movements (stimming).
Common triggers for Meltdowns can include:
· Sensory overload (Noise, light, smell, movement)
· Emotional overload (excitement, fear, anger, happiness)
· Information overload (confusion and inability to process)
It is very important to understand environmental triggers, if your child is triggered by light or noise, or actively seeks out stimulation, they may have a sensory processing issue and we reccommend engaging the services of an Occupational Therapist who can conduct a Sensory Processsing Assessment.
In many cases just as with a typically developing child, an Autistic child does not simply explode and may start showing ‘warning’ signs that they are escalating or feeling distressed, and trying to cope with this escalation by:
· Pacing back and forth or around in circles,
· Verbal repetitions,
· Stereotypic movements including body rocking,
· Express physical illness symptoms
This is the time in which Carers and Parents can implement measures to prevent meltdowns.
Calming an Autistic Child During a Meltdown
As previously mentioned, the first step in calming a child who is escalating is identifying the cause. By doing this, you can effectively remove the trigger, or prevent it in the first place, effectively avoiding
it. To do this, it is vital to keep a diary, writing down the situations and locations in which the child was triggered, how they responded.
Calming an autistic child during a meltdown can be difficult as the child is so overwhelmed that they will not respond to commands. This is best explained through the Dan Seigel model of the brain titled “Flipping your lid.
The hand model of the brain is a helpful
way of showing the functions of the brain and what happens when we ‘flip our lids’. This is what happens when the lower parts of our brain take over (fight, flight or freeze) and our thinking brain becomes disconnected.
Although the picture below is useful in illustrating the hand model, we recommend taking a look at one of the videos on Youtube, where this model is easily explained.
Below are some links to make it easy for you:
To effectively implement a strategy that can be used in this dysregulated state, it is important to teach the child strategies when they are calm and can focus on what you are teaching them.
Although meltdowns can wear out the child, having a calming routine in place for them to call on in times of distress can assist the child to calm down faster and more effectively, and with time, help them avoid the meltdown altogether.
This could include specific exercise
s including deep breathing, images or objects of choice, a weighted blanket, or favorite soft toy,
or even a centering object (particularly for those who become overwhelmed by sensory input).
During a meltdown, you should always be calm, and within reach of the child incase they seek you out for comfort during this time, you are the safest place a child can know when distressed. Also, do not try to rationalize with them, they are in a state of distress and lack the ability to fully rationalize at the best of times. Always make sure they are safe, remove any objects that they may unintentionally hurt themselves against, or with during this time.
If you have ever been out in public, you know this can happen to anyone with kids, and it can be just as difficult for the parent as it is for the child. However, it is important to remember that for Autistic children, these meltdowns are not to hurt or upset you, they are simply reacting to stress or are overwhelmed by what they are experiencing, and do not know how to cope.
Flipping Your Lid–The Effects of Trauma on a Child’s Brain
The phrase “traumatic event” is often attached to things like car crashes, mass shootings, and major events or loss. Trauma is currently a major area of focus for study and research in numerous professional fields including mental health and disability support. In fact, Trauma has become a specialist field in Behaviour support and ther
apy in general. But what exactly is trauma and what does it do to the brain of a child?
A traumatic event can be described as any event or incident experienced by an individual that is perceived by that person to be dangerous or a serious threat to their safety (which could include the risk of injury or death serious injury or death. Whether it is a large-scale disaster or only an individual incident, trauma can cause someone to lose their sense of control and safety, sometimes resulting in a state of hyperarousal.
Extensive scientific research into the effects of trauma on the brain reveal that there are three major parts of the brain involved in a response to trauma. The part of the brain affected by trauma is called the “primal brain”, this part is responsible for bodily functions that we need to survive (e.g. regulating heartbeat, lung function, and levels of arousal). The second part of the brain affected by trauma is the limbic system. The limbic system is mainly responsible for emotions and relationships/attachment to others. It works with the brain stem to assess situations and determine if a situation is good or bad (danger). Three important parts of the limbic system include; The Hypothalamus, the command center for hormones; The Amygdala, the emotional switchboard; and the Hippocampus, or the memory center. Lastly, the Cortex is also greatly affected by trauma, this is the outer layer of the brain, at the front (your fingers in the hand model) which controls rational thinking.
When we are calm, all three parts of the brain work together in harmony. However, when a child a child experiences a trauma, there is a disconnect between these parts of the brain, and emotions take over. For a Child with Autism, Trauma does not have to be large or dramatic/catastrophic, it can be as simple as leaving the house and you, or a change in an expected routine. That can make them feel completely unsafe and even terrified.
This is a brief look at what happens in the brain when a child experiences a traumatic event:
1. Brain stem– Initiates the “fight, flight, freeze, or giggle” response when in times of stress, or trauma.
2. Limbic system–Releases higher levels of cortisol (stress hormone), which results in higher arousal and irritation. When a child experiences trauma, the amygdala may go into overdrive (Amydala Hijack) and cause fear responses to something as simple as doors slamming or loud voices. The hippocampus may then activate and stitch together memories of the previously experienced traumatic event in a way that causes the child to be more fearful of what is happening now.
3. Cortex- Disconnects from other parts of the brain. This may make it hard for a child to
describe an experience and think, the B
rain stem, and Limbic system have taken over and are feeding the heart which has now increased its rate, and beating like the child is running a race. That in turn feeds back to the brain telling the limbic system there is a threat.
For more information about Dan Siegel and his brain model, check out his books: The Whole Brain Child, Mindsight: The New Science of Personal Transformation or his website: https://www.drdansiegel.com/
What Can I DO??? And where do I start?
Before an effective intervention can be identified and implemented, you must first identify the behaviour. Is it a tantrum or a meltdown? Remember, tantrums are exhibited when a need is not met, whilst meltdowns occur when the child cannot cope with external stimulation.
Secondly, as already mentioned, try to uncover the motivation or function of the Bx, that is “what is the behaviour saying?”, this will give you valuable insight into how you can either prevent, or respond to/manage it. E.g., for a tantrum, if they want something, like a toy or attention, recognise this but do not give it to them, more on this in reinforcement.
Thirdly, remove the audience, usually this will either cease the tantrum, or calm them down of it is a meltdown due to overstimulation in a noisy/busy environment. Teaching your child coping strategies in small groups can help avoid tantrums in public/crowds.
Last but certainly not least, do not forget that this is your child, that has feelings and needs, acknowledge what they are feeling and reward/reinforce positive Bx every time. Do this by social praise, not through chocolate or treats. This can look like a hug, or by telling them what a good job they did in that situation. This not only builds up the confidence of the child, it reinforces correct Bx and teaches them that they can achieve what they want/get your attention successfully without tantrums.
More Info on What Can Cause meltdowns and Overstimulation:
According to research 70–96 percent of children with ASD experience difficulties with sensory processing (Ben-Sasson, Hen, Fluss, Cermak, Engel-Yeger, & Gal., 2009). In fact, hyper- or hypo-reactivity to sensory input or unusual interests is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as one of four types of restricted, repetitive patterns constituting diagnostic criteria for ASD.
Furthermore, research has linked ASD-related sensory-processing challenges to decreased participation in, or a withdrawal from social activities, play, academic tasks and self-care, as well as a decreased attention/lack of focus, which are all reliant on executive function which is associated with language and skill development. Sensory Processing Issues (SPI) can, as aforementioned cause meltdowns, and even lead to self-injurious and aggressive behaviors, especially in children who are unable to communicate their issues (Piller, & Barimo., 2019).
Sensory processing can be described as the process by which the nervous system receives, organizes and manages Sensory input (incoming environmental information) via seven (7) sensory systems: vestibular (balance), proprioceptive (body movement), tactile (touch), visual (sight), auditory (hearing), gustatory (taste), and olfactory (smell) (Piller, & Barimo., 2019).
There are two modalities to SPI’s hyper and hypo-reactivity to sensory stimuli. The difference refers to the way in which the child responds to a typical stimulus that would either be noticed by others or not noticed by others. The child will respond in an unusual way to the corresponding stimuli, that is to say, if a noise that would otherwise go unnoticed occurs, a child with Hyper-reactivity would cover their ears or react in a way that suggests discomfort. Likewise, if a noise that would otherwise be heard and disturb most people occurs, a child with hypo-reactivity will not notice. More than 70 percent of children with ASD experience sensory-processing differences, which can cause the child to be in a state of high alert for long periods of time (Piller, & Barimo., 2019).
When the nervous system is in a heightened state of alert, it is very difficult to maintain both attention and self-regulation, resulting in meltdowns. On the other hand, it is also true that if a child suffers from hypo-reactivity does not receive sensory input necessary for stimulation, they may actively seek it out, resulting in disruptive type behaviours (Piller, & Barimo., 2019). Whilst there is ample evidence that the latter can be addressed with sensory objects and activities such as swings, jumping etc., our focus will remain on Hyper-reactivity to sensory input. To that end, children with autism spectrum disorders often exhibit co-occurring SPI’s and receive interventions that target self-regulation.
Sensory interventions can vary greatly, focusing on different theoretical constructs, goals, and procedures. Due to this, in 2015 a meta-analysis was published by Case-Smith, Weaver, & Fristad, examining 19 studies from 2000–2012. The researchers found that two randomized controlled trials published positive effects for sensory integration therapy on child performance using Goal Attainment Scaling (effect sizes ranging from .72 to 1.62); while other studies found positive effects on reducing behaviors linked to sensory problems (Case-Smith, Weaver, & Fristad,, 2015).
Programs & Skills
The idea here is to build skills that the child is lacking, this will enable them to function appropriately and successfully, avoiding the trauma and stress associated with meltdowns and tantrums. Coping skills and associated programs can include negotiation, communicating needs, waiting, accepting no/loss/removals, occupying time independently and following instructions from an adult (particularly when asked to do something they do not want to do).
Reminder, program education and retention will only occur effectively when it is taught while the child is calm, you cannot expect a child to understand, learn or remember, during a heightened state (excitement/agitation/stress). Coping skills are only effective if they can be called upon by the individual as a previously learned skill, during times of duress. Behavioural Therapists work under the scientific discipline of Applied Behavioural Analysis or ABA, which uses empirically proven programs and approaches to manage challenging behaviour through the lens of behaviorism. That is, all behaviours serve a function and communicate that function in some way.
Sensory Programs
Sensory-based interventions are characterized as single strategy interventions that include things like weighted vests or therapy balls, to influence a child’s state of arousal. While some research into the efficacy of such interventions has revealed limited positive effects in sensory-based interventions and indicate that sensory-based interventions may not be effective, a lack of consensus regarding operationalized procedures, and other studies revealing positive effects, more study is needed to determine the efficacy of these programs for children with autism spectrum disorders and SPI’s (Case-Smith, Weaver, & Fristad., 2015).
However, this is not to be confused with the importance of Occupational Therapist guided Sensory based treatment protocols which target sensory based triggers, thus removing irritants or supplying sensory feedback that the individual requires based on a sensory profile assessment.
Physical Exertion
Another evidence-based practice considered to be an effective means of decreasing problem behaviours, or increasing appropriate behaviors is physical exertion Therapy (PET) (Wong et al., 2015). Furthermore, research has demonstrated that PET can effectively address deficiencies in motor skills, which are commonly associated with ASD (Leary and Hill, 1996; Ghaziuddin and Butler, 1998; Ozonoff et al., 2008; Green et al., 2009).
Given the evidence, PET would logically appear to be an appropriate strategy for improving the quality of life in children diagnosed with ASD (Sefen, Al-Salmi, Shaikh, AlMulhem, Rajab, & Fredericks., 2020).
Physical activity is well known for its importance in maintaining health within the general population. Such benefits include the release of endorphins and monoamine neurotransmitters, which mimics the effects of antidepressants, making it a healthy alternative to drug treatments (Zhao and Chen, 2018). Along with the health benefits, research has demonstrated that PET can also improve motor skills and cognitive function in children aged 4–6 years, specifically in the areas of attention, memory, behavior, and academic achievement (Zhao & Chen, 2018). Furthermore, researchers have identified a number of effective strategies that demonstrate improvements in social and communication skills for children with ASD (Zhao & Chen, 2018). However, due to poor motor coordination and balance, often associated with ASD, physical activity levels in children with ASD are generally lower than in typically developing children (Hillier, Buckingham, & Schena., 2020).
Scientific trials examining the efficacy of PET in people with ASD have endorsed the use of PET in the management of ASD. In a review by DeJesus et al. (2020) researchers concluded that dance exhibited a positive effect on the reduction of ASD specific symptoms, including social involvement, behavior, communication skills, body awareness, and mental health. Furthermore, a meta-analysis examining the effects of PET on youth with ASD found that across 29 studies PET had a moderate positive effect on the reduction of symptoms, with a moderate-to-large positive effect found in areas of movement, and large positive effect for social function (Healy, Nacario, Braithwaite, & Hopper., 2018). Supporting this, a recent study on 5–8-year-olds with ASD in China, demonstrated significant improvements in social function in those who participated in the 12-week program (Zhao & Chen, 2018).
Consisting of twice-weekly exercise sessions lasting 60-min, over a period of 12 weeks, participants learned how to interact with and express themselves to others as a key component of the program. The program was evaluated quantitatively using Social Skills Improvement System Rating Scales (SISS) and Assessment of Basic Language and Learning Skills—Revised (ABLLS-R) scores as well as qualitative interviews with parents and staff. SISS assessed seven social skills subdomains and significant improvements were seen in communication, cooperation, and self-control. Improvements were also seen in ABLLS-R scores. Parents and Support staff also gave positive feedback (Zhao and Chen, 2018). Results of the study support PET as an effective intervention for children with ASD due in part to the fact that two of the major deficits associated with ASD (communication and social interaction) were directly and positively effected by the program. However, limitations of the findings include the fact that improvements cannot solely be accounted to the physical exertion, due to the social interaction aspect of the program.
This leaves the question ‘When tailoring a PET program for children with ASD, would an individual-based or a group-based intervention be better?’. Programs structured in a group environment (teams, peers, coaches, parents, and teachers) offer opportunities for social interaction and therefore should enhance development among children with ASD (Rinehart, Jeste, & Wilson., 2018). However, a meta-analysis comparing responses to individual-based and group-based interventions found greatly improved social skills and a higher reduction in challenging behaviors with the individual-based approach (Sowa & Meulenbroek, 2012). Interestingly, the researchers revealed that social skills showed less improvement in group-based programs. Sowa and Mulenbroek (2012) concluded that individual-based interventions offer decreased stress and distraction levels due to the uncontrollable variables associated with group activities. Individual approaches can serve to protect the child from possible negative emotions arising from misunderstood social interactions by others in a heightened state (Sowa and Meulenbroek, 2012; Pan, 2009).
There are clear advantages and disadvantages to both group-based and individual activities which should be taken into account for the child’s individual needs when implementing a program. Individualised education programs for children with ASD are now widely accepted, due to the individual and unique presentation of core and comorbid ASD symptoms for each child, and although counterintuitive, the individualised programs seem to be advantageous with respect to social skills development for children with ASD (Sefen, et al., 2020).
Emotional Regulation
Emotion regulation can be defined as one’s ability to identify and assert control over their own emotions and understand and interpret other people’s emotions. From a psychology perspective, this is in line with Theory of mind, and interventions can include CBT programs that force the individual to rethink a challenging situation to reduce anger or anxiety. From a behavioural perspective, teaching an ASD child emotional regulation can be more effective when focused on the behaviours associated with distress. This could include teaching the child physical calm down techniques, how to identify emotions and label them, reinforcement of alternative behaviours, and so on. These strategies work for children with ASD due to the fact, they do not have to think to hard (The cognitive aspect of CBT) about what they are doing, they are learning physical behaviours that alter their physical and mental state and help them cope with the physical stimulation associated with ASD symptoms and dysregulation. As we mentioned earlier, during these heightened times, ASD children find it hard to focus and think clearly, so they rely on habituated (learned) automatic responses that have been proven to work.
Parents
It is widely recognised that parents play a major role in effective treatment for ASD, as the most effective factor in promoting behavioral change in a child with ASD (Schopler, 1987). As common practice, equipping parents with development-enhancing strategies, while positively engaged with their children, is essential for the success of these interventions (Mendlowitz et al., 1999; Lakin et al., 2004; Landa, 2018). Parental involvement has been shown to enhance treatment approaches, resulting in more positive outcomes, including PET programs, which have shown that family involvement resulted in better outcomes than without (Lakin et al., 2004).
It is important for any parent engaging the services of a professional to treat their ASD child, that the professional is not there all the time, usually 1 day per week. So, it is therefore up to the parent to administer and adhere to the programs without fail, in order for them to be effective. You are the parent, and it is the natural role of the parent to care for, educate and shape their child, Bx intervention programs simply give you a different skillset to arm your child with the ability to function independently, resulting in better relationships and outcomes for them and you.
It is also important for the parent to remember, you are the parent, not the support worker, and if you start to feel overwhelmed or worn out, find support and take time for yourself. You are just as important, and your mental health is important.
Reinforcement
Reinforcement is the foundation on which applied behavior analysis (ABA) rests. Founded on B.F. Skinner’s theory of operant conditioning, ABA suggests that Bx can be shaped and changed through the use of reinforcement to either increase or decrease the likelihood of a certain behavior occurring the next time a given set of circumstances occur.
The logic behind the application of ABA focusses on three functions of Bx, called the ABCs of ABA:
· Antecedent – the prompts leading to the behaviour (trigger).
· Behaviour – the actions performed as a result of the antecedent.
· Consequence – what happens to the person as a direct result of those actions.
To explain this, let’s look at an example: Johnny is given school homework (Antecedent). At home, he promptly finishes his homework (Behaviour). Because he finished his homework, he is allowed to play on the PlayStation before dinner (Consequence). In this case, the reinforcement is the game time on the PlayStation. Being allowed to do something he enjoys because he gets his homework done on time will, encourage him to continue doing his homework. in the future.
While that is an easy and simplistic example, it is important to understand that reinforcement can be through many means and can happen without you realising, resulting in the reinforcement of negative Bx’s. For example, if Johnny has a learning disability that prevents him from finishing his homework, there is no opportunity for positive reinforcement to occur. Johnny may then throw a tantrum, and to stop the tantrum, his parents let him play his game. In this case, the parents just (inadvertently) reinforced the tantrum as a desirable behaviour, that is, Johnny just learned that he will get game time if he throws a tantrum. Understanding when and how to apply reinforcement in a systematic way that leads to an increased likelihood of desired behaviours is the role of the applied behaviour analyst. However, it is important that the parents learn these aspects and follow the procedures created by the behaviour analyst to avoid reinforcing negative Bx.
Reinforcement should also avoid things like buying chocolate or toys for the child every time they go out as an incentive for being good. This looks like bribery and usually is, leading the child to expect treats each time they go out with you, and resulting in negative Bx when they do not. Social and verbal praise not only makes the child feel more confident, it creates the opportunity for social learning and development, without the focus on tangible items. Furthermore, if tangible items are used, reinforcement should both fade and be delivered in a variable ratio, that is, when initiating a program, they should be used each time an appropriate Bx is exhibited, then gradually fade and be rewarded only every 2nd / 5th correct response etc.
Another aspect of reinforcement is when it is used to teach preferable Bx’s over existing Bx’s. Whilst it is easy to reinforce an existing (already learned) Bx, teaching a new Bx requires a differential approach, prompting the child to adopt new (different) responses (Bx) to an existing stimulus. This involves only offering reinforcement selectively, to avoid linking multiple Bx’s to the reinforcement.
There are four basic types of differential reinforcement used by ABAs:
DRI (Differential Reinforcement of Incompatible Behaviours) – Reinforcement is only given when a behaviour is shown that cannot exist simultaneously as the problem behaviour. If a child has a tendency to wander around a classroom, for example, DRI might call for reinforcement to only occur when they are seated.
DRA (Differential Reinforcement of Alternative Behaviours) – This actively rewards behaviours that are alternatives to a problematic behaviour. A good example is when a child performs a task quietly and without fuss, as opposed to loudly or while objecting.
DRO (Differential Reinforcement of Other Behaviours) – This reinforces essentially any other behaviour besides the problem behaviour. Using the previous example, the child might be rewarded if they perform the task while talking or not talking, but not rewarded only in the event of a tantrum.
DRL (Differential Reinforcement of Low Rates – This simply seeks to lower the occurrence of behaviours that may be socially acceptable, but only in some situations or with low frequency. Playing, for example, is perfectly appropriate for most children—however, a therapist may use DRL to encourage that behaviour only at approved times or not to the exclusion of other tasks.
You may find new reinforcers all the time, and remember, they are kids, and kids change their minds and likes all the time so it might be ever changing, but YOU are the best person to identify what your child likes the most, then the Behaviour Support Practitioner can decide if and how it can be used.
According to Applied Behaviour Analysis all behaviour can be seen terms of what reinforces it, once you have an understanding of reinforcement, you will begin to see how you can use reinforcers to help control behaviours.
Thank you for reading, and we hope this has helped in some way to shed light on why Bx can occur and what you can do about it.
References
Ben-Sasson, A., Hen, L., Fluss, R., Cermak, A., Engel-Yeger, B., & Gal, E. (2009). A Meta-Analysis of Sensory Modulation Symptoms in Individuals with Autism Spectrum Disorders. J Autism Dev Disord 39, 1–11 (2009). https://doi.org/10.1007/s10803-008-0593-3
Case-Smith, J., Weaver, L. L., & Fristad, M. A. (2015). A systematic review of sensory processing interventions for children with autism spectrum disorders. Autism, 19(2), 133–148. https://doi.org/10.1177/1362361313517762
DeJesus, B. M., Oliveira, R. C., de Carvalho, F. O., de Jesus Mari, J., Arida, R. M., and Teixeira-Machado, L. (2020). Dance promotes positive benefits for negative symptoms in autism spectrum disorder (ASD): a systematic review. Complement. Ther. Med. 49:102299. doi: 10.1016/j.ctim.2020. 102299
Healy, S., Nacario, A., Braithwaite, R. E., and Hopper, C. (2018). The effect of physical activity interventions on youth with autism spectrum disorder: a meta-analysis. Autism Res. 11, 818–833. doi: 10.1002/ aur.1955
Hillier, A., Buckingham, A., & Schena, D. (2020). Physical activity among adults with autism: participation, attitudes, and barriers. Percept. Mot. Skills 127, 874–890. doi: 10.1177/0031512520927560
Lakin, B. L., Brambila, A. D., and Sigda, K. B. (2004). Parental involvement as a factor in the readmission to a residential treatment center. Resident. Treat. Children Youth 22, 37–52. doi: 10.1300/j007v22n02_03
Landa, R. J. (2018). Efficacy of early interventions for infants and young children with and at risk for, autism spectrum disorders. Int. Rev. Psychiatry 30, 25–39. doi: 10.1080/09540261.2018.1432574
Mendlowitz, S. L., Manassis, K., Bradley, S., Scapillato, D., Miezitis, S., and Shaw, B. F. (1999). Cognitive-behavioral group treatments in childhood anxiety disorders: the role of parental involvement. J. Am. Acad. Child Adolesc. Psychiatry 38, 1223–1229. doi: 10.1097/00004583-199910000-00010
Pan, C.-Y. (2008). Objectively measured physical activity between children with autism spectrum disorders and children without disabilities during inclusive recess settings in Taiwan. J. Autism Dev. Disord. 38, 1292–1301. doi: 10.1007/s10803-007-0518-6
Piller, A., & Barimo, J. (2019). Sensory Strategies to Calm and Engage Children with Autism Spectrum Disorder. Challenges with sensory processing are a hallmark of autism spectrum disorder. Occupational therapists share suggestions for addressing a child’s off-task behavior. doi.org/10.1044/leader.FTR2.24042019.56
Rinehart, N., Jeste, S., & Wilson, R. (2018). Organized physical activity programs: improving motor and non-motor symptoms in neurodevelopmental disorders. Dev. Med. Child Neurol. 60, 856–857. doi: 10.1111/dmcn.13962
Schopler, E. (1987). Specific and nonspecific factors in the effectiveness of a treatment system. Am. Psychol. 42, 376–383. doi: 10.1037/0003-066x.42.4.376
Schultheis, S. F., Boswell, B. B., and Decker, J. (2000). Successful physical activity programming for students with autism. Focus Autism Other Dev. Disabil. 15, 159–162. doi: 10.1177/108835760001500306
Sefen, J., Al-Salmi, S., Shaikh, Z., AlMulhem, J., Rajab, E., & Fredericks, S. (2020). Beneficial Use and Potential Effectiveness of Physical Activity in Managing Autism Spectrum Disorder. Frontiers in Behavioral Neuroscience, 14, 587560–587560. https://doi.org/10.3389/fnbeh.2020.587560
Siegel. D, (2010) The Whole Brain Child in Mindsight: The New Science of Personal Transformation. Retrieved from: https://www.drdansiegel.com/
Sowa, M., and Meulenbroek, R. (2012). Effects of physical exercise on Autism Spectrum Disorders: a meta-analysis. Res. Autism Spectr. Disord. 6, 46–57. doi: 10.1016/j.rasd.2011.09.001