University of Southern California Dissertations and Theses

Social interaction moderates enjoyment and perception of physical activity during exergame play in young adults with autism spectrum disorders

(USC Thesis Other)

Social interaction moderates enjoyment and perception of physical activity during exergame play in young adults with autism spectrum disorders

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content

SOCIAL INTERACTION MODERATES ENJOYMENT AND PERCEPTION
OF PHYSICAL ACTIVITY DURING EXERGAME PLAY IN
YOUNG ADULTS WITH AUTISM SPECTRUM DISORDERS

by
Amanda C. Foran

A dissertation submitted to the faculty of
the University of Southern California
in partial fulfillment of the requirements for the degree of

Doctor of Philosophy
in
Occupational Science

Division of Occupational Science and Occupational Therapy
University of Southern California
May, 2014
2

TABLE OF CONTENTS

Acknowledgments..................................................................................................................4

Key to Abbreviations .............................................................................................................6

Introduction ............................................................................................................................7

Specific Aims and Research Questions .................................................................................9

Sources of Funding ................................................................................................................12

CHAPTER 1: Background
Physical activity and obesity ......................................................................................14
Play ............................................................................................................................16
Partner play ................................................................................................................17
Autism Spectrum Disorder ........................................................................................18
Play in ASD ...............................................................................................................18
Friendship and ASD ...................................................................................................18
Physical activity and obesity in ASD.........................................................................20
Technology and ASD .................................................................................................22
Exergaming ................................................................................................................22
Partner play and exergaming ....................................................................................25
Exergaming and ASD ................................................................................................26
Theoretical Models ....................................................................................................27

CHAPTER 2: Study 1. Videogame survey: Active and traditional videogame ownership and play
patterns among youth with Autism Spectrum Disorders, and relationships to physical activity
Introduction ................................................................................................................33
Method .......................................................................................................................34
Procedure ...................................................................................................................35
Results ........................................................................................................................36
Discussion ..................................................................................................................39
Conclusion .................................................................................................................42
References ..................................................................................................................44
Tables .........................................................................................................................47

CHAPTER 3: Study 2. Exergaming case series: Case Studies on the Feasibility of Exergaming
to Enhance Physical Activity in Youth with Autism Spectrum Disorders
Introduction ................................................................................................................56
Method .......................................................................................................................58
Procedure ...................................................................................................................59
Results ........................................................................................................................65
Summary and Interpretation ......................................................................................72
Conclusion .................................................................................................................75
References ..................................................................................................................77
Tables .........................................................................................................................84

3

CHAPTER 4: Study 3. Exergaming partner play study: The effect of exergaming on physical
activity and enjoyment in young adults with Autism Spectrum Disorder and typical development
Introduction ................................................................................................................90
Method .......................................................................................................................97
Procedure ...................................................................................................................98
Results ........................................................................................................................109
Discussion ..................................................................................................................116
Conclusion .................................................................................................................119
References ..................................................................................................................122
Tables and Figures .....................................................................................................132

CHAPTER 5: Conclusion ......................................................................................................150

References .............................................................................................................................157

Appendices .............................................................................................................................177
4

Acknowledgments

I would like to express the deepest appreciation to my committee chair and mentor, Dr.
Sharon Cermak. Dr. Cermak supported me throughout my doctoral journey, from near and far.
She encouraged me to think creatively about my project, and to incorporate my many research
interests, which I once thought to be too broad and unrelated, into a unique and powerful study.
Utilizing her many connections, Dr. Cermak pushed me to seek out information and support
from all over the world, which has allowed me to become a more independent scientist, and to
collaborate with a brilliant community of scholars whom I am honored to now call colleagues.
Dr. Cermak was immeasurably patient, and firm but caring in her feedback; without her
guidance, my work would not be nearly as rich or meaningful.
It is with sincere and immense gratitude that I acknowledge the support of Dr. Donna
Spruijt-Metz, who welcomed me into her laboratory and allowed me the opportunity to learn
new analysis skills not available in my home department. She was persistent and unwavering in
her support for a number of trying data analyses and publication submissions. Her trust in the
final outcome gave me the confidence to continue when I felt overwhelmed or stuck.
It gives me great pleasure to acknowledge the contributions of Dr. Erna Blanche, an
incredibly positive presence and world-class clinician, who always reminded me to “bring it back
to the people.” Her insights helped me to refine my longwinded writing and often too-lofty ideas,
connecting them clearly to the good work we do as Occupational Therapists.
I am indebted, too, to Drs. Ann Neville-Jan and Jennifer Unger, who served on my
proposal guidance committee, and spent much time and thought on my work, helping to improve
my writing, research design, and analysis from the beginning of this journey.
I would like to thank Jaclyn Brunn, my fearless research assistant, who enthusiastically
stood by me for many hours as we collected data for the final study, and pushed outside her own
comfort zone by becoming more intimately engaged with young adults on the Autism Spectrum.
5

I’d also like to thank the staff and participants of the Hussman Center for Adults with Autism.
Without you, these studies would not have been possible. I am honored to have worked with you;
your participation and insights were extremely meaningful to me, and I hope to continue our
relationship in the future.
This dissertation would not have been possible without the loving support of my friends
and family, who have seen me through all the ups and downs of doctoral life. Thank you
especially to my parents, who instilled in me an appetite for learning and a healthy skepticism of
“the way things are” – you have taught me to be curious, and to always think critically and
independently. You have modeled for me a lifetime of inquiry, passion, and community, which I
hope one day to emulate. To my “family” of friends and colleagues, most especially Dr. Julie
Werner, who listened, read, and simply understood… you were always just what I needed, and I
couldn’t have done it without you.
Finally, I would like express my deepest appreciation to my beloved Michael, who spent
many sleepless nights with (and without) me, and was my constant supporter and cheerleader,
even in the moments when it seemed there were no answers. Thank you for always having faith
in me, and in us, at my most ugly, challenging, and exhausted, as well as my most excited and
endlessly talkative. I can’t wait to start our next chapter together.

~
6

Key to Abbreviations

The following abbreviations are used throughout the manuscript and are provided here for reference.

ASD Autism Spectrum Disorder

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

BOX Kinect Sports boxing exergame

EE Energy expenditure

EG Exergame

HR Heart rate

MVPA Moderate-to-Vigorous Physical Activity

NT Neurotypical

PA Physical Activity

RPE Rating of Perceived Exertion

TEN Kinect Sports tennis exergame

TSVG Traditional Seated Videogame

7

Introduction

Although overweight and obesity rates among youth and young adults in the United
States are beginning to slow, they continue to remain alarmingly high (Mitka, 2013). When
individuals are overweight or obese, they are at elevated risk for health conditions such as
diabetes and cardiovascular disease (Carson et al., 2014). Lack of engagement in physical
activity and increased sedentary behavior are major factors contributing to this problem (Carson
et al., 2014; Tremblay et al., 2011). Despite the contribution of technology to improved quality
of life for many Americans, it may also be negatively influencing the level of daily physical
activity achieved by individuals, especially youth and young adults who are more “plugged in”
to screen media and other technologies than ever. One population that is particularly drawn to
technology-based systems and activities is individuals with Autism Spectrum Disorder (ASD)
(Goldsmith & LeBlanc, 2004). For these individuals, technology is often a useful tool to enhance
communication and social engagement, which are typically areas of difficulty for this population
(Rayner, Denholm, & Sigafoos, 2009). However, the vast majority of screen-based media such
as computers, videogames, and television are both sedentary and solitary activities.
Exergaming is an emerging technology which utilizes active videogame systems to
incorporate physical activity into gameplay. Exergames may be of particular relevance to
individuals with ASD, who have limited opportunities for community-based physical activity,
leading to decreased participation and social engagement compared to neurotypical (NT) peers
(Pan & Frey, 2006; Obrusnikova & Cavalier, 2011). Exergames have been lauded as an effective
way to increase daily physical activity levels in NT youth and adults, and exergaming with a
partner versus alone has been shown to increase energy expenditure, enjoyment, and motivation
for physical activity in these individuals (Daley, 2009). To date, studies of exergaming in
individuals with ASD are limited and have focused on the effects on executive function and
reducing repetitive behaviors (Anderson-Hanley, Tureck, & Schneiderman, 2011b; Flynn, 2012).
8

The effect of exergaming on physical activity and enjoyment has not been measured in those
with ASD, and little is known about current videogame playing habits in this population.
However, youth and young adults with ASD are an especially important population to study, as
they are at risk for overweight, obesity, and related health conditions due to their increased
likelihood of sedentary lifestyle (Pan & Frey, 2006; Obrusnikova & Cavalier, 2011). As such,
active videogames may be a good substitute for a traditionally sedentary activity.
To address the gaps in the literature concerning exergaming and individuals with ASD,
three studies were conducted: (a) a survey to describe videogame ownership trends among
families of youth with ASD, patterns of videogame play within this population, and to report
relationships between active and traditional videogame play and parents' satisfaction with their
child's current physical activity level; (b) a series of case studies to explore the feasibility of
using an exergaming system with youth with ASD, how much exercise they get from
exergaming, and how much assistance they need to play exergames; and (c) a participatory
program study to determine the amount and intensity of physical activity young adults with ASD
achieve while exergaming alone and with a playing partner, and their level of enjoyment while
exergaming under various conditions.
The following is a compendium of the three studies, each of which builds on the findings
of the previous work. It is my hope that these papers will contribute to a better understanding of
the correlates of physical activity and social technology use in this population, and that
neurodiverse individuals, as well as the clinicians, educators, and caregivers who work with
them, may find this project useful for enhancing current routines, as well as designing healthy
lifestyle change.

9

Specific Aims and Research Questions
Study 1: Videogame survey
In order to determine whether the use of exergames with individuals with ASD is realistic and
feasible as a potential community-based strategy to enhance physical activity in daily life, a
survey of approximately 200 parents of youth with ASD was conducted. The survey examined
ownership and use of videogames among families with children with ASD. The aims of the
survey study were:
1. To examine videogame ownership trends among families of youth with ASD.
2. To measure videogame play patterns of youth with ASD, including the
frequency/duration of videogame play, and the level of assistance needed to play both
active and traditional seated videogames.
3. To describe relationships between videogame play habits of youth with ASD, and factors
such as age, gender, family size, and diagnostic category.
4. To assess parents’ satisfaction with their child’s current daily physical activity level.

Study 2: Exergaming case studies
Little is known about the effect of exergaming on physical activity and enjoyment in youth with
ASD, or how feasible it is for these youth to participate in exergaming. A series of five
exploratory case studies in the homes of youth with ASD was conducted to contribute to a better
understanding of the potential for exergaming to enhance motivation and participation in
physical activity for youth and young adults with ASD. The aims of the case studies were:
1. To assess the feasibility of training youth with ASD to play exergames. This included
determining the level of assistance required by subjects to learn and play exergames, their
tolerance to an exergame playing protocol, and parents’ perceptions of the value of
exergaming for their children.
10

2. To obtain initial pilot data on the effects of exergaming on enjoyment, heart rate, and
activity level (as measured by accelerometer and rating or perceived exertion) for five
youth with ASD.
3. To describe challenges encountered by subjects to learn and play exergames, and to
incorporate family feedback to inform future studies.

Study 3: Exergaming partner play study
Informed by the results of the case studies, a repeated-measures crossover trial was conducted to
test differences in the effects of videogame play on physical activity and enjoyment with young
adults with ASD and typically developing peers by examining:
(a) Type of videogame (exergame vs. traditional seated videogame)
(b) Playing condition (alone vs. with a partner)
We sought to determine whether physical activity and/or enjoyment levels while playing
videogames differ by type of game or playing condition in young adults with ASD, and whether
these differences are similar to those experienced by typically developing young adults. The
specific aims for this study were:
1. To compare heart rate, activity counts, perceived exertion, and self-reported enjoyment
achieved by young adults with ASD, between videogame types, playing conditions, and
to baseline/rest.
2. To compare physical activity and enjoyment results of individuals on the Autism
Spectrum to those achieved by NT young adults while exergaming.
An additional exploratory aim was:
3. To examine factors associated with physical activity in individuals with ASD, including
body coordination, body mass index, previous videogame exposure, and daily activity
11

habits, and to report relationships between these factors and physical activity levels
achieved during videogame play.
12

Sources of Funding

The three dissertation studies were supported by a research grant from the California
Foundation for Occupational Therapy (2011), a Towson University Alumni Association
Professional Development Grant (2012), and Research Assistanceship funding generously
provided by the University of Southern California Division of Occupational Science and
Occupational Therapy (2008-2011).

13

CHAPTER 1

Background
14

Background

The long-term health of the nation’s youth and young adults is currently threatened by
increasing rates of overweight and obesity. One of the primary reasons for this trend is
inadequate rates of engagement in physical activity. For individuals with disabilities such as
Autism Spectrum Disorder, meeting physical activity participation guidelines may be
particularly challenging, as there are few opportunities for community-based physical activity
tailored to the special needs of this population. One strategy to increase physical activity for
youth and young adults is to combine their interest in technology with an enjoyable activity such
as exergaming, or active videogame play. The following presents a review of current literature
on physical activity, health implications for individuals with ASD, and the promise of
exergaming as a potential strategy to enhance physical activity for youth and young adults with
ASD.
Physical activity and obesity
One of the primary factors believed to influence increasing rates of overweight and
obesity is a lack of participation in adequate amounts of physical activity (Ball et al., 2005; Butte
et al., 2007). Physical activity (PA) increases bone health, cardiovascular fitness, muscle
strength, and improves body composition, while decreasing risk for cardiovascular and metabolic
disease and reducing anxiety and depression (Centers for Disease Control and Prevention [CDC],
2008; Rowland, 2007; United States Department of Health and Human Services [USDHHS],
2007). Participation in physical activity is particularly important for health promotion and
disease prevention in youth and young adults. Despite the well-known benefits of physical
activity, the number of overweight youth continues to increase, suggesting that the number of
young people who are not participating in adequate amounts of physical activity is also
increasing (CDC, 2011). Nearly 2/3 of youth do not meet physical activity recommendations,
with rates decreasing dramatically with age and overweight/obesity (Deckelbaum & Williams,
15

2001; Troiano et al., 2008). Low physical activity levels among youth and young adults are a
significant and important problem. While risk factors for chronic disease present in both
overweight adults and children, research suggests that a physically active lifestyle established in
childhood and adolescence tends to persist in adulthood (Aaron, et al., 2002; Pate et al., 1996).
Adults with a Body Mass Index (BMI) greater than 30 are considered obese, and for
children, obesity is classified as BMI at or above age-and gender-specific 95
th
percentile cutoff
points provided by the CDC (2011). Obesity now affects approximately 12.5 million children
and teens (CDC, 2007), and greater than 1/3 of U.S. adults are considered obese (Kit, Ogden, &
Flegal, 2014). Even more alarmingly, nearly 75% of all U.S. adults over the age of 20 are
considered either overweight, obese, or extremely obese (Ogden & Carrol, 2010). The trend
toward increasing levels of overweight and obesity among both adults and young people is of
primary concern to clinicians and public health officials, and the prevalence of overweight and
obesity may be even greater among individuals with disabilities such as Autism Spectrum
Disorder (ASD; Pan & Frey, 2006; Pitetti et al., 2007; Rimmer et al., 1996, 2011; USDHHS,
2004). For example, Rimmer (2011) recently reported that a cohort of adolescents with ASD and
other disabilities had a significantly higher prevalence of obesity compared to a group of youth
without disabilities, and that obesity rates were highest among males with disabilities who were
approaching adulthood (age 18).
Despite the clear need for obesity-related health promotion programs, published
interventions to increase physical activity in youth and young adults have seen limited success in
the long term (van Sluijs et al., 2008). For example, the vast majority of studies systematically
reviewed by Stice et al (2006) and Summerbell et al. (2005) demonstrated either no reduction or
a non-significant reduction in BMI.
Physical activity has been associated with psychosocial factors such as enjoyment, social
support, and motivation, and perceived barriers have been linked to decreased physical activity
16

participation (Dishman et al., 2005; 2010b; Schneider & Cooper, 2011; Sallis et al., 1999b; 2000;
Trieber et al., 1991). The reinforcing value (or motivating value) of an activity relative to
sedentary alternatives has also been connected to physical activity participation (Epstein et al.,
1999; 2007). In addition, the presence of others is related to enhanced occupational performance
(Strauss, 2001). Theoretical models including the Person-Environment-Occupation-Performance
Model (Baum & Christiansen, 2005) and Social Facilitation theory (Zajonc, 1965) will be
referenced throughout the three studies as possible explanations for these relationships.
Play
It has been said that “play is a part of the human condition; basic to human nature, and,
therefore, universal” (Westland & Knight, 1982, p. 169), and that “playing is a necessity…it
removes constraints and produces joy” (Rouard & Simon, 1977, p. 12). Play and developmental
theorists such as Piaget (1951) have long maintained that as a child physically interacts with his
or her environment, movement and sensory stimulation contributes to learning and thus the
child’s progression through developmental levels or stages. The occupation of play, in particular,
is thought to support the kinds of cognitive and sociocultural learning that should occur at each
developmental level (Johnson, et al., 1999; Mercogliano, 2007; Scarlett et al., 2005).
Erik Erikson (1963) also describes the role of play in development, noting that the nature
of play is different from other types of occupations – Erikson situates play in opposition to work
and other obligations. Erikson writes that play should be free of passions, fears, and serious
consequences, and is a “vacation from social and economic reality” (Erikson, 1963, p. 212). In
contrast, Westland and Knight (1982) write that the opposite of play is not work, but boredom,
and that children must be actively engaged in activities in order to continue to move along
developmental pathways.
Occupational scientists understand the value of meaningfulness and social context on
motivation and participation in occupations such as play. However, it should not be assumed that
17

youth or those with disabilities such as Autism Spectrum Disorder have the capacity to create a
space that affords good play without assistance. This is the task of occupational scientists and
therapists: to advocate for and design opportunities that allow such individuals to play (or
perform other meaningful occupations) within a dynamic system (Clark et al., 1991) and to
facilitate optimal play experiences, including “advocating for safe, inclusive play environments
that are accessible to all” (American Occupational Therapy Association [AOTA], 2008, p. 707).
According to the AOTA (2008), “The absence of childhood play, or reduced opportunities for it,
deprives children of an essential context for their optimal development and learning” (AOTA, p.
707).
Partner Play. One area of research that is gaining increasing attention among physical
activity scholars is the effect of peer influence on physical activity levels during play (Dishman
et al., 2005; Hartup, 2005; Rittenhouse, 2008; Salvy et al., 2008a/b). Of particular relevance to
the current project is the growing evidence that for NT individuals, playing with a partner can
increase motivation and physical activity levels (Efrat, 2009), in comparison to playing alone.
Recent research utilizing self-reported data demonstrated that both lean and overweight children
were more likely to engage in physical activity when with peers compared to when they are
alone (Salvy et al., 2008a/b).
In addition, playing with a peer may enhance overall enjoyment and performance
(Schneider & Cooper, 2011). For example, in a study using a computer-based task, typically-
developing youth who played together on one computer had increased task performance,
enjoyment, and problem-solving than while playing alone (Inkpen et al., 1995). Although this
area of research is receiving increasing attention, to date, only two controlled studies examining
the impact of peer influence on youths’ physical activity patterns have been published, and both
of these included only typically developing subjects (Rittenhouse, 2008; Salvy et al., 2008a/b).
For individuals such as those with intellectual and developmental disabilities, partner play may
18

be less accessible, as social and cognitive deficits can result in exclusion from typically
developing peers (Engel, 2011).
Autism Spectrum Disorder
Autism Spectrum Disorder (ASD) is defined as a neuro-developmental disorder of
impaired social interaction, language, and communication, and the presence of repetitive,
stereotyped or restrictive behaviors (American Psychological Association [APA], 2013). In the
United States, the prevalence of ASD is increasing, and the disorder now affects 1 in 68
individuals (CDC, 2014). The gender distribution is approximately five males to one female
(CDC, 2014).
Play and ASD. Both Piaget (1951) and Vygotsky (1967) acknowledged the significance
of symbolic play for normal development. For individuals with intellectual and developmental
disabilities such as Autism Spectrum Disorder, limited social communication and increased
sensitivity to external stimuli make play difficult or even unpleasant (Wolfberg, 2009). However,
it has been suggested that with the appropriate activity modifications and environmental
accommodations (such as support from adults and a structured schedule or routine), these
youths’ play may be enhanced (Wolfberg, 2009). For this population, the act of play may extend
beyond recreation, and enable the learning of skills such as decision making, turn-taking,
language use, social interaction, perspective-taking, and reciprocity when individuals play with
others (Bauminger & Kasari, 2000; Preissler, 2006). Improved quality of play can also increase
participation in physical activity and lead to the incorporation of healthy behaviors into an
individual’s daily routine (Lewis, 2010).
Friendship and ASD. Despite the fact that friendship is considered a major area of
difficulty for individuals with ASD (Baron-Cohen, 1989a; 1989b; Dawson & Adams, 1984;
Lewy & Dawson, 1992; Mundy et al., 1986; 1987; Sigman & Ruskin, 1999; Wetherby &
Prutting, 1984), the evidence suggests that friendship is experienced by many of these
19

individuals, especially those who are “higher-functioning” (Bauminger & Kasari, 2000; Jordan,
2003; Wolfberg, 1999; Wolfberg et.al., 1999). Bauminger and Kasari (2000) surveyed youth and
young adults with ASD and all reported having at least one best friend. However, it seems that
such friendships rarely emerge spontaneously or continue without support and assistance from
others in the individuals’ social environment, such as parents and teachers (Bauminger &
Shulman, 2003). A number of studies have suggested that for individuals with ASD, failure to
make friends can be a source of frustration and unhappiness, indicating that a lack of friends is a
result of social deficits, however, and not a lack of desire for involvement in social relationships
with others (Bauminger & Shulman, 2003; Bemporad, 1979; Birch, 2003; Carrington et al.,
2003; Filipek et al., 1999; Gus, 2000; Hill & Frith, 2003; Howard et al., 2006; Hurlbutt &
Chalmers, 2002; Jackson, 2003; Jones et al., 2001; Jones & Meldal, 2001; Lawson, 2001;
Mesibov & Handlan, 1997; Miller 2003; Rutter, 1970; Sainsbury, 2000; Volkmar & Klin, 1995).
As they age, the desire for companionship and peer acceptance may become stronger in
youth and young adults with ASD, but challenges in developing and maintaining friendships may
limit their ability to proceed from acquaintanceship to mutual friendship (Mesibov & Handlan,
1997; Rutter, 1970; Schopler & Mesibov, 1983; Volkmar & Klin, 1995). For adolescents and
young adults on the Autism Spectrum, decreased language skills and increased stereotyped
behaviors may limit social interaction and the potential for friendships (Orsmond, Krauss, &
Seltzer, 2004; Shattuck, Orsmond, Wagner, & Cooper, 2011). More than half of recently
surveyed adolescents and young adults with ASD reported never being invited to social activities
with peers (Shattuck, Orsmond, Wagner, & Cooper, 2011).
In addition, although high-functioning individuals with ASD have been found to exhibit a
good understanding of entering or initiating a peer interaction, this understanding is often not
clearly linked to their subsequent behavior (Attwood, 2000; Bauminger & Kasari, 2000; Sigman
& Ruskin, 1999; Volkmar & Klin, 2000). Therefore, supports are needed to allow individuals
20

with ASD to seek and develop friendships with others, and engaging in a shared activity may be
a good way to promote such relationships.
Physical activity and obesity in ASD. While decreased physical activity and increased
obesity rates are problematic for all youth and young adults, they may be particularly
troublesome for those with disabilities (Pitetti et al., 2007; Rimmer at al., 1996; Rowland, 2007;
Sandt & Frey, 2005). Research has indicated that people with intellectual and developmental
disabilities such as ASD are less physically active than their typically developing peers (Dwyer,
2009; Rimmer, 2006) and are at similar or even greater risk than neurotypical (NT) peers for
overweight and obesity (Curtin et al., 2005; Ghaffari et al., 2009; Ho et al., 1997; Rimmer et al.,
1996, 2011; Pan & Frey, 2006; Pitetti et al., 2007; Tyler et al., 2011; USDHHS, 2004). In their
study on obesity in children with ASD, Ho et al. (1997) reported that nearly half the sample of
children with ASD had a low level of activity during the day.
There are many factors that may contribute to decreased physical activity in youth and
young adults with ASD. Individuals with ASD often present with restrictive, repetitive behaviors
and limited social interaction and relatedness, which may be prohibitive of participation in sports
teams or other recreational activities with NT peers (Pan, 2008; Pan & Frey, 2006). Due to these
deficits, individuals with ASD may be present, but choose to sit and watch a group of peers
playing, rather than interact - limiting the actual time spent engaged in physical activity (Pan,
2008). Limited participation can lead to decreased fitness which, combined with higher rates of
motor coordination challenges in this population, can negatively impact interest and further
impede ability to participate in physical activity (Gillberg, 2003). Individuals with ASD may also
have difficulty with spontaneous play or remaining engaged in physical activity for extended
periods of time, and can easily become overwhelmed, especially in large groups or where
frequent communication is required (O’Neill & Jones, 1997).
21

Other barriers to participation in physical activity may be more specific to the individual.
Some people with ASD report disliking “feeling sweaty” and others describe a lack of enjoyment
or feelings of discomfort with movement (Pan & Frey, 2006). Frequently used medications such
as Risperidone often cause weight gain (Ho et al., 1997; Hughes, 2008; Pan & Frey, 2006; Pitetti
et al., 2007). Excess weight from medications and poor nutrition, common among individuals
with ASD, may further affect coordination and fitness, which can also limit participation (or
quality of participation) in physical activity (American Dietetic Association [ADA], 2007; Ho et
al., 1997). In addition to these internal barriers to physical activity, fewer opportunities for
organized extracurricular activities targeted toward the special needs of individuals with ASD
exist in the community (Pan & Frey, 2006). Highly-specialized physical activity programs
offering ASD-specific accommodations are rarely available, and are often not valued as highly
by peers as activities such as traditional team sports.
Individuals with ASD present with unique challenges to health educators and
practitioners, as their special needs may make it more difficult for them to participate in
educational and recreational programs designed for their typically developing peers. Because of
this, youth and young adults with ASD may be less likely to develop healthy physical activity
habits early in life, leading to increased problems with co-morbid conditions such as obesity,
cardiovascular disease, and diabetes as they age (Pitetti et al., 2007; Rimmer at al., 1996;
Rowland, 2007; Sandt & Frey, 2005). Despite these barriers, physical activity has been shown to
be particularly beneficial for individuals with ASD, as it can decrease repetitive behaviors and
improve executive function and socialization (Anderson-Hanley, 2011b; Finklestein et al., 2010).
However, of the limited exercise studies on youth and young adults with disabilities
(including ASD), most focused on the reduction of undesirable or repetitive behaviors, rather
than increasing physical activity or fitness (Pitetti et al., 2007). Therefore, more studies are
needed to examine effective methods of increasing exercise capacity and decreasing sedentary
22

behavior in this population. Fortunately, many of the challenges to physical activity engagement
for youth and young adults with ASD can be reduced when the appropriate environmental and
programmatic accommodations are made. The use of active videogames is a unique approach to
enhancing quality and quantity of engagement in physical activity for this special population
(Anderson-Hanley et al., 2011b).
Technology and ASD. Although individuals with ASD present with varying degrees of
impairment, researchers report that youth and young adults in this population consistently enjoy
interacting with technology such as computers and videogames (Putnam & Chong, 2008; Sicile-
Kira, 2004). In a study of children’s leisure time use, Larkin and Parker (1999) found playing
video- and computer games was even more common in youth with disabilities than in NT youth.
Chapter 2 presents the results of a nation-wide survey of households of youth with ASD
regarding the types of videogame systems they own, and videogame play habits among family
members with ASD. In that study, use of videogames among youth with ASD was found to be
similar to that of NT youth, and ownership among families who had a child with ASD was
slightly higher than in previously published reports of ownership among typically developing
individuals (Foran & Cermak, 2013).
Livingstone and Bovill (1999, cited in O’Neill et al., 2005) characterized the
contemporary child’s world as an environment rich in media and technology for both
entertainment and communication. Often, individuals with ASD will seek out screen media and
technology to enhance their leisure and educational pursuits, as through the medium of
technology, communication with others is often considered less socially challenging (Hanner et
al., 2003; Moore et al., 2005). Therefore, using screen media such as videogames may be an
especially relevant mechanism to target physical activity in this population.
Exergaming
23

Exergaming, or active videogame play, has been used to enhance physical activity in
typically-developing individuals. Exergaming systems require the player to engage in gross body
movements such as “walking, running, sliding, jumping, throwing, and hitting” (Adams et al.,
2009), in comparison to traditional seated video games (TSVGs), which are typically classified
as sedentary activities and do not require more than small movements of the thumb and fingers
on the controller. Currently, there are a number of exergaming systems available off-the-shelf to
the consumer at relatively low cost (between $100 and $400 on average), such as the Nintendo
Wii, Sony Playstation’s EyeToy and Move, and the Kinect for Xbox 360.
Despite the rapid growth of exergaming research in the last five to ten years, the number
of intervention studies to enhance physical activity over time remains limited and sample sizes
have generally been small. For example, 73% of studies identified in a recent systematic review
had n ≤ 30 (see Appendix A for a complete review of exergaming studies). Therefore, more
research is needed to confirm the efficacy of exergaming as an intervention for increasing
physical activity and preventing obesity in the long term. To date, the most positive research
findings concern short-term use of exergaming systems. The results of two randomized
controlled trials are pending (see Maddison et al., 2009; Straker et al., 2009). The forthcoming
study by Maddison, et al. has the potential to greatly enhance the validity of exergaming
interventions, as the researchers plan to study the effects of a 12-week intervention on 330
Australian youth, by far the largest sample to date.
In general, the literature concerning the immediate effects of exergaming in both youth
and adult NT players is positive, particularly when exergaming is compared to rest or TSVGs
(Daley, 2009; Mark et al., 2008). Although exergames provide greater opportunity for physical
activity than TSVGs, most provide only moderate intensity physical activity and therefore should
not be replaced entirely for traditional sports or other higher-intensity activities. However for
individuals who are primarily sedentary, exergaming is a good addition to their repertoire of
24

activities, especially if it is used as a substitute for TSVG play or other sedentary screentime
(Baranowski et al., 2008; Daley, 2009; Foley & Maddison, 2010; Mark et al., 2008).
Adherence to the use of exergames (i.e., motivation) also appears to be an important
issue, as it is recognized as a moderator of health outcomes for exergame players (Dixon et al.,
2010; Ryan et al., 1997). Two recent studies that look at choices of interactive electronic games
are relevant here (Sit et al., 2010; Leininger et al., 2010). Sit and colleagues (2010) examined
preferences and activity levels during interactive and on-line electronic games in children.
Children chose to spend more than half the available time with interactive games, and engaged in
more moderate-to-vigorous physical activity (MVPA) during these games than the sedentary
versions, suggesting that given the opportunity, players may select active videogames over
TSVGs. Leininger et al. (2010) measured enjoyment after exergaming and engaging in
traditional exercise, and found that participants consistently rated an interactive dance videogame
as more highly enjoyable. Additionally, Sinclair et al. (2007) reported that youth were more
motivated to engage in physical activity while exercising in a virtual environment versus typical
exercise.
As Epstein et al. (2004, p. 241) contend, “the challenge of substituting physical activity
for sedentary behaviors is greatest when highly valued and reinforcing sedentary alternatives are
available.” Exergaming is a unique combination of reinforcing activity (playing a videogame),
and the opportunity to get up and move (Anderson et al., 2008; Chamberlin & Gallagher, 2008;
Marshall et al., 2006). However, further research is needed to examine potential challenges to
implementing an exergaming intervention for improving health. In addition, more evidence must
be generated to explain the underlying mechanisms for the positive outcomes reported in
currently available studies. From this evidence, game development can focus on optimal
movement patterns and preferences that will further enhance the therapeutic effect of
exergaming.
25

Although the evidence is inconclusive regarding whether or not exergaming increases
activity levels enough to meet recommended guidelines for cardiovascular health and fitness, it is
clear that for typically developing individuals, exergames afford more movement, higher heart
rates, and increased energy expenditure compared to TSVGs. Exergaming is therefore a good
alternative to typical sedentary screentime activities (Daley, 2009; Foley & Maddison, 2010;
Mark et al., 2008). Because youth increasingly spend more of their day indoors (McCurdy et al.,
2010), exergaming is also a convenient way for youth and young adults to increase physical
activity levels while being supervised in the home, if needed.
While it is important to understand how exergaming works in the real world, exergames
may also provide unique opportunities for researchers and clinicians to measure physical activity
in a controlled, safe clinical environment. Exergames that require gross body movements and
cardiovascular endurance are especially well-suited suited for research because many can be
programmed to record images, performance measures, and physiological characteristics such as
calorie expenditure as part of the game (Gourlay et al., 2000; Nyberg et al., 2006). In Study 3,
physical activity and enjoyment levels achieved during exergame play are compared to TSVGs,
and the potential effect of playing videogames with a partner for young adults with and without
ASD is examined.
Partner play in exergaming. Two recent studies have described the effect of partner
play on physical activity levels while exergaming. Exner et al. (2009) and Staiano and Calvert’s
(2010) research reinforces findings by Salvy et al. (2008) regarding the effect of solitary play
versus play with peers. In both studies, participants played at higher physical activity intensities
with peers than while alone. The authors suggest that perhaps by promoting gameplay with
others, youth of different abilities and body compositions may be more likely to use exergames
for longer periods of time, and more social interaction among players may be encouraged.
Staiano and colleagues (2012) also found that for overweight and obese adolescents, playing in a
26

cooperative manner with a partner resulted in increased energy expenditure and enjoyment.
However for youth and young adults with ASD, the effect of social interaction on physical
activity in general remains unclear.
Exergaming and ASD. According to Lotan et al. (2009) and Wuang et al. (2010),
exergaming may be particularly attractive to individuals with ASD, intellectual, and developmental
disabilities, because this population is often more comfortable interacting with digital media than
with peers, which could help motivate them to participate. Exergaming platforms such as the
Microsoft Kinect for Xbox 360 may be especially applicable to individuals with ASD because this
system allows the player to see him or herself projected on the screen interacting with the game
environment, a feature that is not available in TSVGs, as well as other exergaming systems such
the Nintendo Wii.
When players can see themselves on the screen engaging in physical activity, they are
better able to understand that they are causing the actions and movements they see - unlike other
video games, which are often too abstract to understand (Lotan et al., 2009). In addition, the Kinect
does not require a hand-held controller, so players use their whole body to control the game and
interact in the virtual context. Furthermore, because video-capture exergaming systems such as
the Kinect provide “appropriate, real-time feedback about the movements and the interactions of
the user” (Finklestein et al., 2010, p. 4192), they have been identified as especially useful for
individuals with ASD. For example, Finklestein et al. (2010) contend that such games can help
players with ASD become more aware of how they need to move their limbs to get the desired
response from the virtual environment.
Wuang et al. (2010) used the Nintendo Wii with a group of children with Down
Syndrome, and found that for those who used the exergaming system, motor proficiency, visual-
integrative ability, and sensory integrative functioning was enhanced, compared to those who
received standard occupational therapy services. The researchers also found that there was a
27

positive relationship between BMI and energy expenditure in their sample as participants with
the highest BMI played the hardest during Wii gameplay (Wuang et al., 2010). In addition,
Bellini and Akullian (2007) reviewed the literature on video-modeling interventions for children
with ASD, and found that such interventions, which would include the use of a video-capture
system like the Kinect for Xbox 360, are appropriate evidence-based strategies to address social
communication and functional skills in this population.
Compliance with physical activity routines is challenging in all populations, and has been
shown to be especially difficult among individuals with ASD (Lochbaum & Crews, 1995; Pan &
Frey, 2006). However, Anderson-Hanley et al. (2011b, p. 131) note that exergaming may hold
“particular promise as an exercise intervention [for this population], given the research… on
increased motivation, enjoyment, and energy expenditure.” Exergaming has also been shown to
be beneficial to individuals with decreased balance and coordination due to stroke or other
injuries requiring rehabilitation (Finklestein et al., 2010; Foran, 2011). In their preliminary
testing of an immersive virtual reality exergame for youth with ASD, Finklestein and colleagues
suggest that these benefits may also carry over to individuals with ASD, who often have
impaired balance and coordination due to sensory deficits and decreased body awareness
(Werner et al., 2011). Future studies on the use of exergames by individuals with ASD may
reveal that regular use of exergames can enhance motor planning, coordination, and action
representation in this population. Chapter 3 describes a series of case trials using this system in
the homes of youth with ASD.
Theoretical Models
Founded in 1917, occupational therapy is a professional healthcare field in which
practitioners can serve in a wide variety of clinical and community-based settings, working with
clients in areas as diverse as orthopedics, mental health, developmental disabilities, and health
promotion with well-populations. Despite the wide scope of occupational therapy practice, the
28

profession recognizes a number of theoretical assumptions as central and unique to occupational
therapy.
Concepts from the theoretical models described below have been used to frame the three
studies. It is my belief that by providing the appropriate conditions, including a motivating and
enjoyable activity (exergaming), support and accommodation of individual needs, and a social
playing partner, youth and young adults with ASD will be likely to have a positive experience
while exergaming, which could lead to increased physical activity participation and the
promotion of healthy lifestyle behaviors.
Occupational Therapy and Occupational Science. Occupations, or those things “that
people want, need, or have to do” (Wilcock, 2005, p. 8) are the primary treatment modality used
in occupational therapy. Occupational therapy practitioners believe that in order to be therapeutic
for the individual, occupations must be both meaningful and purposeful (Nelson, 1996) and that
occupations such as work, self-care, and leisure activities can be used to achieve health and well-
being, especially when an appropriate balance exists between each area of occupation (Law et
al., 1999). Another key assumption is that a full life is realized through experience and
performance of occupations, as people use occupations to organize and give meaning to life
(Meyer, 1977). Occupational therapists Charles Christiansen and Carolyn Baum (1997) write
that through doing, individuals achieve mastery and competence by learning skills for coping and
adaptation. By providing occupation-based interventions in real-world contexts, occupational
therapists help people to reach greater levels of independence and function, assessing their
environments and personal ability level so that they can develop such skills and improve their
quality of life (Wood, 1995; Crepeau, Cohn & Schell, 2003).
The discipline of occupational science was developed to address the need for theoretical
and basic science evidence to support the good work of occupational therapy (Clark et al., 1991).
Like occupational therapy, occupational science is holistic in its conception of the individual and
29

her or his place in society. Another defining characteristic is an inherently interdisciplinary
approach to inquiry taken up by occupational scientists, which can include scholars in fields such
as sociology, anthropology, psychology, and medicine (Zemke & Clark, 1996). Other central
theoretical assumptions in occupational science include the ideas that (a) occupation shapes
personal identity; (b) activity carries a symbolic value for individuals and groups; (c) occupation
encompasses all human pursuits (including mental, physical, social, and spiritual domains); and
(d) engagement in occupation is fundamental to autonomy, health, well-being, and justice (Clark
et al., 1991; Yerxa, 1993; Larson et al., 2003; Wilcock, 2003; Molke et al., 2004). In addition,
evidence from occupational science is used to inform occupational therapy practice, and can
provide justification for treatment and reimbursement decisions (Clark et al., 1991; Yerxa, 1993;
Larson et al., 2003; Wilcock, 2003; Molke et al., 2004). Both the conception of the dissertation
studies, as well as the discussion of outcomes, will be through the lens of occupation, with an
emphasis on the Social Facilitation (Zajonc, 1965) and the Person-Environment-Occupation-
Performance Model (Baum & Christiansen, 2005).
Social Facilitation. First described by Triplett in 1898 and expanded upon by Zajonc
(1965), Social Facilitation theorists observed that when individuals are in the presence of others,
they tend to work harder or perform with greater quality (Strauss, 2001). This effect can be
described as enhanced occupational performance. Zajonc (1965) hypothesized that arousal due to
social interaction was responsible for this increased drive, but that sometimes, over-arousal could
impair performance. Individuals on the Autism Spectrum, however, often have difficulty
maintaining appropriate arousal levels (and subsequently social behavior) due to sensory
dysregulation (Ayres, 1972). As a result, individuals with ASD are frequently characterized as
having little interest in social interaction, and therefore the presence of others is thought to have
a neutral or negative effect on their task performance.
Person-Environment-Occupation-Performance Model. The Person-Environment-
30

Occupation-Performance Model (PEOP) was developed by Baum and Christiansen (2005),
occupational scientists who sought to describe an “occupation focused construct to explain the
process and practice of occupational therapy” (Duncan, 2005, p. 62). The model expands on the
work of Bandura (1977) and others, incorporating the idea that health and well-being are
enhanced as performance is supported by the optimal interaction of internal (person), external
(environment), and task (occupation) conditions. Baum and Christiansen described components
of the person and environment that contribute to efficacious performance, and also examined
activity-related factors such as the structure and required actions necessary to complete a given
task.
In order to fully understand the complexities of the interactions between participants, the
play environment, and videogame play activities, it is necessary to employ a frame of reference
that highlights the role of context in the system. The PEOP model is one way that scientists can
conceptualize play and its relation to health and development. In this model, the influence of an
individual’s environment (or context) on his or her behavior and performance is stressed Baum
& Christiansen, 2005).
Occupational science posits that the relationship of the organism to his or her
environment is interactional, meaning the person is both affected by and affects his or her
context (Zemke & Clark, 1996). By utilizing the environment to support participants’
performance, an individual can engage in a range of occupations which are available based on
his or her skills, abilities, and interests, and the environmental supports and barriers to
performance (Baum & Christiansen, 2005). Within this optimal performance range, the person,
environment, and occupation are considered to be the most adaptable. Therefore by providing the
appropriate play setting and conditions for participants, performance may be enhanced and
developmental tasks facilitated.
Framing the studies. The social condition is of particular interest to me, as I frequently
31

observed individuals with ASD in both clinical and recreational settings engaging in physical
activity. Although the literature does not yet support the idea that social interaction can enhance
occupational performance for individuals with ASD, I have observed this to be the case on many
occasions. Using the PEOP model to frame my ideas, I hypothesized that if appropriate
environmental supports and occupational adaptations were provided, individuals with ASD could
learn to use exergames, which combine a rewarding technology-based experience with physical
activity and social interaction. Perceived competence in physical activity, in turn, would then
increase the likelihood of spontaneous or leisure-time engagement in physical activity (Carroll &
Loumidis, 2007). When such conditions are put in place, the child or young adult with ASD may
feel empowered to engage in exergaming, and be more likely to select it as a leisure-time activity
in the future, leading to increased participation in physical activity and social interaction.

32

CHAPTER 2
Study 1: Active and traditional videogame ownership and play patterns among youth with
Autism Spectrum Disorders, and relationships to physical activity
33

Active and traditional videogame ownership and play patterns among youth with Autism
Spectrum Disorders, and relationships to physical activity

Introduction
Children are spending increasingly more time engaging with videogames and other
screen media (Biddiss & Irwin, 2010). Exergaming, or active videogame play which requires
larger body movements than traditional seated gaming, has been touted as a natural way to
incorporate physical activity into children’s daily routines. Exergaming systems, also called
active or “new generation” videogames, require the player to engage in gross body movements
such as “walking, running, sliding, jumping, throwing, and hitting” (Adams, et al., 2009, para.
2), in comparison to traditional seated videogames (TSVGs), which are typically classified as
sedentary activities and do not require more than small movements of the thumb and fingers on a
hand-held controller. In a recent review of exergaming studies with typically developing youth,
Daley (2009) asserted that for those who are primarily sedentary, exergaming may increase
physical activity and assist in weight management. This benefit may be especially important for
children such as those with physical and developmental disabilities or limited social skills that do
not have access to organized sports programs and other opportunities for physical activity in the
community.
Currently, there are a number of videogame systems available to the consumer, although
little is known about the types of systems families of youth with disabilities own, and how much
assistance these youth need to play the games. The objectives of the current study were to
describe videogame ownership trends among families of youth with autism spectrum disorders
(ASD), to assess patterns of videogame play within this population, and to report relationships
between the youths' active and traditional videogame play and parents' satisfaction with their
child's current physical activity level. In addition, we examined the characteristics of videogame
ownership among families with regard to family size, child age, gender, and diagnosis, in order
34

to better understand ownership trends and play patterns in this population.
Method
Participants
Approximately 900 families of children with special needs residing in the Los Angeles
metropolitan area were provided with surveys. In addition, approximately 2000 families who
participate in a national online database of individuals with ASD were provided with a link to the
survey. Subjects in this group were recruited with the assistance of the Interactive Autism
Network (IAN) Project at the Kennedy Krieger Institute, Baltimore, Maryland.
Instrument
Videogame Survey. This 10-item survey was created to examine the availability of
videogame systems in the homes of youth with ASD and to assess the videogame playing habits
of those youth. The survey was developed by the authors, in consultation with experts in
computer and videogame technology as well as pediatric occupational therapists. It was
translated from English into Spanish by native speakers in health-related fields, and checked for
accuracy by a second translator. In addition to basic demographic information about the child,
the survey included the following questions:
1. Which game systems do you currently have in your home? (a list was provided -
see Table 2)

2. Does your child play videogames?*

3. On average, how many hours per day does your child spend playing traditional
seated videogames or computer games (ie., child sits while playing and uses a
hand-held controller)?
 Options included 0, ½, 1, 1 ½, 2, 2 ½, 3, 3 ½, and 4 or more hours per day

4. When your child plays traditional seated videogames/computer games, does
he/she usually play alone, or with a partner?

5. How much assistance does your child require to set up and play traditional seated
videogames/computer games? (see Table 1 for list of response options)

6. On average, how many hours per day does your child spend playing active
videogames requiring standing or large body movements
35

 Options included 0, ½, 1, 1 ½, 2, 2 ½, 3, 3 ½, and 4 or more hours per day

7. When your child plays active videogames, does he/she usually play alone, or with
a partner?

8. How much assistance does your child require to set up and play active
videogames?
 Options included:
Independently sets up and plays
Set up
Verbal directions while playing
Assistance using controller
Constant supervision/assistance to understand rules and keep game play going

9. If your child plays active videogames please list the names of his/her 3 favorite
games:

10. Do you feel that your child has enough physical activity in his/her daily routine?

*Note: Respondents were directed to skip to item #10 if they answered “no” on item #2.

Procedure
To identify types and systems of traditional and active videogames, a search for all
commercially available videogame platforms (in the United States) was conducted by accessing
company websites, meeting with experts at local electronics stores, and reviewing previously
published literature. Twenty options were identified and included in the survey (see Results
section). Paper surveys were sent home to parents of children in special education classrooms in
three Los Angeles Unified School District schools, and they were asked to return the survey to
the classroom teacher within one month. An electronic message about the study which included a
weblink to an online version of the survey was distributed to families via the IAN network.
Data Analysis
Summary statistics were generated to describe the demographic and clinical
characteristics of the families surveyed, as well as the frequency and proportion of responses to
survey items. Demographic data such as age, gender, and diagnostic category were grouped to
form dichotomous categorical variables for analysis. Responses on videogame and computer
36

system ownership, hours played, and level of assistance needed to play both active and
traditional seated videogames were analyzed for the whole sample and by demographic group.
To determine whether there were significant differences between groups, we used a 2-sample t-
test when the data were distributed approximately normally, the Wilcoxon 2-sample test if the
data were skewed, and chi-square or Fisher’s exact tests for dichotomous and categorical
variables.
Results
Participants
One hundred ninety two families responded online (190 in English, 2 in Spanish) via a
survey weblink sent out through the Interactive Autism Network, and 58 families returned paper
surveys through the Los Angeles Unified School District (46 English, 12 Spanish). Surveys were
completed by families living in over 40 U.S. states. Thirty-four respondents were parents of
youth with disabilities other than ASD. These surveys were excluded from analysis for this
paper, resulting in a final sample size of 215. Characteristics of the families and youth with ASD
are summarized in Table 1. Subjects were predominantly male (86%), consistent with gender
distributions in ASD (CDC, 2009). In addition to a primary diagnosis of ASD, parents were
asked to indicate if their child had a comorbid physical and/or intellectual disability. Eighty-one
percent (n = 174) had ASD only, and 19% (n = 41) also had a physical and/or intellectual
disability in addition to ASD.
Videogame ownership
As described in Table 2, almost 95% of families surveyed owned at least one videogame
system or computer, and 82% of families owned either an exergaming (EG) platform or one that
could be upgraded to an exergaming system with the addition of a commercially available device
for approximately $100. Among families of youth with ASD and other special needs, the most
commonly owned systems (after a computer) were the Nintendo Wii and Nintendo DS. Youth
37

with siblings were significantly more likely to own EGs than those living in single-child
households (p <.01), but there was no significant difference in ownership of TSVGs by family
size (single vs. multiple-child families).
Videogame play
Of those surveyed, nearly 84% of youth played TSVGs at least 30 minutes per day and
over 52% played EGs at least 30 minutes per day. There were significant differences in
videogame play between age, gender, and diagnostic groups, but not between only children and
those who live with siblings (see Table 3). Youth with ASD were more likely to play TSVGs
(87%) and EGs (56%) if they did not have a comorbid condition; only 66% of parents whose
children had both ASD and either an intellectual disability or physical limitation reported that
their child played TSVGs, and just 34% played EGs. None of the families reported that their
child played exclusively EGs, although 38% of those who played videogames played exclusively
TSVGs.
Collectively, subjects played an average of 1.73 hours of videogames per day (1.34 hours
playing TSVGs and 0.39 hours playing EGs), with boys playing significantly longer than girls.
Youth with ASD only played longer that those with comorbid conditions (see Table 4). Among
youth who played EGs, none reported playing more than two hours per day (average 0.75 hours),
while the average time spent playing TSVGs among those who played was over twice that (1.59
hours). A positive relationship between age and hours per day spent playing videogames was
noted (r = 0.23, p < .001), with older children spending more time in videogame play. Regression
analysis revealed that time spent playing EGs was predicted by age, diagnostic category (ASD
only vs. ASD plus another disability), and time playing TSVGs for males (p <.01). However for
females, only time spent playing TSVGs predicted daily exergaming time (p <.0001).
Table 5 presents the data on youths’ videogame playing partners. Parents reported that
their children most often played TSVGs alone, but were about equally as likely to play EGs
38

alone or with a partner. The most frequent playing partner was a sibling or parent, and only about
5% of youth with ASD played either type of videogame with a friend. On the whole, playing
partner did not differ between videogame type.
Level of assistance
We found a small but significant inverse relationship between age and level of assistance
needed to play EGs (r =-0.15, p < .05), but not TSVGs (r =.11, p=0.10). In general, subjects
required more assistance playing EGs than TSVGs; 49% needed one or more supports while
exergaming versus 34% of those playing TSVGs (p< .01; see Table 6). Boys and girls required
similar levels of assistance playing both TSVGs and EGs, with 25-42% needing one or more
supports such as verbal cues, assistance with set-up, or help using the controller, and 6-8%
requiring constant supervision while playing. However, girls were less likely to need any
assistance while playing - according to their parents, 67% of girls who play videogames were
able to set up and play independently, versus only 59% of boys (p<.01). When subjects were
divided by diagnostic category, those with ASD only were much more likely to set up and play
videogames independently than those with other conditions in addition to ASD (p=.0001). There
was also a significant correlation between the level of assistance needed by subjects to play
TSVGs and level of assistance needed for EGs (r =.44, p<.0001).
Physical Activity
Approximately 58% of parents in this study reported dissatisfaction with their child’s
current physical activity level. Compared to those whose children do not play exergames,
slightly more parents of children who play EGs were satisfied with their physical activity (46%
vs. 38%), although this difference was not statistically significant. However, parents were
significantly more likely to report dissatisfaction with their child’s daily physical activity level if
their child was 12 years old or older (p = .0001). Fifty-three percent of parents of youth under 12
reported satisfaction, while only 20% of parents with older children thought their child achieved
39

a satisfactory daily physical activity level. There were no significant differences in parental
satisfaction between genders or diagnostic groups.
Discussion
Participation in physical activity is important to prevent and limit overweight and obesity,
a growing national epidemic in youth (USDHHS, 2007). Physical activity increases bone health,
cardiovascular fitness, muscle strength, and improves body composition, while decreasing risk
for cardiovascular and metabolic disease and reducing anxiety and depression (USDHHS, 2008).
However, nearly 2/3 of youth do not meet physical activity recommendations, with rates
decreasing dramatically with age and overweight/obesity (Troiano et al., 2008). The current data
suggest that parents of youth with ASD and related co-morbidities are generally dissatisfied with
their child’s current physical activity level. The majority of all parents surveyed (58%) reported
that their child did not, in their opinion, get enough physical activity. To date there have been no
other published reports of parental satisfaction with physical activity levels in youth with special
needs such as ASD. However, this finding appears consistent with the literature on increased
barriers to physical activity for youth with disabilities compared to typically developing youth.
Social and language restrictions, behavioral issues, transportation barriers, expense, and family
time constraints can limit physical activity participation in this population (King et al., 2003;
Law et al., 2007; Rimmer & Rowland, 2008).
The increased physical activity levels reported in studies of exergaming versus traditional
seated videogame play show promise that exergames may be a new tool contributing to the fight
against childhood obesity (Daley, 2009; Staiano & Calvert, 2011). This study provides evidence
that exergaming systems are widely available in the community, including in the homes of youth
with special needs. Therefore, incorporating exergaming into the daily lives of youth with
disabilities such as ASD seems feasible, given the high rate of system ownership reported by
parents. No previous studies of videogame ownership or use patterns of youth with special needs
40

have been published. Typically developing youth spend an average of 1-2 hours per day playing
videogames (Swing et al., 2010; Gentile, 2009; Vandewater et al., 2004), although no studies
have distinguished between TSVG and EG play when reporting these values. Our study reveals
that use of videogames among youth with ASD is similar to that reported for neurotypical
children, but may be decreased in those who have other comorbid conditions such as physical
and intellectual disabilities.
A recent survey of typically developing youth found that 36% of those aged 8-18 owned a
Nintendo Wii exergaming console in 2009 (Rideout et al., 2010). In our study, more than 60% of
families reported owning a Wii. This increase may be due to the growing popularity and
affordability of the system in the past few years. In addition, no data on families’ socioeconomic
status (SES) was collected in this survey, although zipcode analysis revealed that a portion of our
sample resided in inner-city Los Angeles neighborhoods known to be primarily composed of
low-SES homes. Despite this, there is little evidence that videogame system ownership differs
between low and higher SES households (Lenhart, 2008; Rideout, et al., 2010), making
exergaming a feasible activity for a broad portion of the population.
Although there was a significant difference in EG system ownership between families
whose only child had a disability and those with additional children in the home (single-child
families were less likely to own an EG system, p <.01), there was no difference between these
groups in EG play. No significant age difference was found between youth from single-child
homes and those who lived with other children, it appears that presence/absence of a sibling does
not dictate videogame play. However, age, gender, and diagnosis may influence who plays both
TSVGs and EGs. Males with ASD over age 12 were the most likely to play TSVGs, and males
under age 12 were the most likely to play EGs. One explanation for the age differences may be
that because EG systems are relatively new, older youth may have been exposed to TSVGs for
longer periods of time and are more familiar with these systems, compared to younger children,
41

who may have been exposed to both types of systems equally, so have not developed a
preference or familiarity for one system yet. Alternatively, research has shown that as youth age,
they become less active in general (CDC, 2010), so older subjects may prefer the sedentary
TSVGs as a leisure activity compared to the generally more active younger group, which is
consistent with the marked difference in parental satisfaction with subjects’ physical activity
levels between age groups.
While only two studies have examined the effect of partner play on physical activity
levels while playing EGs, both found that typically developing youth play at higher physical
activity intensities with peers than while alone (Exner et al., 2009; Staiano & Calvert, 2010). It is
interesting to note that in our study, more youth with ASD played EGs with a partner more often
than they did TSVGs. Although the subjects may have played EGs with a partner because they
those games were more challenging than TSVGs, EGs may also encourage social interaction and
increased physical activity levels in individuals with ASD.
In general, more assistance was needed by subjects to play EGs than TSVGs. This may be
due to a number of factors. First, EG systems are relatively new to the market compared to
TSVGs (available only within the last 5 years or so), so youth may not be as familiar with this
type of system and would need to learn new rules on how to control the device and play the
game. Additionally, parents reported that youth with special needs spend less time playing EGs
overall, and it is difficult to determine the direction of this relationship – do youth play less EGs
than TSVGs because they are more challenging to play, or are EGs more challenging because
they are played less often? Youth with ASD and other developmental disabilities often have
coordination and fine motor deficits (Bhat et al., 2011; Fournier et al., 2010; Matson et al, 2011).
Given that a number of the newer EG systems do not require a hand-held controller or fine motor
manipulations, it is likely that those with special needs will require less assistance playing EGs
and be more able to participate in the future.
42

One limitation of the study is the fact that all diagnostic information was based on parent
report and we cannot know if subjects have been formally diagnosed with ASD, intellectual
disabilities, or other conditions. However, the majority of the sample came from parents who are
part of the Interactive Autism Network through the Kennedy Krieger Institute, and many of these
families actively participate in ASD research requiring formal diagnosis for inclusion. In
addition, because of the variety of different game systems used, we were unable to report on
specific preferred exergames, as no consistent game titles emerged from the data.
Finally, our very low response rate indicates that the results of this study should be
interpreted with caution, although our results are in line with other research showing that lower
response rates are likely to result from online surveys than mailed surveys (Scott et al., 2011;
Shih & Fan, 2008; VanGeest et al., 2007). Even though we received survey responses from
families who indicated that they did not own a videogame system, or that their child with ASD
did not play videogames, it is possible that the individuals who completed the survey were more
likely to own videogame systems or be interested in videogaming. Thus, self-selection bias may
have inflated the videogame ownership and playing rates we reported in this study. However,
given the very high overall ownership and use rates reported in our sample, we are confident that
incorporating exergaming into the daily lives of youth with ASD seems feasible as a future
community-based physical activity intervention.
Conclusions
The results of this study suggest that videogame ownership and use among youth with
ASD is similar to typically developing children, even when the child with a disability is the only
child in the household (and therefore it is clear the system is not owned by a neurotypical
sibling). However, these youth are likely to require some assistance playing videogames,
especially when using active game systems, or if they have motor or intellectual limitations in
addition to their ASD diagnosis.
43

Given the prevalence of videogame platform ownership, we believe that an in-home
intervention study using active videogames in this population would be feasible and realistic.
Health promotion practitioners value naturalistic intervention, therefore determining ownership
and use trends is important to ensure that using active videogame systems as a potential modality
for enhancing physical activity is appropriate for this population.
Exergaming is a promising way to counteract increasing rates of childhood obesity and
reduce sedentary behavior, allowing children of all abilities to participate in highly valued
occupations of childhood, while simultaneously increasing engagement in physical activity and
improving cardiovascular health and fitness. More information about specific modifications and
strategies is needed in order to provide recommendations for the development of accessible EGs
that have the potential to increase physical activity levels within this population, and to carry out
interventions using exergaming with youth with disabilities.
44

References
Adams, M. A., Marshall, S. J., Dillon, L., Caparosa, S., Ramirez, E., Phillips, J., & Norman, G. J.
(2009). A Theory-based framework for evaluating exergames as persuasive technology.
University of California, San Diego Center for Wireless and Population Systems.
Retrieved from: http://delivery.acm.org/10.1145/1550000/1542006/a45-
adams.pdf?ip=128.125.110.89&acc=ACTIVE%20SERVICE&CFID=48093738&CFTO
KEN=82097789&__acm__=1318621848_6bbffacb41abfd3ca4319d9a8a435b4b
Bhat, A. N., Landa, R. J., & Galloway, J. C. (2011). Current perspectives on motor functioning
in infants, children, and adults with Autism Spectrum Disorders. Physical Therapy, 91(7),
1116-1129. doi: 10.2522/ptj.20100294
Biddiss, E., & Irwin, J. (2010). Active video games to promote physical activity in children and
youth. Arch Pediatr Adolesc Med, 164(7), 664-672. doi:10.1001/archpediatrics.2010.104
Centers for Disease Control and Prevention. (2009). Prevalence of Autism Spectrum Disorders --
- Autism and Developmental Disabilities Monitoring Network. Retrieved from:
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5810a1.htm
Centers for Disease Control and Prevention. (2010). Youth risk behavior surveillance – United
States, 2009. MMWR, 59(SS-5), 1–142.
Daley, A. J. (2009). Can exergaming contribute to improving physical activity levels and health
outcomes in children? Pediatrics, 124(2), 763-771. doi: 10.1542/peds.2008-2357
Fournier, K. A., Hass, C. J., Naik, S. K., Lodha, N., & Cauraugh, J. H. (2010). Motor
coordination in Autism Spectrum Disorders: A synthesis and meta-analysis. J Autism Dev
Disord, 4, 1227-1240. doi: 10.1007/s10803-010-0981-3
Gentile, D. (2009). Pathological video-game use among youth ages 8 to 18: A national study.
Psychol Sci, 20(5), 594-602. doi: 10.1111/j.1467-9280.2009.02340.x
King, G., Law, M., King, S., Rosenbaum, P., Kertoy, M. K., & Young, N. L. (2003). A conceptual
45

model of the factors affecting the recreation and leisure participation of children with
disabilities. Phys Occup Ther Pediatr, 23(1), 63-90.
Law, M., Petrenchik, T., King, G., & Hurley, P. (2007). Perceived environmental barriers to
recreational, community, and school participation for children and youth with physical
disabilities. Arch Phys Med Rehabil, 88(12), 1636-1642. doi:10.1016/j.apmr.2007.07.035
Matson, M. L., Matson, J. L., & Bigley, J. S. (2011). Comorbidity of physical and motor
problems in children with Autism. Res Dev Disabil, 32, 2304-2308.
doi:10.1016/j.ridd.2011.07.036
Rimmer, J. A., & Rowland, J. L. (2008). Physical activity for youth with disabilities: A critical
need in an underserved population. Dev Neurorehabil, 11(2), 141-148.
doi:10.1080/17518420701688649
Scott, A., Jeon, S-H., Joyce, C.M., Humphreys, J.S., Kalb, G., Witt, J., & Leahy, A. (2011). A
randomized trial and economic evaluation of response mode on response rate, response
bias, and item non-response in a survey of doctors. BMC Medical Research Methodology,
11, 126-37.
Shih, T.H. & Fan, X.T. (2008). Comparing response rates from Web and mail surveys: A meta-
analysis. Field Methods, 20, 249-271.
Staiano, A. E., & Calvert, S. L. (2011). Exergames for physical education courses: Physical,
social, and cognitive benefits. Child Dev Perspect, 5(2), 93-98. doi: 10.1111/j.1750-
8606.2011.00162.x
Swing, E. L., Gentile, D. A., Anderson, C. A., & Walsh, D. A. (2010). Television and video game
exposure and the development of attention problems. Pediatrics, 126(2), 214-221. doi:
10.1542/peds.2009-1508
Troiano, R .P., Berrigan, D., Dodd, K. W., Masse, L. C., Tilert, T., & McDowell, M. (2008).
Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc,
46

40(1), 181-188. doi: 10.1249/mss.0b013e31815a51b3
United Stated Department of Health and Human Services [USDHHS]. (2007). The Surgeon
General's call to action to prevent and decrease overweight and obesity. Retrieved from:
http://www.surgeongeneral.gov/topics/obesity/index.htm
Vandewater, E. A., Shim, M-S., & Caplovitz, A. G. (2004). Linking obesity and activity level
with children’s television and videogame use. Journal of Adolescence, 27, 71-85.
doi:10.1016/j.adolescence.2003.10.003
VanGeest, J.B., Johnson, T.P., & Welch, V .L. (2007). Methodologies for improving response rates
in surveys of physicians: A systematic review. Evaluation & the Health Professions, 30,
303-321.

47

Tables
Table 1. Characteristics of subjects (N=215).
Mean (S.D.) Range
Age of child 10 yrs, 4 mo (4 yrs, 4 mos) 3 yrs – 22 yrs

No. additional children in family 1.28 (1.18) 0-6 children

n % of sample
Gender
Male 184 85.58
Female 26 12.09
Not stated 5 2.34

Diagnostic category
ASD only 174 80.93
ASD + physical and/or intel. disability 41 19.07

Note: Exergame(s) = EG(s), TSVG(s) = traditional seated videogame(s).

48

Table 2. Videogame system ownership (N = 215).
n (% of sample)

Family owns at least one videogame system or computer 204 (94.88)

Family owns at least one exergaming system or platform 177 (82.33)
that can be upgraded to exergaming system

System
Nintendo 64 28 (13.02)
Nintendo Gameboy 47 (21.86)
Nintendo GameCube 37 (17.21)
Nintendo DS 121 (56.28)
Nintendo Wii 132 (61.40)
Sony Playstation 12 (5.58)
Sony Playstation 2 53 (24.65)
Sony Playstation 3 41 (19.07)
EyeToy for Playstation 6 (2.79)
Sony PSX 0 (0.00)
Sony PSP 28 (13.02)
Playstation Move 6 (2.79)
Microsoft Xbox 16 (7.44)
Microsoft Xbox 360 57 (26.51)
Dance Pad for “Dance Dance Revolution” 15 (6.22)
Kinect for Xbox 360 24 (11.16)
VTechV .Smile 17 (7.91)
Computer 160 (74.42)
None of the above 5 (2.33)
Other 28 (13.02)

49

Table 3. Videogame play by age, diagnostic category, and gender.
N (% of group) N (% of group) p-value

Under 12 years (n = 143) 12 years & older (n = 69)
Plays TSVGs 117 (81.82) 62 (89.86) ns
Plays EGs 83 (52.07) 29 (42.03) <.05

ASD only (n = 174) ASD + other (n = 41)
Plays TSVGs 152 (87.36) 27 (65.85) <.01
Plays EGs 98 (56.32) 14 (34.15) <.05

Males (n = 184) Females (n = 26)
Plays TSVGs 161 (87.50) 16 (61.54) <.01
Plays EGs 102 (55.43) 8 (30.77) <.05

Note: Exergame(s) = EG(s), TSVG(s) = traditional seated videogame(s).

50

Table 4. Daily time spent playing videogames (TSVG vs. EG) by age, diagnostic category, and gender.
TSVG EG p-value
Mean hours (S.D.) Mean hours (S.D.)

Under 12 years (n = 143) 1.08 (0.99) 0.44 (0.49) <.0001
12 years & older (n = 69) 1.88 (1.40) 0.30 (0.45) <.0001
<.001 ns

ASD only (n = 172) 1.44 (1.22) 0.43 (0.48) <.0001
ASD + other (n = 41) 0.90 (1.01) 0.24 (0.42) <.0001
ns ns

Males (n = 184) 1.41 (1.20) 0.40 (0.46) <.0001
Females (n = 26) 0.92 (1.11) 0.31 (0.58) <.001
ns ns

Note: Exergame(s) = EG(s), TSVG(s) = traditional seated videogame(s).

51

Table 5. Frequency of playing partner (TSVG vs. EG).
TSVGs EGs p-value
N (%) N (%)

Alone 103 (48.58) 37 (17.45) <.0001
With a partner 8 (3.77) 22 (10.38) <.0001
Combination of alone & with a partner 67 (31.60) 52 (24.53) ns
N/A (does not play) 34 (16.04) 101 (47.64)

Friend 8 (3.77) 7 (3.30) ns
Sibling 31 (14.62) 38 (17.92) <.01
Parent 30 (14.15) 27 (12.74) ns
Other 3 (1.42) 1 (0.47) ns
N/A (does not play or only plays alone) 137 (64.62) 138 (65.09)

Note: Exergame(s) = EG(s), TSVG(s) = traditional seated videogame(s).
52

Table 6. Level of assistance needed (by subjects who play videogames) to play TSVGs and EGs
by, age, diagnostic category, and gender.
TSVG EG
N (% of group) N (% of group)

Under 12 years old
Independent 64 (54.70) 38 (45.78)
One or more supports 45 (38.46) 36 (43.37)
Constant supervision 8 (6.84) 9 (10.84)

12 years & older
Independent 51 (82.26) 19 (65.52)
One or more supports 8 (12.90) 10 (34.48)
Constant supervision 3 (4.84) 0 (0.00)

ASD only
Independent 112 (73.68) 53 (54.08)
One or more supports 38 (25.00) 40 (40.82)
Constant supervision 2 (1.32) 5 (5.10)

ASD + other
Independent 3 (11.11) 4 (28.57)
One or more supports 15 (55.56) 6 (42.86)
Constant supervision 9 (33.33) 4 (27.57)
Males
Independent 105 (65.22) 51 (50.00)
One or more supports 47 (29.19) 43 (42.16)
Constant supervision 9 (5.59) 8 (7.84)

Females
Independent 11 (68.75) 5 (62.50)
One or more supports 4 (25.00) 3 (37.50)
Constant supervision 1 (6.25) 0 (0.00)

Note: Exergame(s) = EG(s), TSVG(s) = traditional seated videogame(s).

53

CHAPTER 3

Study 2: Case Studies on the Feasibility of Exergaming to Enhance Physical Activity in
Youth with Autism Spectrum Disorders
54

Abstract
Background
Technology has been used successfully to enhance social engagement for individuals
with Autism Spectrum Disorder (ASD), yet the majority of screen-based media are considered
sedentary and solitary activities. Youth with ASD are at risk for overweight/obesity and
sedentary behavior. Exergaming is a technology-based strategy that incorporates physical
activity (PA) into videogame play, which could benefit youth who may have limited
opportunities for PA at home and in the community. However, few studies have examined
exergaming with individuals on the Autism Spectrum.
Method
Case studies were conducted to explore the feasibility of using an exergaming system
with youth with ASD, and to obtain pilot data on enjoyment, heart rate, and activity level while
exergaming.
Results
Participants reported high levels of enjoyment and perceived exertion while exergaming
over six, 30-minute sessions. All participants showed increased heart rate, maintained target HR
for ≥80% of each session, and expended 5-7 kCals/min during gameplay. We also describe
challenges encountered by participants in learning to play exergames, and incorporate family
feedback to inform future studies.
Conclusion
Exergaming is feasible for this population, many of whom are at risk for sedentary
lifestyle and overweight/obesity. For older children and adolescents with ASD, exergaming may
be a socially and developmentally appropriate substitute for sedentary activity that can increase
daily PA and assist in weight management.
Keywords
55

Accelerometry, Autism Spectrum, enjoyment, exergaming, occupational therapy, participation,
physical activity, technology, videogames
56

Case studies on the feasibility of exergaming to enhance physical activity in youth with
Autism Spectrum Disorders
Autism Spectrum Disorder (ASD) is characterized by a range of deficits that impair daily
functioning, including impaired social communication and patterns of restricted/repetitive
behaviors (American Psychiatric Association, 2013). For individuals with ASD, opportunities for
community-based physical activity may be limited, which could impact their overall physical
activity level, resulting in decreased fitness and health problems such as obesity and
cardiovascular disease (Curtin et al., 2005; Ghaffari et al., 2009; Ho et al., 1997; Pan & Frey,
2006; Pitetti et al., 2007; Rimmer et al., 1996, 2011; Tyler et al., 2011; USDHHS, 2004).
Exergaming, or active videogame play, has been shown to facilitate increased heart rate,
energy expenditure, and enjoyment in typically-developing youth, compared to traditional seated
videogames (Daley, 2009, Witherspoon & Manning, 2012). Exergaming may be particularly
appropriate for individuals with ASD, because this population is often more comfortable
interacting with digital media than with peers, which could help motivate them to participate
(Getchell, et al., 2012).
This report describes the immediate physiological responses of five youth with ASD who
participated in a program to determine the feasibility of using exergaming systems in youth with
ASD, as a potential method of enhancing physical activity participation. Because many young
people with special needs tend to be sedentary for much of the day, participation in the study
provided an opportunity to get moving and have fun, enhancing the participants’ daily routine.
Introduction
Physical activity is facilitates cognitive and motor development, enhances the
development of self-efficacy, and reduces the risk of obesity and related cardiovascular disease
and diabetes (CDC, 2008; Rowland, 2007). Exergaming (active videogame play) has the
potential to increase physical activity for youth who are primarily sedentary, although
57

exergaming should not be considered as a replacement for traditional activities such as sports,
that typically provide higher levels of physical activity (Daley, 2009; Witherspoon & Manning,
2012). However with improving technology and continued research, exergaming may be an
especially effective way to counteract increasing rates of childhood obesity and sedentary
lifestyle, allowing youth of all abilities to participate in highly valued occupations that they may
not normally be exposed to, while simultaneously increasing engagement in physical activity and
improving cardiovascular health and fitness.
Exergaming can expand occupational experiences, as those who are unable to participate
in activities due to social or physical limitations or other barriers may be able to do so in a virtual
context. For example, a child with a physical disability who is unable to play a traditional game
of golf may be able to play a “Wii Golf” game; an adolescent who lives in a geographical area
with limited access to motorsports may be excited to try out a high-energy driving simulation
game; or a young adult with Autism Spectrum Disorder (ASD) may feel less anxiety interacting
with peers while playing a group dancing exergame in preparation for a highly stressful school
dance. Additionally, given evidence of increased comorbidity of mental health concerns in youth
with ASD (Crabtree & Delaney, 2011; Mazzone et al., 2013), research has indicated that
engagement in physical activities can benefit mental health in youth by enhancing mood and
decreasing anxiety and depression (Biddle & Asare, 2011).
Physical activity programs targeting youth with special needs are difficult for families to
locate, and often youth are unable to participate due to behavioral issues, physical and social
limitations, financial restrictions, and transportation barriers. For these individuals, such as youth
with ASD, exergaming may be one way to incorporate physical activity into daily routines. Few
studies of exergaming in young people with disabilities such as ASD currently exist. Rather than
examining its effect on physical activity level, the majority of these studies involve using
exergaming therapeutically (Foran, 2011; Griffiths, 2003; Wiederhold & Wiederhold, 2004). For
58

example, one researcher found that exergaming may enhance executive function or contribute to
a decrease in repetitive behaviors (Anderson-Hanley, 2011b). However, a program using
exergaming to enhance physical activity was successfully completed in Israel with young adults
with intellectual disabilities (Lotan et al., 2009), and a recent study compared adolescents with
and without ASD while exergaming and found that the benefits of exergaming (increased energy
expenditure) were similar in both groups (Getchell et al., 2012).
There is also a need to develop a better understanding of appropriate strategies to assist
individuals with ASD to participate in exergames. A recent national survey (Foran & Cermak,
2013) indicated a high prevalence of videogame platform ownership among the families of youth
with ASD. More than 90% of responding families reported owning at least one videogame
system, which is similar to ownership levels reported by families of typically developing youth
(Hersey & Jordan, 2009, Rideout et al., 2010). Thus, the use of videogames with individuals with
ASD in the home is considered age-appropriate and accessible.
This series of exploratory case studies of youth with ASD examined the use of the Xbox
Kinect exergaming system in the home, and contributes to a better understanding of the potential
for exergaming to enhance participation in physical activity for individuals with ASD. We
hypothesized that for each individual participant, greater levels of physical activity (as measured
by accelerometry, perceived exertion, and heart rate) would result from exergaming, as
compared to rest and to traditional seated videogame (TSVG) play.
Method
Participants
Participants were between the ages of 8 and 18 years old, and carried a parent-reported
diagnosis of Autism Spectrum Disorder, Asperger's Syndrome, or Autistic Disorder. Eligible
participants were able to follow single-step verbal directions in English, and maintain attention to
task for a minimum of 10 minutes with support (based on parent report).
59

Study Design
This is a descriptive study of exergame and traditional seated videogame play in youth
with ASD. For this study, we were interested in measuring the responses of a range of youth with
ASD while playing exergames and a TSVG. We also obtained qualitative feedback from the
participants and their families on both challenges encountered while learning to use the
exergaming system, as well as enjoyment and perceived exertion while playing selected games.
Procedure
Institutional ethical review board approval was obtained; the procedures followed were in
accordance with the ethical standards of the University of Southern California, and consistent
with the revised (2000) Helsinki Declaration.
Participants were recruited through Los Angeles-area schools, therapy clinics, and
disability resource centers. Prior to the first session, participant assent and parent consent were
obtained. Five youth with ASD participated in exergame play one to two times per week for
approximately 30 minutes each session for a total of six sessions over the course of 3-6 weeks,
depending on family schedule and availability. Motor assessments, videorecordings,
researcher/research assistant observations, measures of heart rate, accelerometer counts,
perceived exertion and enjoyment were collected for each of the participants at each of the six
sessions.
Data were collected during each of six sessions over the course of 3-6 weeks. Height and
weight were provided by the parent at the first session, and BMI was calculated from this
information using standard equations (Ogden et al., 2008). Baseline coordination was assessed at
the first session by the researcher, using the BOT-2 Body Coordination sub-test (Bruininks &
Bruininks, 2005). The sessions took place in the participant's home or at a University research
facility (based on family preference), at a time convenient for the participants, with each session
being videotaped to guarantee accuracy of records.
60

During the first session, participants and their parents were introduced to the exergaming
and activity and heart rate monitoring equipment, and data recording forms. At each of the six
sessions, participants wore a Polar© heart rate monitor and ActiCal© accelerometer while
exergaming, and also wore them during one session to obtain a measure of activity level at rest
and while playing a TSVG. The heart rate monitor was worn on a chest strap with accompanying
sensor wristwatch; the accelerometer was worn on the hip using a waist band according to
standard procedures developed by Mini-Mitter (2003).
In each session, participants played one to two exergames selected by the researcher
based on the participants’ interests and abilities, for a total exposure to three games per
participant over the course of the study. After playing each game, participants were asked to rate
their enjoyment and perceived exertion during gameplay using a three-point visual scale. Field
notes were taken by the researcher to describe the level of assistance needed by the participant to
set up and play each game. Feedback from the parents, and researcher impressions were also
reviewed to describe participants’ experiences of exergaming.
Equipment
The Kinect for Xbox360 was selected as the exergaming platform to be used in the study.
The Kinect, released in late 2010, is a webcam-like “video capture” device that plugs into the
Xbox 360 videogame console and tracks the user’s motions, projecting his or her image onto the
television screen, and eliminating the need for a controller. As Sandlund et al. (2009: 350) noted,
“because [users’] free body movements in physical space are tracked and used as inputs to the
game, a merged physical/media space is created during play. This may give players a more
immersive and physically challenging gaming situation, and can also produce a strong
psychological feeling of presence within the merged space. This in turn may facilitate players’
performance and maintain motivation and interest in the game." Few studies of physical activity
using the Kinect system have been published to date, but reviews of the Kinect have been highly
61

positive (Greenwald, 2010; Sinclair, 2010), and it is anticipated that with the recent release of
both the Kinect and updated Wii systems, more families will have in-home access to exergaming
in the coming years. One study indicates that the Kinect may require greater energy expenditure
than the Wii, as it uses whole-body movements versus the primarily upper body/limb movements
required by the Wii (Smallwood et al., 2012).
Prior to the present study, 13 exergames were reviewed by the researcher and classified
by their gameplay characteristics, such as the level of difficulty to navigate through start menus,
amount of body movement required, sensitivity to user’s actions, etc. Games selected for review
were games that did not involve shooting or killing. A grid containing information on the games
reviewed is provided in Table 1. Using the results of the pre-study pilot testing and the
researcher’s clinical knowledge of working with youth with ASD, five games were selected for
use with the participants in this study: Fruit Ninja, Kinect Sports Boxing, Kinect Sports Track
and Field, Kinect Sports Soccer, and Just Dance 3. The TSVG game that was used varied by
participant – for those who owned a TSVG system, the participant was asked to demonstrate
their “favorite” game to the researcher. For those unfamiliar with TSVG play, the participant was
introduced to the “GameRoom” area included with every Xbox 360 system, which has a variety
of simple arcade-style games that require no complicated or multi-button maneuvers of the hand-
held controller.
Measures
Actical® accelerometers (Mini-Mitter Co., Bend Oregon) were used to measure physical
activity level (Energy Expenditure and time in MVPA). Actical® is a small physical activity
monitor used to measure the number of counts or amount of activity in three dimensions. Counts
per minute while playing were recorded and described for each participant, and were adjusted to
equalize the average playing time to 15 minutes for each session. Activity counts were converted
to time in minutes for “sedentary”, “light”, “moderate” and “vigorous” periods of activity with
62

age-specific criteria for activity intensity using proprietary Actical cut-points. Accelerometers
have been found to provide a valid and reliable measure of physical activity in children (Eslinger
et al., 2007; Graves et al., 2008), and have been used successfully in youth with disabilities,
including ASD (e.g., Getchell et al., 2012; Pan & Frey, 2006; Selvadurai, et al., 2002).
Heart rate (HR) was assessed using a Polar monitor with an elastic chest strap and sensor
attached. HR during activity was monitored during each of the sessions prior to videogame play,
during play, and between games while at rest. Pre-exercise heart rate, average heart rate during
game play, and percent of time in target zone (60-80% of maximum heart rate [Pollock et al.,
1998]) was recorded. Maximum heart rate was calculated using a standard formula that accounts
for individuals’ age and gender (Warburton et al., 2008). Change in heart rate may be considered
a proxy measure of the effort exerted (Freedson & Miller, 2000); monitoring simultaneous heart
rate with measures of motion such as accelerometry may facilitate more accurate examinations
of physical activity response.
The Demographic and Physical Activity Questionnaire (Foran & Cermak, 2010) was
modified from two questionnaires used by Cermak (2004) in a study of youth with
Developmental Coordination Disorder. Parents were asked to indicate which sedentary and
physical activities the participant chooses to participate in most often, and how his/her motor
coordination affect his/her daily living skills and functional ability. The questionnaire included
information on the participants’ age, race/ethnicity, and other pertinent variables (see Table 2).
The Bruininks Oseretsky Test of Motor Proficiency – Second Edition (BOT-2) is a
widely-used, norm-referenced test that assesses gross and fine motor coordination, and has been
standardized in youth and young adults from 4 years through 21 years 11 months (Bruininks &
Bruininks, 2005). The Body Coordination Composite includes the Balance (9 items) and
Bilateral Coordination (7 items) subtests was used in this study. This measure has been used to
assess motor skills in individuals with ASD in several studies (e.g., Dietz et al., 2007; Wuang &
63

Su, 2009). The Body Coordination Composite has an internal consistency (Chronbach's alpha)
rating of .99, and a test-retest reliability coefficient of .87 (Wuang & Su, 2009). Age-based
standard scores and percentile ranks are provided, and can be used to evaluate both typically
developing youth and young adults, and those with special needs, including ASD (Bruininks &
Bruininks, 2005). The Body Coordination subtests of the BOT-2 were administered during the
first session to obtain baseline body coordination scores for each participant.
Rating of perceived exertion (RPE) was assessed immediately after playing each
videogame. Participants were shown a modified three-point visual RPE scale developed by the
authors, which was explained to participants with a standardized set of instructions. Perceived
exertion was defined as “How tired did your body feel while you were playing the game?” After
engaging in videogame play, participants were asked to indicate if they felt like they were
“resting quietly/watching TV,” “walking/light playing,” or “running/playing sports.” Three point
RPE scales are commonly used by fitness experts, who use similar descriptors to those in our
scale (SCW Fitness, 2008).
Participants rated their enjoyment of videogame play using a visual scale developed by
the authors. The three-point scale ranges from frowning “I didn’t like this,” to smiling “I liked
this a lot.” The ratings were made immediately following the final minute of each videogame
playing session. There is currently no known data regarding the validity of visual scale methods
in relation to “liking” (Rittenhouse, 2008), however, visual scores for feelings regarding school
and sports have been shown to correlate well with numeric liking scores with a coefficient of
0.80 when used by typically developing children (Roemmich et al., 2008). Liking for physical
activity has also been shown to be an independent predictor of the amount of physical activity
children participate in (Roemmich et al., 2008). Three-point Likert scales have also been used
successfully to measure differences in happiness and enjoyment in youth (Abdel-Khalek, 2006;
64

Kazdin, 1990), although no studies were identified that have used these scales with youth with
ASD.
A 10-item “Videogame Survey” (Foran & Cermak, 2013) was developed by the authors
to assess current videogame system ownership, level of assistance needed to play videogames,
and videogame playing habits among youth and young adults. It was completed by the
participants’ parent or guardian, and used to describe previous exposure to videogame systems.
The expressive and receptive language portions of the Vineland Adaptive Behavior
Scales, Second Edition (Vineland-II; Sparrow et al., 2005) were used a measure of adaptive
communication skills. Combined, the parent checklists include 49 questions, and provide a
measure of social competence in language skills as reported by the parent, including what the
individual says, and how he or she uses words and sentences to gather and provide information
(Sparrow et al., 2005). Standardized and scale scores from these measures can be used as a
surrogate measure for global social functioning in individuals with ASD (Sparrow et al., 2005).
Norming and standardization is available for eleven clinical groups, including “autism-verbal”
and “autism-non-verbal” (Sparrow et al., 2005). Internal consistency is rated at .84-.93 in the
socialization domain, and test-retest reliability ranges from .76 to .92 (Early Childhood
Measurement and Evaluation Resource Centre, 2012).
Finally, a field notes form was developed by the authors and was used to record
observations during each session on levels of assistance needed to play each game, difficulties
encountered and strategies used, participants’ RPE and enjoyment level for each game played,
and qualitative comments on the child’s gameplay experience.
Data Analysis
Each case was analyzed and presented in a descriptive case-series format, as this study
was exploratory and therefore inappropriate for analysis with formal statistical methods.
Examination of qualitative information was conducted on written and videorecorded data, and
65

included a narrative summary of the level of assistance each participant needed to play
exergames, learning effect over the course of the program, parent feedback, and each youths’
enjoyment and perceived exertion while exergaming.
Results
Participants
Five individuals between the ages of 10 and 14 (four males, one female) volunteered to
participate in the study (see Table 2 for detailed demographic information). Clinical information
which helps describe participants’ phenotype, such as weight status, expressive and receptive
language ability, and motor coordination are also presented in Table 2.
Participant 1. Participant 1 attended a special needs middle school. According to her
mother, Participant 1 became quickly fatigued during physical activity, and a lack of
understanding of rules during group sports often caused her to be frustrated. In addition,
Participant 1’s comorbid diagnosis of Neurofibromatosis contributed to frequent injury (broken
bones and soft tissue injury), which prevented her from participating in many physical activities.
Participant 1 was in the obese range for BMI and had below average motor skill based on both
objective testing (BOT-2) and parent report (see Table 2). Prior to the study, Participant 1
played seated videogames often (up to 4 hours per day), and would sometimes play exergames
when visiting a peer’s home.
Participant 2. Participant 2 attended a special needs elementary school. Participant 2
especially enjoyed swimming, and according to his mother, would do this “non-stop” if given the
opportunity. Participant 2 played TSVGs approximately 1 hour per day, and was able to set up
his own system and play independently. About once or twice a month with encouragement from
family members, Participant 2 would play with the Nintendo Wii exergaming system, although
his mother reported that he quickly became fatigued while playing and would try to “cheat” the
game by playing while seated or asking his mother to play for him.
66

Participant 3. Participant 3 attended a traditional middle school, with intermittent support
from special education staff. Participant 3’s mother reported that the family owned both a
PlayStation 3 game system and a Nintendo Wii. Participant 3 spent an average of 1 hour per day
playing TSVGs on the PlayStation 3, and approximately 30 minutes per day playing games on
the Nintendo Wii, an exergaming system. However, Participant 3’s mother indicated that
although the Wii games were designed to play while standing up and moving around, her son
had figured out how to move the handheld controller while sitting, so that he could remain
sedentary during Wii gameplay. Participant 3’s mother indicated that when given the choice, he
consistently chose sedentary activities such as reading, watching TV, and playing videogames as
his preferred leisure activities, but she noted that he would participate in skiing and swimming
when on family vacations, and that he enjoyed these activities. His mother indicated that in
general, she was not satisfied with the amount of physical activity Participant 3 engaged in as
part of his daily routine.
Participant 4. Participant 4 participated in a “reverse mainstreaming” classroom at his
elementary school (regular education students are brought into the special education class).
Although he enjoyed physical activities, if left to his own choice, Participant 4’s parents stated
that he would watch TV or play traditional seated videogames - but if asked, he would engage in
physical activity and he would often excel at it.
Participant 5. Participant 5 attended a traditional elementary school. According to his
father, Participant 5 often became frustrated and refused to follow directions during sports and
games. Participant 5 played on a soccer team with typically developing peers, but his father
reported that he rarely ran on the field, and had a difficult time sharing the ball with others, so he
did not get much playing time. Given the choice, Participant 5 “almost always” chose quiet
recreation activities, especially videogames.
Physical responses to videogame play
67

Descriptive statistics are used to present quantitative physiological response effects of
exergame play for each participant (Table 3). Transcripts and field notes were coded for
emergent themes. Below, a summary of each participant’s experiences and feedback from his/her
family is provided. Levels of assistance are described in Note 1.
Participant 1. Participant 1 had some prior experience with videogames, although she
primarily played with a Nintendo DS, a handheld game device similar to a Gameboy,
approximately 1 hour per day. At baseline, Participant 1 required Minimal Assistance (Min
Assist; see Note 1) to unpack the game system, turn on the TV, change the TV input mode, and
insert the game disc. She required Maximal Assistance (Max Assist) to correctly plug cords into
the game system, to navigate through the game menus, and to maintain gameplay.
Over the course of the program, Participant 1 played “Kinect Sports Boxing,” “Just
Dance 3,” and “Fruit Ninja for Kinect.” She reported high perceived exertion for all three games,
and high enjoyment levels for both the dancing game and “Fruit Ninja.” Participant 1 stated that
boxing was more of a “boy game,” and rated it “moderately” enjoyable, but when (after testing
while waiting for her mother to pick her up), she played it against the researcher, Participant 1
expressed increased enjoyment and played for longer than she did had when alone. Participant 1
was familiar with the iPhone version of Fruit Ninja, and thought it was “neat” to play it with her
whole body. In addition, she expressed excitement in recognizing current pop songs in “Just
Dance 3,” and stated that peers at school played this game.
Following six sessions, Participant 1 was independent at unpacking the game system,
turning on the TV, changing the TV input mode, and inserting the game disc. She required Min
Assist to plug electrical cords into the system, and to navigate through menus and gameplay. In
terms of physiologic response to game play, Participant 1 showed a 38% increase in heart rate
while exergaming compared to at rest, with 84% of her time in the target HR zone. There was no
significant difference in heart rate between resting and TSVG play.
68

Participant 2. Participant 2 required Max Assist to complete all tasks related to set-up
and playing of the Kinect games at the start of the program. He was introduced to “Kinect Sports
Track and Field,” Fruit Ninja for Kinect,” and “Just Dance 3.” Like Participant 1, he rated all
three games as “high” exertion, and also enjoyed the Fruit Ninja and dancing game the most,
rating them highly despite the fact that he was unable to follow the dance steps. When the “Just
Dance” game was switched to “free dance” mode, Participant 2 moved his body throughout the
entire song to his own rhythm, expressing great pleasure. While playing Fruit Ninja, Participant
2 often jumped up and down and squealed with excitement. The track and field game was more
difficult for Participant 2, and he rated his enjoyment of this game as moderate. However, he
benefitted from viewing the optional “training” instructions prior to each “event,” and was able
to learn the movement required to “compete” in the game.
At the end of the study, Participant 2 was able to unpack the system, turn on the TV,
change its input mode, and insert the game disc with Moderate Assistance (Mod Assist). He
required only Min Assist to plug in electrical cords, and to navigate through menus and complete
gameplay. Over the course of the study, Participant 2 achieved an average energy expenditure of
of 7.11 kCals/min (calculated from accelerometer data), and spent 94% of his time exergaming
in his target HR zone.
Participant 3. At the start of the study, Participant 3 required Min Assist to unpack the
game system, turn on and change the TV input mode, and insert the game disc. He required Mod
assist to correctly plug in the system cords, and to navigate through menus to complete game
play. Participant 3 played “Kinect Sports Boxing,” which he rated as high exertion and highly
enjoyable, “Kinect Sports Track and Field,” which he said required moderate exertion and
produced low levels of enjoyment when played, and “Fruit Ninja for Kinect,” which he rated as
moderate exertion and highly enjoyable.
69

When boxing, Participant 3 became very competitive with the character on screen, and
worked very hard (breaking a sweat and breathing heavily throughout gameplay) as he attempted
to “win” matches. During the track and field game, Participant 3 became frustrated by repeatedly
“fouling” in the “long jump” event, and requested to end the session. Participant 3 got very into
the Fruit Ninja game, which was highly motivating for him, as he often bargained for more
playing time at the end of the session.
Following the study, Participant 3 was independent in unpacking the system, turning on
the TV and changing the input mode, and inserting the game disc. He required Stand-by
Assistance/Supervision to navigate through the menus and play the games, and Min Assist to
correctly plug the electrical cords into the game system. Participant 3 demonstrated the lowest
average change in HR from baseline of all the participants with only 22%, although this may be
due to his relatively high resting HR (104 bpm). In addition, Participant 3 maintained his target
HR for 89% of the time while exergaming, and described each game as requiring either moderate
or high levels of exertion.
Participant 4. Participant 4 played TSVGs about 30 minutes per day, and was able to set
up and play his own system (Nintendo Wii) independently prior to the study. According to his
parents, Participant 4 would often played with a parent or sibling. Participant 4 needed Mod
Assist to unpack the system, turn on and change the TV input mode, and insert the game disc at
the start of the study. He also required Min Assist to navigate through game menus and maintain
gameplay, and to correctly plug in the electrical cords.
For Participant 4, “Fruit Ninja for Kinect” was the most enjoyable (high), and required
moderate exertion. Participant 4 enjoyed a number of the various Fruit Ninja gameplay modes,
especially those that incorporated a time-limit, as he was motivated by the “countdown clock”
and racking up increasing scores. He reported moderately enjoying both “Kinect Sports Boxing”
and “Kinect Sports Track and Field,” which were rated as moderately exerting and highly
70

exerting, respectively. Participant 4 enjoyed boxing more when with a partner (his father or the
researcher) versus against an in-game character. Similarly to Participant 3, Participant 4 found
some track and field “events” to be difficult and/or frustrating, but he greatly enjoyed viewing
the “instant replay” videos that were shown on screen at the end of each game.
After six sessions, Participant 4 was independent at unpacking the game system, turning
on the TV, changing the TV input mode, and inserting the game disc. He required only Min
Assist to plug electrical cords into the system, and to navigate through menus and gameplay by
the end of the study. Participant 4’s energy expenditure was calculated to be 6.07 kCals/min
while exergaming, and he achieved an average HR of 132.4 bpm, which is equivalent to a 34%
increase from baseline.
Participant 5. Participant 5 independently played about 90 minutes of TSVGs per day on
either the Nintendo 64 or the computer. He also played exergames with the Nintendo Wii a few
times a week for 30 minutes or less, usually with a parent or sibling. Participant 5 required Mod
Assist to unpack the study system, turn on the TV, change the TV input mode, and insert the
game disc into the system when the study began. He also needed Min Assist to navigate through
the menus and gameplay, and to plug in the electrical cords properly.
Participant 5 played “Kinect Sports Boxing,” “Kinect Sports Track and Field,” and “Fruit
Ninja for Kinect,” which were all rated “high” for perceived exertion while playing. He enjoyed
Fruit Ninja the most, rating it highly. He expressed pleasure throughout gameplay, and thought
that hitting the “bombs” (thus causing him to lose points in the game) was very funny.
Participant 5 was also noted to use smaller body movements in this game compared to
some other participants, despite his high exertion rating. During the boxing game, Participant 5
became fatigued quickly, and sometimes got frustrated by the game automatically pausing due to
low lighting levels in his home not picking up on his body movements. He rated this game as
moderately enjoyable. The least enjoyable game for Participant 5 was Track and Field. Some of
71

the “events” were difficult for him to master, but he was motivated by seeing videos of himself
competing and “standing on the awards podium” at the end of each game.
Following the study, Participant 5 could unpack the system, turn on and switch the input
mode on the TV, insert the game disc, and correctly plug in the cords with Min Assist. He
required only Stand-by Assistance/Supervision to navigate through the game menus and
complete gameplay. His HR during gameplay was elevated by 62% from baseline, and he spent,
on average, 82% of the time in his target HR zone while exergaming.
Overall physiological response
All participants rated the exergames as requiring “moderate” or “high” physical exertion.
This is consistent with the physiological finding that heart rate increased for each of the
participants for videogame play. As shown in Table 4, heart rate during game play increased
between 22% and 118% while exergaming compared to at rest. Participants spent between 82-
94% of their time exergaming in their target HR zone. Target HR, or 60-80% of HRmax, is
considered the optimum range for cardiovascular conditioning, fat burning, and efficient oxygen
use, and one way to measure moderate-to-vigorous physical activity ([MVPA]; Swain et al.,
1994). Thus from our calculations, exergaming contributed roughly 24-28 minutes per session to
participants’ daily MVPA. National guidelines recommend that youth engage in at least 60
minutes of MVPA per day (United States Department of Health and Human Services
[USDHHS], 2008).
Gameplay experience and learning effect
With support from researchers, participants were able to learn to use the exergaming
system with minimal external support, and reported high enjoyment while doing so. The games
with fewer specific rules such as dance-based games and those requiring gross upper limb
movements such as punching and “slicing” were the most favored, and led to the least
frustration, as compared to track and field events that required greater full-body coordination and
72

timing to successfully execute. When asked what they thought would make exergaming easier
for their children, parents stated that while the games were great, the system itself could continue
to be refined so that it was more sensitive to some of the player’s smaller movements, and could
pick up movements with less light required in the room.
Lively music, post-game video replay, and peer influence were particularly motivating,
and appeared to enhance overall enjoyment of exergaming. For example, Participant 1 enjoyed
all the games, but stated that Fruit Ninja and Dance Central 3 were the most fun, especially since
she knew that some of her peers at school played these games, and she was excited to learn how
to play them as well. Participant 2 indicated that he enjoyed the Fruit Ninja game because he was
familiar with the mobile phone version, and he as he played, he called out the scores and fruit
names to his mother, who also played the game on her cellular phone.
Researcher observations and family feedback also indicated increased feelings of self-
efficacy in participants following the exergaming program. For example, when asked to describe
how his body felt after exergaming, Participant 3 said “warm” and “strong,” and he often flexed
his muscles and raised his arms in celebration upon completing a game. Following the sixth
session, some parents indicated that participants had expressed their enjoyment for exergaming
without prompting, and that they would miss having the researcher come to their homes to play.
In addition, parents uniformly stated that they were glad for the opportunity to encourage
physical activity in their children, and all reported looking into purchasing the Kinect system as
an upcoming birthday or holiday gift, an excellent sign of family buy-in into this accessible and
affordable activity.
Summary and Interpretation
This report presents the cases of five youth with autism spectrum disorder who
participated in exergame play once to twice a week for up to six weeks. All participants’ parents
indicated satisfaction with the level of physical activity they achieved while playing, compared
73

to their typical leisure activities. The energy expenditure and changes in heart rate experienced
by participants during exergaming fell within the moderate-to-vigorous physical activity
(MVPA) classification, and contributed to the 60-minutes per day of MVPA that is
recommended for youth (CDC, 2008). After just a few sessions, children were able to unpack the
system, correctly plug in the electrical cords, set up the system, and navigate through game
menus with minimal support.
In a recent study, participation in exergaming elicited 65-68% HRmax, in youth, and
approximately 15-18 minutes of MVPA per ~30-minute session based on HR (Perron et al.,
2011). Accelerometers were also used, although the results were not reported, perhaps due to the
limitations of hip-mounted accelerometers discussed below. In our study, exergaming
contributed to greater than 20 minutes of MVPA per session for each of the participants when
heart rate was used as the physiological indicator, and about 3.5 minutes of MVPA per session
when accelerometer cut-points were used. Despite this wide discrepancy in results based on
method of measurement, it appears that for the youth with ASD in our study, exergaming
provided a substantial amount of MVPA when MVPA was measured calculated from HR, and is
similar to levels described in other studies.
In our study, accelerometers were worn on the hip, which has long been considered the
gold standard for measuring physical activity in youth (Puyau et al., 2002; 2004). However, hip-
placed accelerometers have been cited in many exergaming studies as contributing to under-
estimated activity measurement, as most exergames require much more upper body/limb
movement (Graves et al., 2008; Perron et al., 2011). In addition, more recent research suggests
that wrist-worn accelerometer data may be preferable in children (Routen et al., 2012). Despite
the likelihood of activity under-estimation by the accelerometer, the EE rate of 5.77-7.11 kCals
per minute found in our study was similar (but slightly higher) than that reported in other
exergaming studies (Sell et al., 2008; Staiano & Calvert, 2011; Unnithan et al., 2006), and would
74

contribute significantly to the 150-400 kCal daily energy expenditure recommendations
(American College of Sports Medicine, 2005), if this level of intensity were maintained for the
duration of the 30-minute session or each session had been designed to last longer.
Enjoyment may be a particularly useful factor for further study of exergaming and other
physical activities in this population, as it contributes greatly to mental health and
well-being (Fredrickson, 2001). Participation in enjoyable occupations helps foster mental
health, which could be a protective factor against further disability in individuals with ASD
(Mazzone et al., 2013). When people enjoy what they’re doing, they want to repeat it. By helping
children with ASD experience enjoyment in healthy occupations, this study demonstrated that
exergaming is a not just a novel and enjoyable occupation, but a health-giving activity that may
be taken up and played regularly by children with neurodevelopmental differences.
This study has a number of strengths and limitations that must be noted. One strength of
the study is that it combined both objective measures and subjective measures of physical
activity via heart rate monitoring and accelerometry, in addition to RPE. The inclusion of a
variety of game titles also enhanced the broad picture of exergaming with the ASD population,
and contributed to a better understanding of gameplay factors that may contribute to both
increased energy expenditure and enjoyment. While small, the sample was ethnically diverse and
included both overweight/obese and healthy-weight youth. However, the use of hip-mounted
accelerometers may have resulted in an underestimation of physical activity from upper
body/limb movement, and measures of perceived exertion and enjoyment are participant to bias
and recall limitations. Finally, small sample size and the wide range of functional abilities
(typical of ASD) between participants limits our ability to draw conclusions about the immediate
physiological effect of exergaming with this population. However given the exploratory nature
of the study, rich qualitative data emerged (including feedback from participants and parents, as
75

well as session observations), that will be useful in planning future studies using exergaming
with youth and young adults with ASD.
Conclusion
Based our pilot results, we advocate use of exergaming for older children and adolescents
with ASD who are primarily sedentary. Exergaming is a socially and developmentally
appropriate alternative to sedentary activity that can increase daily physical activity and may
assist in weight management. The case studies provide important feasibility information, and
initial physiologic response and activity level data, that can be used in the future to develop
physical activity programs for youth with ASD and other developmental and intellectual
disabilities who are at risk for sedentary lifestyle and overweight/obesity (Curtin et al., 2005;
Ghaffari et al., 2009; Ho et al., 1997; Pan & Frey, 2006; Pitetti et al., 2007; Rimmer et al., 1996,
2011; Tyler et al., 2011; USDHHS, 2004).
These cases will be used to develop a better understanding of appropriate strategies to
assist individuals with ASD to learn to play exergames, and how they respond to participation in
exergaming. Self-reported enjoyment level, notes on level of assistance needed, and challenges
playing the exergames will be used to develop recommendations for the use of exergames with
this population, so that youth with ASD may be able to participate in exergaming more
independently in the future, and maximal fitness-related benefits can be achieved.
76

Note 1: Max assist = Constant verbal cues and/or physical prompts, Mod assist = Frequent
verbal cues and/or physical prompts, Min assist = intermittent verbal cues and/or physical
prompts, Stand-by assist/Supervision = Infrequent/rare assistance or supervision necessary for
safety, Independent = No supervision or assistance required.

Acknowledgments
This research was supported in part by a California Foundation for Occupational Therapy
Research Grant (2011), and a Graduate Research Fellowship from the University of Southern
California Division of Occupational Science and Occupational Therapy.

77

References
Abdel-Khalek, A. M. (2006). Measuring happiness with a single-item scale. Social Behavior and
Personality, 34, 139-150.
American College of Sports Medicine. (2005). American College of Sports Medicine's
Guidelines for Exercise Testing and Prescription. 7th ed. Philadelphia: Lippincott
Williams and Wilkins.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (Fifth Ed.). Arlington, VA: American Psychiatric Publishing.
Anderson-Hanley, C., Tureck, K., & Schneiderman, R.L. (2011). Autism and exergaming:
Effects on repetitive behaviors and cognition. Psychology Research and Behavior
Management, 4, 129–137.
Biddle, S.J. & Asare, M. (2011). Physical activity and mental health in children and adolescents:
A review of reviews. British Journal of Sports Medicine, 45, 886-895.
Bruininks, R.H. & Bruininks, B.D. (2005). Test of Motor Proficiency, 2nd Edition Manual. AGS
Publishing. Circle Pines, MN.
Centers for Disease Control and Prevention (CDC). (2008). Physical Activity and Health.
Retrieved from: http://www.cdc.gov/physicalactivity/everyone/health/index.html.
Cermak (2004). Demographic and physical activity questionnaire. Unpublished manuscript,
Department of Occupational Therapy, Boston University, Boston, Massachusetts.
Curtin, C., Bandini, L., Perrin, E., Tybor, D., & Must, A. (2005). Prevalence of overweight in
children and adolescents with attention deficit hyperactivity disorder and autism spectrum
disorders: A chart review. BMC Pediatrics, 5(1), 48.
Daley, A. (2009). Can exergaming contribute to improving physical activity levels and health
outcomes of children? Pediatrics, 124, 763-771. doi: 10.1542/peds.2008-2357
Dietz, J.C., Kartin, D., & Kopp, K. (2007). Review of the Bruininks-Oseretsky Test of Motor
78

Proficinecy. Second Edition (BOT-2). Physical & Occupational Therapy in Pediatrics,
27(4), 87-102.
Early Childhood Assessment and Development Centre. (2012). Vineland Adaptive Behavior
Scales-Second Edition (Vineland-II). Retrieved from http://www.cup.ualberta.ca/wp-
content/uploads/2012/07/FINAL_Vineland_June-2012.pdf
Eslinger, D.W., Probert, A., Gorber, S.C., Bryan, S., Laviolette, M., & Tremblay, M.S. (2007).
Validity of the ActiCal accelerometer step-count function. Medicine and Science in Sports
and Exercise, 39, 1200-1204.
Foran, A.C. (2011). Learning from experience: The relation of virtual reality and occupational
therapy. International Journal of Therapy and Rehabilitation, 18(7), 362-369.
Foran, A.C. & Cermak, S.A. (2013). Active and traditional videogame ownership and play
patterns among youth with Autism Spectrum Disorders, and relationships to physical
activity. PALAESTRA, 27(1), 42-48.
Fredrickson, B.L. (2001). The role of positive emotions in positive psychology. American
Psychologist, 56, 218-226.
Freedson, P.S., & Miller, K. (2000). Objective monitoring of physical activity using motion
sensors and heart rate. Research Quarterly for Exercise and Sport, 71(2 Suppl), 21-29.
Freedson, P., Pober, D., & Janz, K.F. (2005). Calibration of accelerometer output for children.
Medicine and Science in Sports and Exercise, 37(11 Suppl), S523-30.
Getchell, N., Miccinello, D., Blom, M., Morris, L., & Szaroleta, M. (2012). Comparing energy
expenditure in adolescents with and without Autism while playing Nintendo Wii games.
Games for Health, 1(1), 58-61.
Ghaffari M., Malone, R.P., Kahn, A., West, S.H., Delaney, M.A., Lawrence, T., Newschaffer,
C.J., & Hardison, H.H. (2009, July). Obesity in children with Autism Spectrum
Disorders. Paper presented at the 49
th
Annual NCDEU Meeting, Hollywood, Florida,
79

USA. Retrieved from:
http://www.cmeinstitute.com/postersession/2009Session2/ORIGGhaffari.pdf
Graves, L.E.F., Ridgers, N.D., & Stratton, G. (2008). The contribution of upper limb and total
body movement to adolescents’ energy expenditure whilst playing Nintendo Wii.
European Journal of Applied Physiology, 104, 617-623. doi: 10.1007/s00421-008-0813-8
Greenwald, W. (2010). Kinect vs. PlayStation Move vs. Wii: Motion-control showdown.
Retrieved from: http://www.pcmag.com/article2/0,2817,2372244,00.asp.
Griffiths, M. (2003). The Therapeutic use of videogames in childhood and adolescence. Clinical
Child Psychology and Psychiatry, 8, 547-554.
Hersey, J. C. & Jordan, A. (2007). Reducing children's TV time to reduce the risk of childhood
overweight: The children's media use study. Retrieved January 16, 2009, from
http://www.cdc.gov/nccdphp/dnpa/obesity/pdf/TV_Time_Highligts.pdf
Ho, H.H., Eaves, L.C. & Peabody, D. (1997). Nutrient intake and obesity in children with
autism. Focus on Autism and Other Developmental Disabilities, 12, 187-192. doi:
10.1177/108835769701200308
Kazdin, A. E. (1990). Evaluation of the Automatic Thoughts Questionnaire: Negative cognitive
processes and depression among children. Psychological Assessment, 2, 73–79.
Lotan, M., Yalon-Chamowitz, S. & Weiss, T. (2009). Improving physical fitness of individuals
with intellectual and developmental disability through a virtual reality intervention
program. Research in Developmental Disabilities 30, 229-239. doi:
10.1016/j.ridd.2008.03.005
Mazzone, L., Postorino, V., De Peppo, L., Fatta, L., Lucarelli, V/. Reale, L., … Vicari, S. (2013).
Mood symptoms in children and adolescents with Autism Spectrum Disorders. Research
in Developmental Disabilities, 34, 3699-3708.
80

Mini Mitter. (2003). Actical: physical activity monitoring system. Instruction manual software
version 2.0. Bend, OR: Mini Mitter Co.
Inc; 2003.Pan, C-Y. & Frey, G.C. (2006). Physical activity patterns in youth with autism
spectrum disorders. Journal of Autism and Developmental Disorders, 36, 597-606. doi:
10.1007/s10803-006-0101-6
Perron, R.M., Graham, C.A., Feldman, J.R., Moffett, R.A., & Hall, E.E. (2011). Do exergames
allow children to achieve physical activity intensity commensurate with national
guidelines? International Journal of Exercise Science, 4(4), 257-264.
Pitetti, K.H., Rendoff, A.D., Grover, T. & Beets, M.W. (2007). The Efficacy of a 9-month
treadmill walking program on the exercise capacity and weight reduction for adolescents
with severe autism. Journal of Autism and Developmental Disorders, 37, 997-1006. doi:
10.1007/s10803-006-0238-3
Pollock, M., Gaesser, G.A., Butcher, J.D, Depres, J.P., Dishman, J.K., Franklin, B.A., & Garber,
C.E. (1998). ACSM position stand on the recommended quantity and quality of exercise
for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in
adults. Medicine and Science in Sports and Exercise, 30, 975-991.
Puyau, M. R., Adolph, A. L., Vohra, F. A., & Butte, N. F. (2002). Validation and calibration of
physical activity monitors in children. Obesity Research, 10, 150–157.
Puyau, M. R., Adolph, A. L., Vohra, F. A., Zakeri, I., & Butte, N.F. (2004). Prediction of activity
energy expenditure using accelerometers in children. Medicine and Science in Sports and
Exercise, 36, 1625–1631.
Rideout, V ., Foehr, U., & Roberts, D. (2010). Generation M2: Media in the lives of 8–18 year
olds. Retrieved from: http://www.kff.org/entmedia/8010.cfm
Rimmer, J.H., Braddock, D. & Pitetti, K.H. (1996). Research on physical activity and disability:
an emerging priority. Medicine and Science in Sports and Exercise, 28, 1366-1372.
81

Rimmer, J.H., Yamaki, K., Davis, B.M., Wang, E., & Vogel, L.C. (2011). Obesity and
overweight prevalence among adolescents with disabilities. Preventing Chronic
Disability,8(2):A41.
Rittenhouse, M.A. (2008). The effect of peer influence on the amount of physical activity
performed in 8-12 year old boys. (Doctoral dissertation). Retrieved from
http://etd.ohiolink.edu/view.cgi/Rittenhouse%20Melissa%20A.pdf?kent1227294426
Roemmich, J.N., Barkley, J.E., Lobarinas, C.L., Foster, J.H., White, T.M., & Epstein, L.H.
(2008). Association of liking and reinforcing value with children’s physical activity.
Physiology & Behavior, 93(4-5), 1011-1018.
Routen, A.C., Upton, D., Edwards, M.G., & Peters, D.M. (2012). Discrepancies in
accelerometer-measured physical activity in children due to cut-point non-equivalence
and placement site, Journal of Sports Sciences, 30(12), 1303-1310.
Rowland, T.W. (2007). Promoting physical activity for children’s health: Rationale and
strategies. Sports Medicine, 37, 929-936.
Sandlund, M., Hoshi, K., Waterworth, E.L., & Hager-Ross, C. (2009). A conceptual framework
for design of interactive computer play in rehabilitation of children with sensorimotor
disorders. Physical Therapy Reviews, 14(5), 348-354.
SCW Fitness (2008). RPE. SCW Newsletter, 11/19/08. Retrieved from:
http://www.scwfitness.com/index.php?story=1608
Sell, K., Lillie, T., & Taylor, J. (2008). Energy expenditure during physically interactive video
game playing in male college students with different playing experience. Journal of
American College Health, 56(5), 505-511.
Selvadurai, H.C., Blimkie, C.J., Meyers, N., Mellis, C.M., Cooper, P.J., & Van Asperen, P.P.
(2002). Randomized controlled study of in-hospital exercise training programs in
children with cystic fibrosis. Pediatric Pulmonology, 33(3), 194-200.
82

Sinclair, J., Hingston, P., & Masek, M. (2007). Considerations for the design of exergames.
Paper presented at the Proceedings of the 5th international conference on Computer
graphics and interactive techniques in Australia and Southeast Asia.
Smallwood, S.R., Morris, M.M., Fallows, S.J., & Buckley, J.P. (2012). physiologic responses
and energy expenditure of Kinect active video game play in schoolchildren. Archives of
Pediatric and Adolescent Medicine, in press. Epub ahead of print retrieved September 29,
2012, from http://archpedi.jamanetwork.com/article.aspx?articleid=1362182
Sparrow, S.S., Balla, D.A., & Cicchetti,. D.,V.(2005). Vineland II Adaptive Behavior Scales.
Circles Pines: AGS Publishing.
Staiano, A.E. & Calvert, S.L. (2011). The Promise of exergames as tools to measure physical
health. Entertainment Computing, 2(1), 17-21.
Swain, D.P., Abernathy, K.S., Smith, C.S., Lee, S.J., & Bunn, S.A. Target heart rates for the
development of cardiorespiratory fitness. Medicine and Science in Sports and Exercise,
26(1), 112-116.
Tyler, C.V., Schramm, S.C., Karafa, M., Tang, A.S., & Jain, A.K. (2011). Chronic disease risks
in young adults with Autism Spectrum Disorder: Forewarned is forearmed. American
Journal on Intellectual and Developmental Disabilities, 116(5), 371–380.
Unnithan, V.B., Houser, W., & Fernhall, B. (2006). Evaluation of the energy cost of playing a
dance simulation video game in overweight and non-overweight children and
adolescents. International Journal of Sports Medicine, 27, 804-809. doi: 10.1055/s-2005-
872964
USDHHS (2004). National initiative on physical fitness for children and youth with disabilities.
Retrieved from: http://www.hhs.gov/od/physicalfitness.html.
Warburton, D.E.R., Nicol, C.W., & Bredin, S.S.D (2006). Prescribing exercise as preventive
therapy. Canadian Medical Association Journal, 174(7), 961-974.
83

Wiederhold, B.K. & Wiederhold, M.D. (2004). The Future of cybertherapy: Improved options
with advanced technologies. Studies in Health Technology and Informatics, 99, 263-70.
Witherspoon, L. & Manning, J.P. (2012). Active gaming: The Future of play? American Journal
of Play, 4(4), 464-487.
Wuang, Y-P. & Su, C-Y. (2009). Reliability and responsiveness of the Bruininks–Oseretsky Test
of Motor Proficiency-Second Edition in children with intellectual disability. Research in
Developmental Disabilities, 30, 847-855.

84

Tables
Table 1. Characteristics of reviewed games for Kinect for Xbox 360.
1

Title of game

Ease of Menu
Navigation

Upper Body
Movement:
Difficulty

Upper Body
Movement:
Amount

Lower Body
Movement:
Difficulty

Lower Body
Movement:
Amount

Sensitivity
to Light

Space
Required

Sensitivity
to User
Movement

Gameplay
Strategy
and Rules

Overall
Rating
(out of 27)
2
Kinect
Adventures
RallyBall

D M H M M M H M M 17
Kinect
Adventures
SpacePop

D H H M L M M M D 17
Kinect
Adventures
20,000 Leaks

D M H H H M H M M 17
Kinect
Adventures
Reflex Ridge

D M M H M M M M M 16
Kinect
Sports
Boxing

M M H L L P L M E 20
Kinect
Sports
Bowling

M M M L L M M M D 17
Kinect
Sports Track
and Field

M M H M H M H M M 19
Kinect
Sports
Soccer

M L L H H M H M D 16
85

Fruit Ninja
for Kinect

E L H L M H M H E 25
Dance
Central 2

D M M M H M H H M 18
Just Dance 3

M H H H H M H H D 17
GameParty:
In Motion

M M M M M P M P M 16
Kinectimals

M M L M M M H M D 15
1
D = Difficult, E = Easy, H= High, L = Low, M = Moderate, P= Poor.
2
Score (out of 27) was derived from summing the points awarded in each category using the following metric: Menu Navigation: E=3,
M=2, D=1; Movement Difficulty: H=1, M=2, L=3; Movement Amount: H=3, M=2, L=1; Sensitivity to Light/Movement: H=3, M=2, P=1;
Space Required: H=1, M=2, L=3; Gameplay Strategy: D=1, M=2, E=3.

86

Table 2. Participant characteristics and baseline intervention-related variables.

Participant

Age

Gender

Ethnicity

Diagnoses

BMI
percentile
Weight
category
1

BOT-2
Baseline Body
Coordination
Std Score (P)
Classification

Physical Activity
2

Activity Level
Enjoyment of PA

Motor Skills
2

Gross Motor (GM)
Fine Motor (FM)

Language
3

Scale score
(95% CI)
Adaptive Level
1 14 years,
8 months

Female non-
Hispanic
white
 ASD
 Learning Disability
 Sensory Integration
Disorder
 Neurofibromatosis

95
Obese
33 (5)
Below Average

Very inactive
Much less than others
GM: Much worse
than others
FM: Much worse
than others
Expressive: 9
(7-11)
Low/Mod low

Receptive: 8
(6-10)
Low

2 10 years,
0 months

Male Hispanic  ASD
 Developmental
Delay
 Learning Disability
 Sensory Integration
Disorder

95
Obese
30 (2)
Well-below
Average

Mostly inactive
About the same as
others

GM: Much worse
than others
FM: Somewhat
worse than others
Expressive: 9
(7-11)
Low/Mod low

Receptive: 7
(4-10)
Low

3 14 years,
4 months

Male Hispanic
and non-
Hispanic
white
 ASD
 Developmental
Delay
 Sensory Integration
Disorder

96
Obese
29 (2)
Well-below
Average

Very inactive
Somewhat less than
others
GM: Somewhat
worse than others
FM: Much worse
than others

Expressive: 10
(8-12)
Mod low

Receptive: 11
(9-13)
Mod low

4 11 years,
3 months
Male Non-
Hispanic
white
 ASD
 ADHD
 Motor planning
challenges
 Sensory Integration
Disorder
 Speech/language
46

Healthy
weight
52 (58)
Average

Active
Somewhat more than
others
GM: Much better
than others
FM: About the
same as others
Expressive: 8
(6-10)
Low

Receptive: 10
(7-13)
Mod low
87

Impairment

5 10 years, 8
months
Male Hispanic
and non-
Hispanic
white

 ASD
 Developmental
Coordination
Disorder
62
Healthy
weight
46 (35)
Average

Mostly inactive
Somewhat less than
others
GM: Somewhat
worse than others
FM: Somewhat
better than others
Expressive: 10
(7-13)
Mod Low

Receptive: 11
(9-13)
Mod low

1
Weight category (underweight, healthy weight, overweight, or obese) from CDC guidelines based on BMI percentile, age, and gender (Ogden et al., 2008).
Anthropometric characteristics per parent report on the Demographic and Physical Activity Questionnaire (Foran & Cermak, 2010).
2
Per parent report on Foran & Cermak (2010), as compared to same-age and same-gender youth without disabilities.
3
Communication “Adaptive Levels” corresponding to subdomain v-scale scores from Sparrow et al. (2005, p. 253): Low = 1-9; Moderately Low = 10-12;
Adequate = 13-17; Moderately High = 18-20; High = 21-24.

88

Table 3. Summary of physical activity related variables during exergaming.

Participant

Avg
kCals/
min
1

Avg % of
session in
MVPA
1

Pre-
game
HR
2

(bpm)

Avg HR
while
exergaming
2
(bpm)

Average change in
HR from baseline
(rest) while
exergaming

% of time
in target
HR zone
3

1 5.8 2.4% 87 119.7 33 bpm (38% increase) 84%

2 7.1 26.1% 60 130.8 71 bpm (118%
increase)
94%

3 5.9 9.5% 104 126.7 23 bpm (22% increase) 89%

4 6.1 19.4% 99 132.4 33 bpm (34% increase) 91%

5 6.4 20.3% 77 125.0 48 bpm (62% increase) 82%
1
From ActiCal© accelerometer proprietary software equation calibrated to individual participant characteristics.
2
From Polar© HR monitor proprietary software equations calibrated to individual participant characteristics.
3
60-80% age- and gender-adjusted HR
max
(ACSM, 1998).

CHAPTER 4

Study 3: The effect of exergaming on physical activity and enjoyment in young adults with
Autism Spectrum Disorder and typical development
90

The effect of exergaming on physical activity and enjoyment in young adults with
Autism Spectrum Disorder and typical development

Background and Importance of Study
Autism Spectrum Disorder (ASD) is characterized by deficits in social
communication, difficulties processing and modulating sensory information, and by the
presence of restrictive or repetitive behaviors (American Psychological Association [APA],
2013). For individuals with ASD, opportunities for community-based physical activity (PA)
may be limited, which could impact overall physical activity level and lead to decreased
fitness and health problems such as obesity and cardiovascular disease (Curtin et al., 2005;
Ghaffari et al., 2009; Ho et al., 1997; Rimmer et al., 1996, 2011; Pan & Frey, 2006; Pitetti et
al., 2007; Tyler et al., 2011; USDHHS, 2004), so it is critical to identify enjoyable, feasible
methods of incorporating physical activity into their daily lives. Active videogame play
(exergaming) as a leisure activity may be an important strategy to increase participation in
physical activity for young adults with ASD.
Exergaming has been shown to increase energy expenditure compared to traditional
seated videogames (Daley, 2009). Current physical activity guidelines suggest that for health
promotion interventions to be effective, they should focus on activities that individuals have
access to on a daily basis (Barkley, 2008). A recent study has indicated that ownership of
videogame systems among families of youth with ASD may be similar to that of typically
developing children in the community. Of families surveyed, exergames were available in
over half the homes of those who responded (Foran & Cermak, 2013).
Emerging interactive technologies such as exergames may be especially important for
individuals with ASD, as they often do not have access to organized sports programs and
other opportunities for physical activity in the community due to behavioral or social issues,
financial limitations, and transportation barriers (King et al., 2003; Law et al., 2007; Rimmer
91

& Rowland, 2008). Limited participation in physical activities can lead to decreased fitness
which, combined with higher rates of motor coordination challenges in individuals with ASD,
can negatively impact their interest in and further impede their ability to participate in
physical activities such as team sports (Gillberg, 2003). For individuals with ASD, exergame
systems are a socially-appropriate, commercially available substitute for a typically sedentary
leisure activity, and may also provide a less-threatening medium for social interaction with
peers than direct sports and games (Anderson-Hanley, 2011b; Finklestein, 2010).
Enjoyment or “liking” of an activity has been identified as an important factor that is
positively associated with physical activity participation levels (Roemmich et al., 2008;
Schneider & Cooper, 2011). In addition, according to the Person-Environment-Occupation-
Performance Model (Baum & Christiansen, 2005), when an individual is provided with the
appropriate level of task challenge and environmental supports, he or she can achieve optimal
performance, which in turn will enhance enjoyment and encourage future participation.
Exergaming has been reported to be highly enjoyable for both typically developing
individuals and those with disabilities, and tends to be preferred to traditional exercise
activities as a method of increasing physical activity (Leininger et al., 2010; Yalon-Chamovitz
& Weiss, 2008). Understanding the parameters of physical activity that are most reinforcing is
important so that exercise guidelines can be developed that promote physical activity
intensities and durations that young adults are the most motivated to engage in. Increasing the
liking or enjoyment of physical activity may subsequently increase motivation to take part in
that activity (Roemmich, 2008; Scanlan & Simons, 1992; Schneider & Cooper, 2011).
A few studies using exergaming systems with individuals with ASD and other
developmental disabilities have been reported in the literature, although these have been
limited to examinations of the effect of exergaming on sensory integration, balance and
coordination, attention/executive function, and enjoyment. One study found promising results
92

for the use of exergaming to increase motor coordination and sensory integration among youth
with special needs who regularly played exergames (Wuang et al., 2010). In another study,
Lotan et al. (2008) found that individuals with developmental disabilities reported high
enjoyment while exergaming, and were motivated to continue an exergaming-based fitness
program. More research is needed to test the effects of exergaming on physical activity level
in this population.
Previous studies with neurotypical (NT) individuals have demonstrated that physical
activity intensity, and motivation to continue playing, increase when a peer is present rather
than being alone (Strauss, 2001; Salvy et al., 2008, Efrat, 2009). This effect also appears to
hold true during exergame play (Exner et al., 2009; Staiano & Calvert, 2010). However,
research examining the impact of peer influence on the physical activity patterns of
individuals with ASD is limited primarily to studies of classroom or recess behavior. It is
generally found that physical activity can help to decrease repetitive behaviors and increase
attention in individuals with ASD, but that partner play is typically limited to “parallel”
interactions rather than reciprocal social engagement with peers (Engel, 2011; Pan & Frey,
2006; Pan et al., 2011a/b). There have been no studies to date examining differences between
computer-generated and real-life partner play in this population.
Because of the social challenges inherent to ASD, individuals may become anxious or
uncomfortable during direct social interaction, and often avoid such situations, another reason
for limited participation in traditional sports and games (O’Neill & Jones, 1997). However, a
number of studies have highlighted technology as a less stressful medium through which
individuals with ASD can interact with others in a socially acceptable manner (Davidson,
2008; Feil-Seifer & Mataric, 2008; Gorini et al., 2008; Moore et al., 2005; Sherer et al., 2001;
Sturmey, 2003). For example, individuals with ASD report less anxiety when speaking to
someone over an internet video phone service (Skype) than directly to another person
93

(Herskowitz, 2009). Online communities such as Second Life allow users to create avatar
characters that represent themselves, and develop social relationships through the website,
which many people with ASD consider less threatening than real life social situations (Gorini
et al., 2008; Shane et al., 2012).
Playing an active videogame with a peer may be another method of social interaction
that allows for less threatening engagement in physical activity play without additional
modification to the game. Videogame play is inherently a parallel or associative activity, in
which players must remain near one another but are required to engage in limited social
interaction. For this reason, it may be an ideal naturalistic and non-stigmatizing occupation
that accommodates the social limitations of ASD. The results of the Videogame Survey (see
Chapter 2) indicate that most youth with ASD play videogames alone, and if they play with a
partner, the partner is most often a parent or sibling and rarely a friend/peer (Foran & Cermak,
2013).
Individuals with ASD have been reported to have overall lower motivation for
physical activity compared to their typically developing peers (Pan et al., 2011a/b), so
recruiting their interest in a technology-based physical activity may aide in increasing
motivation for participation. For example, in a study of middle school students, those with
ASD were less physically active that NT peers, but was greater when the physical activities
included a social component. The addition of a playing partner to exergaming may also
enhance motivation for and enjoyment of the activity, leading to longer playing time or
playing with greater intensity.
Although the literature supports a consistent understanding that individuals with ASD
typically have impoverished play routines and social relationships, there is a paucity of
literature on the effects of play-based interventions for individuals with ASD. Descriptions of
94

case reports are the most common, and can be difficult to generalize to a population already so
variable (Joesfi & Ryan, 2004; Volkmar et al., 2005).
One method of play and social skills intervention for this population is a scaffolding
approach (Vygotsky, 1978). Clinicians, adults, and peers provide support to enable the “just
right challenge” within an individual’s developmental level. This support (or scaffolding) is
provided through modeling, assisting, and reinforcing positive or adaptive behaviors, which
then enables advancement to the next developmental stage or task level. According to this
theory, for interactions with peers to be most effective with individuals with ASD, the
inclusion of a more able peer is essential to provide social modeling and opportunities to learn
by imitation (Shuler & Wolfberg, 2000). Although the scaffolding approach is a guided form
of intervention, it allows for spontaneity on the part of the play participants, which enhances
the real-life or “naturalistic” quality of participation (Preissler, 2006).
According to Wolfberg (2004), peers perform a distinct role in supporting
development through play, and this role is essentially impossible for adults to duplicate. In
studies of social play in individuals with ASD, peer “buddy” programs have been shown to
elicit more appropriate play skills, increase the amount of peer interaction time, and generalize
across multiple peers (Bass & Mulick, 2007). In this study, we expected that as the young
adults learned the new skill of exergaming, the task would be perceived as less challenging
and more enjoyable if appropriate supports were put in place to allow for optimal performance
and enjoyment; for example by choosing the “just right” game, encouraging engagement with
a dedicated peer playing partner, and receiving positive feedback during gameplay.
In this study, differences in both physical activity level and enjoyment between
exergame playing conditions (playing alone vs. playing with partner) were examined in
individuals with ASD. Preliminary data from the case series described in Chapter 3 suggests
that the subjects studied enjoyed playing exergames more than TSVGs, and that they
95

consistently achieved moderate or moderate-to-vigorous physical activity levels while
exergaming (as measured by accelerometer). The present study examined the effect of a social
condition (partnered exergame play) on physical activity in individuals with ASD. We sought
to determine if the physiological and psychological responses of young adults with ASD to
videogame play under varying conditions would be similar to previously reported data in
typically developing individuals, which indicates that when playing with a partner, people
tend to be more active and enjoy the activity more than while playing alone.
This study is the first to describe the relationship of exergaming and physical activity
levels in young people with ASD, and to determine if exergame playing condition (alone versus
with a peer partner) influences physical activity level and/or enjoyment. In particular, the study
provides evidence of consistency with prevailing literature that physical activity is heightened
during play with a peer, which could have clinical implications related to the overall care of
individuals with ASD who are at risk for sedentary lifestyle and overweight and obesity.
Results of the study will inform future research using videogame technology as a way to
promote physical activity for individuals with ASD, and will enhance our understanding of the
role technology can play in enhancing the social worlds of young adults on the Autism
spectrum.
Specific Aims and Hypotheses
Informed by the results of the case studies, a repeated measures crossover trial with
randomized conditions was conducted to test differences in the effects of videogame play on
young adults with ASD and their typically developing peers by:
(a) Type of videogame play (exergame vs. traditional seated videogame)
(b) Playing condition (alone vs. with a partner)
The specific aims for this study were:
96

1. To compare heart rate, activity counts, perceived exertion, and self-reported enjoyment
achieved by young adults with ASD, between videogame types and playing
conditions.
Hypothesis 1.1: Heart rate, physical activity (measured by accelerometer and
perceived exertion), and self-reported enjoyment while exergaming will be
greater than while playing a TSVG or resting for young adults with ASD.
Hypothesis 1.2: Heart rate, activity level (accelerometer counts and perceived
exertion), and self-reported enjoyment while playing videogames with a
partner be greater than while playing alone for young adults with ASD.
2. To compare physical activity and enjoyment responses of individuals on the Autism Spectrum
to those achieved by NT young adults while exergaming.
Hypothesis 2.1: The magnitude of changes in enjoyment, heart rate, and
activity level (accelerometer counts and perceived exertion) resulting from
exergaming (compared to TSVGs and rest) will not differ significantly
between young adults with and without ASD.
Hypothesis 2.2: The magnitude of changes in enjoyment, heart rate, and
activity level (accelerometer counts and perceived exertion) while playing
videogames with a partner vs. playing alone will not differ significantly
between NT young adults and those with ASD.
3. (Exploratory Aim) To examine factors associated with physical activity in individuals
with ASD, including body coordination, body mass index, previous videogame
exposure, and daily activity habits, and to report relationships between these factors
and physical activity levels achieved during videogame play.
Research Question 3.1: What is the relationship between individual
characteristics and physical activity-related outcomes while exergaming?
97

Method
A quantitative approach was appropriate for this study, as we sought to measure
differences in physical activity levels within and between subjects with and without ASD,
while exergaming and playing a TSVG with and without a partner, as measured by
accelerometer, heart rate monitor, and ratings of perceived exertion.
Study design and framework. To test the hypotheses presented above, a repeated
measures crossover design was employed to determine the relationship between primary study
variables, and to examine potential relationships between these factors. In this case, the two
independent conditions were: EG vs. TSVG game type, and solitary vs. social playing
condition. Dependent response variables were physical activity (heart rate, activity counts,
and perceived exertion) and enjoyment. Young adults with typical development participated
in the study to enhance analysis and provide comparison to other exergaming studies, which
are largely comprised of NT subjects. In addition, we examined if the levels of physical
activity and enjoyment achieved by the subjects with ASD during exergaming was similar to
that of NT subjects. Diagnostic group served as the between subjects variable, and within
subjects, physical activity and enjoyment were analyzed by playing status and game type.
Over the course of the study, each gameplay condition was repeated twice per subject in
random sequence, and subject pairs were assigned to one of these sequences using SAS
statistical software. The duration of the study was two waves of 6 months each, with six
additional months for recruitment. Each ASD subject (N=18) participated in a total of eight
sessions, as outlined in Procedures. The NT partner subjects (N=18) participated in a total of
eleven sessions, as they played each game alone twice, with their ASD buddy twice, and once
with another NT peer (each gameplay condition is described in detail in Procedures).
98

Procedures
Study procedures were approved through both the Towson University and University of
Southern California Institutional Review Boards.
Participants. Eighteen subjects with ASD from the Hussman Center for Adults with
Autism (CAA) at Towson University (Hussman Center) participated in the study, in addition to
eighteen neurotypical partners (students at Towson University). Subjects participating in the
CAA carry a self-reported diagnosis of ASD, which was confirmed by researcher review of
physician or educational documentation provided by the subject or subject’s caregiver.
All subjects were 18-25 years old. This age range was selected for the study because
many individuals in this age group enjoy and participate in videogame play in their everyday
routine, and are at a critical transition age for young people with ASD (Eaves & Ho, 2008). In
addition, exergaming is a developmentally and socially appropriate substitute for sedentary
activity for young adults. Exergaming targets the increased risk for overweight/obesity and
related health conditions common in young adults with ASD.
Outreach for recruitment of ASD-NT partner pairs occurred through the Hussman
Center programs and classes at Towson University in the Autism Studies, Occupational
Therapy, Education, and Speech-Language Pathology Departments. Through the Hussman
Center, NT subjects were invited to participate in social events with their partners with ASD,
and develop peer relationships outside the study. The NT partners were of a similar age as the
group with ASD, as they were all University undergraduate students.
Randomization and assignment. Prior to enrollment, potential subjects were sent a
packet with study information, as well as consent/assent forms to review. According to the
requirements of the Institutional Review Boards of the University of Southern California and
Towson University, written consent and/or assent forms were included in the packet, and a
researcher followed up with each potential participant/caregiver by phone to answer any
99

questions regarding study participation. For those with ASD with a legal guardian, the
guardian was asked to complete the consent form indicating their agreement for the individual
to participate in the study.
Once a subject with ASD and their respective NT partner were recruited, a
randomization sequence was generated by the SAS v. 9.2 (SAS Corporation) program. This
sequence was used to assign enrolled subjects to a specific sequence of the six gameplay
conditions. For example, some participants played active videogames first; others played the
traditional seated videogames first. Some participants played alone first, while others first
played with a partner. Within exergame play, some subjects played the Tennis game first;
others first played Boxing.
Randomization to the gameplay sequence helped to control for the possible effects of
learning or novelty on physical activity and enjoyment during the different play conditions.
Neither the participants nor the researchers were blinded to sequence assignment, because this
was not possible given the interactive nature of the study, and unnecessary because knowing
the sequence of gameplay conditions was not expected to alter measurement or analysis.
During enrollment and assignment of the partner pairs in Spring 2013, recruitment of
additional pairs continued, with later pairs assigned to a second wave of data collection in Fall
2013.
Session protocol. During the first session, eligible participants reported to a private
research room at the Hussman Center. Height, weight, and waist circumference measurement
was completed, the subject was familiarized with the researchers, heart rate and activity
monitors, and videogame equipment, and future sessions were scheduled. A trained
occupational therapist administered the Bruininks-Oseretsky Test of Motor Proficiency-II
subtest of Body Coordination (comprised of Balance and Bilateral Integration; Bruininks &
Bruininks, 2005).
100

Upon completion of anthropometric and Body Coordination testing, a trained
occupational therapist and/or occupational therapy student research assistant demonstrated the
use of both the TSVG and exergames. Subjects were required to demonstrate that they would
be able to navigate through the start menu to initiate each of the three games with minimal
assistance from the researcher for sequencing. If a subject was unable to do so or requested
additional instruction, he or she had the opportunity to participate in up to two additional
familiarization sessions prior to testing.
Seven gameplay sessions followed the initial session, during which subjects played for
ten minutes under two of six conditions in random order: either one of the two exergames or a
TSVG, either alone or with a partner, with a break provided between games. Each session
lasted approximately 30 minutes. NT subjects participated in three additional gameplay
sessions following the first seven, during which they played the TSVG and two exergames
alone and with another NT playing partner. For all sessions, after playing each game, subjects
were asked to rate their enjoyment and their perceived exertion while playing, using rating
scales appropriate to their functional level (described in Measures).
The six gameplay conditions are as follows:
1. TSVG alone – The subject played a traditional seated videogame (TSVG) for 10
minutes alone while wearing a heart rate monitor and accelerometer.
2. TSVG with a partner – The subject played a traditional seated videogame (TSVG) for
10 minutes with their paired partner while wearing a heart rate monitor and
accelerometer.
3. Tennis EG alone – The subject played the Kinect Sports Tennis exergame for 10
minutes alone while wearing a heart rate monitor and accelerometer.
101

4. Tennis EG with a partner – The subject played the Kinect Sports Tennis exergame for
10 minutes with their paired partner, while wearing a heart rate monitor and
accelerometer.
5. Boxing EG alone – The subject played the Kinect Sports Boxing exergame for 10
minutes alone while wearing a heart rate monitor and accelerometer.
6. Boxing EG with a partner – The subject played the Kinect Sports Boxing exergame for
10 minutes with their paired partner, while wearing a heart rate monitor and
accelerometer.
The amount and intensity of the physical activity each subject performed was
measured via accelerometer and heart rate monitor during each session. Participants were
compensated with $10.00 per visit (for a total of $80 for the ASD subjects, and $110 for the
NT subjects who completed an additional three sessions), an invitation to and end of study
celebration party, and a certificate of participation in University research.
Throughout the study, the scaffolding approach was used; the researcher, in addition to
the NT partner, worked to provide the most appropriate environmental and activity-level
conditions for the needs of the individual with ASD, in order to enhance performance and
participation in exergaming. These adaptations were achieved through the use of social and
environmental cues such as a line placed on the floor for the player to stand behind, the
selection of appropriate videogames which were less difficult to navigate, and peer modeling
of gameplay.
Exergaming system. The Kinect for Xbox360 was selected as the exergaming
platform for this study. The Kinect, released in late 2010, is a webcam-like “video capture”
device that plugs into the Xbox 360 videogame console and tracks the user’s motions,
projecting his or her image onto the television screen, and eliminating the need for a hand-
held controller. As Sandlund et al. (2009, p. 350) note, “because [users’] free body
102

movements in physical space are tracked and used as inputs to the game, a merged
physical/media space is created during play. This may give players a more immersive and
physically challenging gaming situation, and can also produce a strong psychological feeling
of presence within the merged space. This in turn may facilitate players’ performance and
maintain motivation and interest in the game." Few studies of physical activity using the
Kinect system have been published to date, but reviews of the Kinect have been positive
(Greenwald, 2010; Sinclair, 2010), and it is anticipated that with the recent release of both the
Kinect and Wii systems, more families will have in-home access to exergaming in the coming
years.
To control for the possibility that gameplay of a particular exergame varied between
alone and partner conditions in a manner that could affect heart rate or other variables, two
games were selected using the criteria described in Chapter 3: Kinect Sports Tennis and
Kinect Sports Boxing. For example in the tennis game, an alone player controls a single
tennis player onscreen against a computer-generated opponent; when playing with a partner,
he/she controls a single tennis player against a partner who controls another tennis player
simultaneously. This way, opportunity for physical activity is the same whether playing alone
or with a partner. Other exergames require players to take turns when playing together, but not
when playing alone – such games were excluded from consideration for this study. In
addition, we chose to test the effects of two exergames, in order to account for the possibility
that subjects may have preferred one game over another, and thus be more motivated to play
or work harder during their preferred game.
The TSVG game used was “Hydro Thunder,” a simple boat-driving simulation game
that requires players to select a racecourse, and navigate their boat around obstacles on the
course. The game can be played alone or against another player, and requires no complicated
or multi-button maneuvers of the hand-held controller.
103

Measures. Table 1 lists the key variables that were used for each construct, its source,
and where applicable, which specific aim it was used to test. Please see Appendix C for copies
of all measures.
BMI percentile. Body weight and height were self-reported on the Demographic
Questionnaire, and a standard calibrated scale and stadiometer were provided if subjects were
unaware of their height and weight. Body mass index (BMI) was calculated as weight (kg)
divided by height (m) squared, and BMI percentile was determined using SAS code provided
by the Centers for Disease Control (CDC), which uses age- and gender-specific growth curves
to calculate BMI. Because BMI is a surrogate measure of body fatness and can be affected by
differing body proportions (Garn et al., 1986), waist circumference was measured at one inch
above the umbilicus in order to calculate waist-to-height ratio and body fat percentage.
Body Coordination Composite of the Bruininks Oseretsky Test of Motor Proficiency
– Second Edition (BOT-2; Bruininks & Bruininks, 2005). The BOT-2 is a widely-used,
norm-referenced test that assesses gross and fine motor coordination, and has been
standardized in young adults from 4 years through 21 years 11 months (Bruininks &
Bruininks, 2005). The Body Coordination Composite includes the Balance (9 items) and
Bilateral Coordination (7 items) subtests. The Body Coordination Composite has an internal
consistency (Chronbach's alpha) rating of .99, and a test-retest reliability coefficient of .87
(Wuang & Su, 2009). Age-based standard scores and percentile ranks are provided, and can
be used to evaluate both typically developing young adults, and those with special needs,
including ASD (Bruininks & Bruininks, 2005). The Body Coordination subtest of the BOT-2
was administered during the first session to obtain baseline body coordination scores for each
subject. This measure has been used to assess motor skills in individuals with ASD in several
studies (Dietz et al., 2007; Wuang & Su, 2009).
104

Acclerometry. An Actical
®
accelerometer (Mini-Mitter Co., Bend Oregon), was used
to measure physical activity level. Accelerometers provide an objective measure of the
amount and intensity of physical activity in which an individual engages, as well as the energy
expended. Actical
®
is a small (37x29x9 mm) and lightweight (17g) battery-operated physical
activity monitor that utilizes a 3-dimensional motion sensor to monitor the occurrence and
degree of motion. The monitor measures the number of counts or amount of activity in 15-
second intervals. Monitors were time-stamped and initialized for each individual in order to
allow for syncing with HR monitor data. After adjustment to equalize the time spent playing,
counts per minute while actively playing were aggregated and described for ASD and NT
subjects playing under each condition. Activity counts were converted to time in minutes for
“sedentary”, “light”, “moderate” and “vigorous” periods of activity using the proprietary
regression equation from the Actical software (Mini Mitter Company, Inc., 2003-2005).
Accelerometers have been found to provide a valid and reliable measure of physical activity in
adults (Metcalf, et al., 2002; Kelly et al., 2013). Accelerometers have been used in individuals
with disabilities, including ASD, in previous studies (e.g., Pan & Frey, 2006; Selvadurai, et
al., 2002).
Heart rate (HR). HR was assessed using a Polar RS400 heart rate monitor watch with
an elastic chest strap and sensor attached. Resting heart rate (HR
rest
) was assessed prior to
gameplay at each session, and HR was monitored during each of the gameplay periods, with a
5 minute break between periods. The Polar monitor stored information on HR during the test
period, and was uploaded to a computer for analysis after each session. Pre-exercise heart rate
(HR
rest
), average heart rate during exercise (HR
avg
), percent of time in target zone (60-80% of
maximum heart rate, equivalent to MVPA), and peak heart rate (HR
peak
) during the session
was recorded. Monitors were time-stamped and initialized for each individual in order to
allow for syncing with accelerometer data. Maximum heart rate was calculated using the
105

formula provided by the Polar ProTrainer software (©PolarElectro, 2002), which accounts for
individuals’ age, height, weight, and gender. Change in heart rate may be considered a proxy
measure of the effort exerted. Freedson & Miller (2000) suggested that monitoring
simultaneous heart rate with measures of motion such as accelerometry may facilitate more
accurate examinations of physical activity response.
Rating of perceived exertion (RPE). Rating of perceived exertion was assessed
immediately following each videogame play period. Subjects were shown a 10-point visual
scale (Perceived Exertion Index, modified from the Children’s Effort Rating Table [CERT;
Williams et al., 1994]), which was designed for use by children age 6 and up. The scale was
explained to subjects with a standardized set of instructions. Perceived exertion was described
to subjects as “How tired did your body feel while you were playing the game?” The purpose
of this scale was to monitor exercise intensity - scores increase in intensity from: 1 (“Not tired
at all”) through 10 (“So tired I can’t go anymore”). The CERT was previously used to
measure exertion level of children who participated in a step test, and the results correlated
well with measured HR and showed good validity and reliability, especially in individuals
over age 9 (Yelling et al., 2002).
Enjoyment/liking of videogame play. Subjects rated their enjoyment of videogame
play using a version of the General Interest (enjoyment) factor of the Pre-Adolescent Attitudes
toward Physical Education Questionnaire [PAAPEQ; Shropshire & Loumidis, 1996]), with
modified wording for videogame play. The PAAPEQ is a self-report scale containing seven
negatively-worded questions regarding subjects’ enjoyment of physical activity. The modified
form consisted of five items measuring enjoyment, liking, interest and value held for
videogame play. Participants responded to a four-point Likert scale, ranging from “Always
true” (4) to “Not at all true” (1). Items were summed (with item #2 reverse-scored) to provide
a single score, with a higher score indicating greater enjoyment of the game in question. The
106

General Interest factor of the PAAPEQ has been reported as having high internal reliability,
with a Cronbach alpha level of .87 (Shropshire and Loumidis, 1996). In a study using the
PAAPEQ to examine the relationships between perceived competence and enjoyment in
physical activity, children with greater perceived confidence participated in more physical
activity outside of structured school time (Carroll & Loumidis, 2007). Liking for/enjoyment
of physical activity has also been shown to be an independent predictor of the amount of
physical activity children participate in (Roemmich, 2007). Three- and four-point Likert
scales have been used successfully to measure differences in happiness and enjoyment in
youth (Abdel-Khalek, 2006; Kazdin, 1990), although no studies were identified which have
used these scales with individuals on the Autism Spectrum.
If individuals were unable to respond to the five questions on the enjoyment measure,
they were asked to indicate by pointing to a four-point visual scale (ranging from “very bad”
to “very happy”). For analysis, visual scale responses were recoded and dichotomized, such
that negative responses were equivalent to an enjoyment scale score of 5/20, and positive
responses were scored as 15/20.
Demographic and Physical Activity Questionnaire. A demographic and physical
activity questionnaire was modified from two questionnaires used by Cermak (2004) in a
study of youth with developmental coordination disorder, and was piloted in the case studies
described in Chapter 3. Respondents (subjects or their guardians) were asked to indicate
information on age, race/ethnicity, anthropometric measurements, gross and fine motor skill
levels, and daily physical activity level.
Videogame Survey (Foran & Cermak, 2013). This 10-item questionnaire was
developed by the investigator to assess current videogame system ownership, level of
assistance needed to play videogames, and videogame playing habits. It was completed by
107

subjects (or a guardian), and used as a measure of previous exposure to videogame systems.
The survey is described in detail in Chapter 2.
Ethical considerations. All sessions were supervised by at least two researchers, one
of whom was certified in cardiopulmonary resuscitation and automatic external defibrillator
use from the American Heart Association and American Red Cross to ensure the safety of all
participants. In addition, at least one of the researchers was a licensed Occupational Therapist
with a background in working with individuals with ASD, who was consulted in the event that
a subject became overwhelmed, anxious, or agitated, and who provided appropriate support
and assistance to subjects when necessary.
Human Subjects Involvement and Characteristics. Participants in the ASD group
were young adults with ASD as confirmed by researcher-reviewed documentation of the
diagnosis. Subjects in the NT partner group did not have ASD. As expected, there were more
males than females in the ASD group, which reflects the population of individuals with ASD
(approximately 5:1; CDC, 2014). NT subjects heavily skewed female, and may reflect the fact
that a majority of the students who participate in Hussman Center activities are studying
Occupational Therapy, Speech Therapy, and Special Education, all historically female-
dominated fields.
Risks. There were no major risks associated with this study. However, subjects had
the potential to become bored, fatigued, short of breath, or lose their balance while playing the
exergames or performing the Body Coordination tests. One subject became frustrated and
agitated during the TSVG play with his partner, and required a supported break during which
he left the room with researcher supervision for 10 minutes in order to “cool off.”
No invasive measures were undertaken. There were no risks associated with wearing
the Actical accelerometer or Polar heart rate monitor, other than minor discomfort from the
chest or hip bands. The Principal Investigator and research assistant were responsible for
108

tracking and identifying any adverse effects, such as dissatisfaction with any aspects of the
study, and intervened early to resolve any issues that arose. All project staff were trained in
adverse events reporting procedures.
Data analysis
The SAS version 9.2 statistical package was used to complete all statistical
calculations, with the level of significance set a priori at p≤0.05, and all significant test results
were reported with either one- or two-tailed probabilities depending on the hypothesis. All
data measures were tested for normality (Kolmogorov-Smirnov test) and variance. Any
statistically significant findings were explored further using Tukey post-hoc tests and t-tests
with Bonferroni corrections as appropriate.
Prior to the testing of aims, preliminary analysis proceeded with examination of
standard summary statistics and verification of outliers. Baseline differences in group
characteristics were analyzed by t-tests for continuous variables (or the Wilcoxon rank sum
test, if appropriate) and chi-square or Fisher's Exact Test for categorical data. Demographic
characteristics were tabulated using descriptive statistics and frequency distributions.
A repeated measures MANOVA was used to analyze the effect of game type (Boxing
EG, Tennis EG, or TSVG), sequence, and game type by sequence (interaction) effects for all
outcome variables. Repeated measures analysis revealed no significant effect of gameplay
sequence on main outcomes. Because no significant difference existed due to randomized
playing order (p>0.05), data for each playing condition (Boxing, Tennis, and TSVG; both
alone and with a partner) were combined for subjects in all random sequence assignments.
The correlation structure of predictors was examined, and basic data visualization
performed, in order to determine potential confounders such as age, gender, and body weight
status. For continuous variables, normalizing transformations were undertaken, where
possible. To make data analogous for comparison purposes, activity counts during each
109

condition were transformed to a 10-minute time frame if gameplay deviated from the
scheduled time allotted.
A two group (ASD vs. NT) by two playing condition (alone vs. with a partner) by
three game (Tennis EG vs. Boxing EG vs. TSVG) by five outcome variable (HR
avg
,
%time
MVPA,
Activity
counts/min,
RPE
,
and Enjoyment) MANOVA was initially considered to
determine if these categorical predictors explained any of the variability in the continuous
response variables, both within and between subject groups. However, due to high correlation
among the dependent variables, this analysis could not be accurately interpreted, so the results
were rejected.
We then employed a series of 2 (Group: ASD/NT) by 2 (Condition: Alone vs. Partner
play) by 3 (Game: BOX, TEN, TSVG) mixed design analyses of variance tests (ANOVAs).
Separate analyses were conducted using HR
avg
, % time in MVPA, Activity counts, RPE, and
Enjoyment as the dependent variables. The Huyn-Feldt adjustment was used when the
assumption of sphericity was violated. When three-way interactions were present, we then
tested two-way interactions at each level of the third variable (generalizing testing of the
simple main effects of the two-way interactions).
One-way ANOVAs were performed to examine differences in subject characteristics
(age, height, weight, BMI percentile, Waist-to-height ratio, and Body Fat percentage) and the
Body Coordination Composite of the BOT-2, between diagnostic groups (ASD vs. NT).
Correlation analyses were performed between pre-participation questionnaire scores
(anthropometric characteristics, physical activity level, enjoyment of physical activity,
videogame playing history) and activity level achieved under each condition.
Results
Participants. Eighteen subjects with ASD and 18 NT partners completed the study.
Additionally, two subjects who fully enrolled, and three subjects who were recruited and
110

scheduled for enrollment, failed to attend any sessions due to scheduling conflicts or
“personal reasons.” Tables 2, 3, and 4 describe the demographic and baseline characteristics
of the sample.
Both groups identified as predominantly white, non-Hispanic. Subjects with ASD
reported co-morbid diagnoses of Learning Disability (67%), Developmental Disability (33%),
Attention Deficit/Hyperactivity Disorder (33%), Intellectual Disability (28%), Sensory
Integration Disorder (22%), Developmental Coordination Disorder (17%), and others
including Anxiety, Executive Function Disorder, Obsessive Compulsive Disorder, Depression
(6-11% each). Subjects with ASD were significantly older than their NT partners (p<.001).
Despite our intent to describe the ASD group with more standardized measures, the
Hussman Center requested that no I.Q. scores or other indicators of diagnostic level (such as
the Autism Diagnostic Observation Schedule) be collected as part of this study. Therefore,
subjects were divided post-hoc by the researcher into three functional descriptive categories,
based on observation and video analysis. Subjects classified as “Low” were either non-verbal
or used only echolalic language, lived with a parent or caregiver, and required verbal cues and
intermittent physical prompts from the researcher to maintain participation in videogame play.
Four subjects (22%) were classified in this category. The eight subjects in the “Moderate”
category (50%) used some spoken language, were able to complete written intake forms with
assistance, and required only verbal cues from the researcher and playing partner to play
videogames. Subjects in the “High” category used fluent expressive language, completed all
forms independently, and required only posted visual cues or intermittent verbal cues from
their playing partner to maintain gameplay. Five subjects (28%) were classified as “High”
functioning using this metric. Analysis of variance revealed no significant differences
between functional level groups on any of the physical activity-related outcomes measures.
111

Research hypotheses In order to determine if heart rate, physical activity (measured
by accelerometer and perceived exertion), and self-reported enjoyment while exergaming
were greater than while playing a TSVG, separate three-way ANOVAs for each dependent
variable were performed. Initially, we had planned to collapse data resulting from the two
EGs (Tennis, Boxing) and analyze them together, but because physical activity response and
enjoyment level varied significantly between Tennis and Boxing (p<.01; p<.05) for both
groups, they were analyzed separately. Analysis revealed that for both groups, the Boxing
exergame was the most enjoyable, was perceived to be the most physically demanding, and
also required the most energy to play, followed by Tennis and the TSVG, respectively (see
Tables 5a and 5b for a summary of physical activity-related response measures for the two
groups group during each gameplay condition). Subject responses were significantly different
between conditions, with partner play yielding greater energy expenditure, enjoyment, and
perceived exertion, compared to solitary play, across each game type (Boxing, Tennis, and
TSVG).
We hypothesized that the magnitude of changes in enjoyment, heart rate, and activity
level resulting from exergaming would not differ significantly between young adults with and
without ASD. However, because all five ANOVAs indicated a main effect of diagnostic group
on the primary outcomes, paired t-tests were completed for all physical activity-related
response variables (HR, activity counts, % of time in MVPA, RPE, and Enjoyment) between
groups. The ANOVA testing also revealed significant group (ASD vs NT) by game type
(Boxing, Tennis, TSVG) interactions, and group by playing condition (alone vs. with a
partner) interactions for most dependent variables (Table 6). Results indicate that although
both groups displayed a similar response pattern to playing each type of game (Boxing was
more strenuous and more fun, followed by Tennis and TSVG play), the magnitude of
response for individuals with ASD was significantly elevated, compared to the NT group (see
112

Table 7). Similarly, although playing with a partner allowed both groups to achieve greater
energy expenditure and enjoyment than while playing alone for all game types, the ASD
group had significantly higher enjoyment, heart rate, and activity level response than the NT
young adults. Table 7 presents the between-groups differences on each of these measures for
the six playing conditions. Thus, the original null hypothesis (no differences between group
outcomes) was rejected. However, results of further post-hoc ANOVA testing resulted in a
deviation from the expected pattern. There were main effects for diagnostic group [F(1,
99.50), p<.001] and gameplay condition [F(1,213.66), p<.001], and a significant three-way
interaction between diagnostic group, playing condition, and enjoyment [F(1, 81.30), p<.001],
once enjoyment scores were dichotomized (high/low) to be investigated as independent
predictors of RPE (Table 6). Post-hoc paired t-testing of perceived exertion data showed that
for subjects on the Autism Spectrum, playing with a partner led to an increase in playing
intensity (HR
avg
, % time
MVPA
, activity counts) and enjoyment, but a decrease in RPE. For NT
subjects, playing with a partner (regardless of the partner’s ASD or NT status) also increased
playing intensity and enjoyment, but RPE increased accordingly (opposite the response of the
ASD group).
Exploratory Questions. To examine factors associated with physical activity in
individuals with ASD, and relationships between these factors and physical activity levels
achieved during videogame play, correlations were run between baseline measures, including
body coordination, body mass index, previous videogame exposure, and daily activity habits,
and the main physical activity-related outcome variables (Table 8). The group with ASD had
lower body coordination scores than their typically developing peers, and engaged less
frequently in physical activities for leisure/recreation (see Table 3). Subjects on the spectrum
also owned more videogame systems, played more frequently, and played alone more often
than subjects in the NT group (Table 4).
113

However for both groups combined, correlation analysis (see Table 8) revealed that no
significant relationships between any physical activity-related outcomes and gender, height,
weight, waist circumference, BMI, waist-to-height-ratio, body fat percentage, gross motor
skills, or pre-study daily hours playing videogames. The strongest correlations (r > 0.6) were
between average HR while exergaming and engagement in physically active recreation or
leisure pursuits (negative relationship). Moderate relationships (0.4 > r < 0.6) were found
between percentage of exergame playing time spent in MVPA, and both engagement in active
pursuits and baseline body coordination scores (p≤0.05). In addition, weak to moderate
relationships (0.1 > r < 0.4) were found between perceived exertion and fine motor skills,
daily activity level, and pre-study enjoyment of physical activity (p≤0.05), with less
coordinated subjects achieving higher heart rates and more activity counts while playing the
exergames. Finally, baseline scores from the BOT-2 (Bruininks & Bruininks, 2005) were
moderately correlated with enjoyment of exergame play, and negatively related to activity
counts achieved (p≤0.05). Moderate negative correlations were found between pre-study
enjoyment of physical activity, baseline activity level, frequency of choosing physically active
recreation/leisure, and perceived exertion during active gameplay. The opposite was true for
these factors and enjoyment of the exergames during the study.
When examining the relationships between individual baseline profiles, self-reported
daily physical activity level was strongly correlated with body characteristics – that is, the
more fit individuals were the most likely to engage in and enjoy physical activity. Baseline
body coordination (as measured by the BOT-2) was also weakly correlated with self-reported
skill level in both fine and gross motor performance for all subjects.
NT subjects, who had significantly better body coordination (p<.01) and more healthy
weight and body fat ranges (p<.05), acheived less time in MVPA (p<.01) and fewer activity
counts per minute (p<.001) while playing the active videogames than their peers with ASD.
114

However, NT subjects still reached MVPA during 77% of exergame playing time (compared
to 86% for subjects with ASD). This indicates that for both groups, exergaming for 20
minutes can contribute at least 15 minutes of MVPA to recommended daily activity. Although
individuals with ASD played all exergames with significantly greater intensity than their NT
peers, both ASD and NT groups had higher heart rates and activity counts when playing with
a partner versus playing alone (p<.01).
To better visualize the physical activity-related response patterns during videogame
play of ASD and NT groups for each of the game conditions, separate Figures for each
measure are presented for HR
avg,
(Figure 2), percent of time subjects spent in MVPA (or 60-
80% age- and gender-specific HR
max
; Figure 3), difference in average activity counts per
minute (Figure 4), average RPE (Figure 5), and average Enjoyment scores (Figure 6). A Key
to the Figures is provided for ease of interpretation.
Although the two diagnostic groups have been depicted separately in the Figures, it is
important to highlight the similarities in response pattern between the groups. For all subjects,
Boxing with a partner was the most physically challenging game condition, followed by
Boxing alone, then Tennis with a partner, Tennis alone, and finally the TSVG games. This
same order describes the most enjoyable games, from Boxing with a partner to solitary TSVG
play. However, RPEs reported by the ASD group were higher when playing alone compared
to playing the same game with a partner, while the NT group reported higher RPEs when
playing with someone else. This effect was explained by interaction testing, which revealed a
moderating effect of enjoyment and the partner play condition (which were found to be strong
covariates) on perceived exertion for the ASD group only (p<.001, see Figure 6). This means
that for the individuals on the Autism Spectrum, the increased enjoyment gained through
social interaction likely influenced the strength of the relationship between perceived exertion
and gameplay.
115

Neurotypical contrast group. In order to provide a comparison to gameplay response,
the NT subjects were paired with another enrolled NT subject in addition to playing alone and
with their partners with ASD. For each main outcome (HR
avg
, % time
MVPA
, activity counts,
RPE, and Enjoyment), there were no significant differences between subjects’ responses when
playing with the NT partner compared to the partner with ASD (p>0.05 for all tests). This
finding is noteworthy, because it indicates that the NT subjects were likely not “playing
down” to their partners with ASD, and that they worked just as hard and reported having just
as much fun with both playing partners. Thus, we can be more confident that the physiological
responses were relatively accurate to “real-world” gameplay, and that playing with a
neurodiverse individual did not limit enjoyment for typically developing young adults.
Unanticipated outcomes. Review of videorecordings and post-study interviews
confirms that both subject groups preferred partner play to solitary play, and that they felt
participation in the study helped them to develop relationships with others outside their typical
social worlds. A number of unanticipated positive outcomes occurred in addition to the
empirical findings. For example, one reserved young NT man, who participated consistently
but did not often exhibit clear signs of enjoyment, told the researcher at the conclusion of the
study that the experience had been “life-changing,” and that he now wished to pusue special
education as a career instead of business.
Another NT subject had enrolled in the study because her education class had assigned
each student a semester-long project to “challenge themselves by doing something
uncomfortable.” This subject admitted that she had never interacted with individuals with
disabilites, and was afraid to do so before the study. By the end, this subject was easily
chatting and joking with her partner with ASD, and even brought him a gift at the end of the
study because she knew she would miss him.
116

Connections were made between families of subjects on the Autism Spectrum and NT
partners, as more than one caregiver asked the NT partner to keep in touch so that they could
spend time outside the study socializing in the future. A number of subjects with ASD
indicated that the study was the first time they had experienced competition with someone
outside their family, and that playing together was more fun and more exercise than they had
anticipated. Each of these examples is encouraging, as they again reinforce the idea that social
interaction can contribute to improved quality of engagement in physical activity.
Discussion
Unexpectedly, prior videogame experience was not related to physical activity-related
responses. One reason for this may be that for both groups, the majority of previous
videogame experience was with TSVGs, and the researcher selected EGs for the study that
were simple to learn and use, increasing the likelihood that most subjects would understand
the rules quickly, and decreasing the possibility of frustration while playing.
Baseline resting HR was significantly higher in subjects with ASD compared to their
NT partners, although when this was controlled for, subjects on the Autism Spectrum still
achieved a greater percentage of time in MVPA while playing all videogames except the
TSVG alone. As the ASD group was slightly older than the NT group, it is possible that age
was one factor in the elevated average HR of this group, which is also reflected in the weak
positive correlation between HR and age noted in Table 8 (Nyakas, Buwalda, Luiten, &
Bohus, 1992). Regression analysis indicates that the anthropometric variables (weight, body
fat, etc.), in combination with lower coordination scores, also likely contributed to this
difference. This result is not surprising, given that from video analysis, individuals with
poorer coordination demonstrated larger, less “smooth” movement patterns while playing,
which were less efficient and therefore may have increased heart rate and activity level.
117

Subjects with ASD reported higher RPEs and expended more energy (as measured by
HR and Activity Counts) during gameplay than their NT partners for all exergaming
conditions, but a critical difference is noted here - subjects with ASD reported greater
perceived exertion when playing alone (p<.05), while NT subjects reported greater perceived
exertion when playing with a partner (p<.05). This finding indicates that although NT
subjects are more accurate in their self-assessment of exercise intensity (RPE was more
strongly correlated with HR and Activity Counts), the subjects with ASD perceived
themselves to be working less when playing with their partner. A test of the interaction effect
of enjoyment indicates that for subjects with ASD, enjoyment (which was greater during
partner play than solitary play) does in fact moderate the experience and/or perception of
energy expenditure during physical activity (p<.01). This finding is important, as it
demonstrates through quantitative physiological data that individuals on the Autism Spectrum
can be motivated for exercise by social interaction – which may in turn increase intensity and
duration of physical activity engagement, and further enhance enjoyment.
Significant differences were found between diagnostic groups for all demographic and
anthropometric measures, although these characteristics were confounded by gender, as there
were significantly more males than females in the ASD group and significantly more females
than males in the NT group. However for comparison of gender-specific variables (such as
BMI percentile and height-to-waist ratio), the ASD group was, on the whole, more likely to be
overweight than the NT partners (p<.01). Despite these group-wise differences, the main
outcomes of concern for this study were the responses of the subjects with ASD to the various
gameplay conditions. Although the ASD and NT group responses were significantly different,
they were similar in overall pattern and direction, which supports the authors’ assumption that
individuals with ASD are likely to work harder and have more fun when playing with a
partner, just as NT subjects have been shown to do. The opportunity for the subjects with
118

ASD to engage in a naturalistic occupation with same-age peers, who as young adults often
desire to interact with the opposite sex, outweighs the possible limitations of confounding on
our interpretation of secondary results.
The primary aim was to determine if young adults on the Autism Spectrum achieved
similar patterns in physical activity-related outcomes as NT individuals in previous studies of
exergaming. The hypothesis was that the both the ASD and NT groups would experience
significantly higher energy expenditure while playing exergames versus TSVGs, and while
playing with a partner versus playing alone. We confirmed that both groups spent more time
in MVPA during exergames play compared to TSVGs although the ASD group played with
greater intensity overall. In addition, we expected that for both groups, playing exergames (as
opposed to TSVGs), and playing together (versus alone) would yield greater enjoyment.
Again, we found this to be true. However, the most interesting finding was the unanticipated
difference in perceived exertion between groups, with subjects with ASD reporting lower
perceived exertion while playing with a partner (at higher intensity), than those in the NT
group. A test of moderating effects yielded the explanation – the greater enjoyment
experienced during partner play moderated the perceived exertion of those in the ASD group
while playing exergames – perhaps leading them to report that they were expending less
energy than they actually were.
Limitations. This study has several limitations. Participants presented with a wide
range of functional abilities (typical of ASD), which, while limiting the true effect size, makes
it more likely that conclusions drawn about the effect of exergaming with this population are
accurate across functional levels. In addition, it was not possible to control for baseline
differences in age, gender, and other variables given that the ASD-NT partner pairs were
recruited using convenience sampling from an existing organization with an unbalanced
119

make-up of participants. Therefore, ASD-NT partner pairs did not have identical age or
gender characteristics.
Furthermore, subjects in this study were a select group who participate in a university-
sponsored social program, which could have led to self-selection bias, and thus the results
cannot be generalized to all young adults with ASD. Finally, the NT subjects, although
encouraged not to do so and supervised by the researcher, may have altered their playing
intensity when playing with their partner with ASD so as to avoid upset and improve their
partner’s self-concept. Although this could explain their lower energy expenditure compared
to the ASD group, because the NT groups’ physical activity response was also lower while
playing alone, it is more likely that the difference in energy expenditure between groups was
caused by the ASD subjects’ poorer body coordination, which likely required increased effort.
Conclusion
This study reinforces previous research that participants expend more energy while
playing active videogames than while playing TSVGs (Daley, 2009; Mark et al., 2008),
although subjects in this study achieved MVPA (as determined by change in heart rate) more
often than has been previously reported. Others have cautioned that exergames may not be as
demanding as more traditional sports and games, and should not be substituted for higher-
intensity activities (Daley, 2009; Foley & Maddison, 2010; Mark et al., 2008). The subjects in
this study experienced MVPA during the majority of exergames playing time, although each
session was limited to one or two bouts of 10 minutes. More research using subjects with
ASD is needed to determine which games in particular may be more likely to elicit MVPA,
and under what conditions. Although each game was repeated twice, the effect of novelty and
the excitement of partner play may have enhanced participants’ motivation to play with high
intensity.
120

In this study, perceived exertion during physical activity was moderated by enjoyment,
and enjoyment of gameplay was increased, when the ASD group played with a partner. This is
consistent with research on physical activity motivation in typically developing individuals,
which posits that people are have more fun and expend more energy when exercising with a
partner versus alone (Exner et al., 2009; Salvy et al., 2008; Staiano & Calvert, 2010).
Although evidence is beginning to show that individuals on the Autism Spectrum do desire
social interaction, many people outside the scientific and special needs communities continue
to perceive this population as uninterested in social interaction and unable to participate in
social activities (Bauminger & Shulman, 2003; Birch, 2003; Carrington et al., 2003; Gus,
2000; Hill & Frith, 2003; Howard et al., 2006; Hurlbutt & Chalmers, 2002; Jackson, 2003;
Miller 2003; Sainsbury, 2000). Our findings suggest that not only to young adults with ASD
enjoy social interaction, but it may help motivate physical activity participation and enhance
the experience of exercising.
Individuals with ASD, who are known to have problems with social interaction, found
exergaming with a peer to be more enjoyable, they worked harder, and they perceived it as
being less effortful in comparison to playing alone. Through the medium of the exergaming
system, participants were encouraged to interact with peers in an enjoyable and active way,
which could promote healthy lifestyle changes increasing engagement in physical activity.
These findings contribute to the scientific literature on factors associated with physical
activity, enjoyment, social play, and the use of videogames in young people with ASD. This
evidence has clinical and health promotion implications for individuals with
neurodevelopmental disabilities who are at risk for sedentary lifestyle and overweight/obesity.
In addition, the results will inform future research using videogame technology to promote
physical activity for individuals with ASD, and increases our understanding of the role
technology can play in enhancing the social worlds of young adults with ASD.
121

We conclude that exergaming is an effective and accessible medium to incorporate
physical activity into daily routines, and has the potential to assist in decreasing risk for
sedentary lifestyle and overweight/obesity in young adults with ASD and other developmental
disabilities. In addition, exergaming with a partner may enhance social skills and increase
interaction between individuals with ASD and their NT peers.
122

References

Abdel-Khalek, A. (2006). Measuring happiness with a single-item scale. Social Behavior and
Personality: an international journal, 34(2), 139-150.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
(DSM-V). 5th Edition. Washington, DC: American Psychiatric Association; 2013.
Anderson-Hanley, C., Tureck, K., & Schneiderman, R.L. (2011b). Autism and exergaming:
Effects on repetitive behaviors and cognition. Psychology Research and Behavior
Management, 4, 129–137.
Barkley, G.S. (2008). Factors influencing health behaviors in the National Health and
Nutritional Examination Survey, III (NHANES III). Social Work in in Health Care,
46(4), 57-79.
Bass, J.D. & Mulick, J.A. (2007). Social play skill enhancement of children with Autism
using peers and siblings as therapists. Psychology in the Schools, 44(7), 727-35.
Baum, C. & Christiansen, C. (1997). The Occupational therapy context: Philosophy –
principles – practice. In: C. Christiansen & C. Baum (Eds.), Occupational Therapy:
Enabling Function and Well-Being (p. 36). Thorofare, NJ: SLACK.
Baum C. & Christiansen, C. (2005). Overview of a PEOP Framework to Support Occupation-
Based Practice Occupations. In: C. Christiansen, C.M. Baum, & J. Bass-Haugen (Eds.)
Occupational therapy: performance, participation, and well-being, 3rd Edition (pp.
242-267). Thorofare, NJ: Slack.
Bauminger, N. & Shulman, C. (2003). The development and maintenance of friendship in
high-functioning children with Autism: Maternal perceptions. Autism, 7(1), 81–97.
Birch, J. (2003). Congratulations! It’s Asperger’s syndrome. London: Jessica-Kingsley
Publishers.
123

Bruininks, R.H. & Bruininks, B.D. (2005). Test of Motor Proficiency, 2nd Edition Manual.
AGS Publishing. Circle Pines, MN.
Carrington, S. B., Papinczak, T. & Templeton, E. (2003). A phenomenological study: The
social world of five adolescents who have Asperger's Syndrome. Australian Journal of
Learning Disabilities, 8(3), 15-21.
Carroll, B. & Loumidis, J. (2007). Children’s perceived competence and enjoyment in
physical education and physical activity outside school. European Physical Education
Review, 7(1), 24-43.
Cermak (2004). Demographic and physical activity questionnaire. Unpublished manuscript,
Department of Occupational Therapy, Boston University, Boston, Massachusetts.
Curtin, C., Bandini, L., Perrin, E., Tybor, D., & Must, A. (2005). Prevalence of overweight in
children and adolescents with attention deficit hyperactivity disorder and autism
spectrum disorders: A chart review. BMC Pediatrics, 5(1), 48
Daley, A. (2009). Can exergaming contribute to improving physical activity levels and health
outcomes of children? Pediatrics, 124, 763-771. doi: 10.1542/peds.2008-2357
Davidson, J. (2008). Autistic culture online: virtual communication and cultural expression on
the spectrum. Social and Cultural Geography, 9(7), 791–806.
Dietz, J.C., Kartin, D., & Kopp, K. (2007). Review of the Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2). Physical and Occupational Therapy in
Pediatrics, 27(4), 87-102.
Efrat, M.W. (2009) The relationship between peer and/or friends’ influence and physical
activity among elementary school children: A Review. Californian Journal of Health
Promotion, 7 (2009), 48–61.
124

Engel, A. (2011). Physical activity participation in children with Autism Spectrum Disorders:
An exploratory study (Master’s thesis). Retrieved from: The University of Toronto
Research Repository. http://hdl.handle.net/1807/29541
Exner, A., Papatheodorou, G., Baker, C.M., Verdaguer, A., Hluchan, C.M., & Calvert, S.L.
(2009, April). Solitary versus social gross motor videogame play: Energy expenditure
among low-income African American adolescents. Poster presented at the biennial
meeting of the Society for Research in Child Development, Denver, CO.
Feil-Seifer, D. & Mataric, M. (2008). Robot-assisted therapy for children with Autism
Spectrum Disorders. Proceedings of the 7
th
International Conference on Interaction
Design and Children, pp. 49-52. New York: ACM.
Finklestein, S., Nickel, A., Barnes, T., & Suma, E. (2010). Astrojumper: Motivating children
with Autism to exercise using a VR game. Presented at IEEE Virtual Reality 2010,
Waltham, Massachusetts, USA. Retrieved from:
http://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber=5444770
Foley, L. & Maddison, R. (2010). Use of active video games to increase physical activity in
children: A (virtual) reality? Pediatric Exercise Science, 22, 7-20.
Foran, A.C. & Cermak, S.A. (2013). Active and traditional videogame ownership and play
patterns among youth with Autism Spectrum Disorders, and relationships to physical
activity. PALAESTRA, 27(1), 42-48.
Freedson, P.S., & Miller, K. (2000). Objective monitoring of physical activity using motion
sensors and heart rate. Research Quarterly for Exercise and Sport, 71(2 Suppl), 21-29.
Garn, S.M., Leonard, W.R., & Hawthorne, V.M. (1986). Three limitations of the body mass
index. American Journal of Clinical Nutrition, 44, 996– 997.
Ghaffari M., Malone, R.P., Kahn, A., West, S.H., Delaney, M.A., Lawrence, T., Newschaffer,
C.J., & Hardison, H.H. (2009, July). Obesity in children with Autism Spectrum
125

Disorders. Paper presented at the 49
th
Annual NCDEU Meeting, Hollywood, Florida,
USA. Retrieved from:
http://www.cmeinstitute.com/postersession/2009Session2/ORIGGhaffari.pdf
Gillberg, C. (2003). Deficits in attention, motor control, and perception: A brief review.
Archives of Diseases in Childhood, 88, 904-910. doi: 10.1136/adc.88.10.904
Gorini, A., Gaggioli, A., Vigna, C., & Riva, G. (2008). A Second Life for eHealth: Prospects
for the use of 3-D virtual worlds in clinical psychology. Journal of Medical Internet
Research, 10(3), e21.
Greenwald, W. (2010). Kinect vs. PlayStation Move vs. Wii: Motion-control showdown.
Retrieved from: http://www.pcmag.com/article2/0,2817,2372244,00.asp.
Gus, L. (2000). Autism: Promoting peer understanding. Educational Psychology in Practice,
16(4), 461-468.
Herskowitz, V. (2009). Autism and Computers: Maximizing Independence through
Technology. Bloomington, Indiana: AuthorHouse.
Hill, E., & Frith, U. (2003). Understanding autism: insights from mind and brain.
Philosophical Transactions: Biological Sciences, 358(1430), 281-289.
Ho, H.H., Eaves, L.C. & Peabody, D. (1997). Nutrient intake and obesity in children with
autism. Focus on Autism and Other Developmental Disabilities, 12, 187-192. doi:
10.1177/108835769701200308
Howard, B., Cohn, E., & Orsmond, G.I. (2006). Understanding and negotiating friendships:
Perspectives from an adolescent with Asperger syndrome. Autism, 10(6), 619-627.
Hurlbutt, K., & Chalmers, L. (2002). Adults with Autism speak out: Perceptions of their life
experiences. Focus on Autism and Other Developmental Disorders, 17(2), 103–11.
Jackson, L. (2003). Freaks, geeks and Asperger syndrome: A User’s guide to adolescence.
London: Jessica Kingsley.
126

Josefi, O. & Ryan, V. (2004). Non-directive play therapy for young children with Autism: A
Case study. Clinical Child Psychology and Psychiatry, 9(4), 533-551.
Kazdin, A.E. (1990). Evaluation of the Automatic Thoughts Questionnaire: Negative
cognitive processes and depression among children. Psychological Assessment: A
Journal of Consulting and Clinical Psychology, 2(1), 73-79.
Kelly, L.A., McMillan, D.G.E., Anderson, A., Fippinger, M., Fillerup, G., & Rider, J. (2013).
Validity of actigraphs uniaxial and triaxial accelerometers for assessment of physical
activity in adults in laboratory conditions. BMC Medical Physics, 13(5).
King, G., Law, M., King, S., Rosenbaum, P., Kertoy, M.K., & Young, N.L. (2003). A
Conceptual model of the factors affecting the recreation and leisure participation of
children with disabilities. Physical & Occupational Therapy in Pediatrics, 23(1), 63-
90.
Law, M., Petrenchik, T., King, G., & Hurley, P. (2007). Perceived environmental barriers to
recreational, community, and school participation for children and youth with physical
disabilities. Archives of Physical Medicine and Rehabilitation, 88(12), 1636-1642.
Leininger, L.J., Coles, M.G., & Gilbert, J.N. (2010). Comparing enjoyment and perceived
exertion between equivalent bouts of physically interactive video gaming and
treadmill walking. Health & Fitness Journal of Canada, 3(1), 12-18.
Lotan, M., Yalon-Chamowitz, S. & Weiss, T. (2009). Improving physical fitness of
individuals with intellectual and developmental disability through a virtual reality
intervention program. Research in Developmental Disabilities 30, 229-239. doi:
10.1016/j.ridd.2008.03.005
Mark, R., Rhodes, R.E., Warburton, D.E.R., & Bredin, S.S.D. (2008). Interactive video games
and physical activity: A review of the literature and future directions. Health and
Fitness Journal of Canada, 1, 14-24.
127

Metcalf, B.S., Curnow, J.S., Evans, C., Voss, L.D., & Wilkin, T.J. (2002). Technical
reliability of the CSA activity monitor: The EarlyBird Study. Medicine and Science in
Sports and Exercise, 34(9), 1533-1537.
Miller, J. (2003). Women from another planet? Our lives in the universe of autism. Milan:
Dancing Mind Books.
Moore, D., Cheng, Y., McGrath, P., & Powell, N.J. (2005). Collaborative virtual environment
technology for people with Autism. Focus on Autism and Other Developmental
Disabilities, 20(4), 231-243.
Nyakas, C., Buwalda, B., Luiten, P.G.M., & Bohus, B. (1992). Effect of low amphetamine
doses on cardiac responses to emotional stress in aged rats. Neurobiology of Aging,
13(1), 123-129.
O’Neill, M. & Jones, R.S.P. (1997). Sensory-perceptual abnormalities in Autism: A case for
more research? Journal of Autism and Developmental Disorders, 27(3), 283-293.
Pan, C-Y. & Frey, G.C. (2006). Physical activity patterns in youth with autism spectrum
disorders. Journal of Autism and Developmental Disorders, 36, 597-606. doi:
10.1007/s10803-006-0101-6
Pan, C-Y, Tsai, C-L, & Hseih, K-W. (2011a). Physical activity correlates for children with
Autism Spectrum Disorders in middle school physical education. Research Quarterly
for Exercise and Sport, 82(3), 491-8.
Pan, C-Y., Tsai, C-L., Chu, C-H, & Hsieh, K-W. (2011b). Physical activity and self-
determined motivation of adolescents with and without Autism Spectrum Disorders in
inclusive physical education. Research in Autism Spectrum Disorders, 5(2), 733-741.
Pitetti, K.H., Rendoff, A.D., Grover, T. & Beets, M.W. (2007). The Efficacy of a 9-month
treadmill walking program on the exercise capacity and weight reduction for
128

adolescents with severe autism. Journal of Autism and Developmental Disorders, 37,
997-1006. doi: 10.1007/s10803-006-0238-3
Preissler, M. A. (2006). Play and Autism: Facilitating symbolic understanding. In D. Singer,
R.M. Golinkoff, & K. Hirsh-Pasek (Eds.), Play=Learning: How play motivates and
enhances children’s cognitive and social-emotional growth (pp. 231-250). New York,
NY: Oxford University Press.
Roemmich, J.N., Barkley, J.E., Lobarinas, C.L., Foster, J.H., White, T.M., & Epstein, L.H.
(2008). Association of liking and reinforcing value with children’s physical activity.
Physiology & Behavior, 93(4-5), 1011-1018.
Rimmer, J.H., Braddock, D. & Pitetti, K.H. (1996). Research on physical activity and
disability: an emerging priority. Medicine and Science in Sports and Exercise, 28,
1366-1372.
Rimmer, J.A. & Rowland, J.L. (2008). Physical activity for youth with disabilities: A critical
need in an underserved population. Developmental Neurorehabilitation, 11(2), 141-
148.
Rimmer, J.H., Yamaki, K., Davis, B.M., Wang, E., & Vogel, L.C. (2011). Obesity and
overweight prevalence among adolescents with disabilities. Preventing Chronic
Disability,8(2):A41.
Sainsbury, C. (2000). Martian in the playground. London: The Book Factory.
Salvy, S. J., Bowker, J. W., Roemmich, J. N., Romero, N., Kieffer, E., Paluch, R., et al.
(2008). Peer influence on children's physical activity: An experience sampling study.
Journal of Pediatric Psychology, 33(1), 39-49.
Salvy, S. J., Roemmich, J. N., Bowker, J. C., Romero, N. D., Stadler, P. J., & Epstein, L. H.
(2008). Effect of peers and friends on youth physical activity and motivation to be
physically active. Journal of Pediatric Psychology, 34(2), 217-225.
129

doi:10.1093/jpepsy/jsn071.
Sandlund, M., Hoshi, K., Waterworth, E.L., & Hager-Ross, C. (2009). A conceptual
framework for design of interactive computer play in rehabilitation of children with
sensorimotor disorders. Physical Therapy Reviews, 14(5), 348-354.
Scanlan, T.K. & Simons, J.P. (1992) The construct of sport enjoyment. In G. C. Roberts (Ed.),
Motivation in sport and exercise (pp. 199–215). Champaign, IL: Human Kinetics.
Schneider, M. & Cooper, D.M. (2011). Enjoyment of exercise moderates the impact of a
school-based physical activity intervention. International Journal of Behavioral
Nutrition and Physical Activity, 8, 64.
Sinclair, B. (2010). Kinect to reach 7.6 million in 2011. Retrieved from:
http://www.gamespot.com/news/6285819.html.
Schuler, A.L., & Wolfberg, P.J. (2000). Promoting peer play and socialization: The art of
scaffolding. In A.M.Wetherby & B.M.Prizant (Eds.), Autism spectrum disorders: A
transactional developmental perspective. Communication and language intervention
series (vol. 9, pp. 251–277). Baltimore, MD: Paul H. Brookes Publishing Co.
Selvadurai, H.C., Blimkie, C.J., Meyers, N., Mellis, C.M., Cooper, P.J. and Van Asperen, P.P.
(2002). Randomized controlled study of in-hospital exercise training programs in
children with cystic fibrosis. Pediatric Pulmonology, 33, 194–200.
Shane, H.C., Laubscher, E.H., Schlosser, R.W., Flynn, S. Sorce, J.F., & Abramson, J. (2012).
Applying technology to visually support language and communication in individuals
with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders,
42(6), 1228-1235.
Sherer, M., Pierce, K., Paredes, S., Kisacky, K., Ingersoll, B., & Schreibman, L. (2001).
Enhancing conversation skills in children with autism via video technology: Which is
better, “Self” or “Other” as a model? Behavior Modification, 25, 140–158.
130

Shropshire, J. and Loumidis, K. (1996). Development of the Pre-adolescent Attitude Towards
Physical Education Questionnaire (PAAPEQ), in C. Robson, B. Cripps and H.
Steinberg (Eds.) Quality and Quantity: Research Methods in Sport and Exercise
Psychology, pp. 44–49. Leicester: British Psychology Society.
Staiano, A. & Calvert, S. (2010, June). Wii Tennis play as physical activity in low-income
African American adolescents. Paper presented at the Annual Meeting of the
International Communication Association, Suntec City, Singapore.
Sturmey, P. (2003). Video technology and persons with autism and other developmental
disabilities: An emerging technology for PBS. Journal of Positive Behavior
Interventions, 5, 3–4.
Tyler, C.V., Schramm, S.C., Karafa, M., Tang, A.S., & Jain, A.K. (2011). Chronic disease
risks in young adults with Autism Spectrum Disorder: Forewarned is forearmed.
American Journal on Intellectual and Developmental Disabilities, 116(5), 371–380.
USDHHS (2004). National initiative on physical fitness for children and youth with
disabilities. Retrieved from: http://www.hhs.gov/od/physicalfitness.html.
Volkmar, F.R., Paul, R., Klin, A., & Cohen, D.J. (2005). Handbook of Autism and Pervasive
Developmental Disorders: Diagnosis, development, neurobiology, and behavior.
Hoboken, NJ: John Wiley & Sons.
Vygotsky, L. S. (1967). Play and its role in the mental development of the child. Soviet
Psychology, 5(3), 6-18.
Williams, J.G., Eston, R.G., & Furlong, B. (1994). CERT: A Perceived exertion scale for
young children. Perceptual Motor Skills, 79, 1451-8.
Wolfberg, P.J. (1999). Play and imagination in children with autism. New York: Teachers
College Press, Columbia University.
131

Wuang, Y-P., & Su, Chwen-Y. (2009). Reliability and responsiveness of the Bruininks-
Oseretsky test of Motor Proficiency – Second Edition in children with intellectual
disability. Research in Developmental Disabilities, 30(5), 847-855.
Yalon-Chamovitz S, Weiss PL. (2008). Virtual reality as a leisure activity for young adults
with physical and intellectual disabilities. Research in Developmental Disabilities.
29(3), 273-87.
Yelling, M., Lamb, K.L., & Swaine, I.L. (2002). Validity of a pictorial perceived exertion
scale for effort estimation and effort production during stepping exercise in adolescent
children. European Physical Education Review, 8(2), 157-175.
132

Tables and Figures

Figure 1. Key to Tables and Figures

BOX1 = Boxing EG (alone)
BOX2 = Boxing EG (with partner)
TEN1 = Tennis EG (alone)
TEN2 = Tennis EG (with partner)
TSVG1 = Seated Videogame (alone)
TSVG2 = Seated Videogame (with partner)
133

Table 1. Measures
Measure Variable(s) Source Aim

Perceived Exertion Exertion during videogame play

Self-report using 10-point
Visual RPE scale
(modified from CERT)

1, 2, 3
Enjoyment Enjoyment during videogame
play
Self-report using 4-point
Likert scale (modified
from PAAPEQ)

1, 2, 3
Physical Activity Activity counts, time and % of
time in MVPA

Actical Accelerometer 1, 2, 3
Physical Activity Heart rate (resting, pre-exercise,
average during exercise, % of
time in target zone, peak HR)

Polar Heart Rate Monitor 1, 2, 3
Subject group ASD diagnosis or Neurotypical
status
Document review
(medical form, physician
note, or approved
educational materials
such as an IEP)
2, 3
Pre-study physical
activity level
Frequency of engagement in
physical activity
Physical Activity and
Demographic
questionnaire

3
Anthropometric
Characteristics
BMI percentile; Weight; Weight
Category; Waist-to-height Ratio;
Body Fat percentage

Measured height, weight,
waist circumference

3
Body Coordination Balance and Bilateral
Coordination

Body Coordination
Composite of the
Bruininks Oseretsky Test
of Motor Proficiency,
Second Edition

3

Demographic and
medical variables

Age, race/ethnicity, diagnoses

Physical Activity and
Demographic
Questionnaire

3

Familiarity with
videogames
Pre-study videogame ownership
and play habits
Videogame Survey

3

134

Table 2. Demographic characteristics of participants.
ASD group NT group
Males
N=16
Females
N=2
Males
N=3
Females
N=15

Age (years)

22.3

20.4

18.6

19.9

Ethnicity 14 White
1 Black
1 Latino

2 White 3 White 14 White
1 Latino
Height (in) 69.9 65 69.7 63.9

Weight (lbs) 170.7 200 162 129

Waist circumference

35.7 40.5 30 30.3

BMI (kg/m
2
)
% overweight/obese

24.4
40.0
33
50.0

23.2
33.3
22.3
20.0
Waist-to-height ratio (%)

50.9 62.1 43.1 47.4
Body fat percentage

18.0 36.8 10.4 29.1
Resting HR 71.2 83.5 68.3 61.8

135

Table 3. Baseline descriptive factors – body coordination and physical activity.
ASD group
(N=18)
NT group
(N=18)

Body Coordination Standard Score
(Descriptive Category)
1

33.4
(Below Avg.)

50.3
(Average)
Self-described Gross motor skills
2

Well-below average
Slightly below average
Average
Slightly above average
Above average

17%
35%
29%
6%
6%

0%
0%
33%
50%
17%

Self-described Fine motor skills
2

Well-below average
Slightly below average
Average
Slightly above average
Above average

29%
18%
35%
18%
0%

0%
6%
50%
39%
6%
Self-described Activity Level
2

Well-below average
Slightly below average
Average
Slightly above average
Above average

18%
24%
24%
21%
6%

0%
0%
22%
39%
39%
Self-described Enjoyment of PA
2

Well-below average
Slightly below average
Average
Slightly above average
Above average

24%
24%
29%
18%
6%

0%
0%
22%
33%
44%

Self-described leisure/recreational
preference
2

Always sedentary
Frequently sedentary
Balance of active/sedentary
Frequently active
Always active

53%
6%
29%
12%
0%

0%
11%
22%
67%
0%
1
Body Coordination descriptive categories are based on age- and gender-specific standard
scores on the BOT-2 sub-test (Bruininks & Bruininks, 2005).
2
From the Demographic and Physical Activity Questionnaire (Foran & Cermak, 2012).

136

Table 4. Baseline descriptive factors – videogame exposure.
ASD
group
N = 18
NT group
N = 18
p-value

Number of videogame
systems owned

5.9

3.3

<.01

Plays videogames 83% 56% <.001

Hours per day playing
TSVGs
2.5 hours 0.75 hours <.01

Hours per day playing EGs 1.0 hours 0.5 hours <.05

Most frequent playing
status
Alone With a friend N/A

137

Table 5a. Response to videogame play under each condition – Subjects with ASD.
Boxing EG Tennis EG TSVG

Alone Partner Alone Partner Alone Partner

HR
avg
(bpm)
S.D.

160.5
5.7

168.2
6.11

118.0
4.8

128.4
4.6

84.5
6.1

90.0
6.9

% time
MVPA

S.D.
91.0
1.5
94.0
1.2
70.0
1.0
90.0
0.9
0.0
0.1
10.0
0.1

Activity
counts/min

S.D.
3016
65
3812
102
664
17
1544
40
15
5
334
7

RPE
S.D.
8.0
1.2
7.5
1.1
4.0
0.2
2.5
0.8
1.0
0.1
1.0
0.1

Enjoyment
S.D.
14.5
1.1
16.0
2.5
15.0
1.6
15.5
2.6
12.5
1.8
15.0
1.0

Table 5b. Response to videogame play under each condition – NT Subjects.
Boxing EG Tennis EG TSVG

Alone Partner Alone Partner Alone Partner

HR
avg
(bpm)
S.D.

151.3
5.0

154.2
3.7

120.6
4.1

122.0
4.5

72.6
2.9

78.0
3.4

% time
MVPA

S.D.
83.0
2.5
88.0
3.1
69.0
1.5
69.0
1.4
0.0
0.0
0.0
0.1

Activity
counts/min

S.D.
839
21
1464
40
371
7
786
16
9
3
70
5

RPE
S.D.
2.5
0.8
4.5
1.0
1.5
0.1
3.5
0.4
1.0
0.0
1.0
0.0

Enjoyment
S.D.
14.0
2.1
14.5
1.5
13.5
2.1
12.5
3.0
11.5
1.8
13.0
2.5

138

Table 6. ANOVA table for effects on main outcome variables as a function of group, social condition, and game type.
Test Factors Dependent
variable(s)
df Outcome

2x2x3 mixed
ANOVA

A: ASD/NT
B: Alone/Partner
C: BOX/TEN/TSVG

HR
avg

df
A
: 1
df
B
: 1
df
C
: 2
df
AB
: 1
df
AC
: 2
df
BC
: 2
df
ABC
: 2
df
total
: 215

Main effect
A
: F 8.91***
Main effect
B
: F 37.04***
Main effect
C
: F 22.39***
Interaction
AB
: F 0.09
Interaction
AC
: F 1.10
Interaction
BC
: F 119.77**
3-way interaction
ABC
: F 29.43*

2x2x3 mixed
ANOVA
A: ASD/NT
B: Alone/Partner
C: BOX/TEN/TSVG
%time
MVPA

df
A
: 1
df
B
: 1
df
C
: 2
df
AB
: 1
df
AC
: 2
df
BC
: 2
df
ABC
: 2
df
total
: 215

Main effect
A
: F 4.41***
Main effect
B
: F 12.75***
Main effect
C
: F 59.83***
Interaction
AB
: F 3.00
Interaction
AC
: F 4.55*
Interaction
BC
: F 0.43
3-way interaction
ABC
: F 38.88*

2x2x3 mixed
ANOVA
A: ASD/NT
B: Alone/Partner
C: BOX/TEN/TSVG
Activity
counts/min

df
A
: 1
df
B
: 1
df
C
: 2
df
AB
: 1
df
AC
: 2
df
BC
: 2
df
ABC
: 2
df
total
: 215

Main effect
A
: F 16.98***
Main effect
B
: F 14.40***
Main effect
C
: F 14.57***
Interaction
AB
: F 0.69
Interaction
AC
: F 15.72*
Interaction
BC
: F 2.99
3-way interaction
ABC
: F 33.54*

2x2x3 mixed
ANOVA
A: ASD/NT
B: Alone/Partner
C: BOX/TEN/TSVG
RPE

df
A
: 1
df
B
: 1
df
C
: 2
df
AB
: 1
df
AC
: 2
df
BC
: 2
df
ABC
: 2
df
total
: 215

Main effect
A
: F 99.50***
Main effect
B
: F 213.66***
Main effect
C
: F 14.09**
Interaction
AB
: F 117.89***
Interaction
AC
: F 50.34*
Interaction
BC
: F 2.72
3-way interaction
ABC
: F 1.01

2x2x3 mixed
ANOVA
A: ASD/NT
B: Alone/Partner
C: BOX/TEN/TSVG
Enjoyment df
A
: 1
df
B
: 1
df
C
: 2
df
AB
: 1
df
AC
: 2
df
BC
: 2
df
ABC
: 2
df
total
: 215

Main effect
A
: F 2.89
Main effect
B
: F 201.41**
Main effect
C
: F 49.50*
Interaction
AB
: F 0.68
Interaction
AC
: F 0.04
Interaction
BC
: F 1.17
3-way interaction
ABC
: F 0.02

2x2x2 mixed A: ASD/NT RPE df
A
: 1 Main effect
A
: F 99.50***
139

ANOVA B: Alone/Partner
C: Hi/Lo Enjoyment
df
B
: 1
df
C
: 1
df
AB
: 1
df
AC
: 1
df
BC
: 1
df
ABC
: 1
df
total
: 143

Main effect
B
: F 213.66***
Main effect
C
: F 65.96**
Interaction
AB
: F 117.89***
Interaction
AC
: F 12.55**
Interaction
BC
: F 18.83**
3-way interaction
ABC
: F 81.30***

*p≤0.05
**p<0.01
***p<0.001

140

Table 7. Differences in response to videogame play between ASD and NT groups (paired t-test).
HR
avg
(SD) % time
MVPA
(SD) Activity
counts/min
(SD) RPE (SD) Enjoyment (SD)
p-value p-value p-value p-value p-value

BOX2
ASD
NT

168.2(6.1)
154.2(3.7)
<.0001

94(1.2)
88(3.1)
<.0001

3812(102)
1464(40)
<.0001

7.5(1.1)
4.5(1.0)
<.0001

16.0(2.5)
14.5(1.5)
<.05

BOX1
ASD
NT

160.5(5.7)
151.3(5.0)
<.0001

91(1.5)
83(2.5)
<.0001

3016(65)
839(21)
<.0001

8.0(1.2)
2.5(0.8)
<.0001

14.5(1.1)
14.0(2.1)
ns

TEN2
ASD
NT

128.4(4.6)
122.0(4.5)
<.001

90(0.9)
69(1.4)
<.0001

1544(40)
786(16)
<.0001

2.5(0.8)
3.5(0.4)
<.0001

15.5(2.6)
12.5(3.0)
<.01

TEN1
ASD
NT

118.0(4.8)
120.6(4.1)
ns

70(1.0)
69(1.5)
<.05

664(17)
371(7)
<.0001

4.0(0.2)
1.5(0.1)
<.0001

15.0(1.6)
13.5(2.1)
<.05

TSVG2
ASD
NT

90(6.9)
78(3.4)
<.0001

10(0.1)
0(0.1)
<.0001

334(7)
70(5)
<.0001

1(0.1)
1(0.0)
ns

15.0(1.0)
13(2.5)
<.01

TSVG1
ASD
NT

84.5(6.1)
72.6(2.9)
<.0001

0(0.1)
0(0.0)
ns

15(5)
9(3)
<.001

1(0.1)
1(0.0)
ns

12.5(1.8)
11.5(1.8)
ns

141

142

Table 8. Correlations between physical activity-related measures and baseline characteristics (groups combined).

Age

Fine motor
skills

Daily
activity
level

Physical
activity
enjoyment

Engagement in
physically active
recreation/leisure

BOT-2
Bilateral
Coordination

BOT-2
Balance

BOT-2 Body
Coordination
BOX2
HR
0.24 -0.34 ns -0.16 -0.61 -0.28 -0.15 -0.29
BOX1
HR
0.22 -0.34 ns -0.30 -0.66 -0.29 -0.15 -0.34
TEN2
HR
0.30 -0.31 ns -0.22 -0.62 -0.2 -0.19 -0.32
TEN1
HR
0.31 -0.32 ns -0.14 -0.45 -0.26 -0.18 -0.28
TSVG2
HR
ns -0.18 ns ns ns ns ns ns
TSVG1
HR
ns -0.23 ns ns ns ns ns ns
BOX2
% MVPA
0.25 -0.34 ns -0.29 -0.44 -0.34 -0.19 -0.45
BOX1
% MVPA
0.22 -0.3 ns -0.23 -0.32 -0.34 -0.21 -0.45
TEN2
% MVPA
0.28 -0.22 ns -0.19 -0.44 -0.32 -0.20 -0.42
TEN1
% MVPA
0.30 -0.31 ns -0.19 -0.41 -0.39 -0.12 -0.39
TSVG2
% MVPA
ns -0.34 ns ns ns ns ns ns
TSVG1
% MVPA
ns -0.26 ns ns ns ns ns ns
BOX2
RPE
ns -0.37 -0.46 -0.52 -0.34 0.12 ns 0.19
BOX1
RPE
ns -0.37 -0.32 -0.53 -0.39 0.20 ns 0.27
TEN2
RPE
ns -0.34 -0.32 -0.50 -0.33 0.21 ns 0.21
TEN1
RPE
ns -0.28 -0.36 -0.56 -0.33 0.20 ns 0.22
TSVG2
RPE
ns ns -0.45 -0.56 -0.62 -0.30 -0.11 -0.31
TSVG1
RPE
ns ns -0.45 -0.61 -0.61 -0.23 -0.14 -0.29
BOX2
Enjoyment
-0.12 -0.22 0.23 0.34 0.33 0.43 0.41 0.52
BOX1
Enjoyment
-0.10 -0.2 0.12 0.34 0.35 0.42 0.40 0.50
TEN2
Enjoyment
-0.13 -0.17 0.19 0.35 0.30 0.45 0.43 0.54
TEN1
Enjoyment
-0.13 ns 0.21 0.39 0.33 0.46 0.38 0.39
TSVG2
Enjoyment
-0.24 ns -0.33 -0.21 -0.19 0.34 0.29 0.32
TSVG1
Enjoyment
-0.20 ns -0.36 -0.10 -0.12 0.39 0.31 0.31
143

BOX2
Act. counts
0.20 -0.11 ns -0.11 -0.20 -0.44 ns -0.49
BOX1
Act. counts
0.18 -0.12 ns -0.19 -0.15 -0.43 ns -0.50
TEN2
Act. counts
0.24 -0.32 ns -0.14 -0.14 -0.34 ns -0.46
TEN1
Act. counts
0.19 -0.21 ns -0.14 -0.13 -0.32 ns -0.49
TSVG2
Act. counts
ns ns ns ns ns ns ns ns
TSVG1
Act. counts
ns ns ns ns ns ns ns ns
Note
1
: There were no significant relationships between any physical activity-related outcomes and gender, height, weight, waist
circumference, BMI, waist-to-height-ratio, body fat percentage, gross motor skills, or pre-study daily hours playing videogames, so
these variables have been removed from the table.
Note
2
: All correlation values (Pearson coefficients) are significant at p ≤ 0.05.
144

Figure 2. Average heart rate (in bpm) during videogame play by ASD and NT groups.

*significant between-groups difference (p<0.05).
145

Figure 3. Average percent of time (during 10 minute session) spent in MVPA by group.

*significant between-groups difference (p<0.05).
Note: HR
target
(a representation of MVPA) is computed for each individual by calculating 60-80% HR
max
by age
and gender.

146

Figure 4. Average activity counts per minute during videogame play by group.

*significant between-groups difference (p<0.05).

147

Figure 5. Average Rating of Perceived Exertion (RPE) during videogame play by group.

*significant between-groups difference (p<0.05).

148

Figure 6. Enjoyment of videogames by group.

*significant between-groups difference (p<0.05).
149

Figure 7. Model of moderating effect (three-way interaction) of enjoyment during partner play on RPE.

150

CHAPTER 5

Conclusion
151

Conclusion

The preceding series of studies highlights three important contributions to the current
literature on Autism Spectrum Disorders and health promotion:
1. For young adults on the Autism Spectrum, exergaming is an accessible and
enjoyable way to engage in physical activity.
2. Young adults with ASD respond similarly to NT young adults when playing
(exercising) with a partner – that is, they expend more energy and report
greater enjoyment than if they were playing alone.
3. The medium of exergaming, in particular, is especially well-suited as a health-
promoting activity for young adults with ASD, as it may contribute to
enhanced physical health, mental health, and social participation.
The three studies clearly demonstrate that exergaming results in increased heart rate
and caloric expenditure, contributing to players’ daily physical activity. This is especially
important for young adults with ASD, as they are more likely than their NT peers to become
overweight or obese, and to develop secondary health conditions related to lack of physical
activity (Coyne & Fullerton, 2004; Pitetti et al., 2007; Rimmer at al., 1996; Rowland, 2007;
Sandt & Frey, 2005). Recently, there has been an increased emphasis in the health behavior
literature on sedentary behavior –decreasing the time people are not moving, as opposed to
focusing solely on meeting recommended time in MVPA (Biddle et al., 2004; Tremblay et al.,
2011). Sedentary behaviors such as TSVG play, a frequent activity for many people on the
Autism Spectrum (Orsmond & Kuo, 2011; Foran & Cermak, 2013), have been linked to
increased cancer biomarkers and poorer cardiovascular health (American Institute for Cancer
Research, 2011; Spruijt-Metz & Hsu, 2012; Wilmot et al., 2012). Reducing the time spent in
sedentary activities, and replacing them with a similar but more active version such as
exergaming, may be a key to lifelong health. Exercise can also increase functional capacity, or
152

performance of activities of daily living (Maiorana et al., 2000). The studies, therefore,
provide initial evidence to support the use of exergames to enhance independence and
decrease caregiver burden for individuals with ASD.
My extensive clinical observations of individuals on the Autism Spectrum during
physical activity led to a hypothesis that young adults with ASD would work harder and have
more fun while exercising with a partner than when alone – just as we know neurotypical
people tend to do. In Study 3, I was able to show that this pattern does, in fact, hold true for
young adults with ASD. Researchers working to develop a videogame to enhance perceptual,
attentional, and social cognitive skills in individuals with ASD write that “many capabilities
that once were assumed to be absent in people with autism are in fact perfectly functional, if
only we set up the right circumstances in which to engage these capabilities” (Autism
Collaborative, 2014). This group posits that exergames may be the most effective way to
capture and maintain the interest of individuals with ASD, while collecting and recording the
behavioral data and physiological responses of concern. Hilton et al. (2014) have also pointed
to exergaming as an emerging technology particularly appropriate for interventions in people
with ASD, writing that “Identification of effective, interesting, and motivating interventions is
important to provide the optimal impact through therapy for [this population]” (p. 64). My
studies add to the growing body of work on using exergaming with people with ASD, and
support the idea that exergames are relevant and enjoyable for this group.
Although many adolescents and young adults with ASD may desire social
relationships, they often have difficulty developing and maintaining them, and report greater
feelings of loneliness compared to their NT peers. A study of young adults with ASD
indicated that only 16% of those surveyed reported one or more friends of their own age with
whom they shared interests and social activities (Howlin, Mawhood, and Rutter, 2000). The
need for interventions to address social interaction for young adults with ASD is clear;
153

however the majority of social interaction training studies involved preschool children (Bass
& Mulick, 2007). My work provides a first step toward developing future interventions to
target sociality among young adults with ASD.
If relationships are the driver of development (Greenspan & Weider, 1998), my studies
align with other early-stage projects that are beginning to show changes in brain development
and function using relationship-based models of treatment (for example, see the Milton and
Ethel Harris Research Initiative, http://www.mehri.ca). In particular, the social component of
partner play in exergaming might lead players to critically evaluate and adjust their exercise
performance in response to the presence of others (Anderson-Hanley et al., 2011a). Anderson-
Hanley and colleagues (2011a) suggest that the Generalized Drive hypothesis (Zajonc, 1965)
helps to explain the increased internal drive, exercise performance, and activation levels
brought about by social facilitation and competition. They contend that a combination of
increased arousal, adrenocortical activity, and mood, due to the presence of another, are the
mechanisms at play to explain the enhanced physiological effect. My third study, which found
a moderating effect of enjoyment of social interaction, adds weight to this hypothesis, and
points to a future research agenda to assess the effects of the social condition on the brain
during physical activity.
These studies also support existing literature regarding mental health for people with
ASD. For individuals on the Autism Spectrum, interacting with peers through video games
can be more predictable and less threatening than direct social interaction (Toppo, 2012),
although my study showed that engaging in videogame play with others often leads to social
connections outside the gaming environment, so they can be used as a springboard for healthy
young adult relationships. The social components of exergaming are also especially
beneficial, and as I have demonstrated, may contribute to enhanced physical activity as well.
According to the Positive Gaming group (2014):
154

Exergaming is a social experience. It provides an opportunity to interact with peers with
similar interests, which can in turn foster friendships among players. The multiplayer
experience and ability to have people playing at different difficulty levels side by side has a
positive effect on self-esteem, especially with children, while the immersive nature of the
game gives them a sense of commonality and collaboration. At the same time, the level of any
player is never compromised, which gives each player a sense of autonomy. Reduced body
self-consciousness is another factor that can contribute to self-esteem, especially with
children. The players' attention is always directed at a screen, not at themselves or at other
players.
Social play involving orientation to others and a common focus on an activity, such as
exergaming, is critical to the development of cognitive, social, and cultural competence, and can lead
to further skill acquisition in other areas (Bass & Mulick, 2007). Regular exercise can also improve
self-esteem – and social interaction may enhance this effect (Barton, Griffin, & Pretty, 2012). Many
researchers have documented the effect of videogame play on cognition (including selective attention,
flexible thinking, spatial navigation, strategic planning/problem solving, working memory, and brain
plasticity), and the link between aerobic activity and cognitive functioning (Flynn, 2012; Glass,
Maddox, & Love, 2013; Kühn et al., 2013; Positive Gaming, 2014). The unique properties of
exergaming such as competition, attention to details in the virtual environment, and the need to
anticipate events and make decisions, may all contribute to enhanced cognitive skills, which are
particularly important for people with ASD and other neurodevelopmental differences (Positive
Gaming, 2014). In addition, educational consultant and movement-based learning specialist Dr. Dan
Lawler recently used exergaming as a behavioral reward in the classroom, and found that it not only
improved behavior during gameplay, but students’ behavior improved afterward, with increased focus
and calm carrying over into the classroom post-exercise (Lawler, 2012).
155

When people are regulated (calm and focused), they are more likely to experience
pleasure and to return to the activity which provided the just-right sensory input to help them
feel calm and in control. Exergaming combines the powerful self-regulating effect of physical
movement with social interaction, in a technology-based activity. As Staiano, Abraham and
Calvert (2012) found in a study of overweight and obese NT adolescents, cooperative
exergame play results in greater intrinsic motivation, and increased energy expenditure. They
write:
Social interaction can increase enjoyment, perceived competence, and self-efficacy for
carrying out the group activity, and when the activity is an exergame or physical
activity, these effects of social interaction correlate positively with physical activity
participation. These motivating aspects of social interaction, combined with increased
self-worth from physical activity, may foster intrinsic motivation to play regularly (p.
813).
Such an activity can be taken up regularly by those with ASD, who often have
difficulty accessing occupations for enjoyment and self-regulation that are not stigmatizing or
solitary in nature, such as repetitive behaviors (Orsmond, Krauss, & Seltzer, 2004; Anderson-
Hanley et al., 2011b; Shattuck et al., 2011).
Finally, physical activity can reduce depression and anxiety and improve overall mood
(Green & Palfrey, 2001; Barton, Griffin, & Pretty, 2012). Green and Palfrey (2001) found that
only 10 minute chunks of physical activity (as in a quick bout of exergame play) can
contribute to positive mental health effects. Experiencing positive emotions contribute to
mental health, especially when these experiences are brought about by engagement in
meaningful and enjoyable occupations (Bazyk, 2010). These experiences promote emotional
resilience and broaden attention and thinking, which influence both physical and
psychological well-being. The features of exergaming utilize personal strengths, allow for
156

choice, and offer a just-right challenge, which increases the likelihood of enjoyment and other
positive emotions, and consequently can improve mental health outcomes and foster further
social interaction and skill-building. Therefore, exergaming not only has implications for
obesity and disease prevention, as well as improved balance and coordination, but playing
together can enhance self-confidence in movement and social interaction, concentration,
spatial awareness, and other skills critical to the well-being of all people, but especially those
with neurodevelopmental differences.
My studies draw attention to an evolving understanding of the complex social worlds
of individuals on the Autism Spectrum; that is, young adults with ASD desire to interact with
peers, but may need more supportive environments or occupations to do so. Given the right
environment and activity, social experience can be enhanced and recruited to promote positive
health behaviors. Due to the serious need for healthy lifestyle programs tailored to the unique
needs of individuals on the spectrum, I sought to measure the response of individuals with
ASD to an occupation carefully tailored to their interests, as well as potential social and
physical challenges. However, I learned that not only is exergaming a “just right” occupation
for this group, but it can be a truly a “normalizing” activity – one that is accessible, socially
appropriate, interactive, and highly enjoyable for many young adults, regardless of diagnosis.
157

References

Aaron, D.J., Storti, K.L.,Robertson, R.J., Kriska, A.M., & LaPorte, R.E. (2002). Longitudianl
study of the number and choice of leisure time physical activities from mid to late
adolescence: Implications for school curricula and community recreation programs.
Archives of Pediatric and Adolescent Medicine, 156(11), 1075-1080.
Adams, M.A., Marshall, S.J., Dillon, L., Caparosa, S., Ramirez, E., Phillips, J., & Norman,
G.J. (2009). A Theory-based framework for evaluating exergames as persuasive
technology. University of California, San Diego Center for Wireless and Population
Systems. Retrieved from: http://delivery.acm.org/10.1145/1550000/1542006/a45-
adams.pdf?ip=128.125.110.89&acc=ACTIVE%20SERVICE&CFID=48093738&CFT
OKEN=82097789&__acm__=1318621848_6bbffacb41abfd3ca4319d9a8a435b4b
American Dietetic Association. (2007). Registered dietitians’ insights in treating Autistic
children. Journal of the American Dietetic Association, 107(5), 727-30.
American Institute for Cancer Research (2011, November 3). New research: Getting up from
your desk can put the “breaks” on cancer: experts urge Americans to rethink outdated
notions of physical activity [Press Release]. Retrieved from:
http://www.aicr.org/press/press-releases/getting-up-from-your-desk.html.
American Occupational Therapy Association. The Representative Assembly Coordinating
Council (RACC), & Primeau, LA. (2008). AOTA's societal statement on play. The
American Journal of Occupational Therapy, 62, 707-708.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
(DSM-V). 5th Edition. Washington, DC: American Psychiatric Association; 2013.
Anderson, S.E., Economos, C.D., & Must, A. (2008). Active play and screen time in US
children aged 4 to 11 years in relation to sociodemographic and weight status
158

characteristics: A nationally representative cross-sectional analysis. BMC Public
Health, 8, 366. doi: 10.1186/1471-2458-8-366
Anderson-Hanley, C., Snyder, A.L., Nimon, J.P., & Arciero, P.J. (2011a). Social facilitation
in virtual reality-enhanced exercise: Competitiveness moderates exercise effort of
older adults. Clinical Interventions in Aging, 6, 275-280.
Anderson-Hanley, C., Tureck, K., & Schneiderman, R.L. (2011b). Autism and exergaming:
Effects on repetitive behaviors and cognition. Psychology Research and Behavior
Management, 4, 129–137.
Attwood, T. (2000). Strategies for improving the social integration of children with Asperger
Syndrome. Autism, 4(1), 85-100.
The Autism Collaborative. (2014). Retrieved from: http://www.autismcollaborative.org/index.html
Ayres, A.J. (1972). Sensory integration and learning disorders. Los Angeles: Western
Psychological Services.
Ball, K. & Crawfors, D. (2005). Socioeconomic status and weight change in adults: A review.
Social Science & Medicine, 60(9), 1987-2010.
Bandura, A., 1977. Self-efficacy: Toward a unifying theory of behavioral change.
Psychological Review, 84, 191–215.
Bandura, A., 1997. Self-efficacy: The exercise of control. New York: Freeman.
Baranowski, T., Buday, R., Thompson, D.I., & Baranowski, J. (2008). Playing for real: Video
games and stories for health-related behavior change. American Journal of Preventive
Medicine, 34, 74-82. doi: 10.1016/j.amepre.2007.09.027
Baron-Cohen, S. (1989a). Joint-attention deficits in Autism: Towards a cognitive analysis.
Development and Psychopathology, 1, 185–9.
Baron-Cohen, S. (1989b). Perceptual role-taking and protodeclarative pointing in Autism.
British Journal of Developmental Psychology, 7, 113–27.
159

Barton, J., Griffin, M., & Pretty, J. (2012). Exercise-, nature- and socially interactive-based
initiatives improve mood and self-esteem in the clinical population. Perspectives in
Public Health, 132(2), 89-96.
Bass, J.D. & Mulick, J.A. (2007). Social play skill enhancement of children with Autism
using peers and siblings as therapists. Psychology in the Schools, 44(7), 727-35.
Baum, C. & Christiansen, C. (1997). The Occupational therapy context: Philosophy –
principles – practice. In: C. Christiansen & C. Baum (Eds.), Occupational Therapy:
Enabling Function and Well-Being (p. 36). Thorofare, NJ: SLACK.
Baum C. & Christiansen, C. (2005). Overview of a PEOP Framework to Support Occupation-
Based Practice Occupations. In: C. Christiansen, C.M. Baum, & J. Bass-Haugen (Eds.)
Occupational therapy: performance, participation, and well-being, 3rd Edition (pp.
242-267). Thorofare, NJ: Slack.
Bauminger, N. & Kasari, C. (2000). Loneliness and friendship in high-functioning children
with Autism. Child Development, 71(2), 447–456.
Bauminger, N. & Shulman, C. (2003). The development and maintenance of friendship in
high-functioning children with Autism: Maternal perceptions. Autism, 7(1), 81–97.
Bauminger, N., Shulman, C., & Agam, G. (2003). Peer interaction and loneliness in high-
functioning children with Autism. Journal or Autism and Developmental Disorders,
33(5), 489-507.
Bazyk, S. (2010). Promotion of positive mental health in children and youth with
developmental disabilities. OT Practice, 15(17), CE1-7.
Bellini, S. & Akullian, J. (2007). A meta-analysis of video modeling and video self-
modeling interventions for children and adolescents with autism spectrum disorders. Council
for Exceptional Children, 73, 264-287.
Bemporad, J.R. (1979). Adult recollections of a formerly autistic child. Journal of Autism and
160

Developmental Disorders, 9, 179-198.
Biddle, S.J., Gorely, T., Marshall, S.J., Murdey, I., & Cameron, N. (2004). Physical activity
and sedentary behaviours in youth: Issues and controversies. Journal of the Royal
Society for the Promotion of Health, 124(1), 29-33.
Birch, J. (2003). Congratulations! It’s Asperger’s syndrome. London: Jessica-Kingsley
Publishers.
Butte, N.F., Puyau, M.R., Adolph, A.L., Vohra, F.A., & Zakeri, I. (2007). Physical activity in
nonoverweight and overweight Hispanic children and adolescents. Medicine and
Science in Sports and Exercise, 39(8), 1257-66.
Carrington, S. B., Papinczak, T. & Templeton, E. (2003). A phenomenological study: The
social world of five adolescents who have Asperger's Syndrome. Australian Journal of
Learning Disabilities, 8(3), 15-21.
Carroll, B. & Loumidis, J. (2007). Children’s perceived competence and enjoyment in
physical education and physical activity outside school. European Physical Education
Review, 7(1), 24-43.
Carson, V., Wong, S.L., Winkler, E., Healy, G.N., Colley, R.C., & Tremblay, M.S. (2014).
Patterns of sedentary time and cardiometabolic risk among Canadian adults.
Preventive Medicine. Advance online publication. doi: 10.1016/j.ypmed.2014.04.005.
Centers for Disease Control and Prevention (CDC). (2008). Physical Activity and Health.
Retrieved from: http://www.cdc.gov/physicalactivity/everyone/health/index.html.
CDC (2011). About BMI for Adults. Retrieved from:
http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html
Centers for Disease Control and Prevention. (2014). Prevalence of Autism Spectrum Disorder
Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring
Network, 11 Sites, United States, 2010. MMWR, 53(SS02), 1-21.
161

Chamberlin, B. & Gallagher, R. (2008, May). Exergames: Using video games to promote
physical activity. Research presentation at the Children, Youth and Families at Risk
(CYFAR) Conference, San Antonio, TX.
Clark, F.A., Parham, D., Carlson, M.E., Frank, G., Jackson, J., Pierce, D., Wolfe, R.J. &
Zemke, R. (1991). Occupational Science: Academic Innovation in the Service of
Occupational Therapy's Future. American Journal of Occupational Therapy, 45(4),
300-310.
Coyne, P. & Fullerton, A. (2004). Supporting individuals with Autism Spectrum Disorder in
recreation. Urbana, IL: Sagamore.
Crepeau, E. B., Cohn, E. S. & Schell, B. A. B. (Eds.) (2003). Willard and Spackman's
occupational therapy (10th ed.). Philadelphia: Lippincott Williams & Wilkins.
Curtin, C., Bandini, L., Perrin, E., Tybor, D., & Must, A. (2005). Prevalence of overweight in
children and adolescents with attention deficit hyperactivity disorder and autism
spectrum disorders: A chart review. BMC Pediatrics, 5(1), 48
Daley, A. (2009). Can exergaming contribute to improving physical activity levels and health
outcomes of children? Pediatrics, 124, 763-771. doi: 10.1542/peds.2008-2357
Dawson, G., & Adams, A. (1984). Imitation and social responsiveness in Autistic children.
Journal of Abnormal Child Psychology, 12, 209–225.
Deckelbaum, R.J. & Williams, C.L. (2001). Childhood obesity: The health issue. Obesity,
9(S11), 239S-243S.
Dishman, R.K., Dunn, A.L., Sallis, J.F., Vandenberg, R.J., & Pratt, C.A. (2010). Social-cognitive
correlates of physical activity in a multi-ethnic cohort of middle-school girls: Two-year
prospective study. Journal of Pediatric Psychology, 35(2), 188–198.
Dishman, R.K., Motl, R.W., Sallis, J.F., Dunn, A.L., Birnbaum, A.S., Welk, G.L., Bedimo-
Rung, A.L., Voorhees, C.C., & Jobe, J.B. (2005). Self-management strategies mediate
162

self-efficacy and physical activity. American Journal of Preventive Medicine, 29(1),
10-18.
Dixon, R., Maddison, R., Ni Mhurchu, C., Jull, A., Meagher-Lundberg P., & Widdowson, D.
(2010). Parents' and children's perceptions of active video games: A focus group study.
Journal of Child Health Care, 14(2), 189–199.
Duncan E (2005). Foundations for practice in occupational therapy. Edinburgh: Churchill
Livingstone.
Dwyer, G., Baur, L., Higgs, J., & Hardy, L. (2009). Promoting children’s health and well-
being: Broadening the therapy perspective. Physical & Occupational Therapy in
Pediatrics, 29, 27-43. doi:10.1080/01942630802574825
Epstein, L.H., Beecher, M.D., Graf, J.L., & Roemmich, J.N. (2007). Choice of interactive
dance and bicycle games in overweight and nonoverweight youth. Annals of
Behavioral Medicine, 33, 124-131. doi: 10.1007/BF02879893
Epstein, L.H., Kilanowski, C.K., Consalvi, A.R., & Paluch, R.A. (1999). Reinforcing value of
physical activity as a determinant of childhood activity level. Health Psychology,
18(6), 599-603.
Epstein, L.H., Roemmich, J.N., Saad, F.G., & Handley, E.A. (2004). The Value of sedentary
alternatives influences child physical activity choice. International Journal of
Behavioral Medicine, 11(4), 236-242.
Erikson, E.H. (1963). Childhood and society. New York: W.W. Norton and Company.
Exner, A., Papatheodorou, G., Baker, C.M., Verdaguer, A., Hluchan, C.M., & Calvert, S.L.
(2009, April). Solitary versus social gross motor videogame play: Energy expenditure
among low-income African American adolescents. Poster presented at the biennial
meeting of the Society for Research in Child Development, Denver, CO.
163

Filipek, P. A., Accardo, P. J., Baranek, G. T., Cook, E. H., Jr., Dawson, G., Gordon, B., et al.
(1999). The screening and diagnosis of autistic spectrum disorders. Journal of Autism
and Developmental Disorders, 29, 439-484.
Finklestein, S., Nickel, A., Barnes, T., & Suma, E. (2010). Astrojumper: Motivating children
with Autism to exercise using a VR game. Presented at IEEE Virtual Reality 2010,
Waltham, Massachusetts, USA. Retrieved from:
http://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber=5444770
Flynn, S., Palma, P., & Bender, A. (2007). Feasibility of using the Sony Playstation 2 gaming
platform for an individual poststroke: A Case report. Journal of Neurologic Physical
Therapy, 31, 180-189. doi: 10.1097/NPT.0b013e31815d00d5
Flynn, R. (2012). Acute effects of physically active versus inactive video game play on
executive functioning skills in children. Proceedings of the International Conference
on the Foundations of Digital Games, pp. 264-266.
Foley, L. & Maddison, R. (2010). Use of active video games to increase physical activity in
children: A (virtual) reality? Pediatric Exercise Science, 22, 7-20.
Foran, A.C. (2013). Learning from experience: The relation of virtual reality and occupational
therapy. International Journal of Therapy and Rehabilitation, 18(7), 362-9.
Foran, A.C. & Cermak, S.A. (2013). Active and traditional videogame ownership and play
patterns among youth with Autism Spectrum Disorders, and relationships to physical
activity. PALAESTRA, 27(1), 42-48.
Ghaffari M., Malone, R.P., Kahn, A., West, S.H., Delaney, M.A., Lawrence, T., Newschaffer,
C.J., & Hardison, H.H. (2009, July). Obesity in children with Autism Spectrum
Disorders. Paper presented at the 49
th
Annual NCDEU Meeting, Hollywood, Florida,
USA. Retrieved from:
http://www.cmeinstitute.com/postersession/2009Session2/ORIGGhaffari.pdf
164

Gillberg, C. (2003). Deficits in attention, motor control, and perception: A brief review.
Archives of Diseases in Childhood, 88, 904-910. doi: 10.1136/adc.88.10.904
Glass BD, Maddox WT, Love BC (2013) Real-Time Strategy Game Training: Emergence of a
Cognitive Flexibility Trait. PLoS ONE 8(8): e70350.
doi:10.1371/journal.pone.0070350
Goldsmith, T.R. & LeBlanc, L.A. (2004). Use of technology in interventions for children with
Autism. JEIBI, 1(2), 166-178.
Gourlay, D., Lun, K.C., Lee, Y.N., & Tay, J. Virtual reality for relearning daily living skills.
International Journal of Medical Informatics, 60, 255-261. doi: 10.1016/S1386-
5056(00)00100-3
Green, M. & Palfrey, J.S. (2001). Bright Futures: Guidelines for Health Supervision of
Infants, Children and Adolescents, 2nd Edition. Washington DC: National Center for
Education in Maternal and Child Health.
Greenspan, S. I. & Wieder, S. (1998). The child with special needs: Encouraging intellectual
and emotional growth. Reading, MA: Perseus Books.
Gus, L. (2000). Autism: Promoting peer understanding. Educational Psychology in Practice,
16(4), 461-468.
Hanner, S., Tomkinson, C., Byrne, J., Boadle, H., Lashley, N., & Stampone, S. (2003).
Results after one year of facilitating autism friendly socialisation (FAFS) using
laptops to network young people with autistic spectrum disorder [Abstract]. In Lisboa
2003— International-Autism-Europe Congress (p. P31). Lisbon, Portugal: Autism-
Europe.
Hill, E., & Frith, U. (2003). Understanding autism: insights from mind and brain.
Philosophical Transactions: Biological Sciences, 358(1430), 281-289.
165

Hilton, C.L., Cumpata, K., Klohr, C., Gaetke, S., Artner, A., Johnson, H., & Dobbs, S. (2014).
Effects of exergaming on executive function and motor skills in children with Autism
Spectrum Disorder: A Pilot study. American Journal of Occupational Therapy, 68(1),
57-65.
Ho, H.H., Eaves, L.C. & Peabody, D. (1997). Nutrient intake and obesity in children with
autism. Focus on Autism and Other Developmental Disabilities, 12, 187-192. doi:
10.1177/108835769701200308
Howard, B., Cohn, E., & Orsmond, G.I. (2006). Understanding and negotiating friendships:
Perspectives from an adolescent with Asperger syndrome. Autism, 10(6), 619-627.
Howlin, P., Mawhood, L., & Rutter, M. (2000). Autism and developmental receptive language
disorder – A follow-up comparison in early adult life. II: Social, behavioural, and
psychiatric outcomes. Journal of Child Psychology and Psychiatry, and Allied Health
Conditions, 41(5), 561-78.
Hughes, J.R. (2008). A recent review of reports on autism: 1000 studies published in 2007.
Epilepsy & Behavior, 13, 425-437. doi: 10.1016/j.yebeh.2008.06.015
Hurlbutt, K., & Chalmers, L. (2002). Adults with Autism speak out: Perceptions of their life
experiences. Focus on Autism and Other Developmental Disorders, 17(2), 103–11.
Inkpen, K., Booth, K.S., Klawe, M., & Upitis, R. (1995). Playing together beats playing apart,
especially for girls. CSCL ’95 Proceedings.
Jackson, L. (2003). Freaks, geeks and Asperger syndrome: A User’s guide to adolescence.
London: Jessica Kingsley.
Johnson, J.E., Christie, J.F. & Yawkey, T.D. (1999). Play and early childhood development.
New York: Addison Wesley Longman.
Jones, R.S.P. & Melsdal, T.O. (2001). Social relationships in Asperger’s Syndrome. Journal
of Learning Disabilities, 5(1), 35–41.
166

Jones, R., Zahl, A., & Huws, J. (2001). First-hand accounts of emotional experiences in
autism: A qualitative analysis. Disability and Society, 16(3), 393–401.
Jordan, R. (2003). Social play and autistic spectrum disorders. Autism: The International
Journal of Research and Practice, 7(4), 347–360.
Kit, B.K., Ogden, C.L., & Flegal, K.M. (2014). Epidemiology of Obesity. In W. Ahrens & I.
Pigeot (eds.), Handbook of epidemiology, 2nd Edition (pp. 2229-2262). New York:
Springer.
Larson, E., Wood, W. & Clark, F. (2003). Occupational Science: Building the science and
practice of occupation through an academic discipline. In E.E. Crepeau, E.S. Cohn &
B.A.B. Schell (Eds.), Willard and Spackman’s Occupational Therapy (10
th
ed., pp. 15-
26). Philadelphia: Lippincott, Williams & Wilkins.
Law, M., Polatajko ,H., Baptiste, S. & Townsend. E. (1999). Core concepts of occupational
therapy. In: E. Townsend, (Ed.). Enabling Occupation: an Occupational Therapy
Perspective (pp. 29-56). Ottawa, Ont: CAOT Publications ACE.
Lawler, D. (2012). Motivation through exergaming. Retrieved from:
http://www.exergamefitness.com/blog/article.php?show=motivation_through_exergam
ing.
Lawson, W. (2001). Life behind glass: A Personal account of Autism Spectrum Disorder.
London: Jessica Kingsley.
Leininger, L.J., Coles, M.G., & Gilbert, J.N. (2010). Comparing enjoyment and perceived
exertion between equivalent bouts of physically interactive video gaming and
treadmill walking. Health & Fitness Journal of Canada, 3(1), 12-18.
Lewis, K.P. (2010). From landscapes to playscapes: The evolution of play in humans and
other animals. In: Sands, R.R. & Sands, L.R. (Eds.), The Anthropology of sport and
human movement (pp. 61-90). Lanham, MD: Lexington Books.
167

Lewy, A., & Dawson, G. (1992). Social stimulation and joint attention in young Atistic
children. Journal of Abnormal Child Psychology, 20, 555–566.
Lochbaum, M.R., & Crews, D.J. (1995). Exercise prescription for autistic populations.
Journal of Autism and Developmental Disorders, 25(3), 335-6.
Lotan, M., Yalon-Chamowitz, S. & Weiss, T. (2009). Improving physical fitness of
individuals with intellectual and developmental disability through a virtual reality
intervention program. Research in Developmental Disabilities 30, 229-239. doi:
10.1016/j.ridd.2008.03.005
Maddison, R., Foley, L., Ni Mhurchu, C., Jull, A., Jiang, Y., Prapavessis, H., … Schaaf, D.
(2009). Feasibility, design and conduct of a pragmatic randomized controlled trial to
reduce overweight and obesity in children: The electronic games to aid motivation to
exercise (eGAME) study. BMC Public Health, 9, 146. doi: 10.1186/1471-2458-9-146
Maiorana, A., O'Driscoll, G., Cheetham, C., Collis, J., Goodman, C., Rankin, S., Taylor, R., &
Green, D. (2000). Combined aerobic and resistance exercise training improves
functional capacity and strength in CHF. Journal of Applied Physiology, 88(5), 1565-
70.
Mark, R., Rhodes, R.E., Warburton, D.E.R., & Bredin, S.S.D. (2008). Interactive video games
and physical activity: A review of the literature and future directions. Health and
Fitness Journal of Canada, 1, 14-24.
Marshall, S.J., Gorely, T., & Biddle, S.J.H. (2006). A descriptive epidemiology of screen-
based media use in youth: A review and critique. Journal of Adolescence, 29, 333-349.
doi: 10.1016/j.adolescence.2005.08.016
McCurdy, L.E., Winterbottom, K.E., Mehta, S.S. & Roberts, J.R. (2010). Using nature and outdoor
activity to improve children's health. Current Problems in Pediatric and Adolescent Health
Care, 40, 102-117. doi: 10.1016/j.cppeds.2010.02.003
168

Mercogliano, C. (2007). In Defense of childhood: Protecting kids’ inner wildness. Boston:
Beacon Press.
Mesibov, G. B. & Handlan, S. (1997). Adolescents and adults with autism. In D. J. Cohen &
F. R. Volkmar (Eds.), Handbook of Autism and Pervasive Developmental Disorders
(pp.309-324). New York: John Wiley & Sons, Inc.
Meyer, A. (1977). The Philosophy of occupational therapy. American Journal of
Occupational Therapy, 31(10), 639-642.
Miller, J. (2003). Women from another planet? Our lives in the universe of autism. Milan:
Dancing Mind Books.
Molke, D.K., Laliberte-Rudman, D. & Polatajko, H.J. (2004). The promise of occupational
science: A developmental assessment of an emerging academic discipline. Canadian
Journal of Occupational Therapy, 71(5), 269-281.
Moore, D., Cheng, Y., McGrath, P., & Powell, N.J. (2005). Collaborative virtual environment
technology for people with Autism. Focus on Autism and Other Developmental
Disabilities, 20(4), 231-243.
Mundy, P., Sigman, M., Ungerer, J. & Sherman, T. (1987). Non-verbal communication and
play correlates of language development in autistic children, Journal of Autism and
Developmental Disorders, 17, 349–64.
Mundy, P., Sigman, M. D., Ungerer, J., & Sherman, T. (1986). Defining the social deficits of
autism: The contribution of non-verbal communication measures. Journal of Child
Psychology and Psychiatry and Allied Disciplines, 27(5), 657–669.
Nelson, D. (1996) Therapeutic Occupation: A Definition. American Journal of Occupational
Therapy, 50(10): 775-782.
169

Nyakas, C., Buwalda, B., Luiten, P.G.M., & Bohus, B. (1992). Effect of low amphetamine
doses on cardiac responses to emotional stress in aged rats. Neurobiology of Aging,
13(1), 123-129.
Nyberg, L., Lundin-Olsson, L., Sondell, B., Backman, A., Holmlund, K., Eriksson, S., …
Bucht, G. (2006). Using a virtual reality system to study balance and walking in a
virtual outdoor environment: A pilot study. CyberPsychology and Behavior, 9, 388-
395. doi: 10.1089/cpb.2006.9.388
Obrusnikova, I. & Cavalier, A.R. (2011). Perceived barriers and facilitators of participation in
after-school physical activity by children with Autism Spectrum Disorders. Journal of
Developmental and Physical Disabilities, 23(3), 195-211.
Ogden, C.L. & Carroll, M.D. (2010). Prevalence of overweight, obesity, and extreme obesity
among adults: United States, trends 1960-1962 through 2007-2008. June 2010.
Retrieved from:
http://www.cdc.gov/NCHS/data/hestat/obesity_adult_07_08/obesity_adult_07_08.pdf.
O’Neill, M. & Jones, R.S.P. (1997). Sensory-perceptual abnormalities in Autism: A case for
more research? Journal of Autism and Developmental Disorders, 27(3), 283-293.
Orsmond, G.I., Krauss, M.W., & Seltzer, M.M. (2004). Peer relationships and social and
recreational activities among adolescents and adults with Autism. Journal of Autism
and Developmental Disorders, 34(3), 245-56.
Orsmond, G.I. & Kuo, H-Y. (2011). The daily lives of adolescents with a Autism Spectrum
Disorder: Discretionary time use and activity patterns. Autism, 15(5), 579-599
Pan, C-Y. (2008). School time physical activity of students with and without Autism
Spectrum Disorders during PE and recess. Adapted Physical Activity Quarterly, 25,
308-321.
170

Pan, C-Y. & Frey, G.C. (2006). Physical activity patterns in youth with autism spectrum
disorders. Journal of Autism and Developmental Disorders, 36, 597-606. doi:
10.1007/s10803-006-0101-6
Pate, R.R., Heath, G.W., Dowda, M., & Trost, S.G. (1996). Associations between physical
activity and other health behaviors in a representative sample of US adolescents.
American Journal of Public Health November, 86(11), 1577-1581.
Piaget, J.C. (1951). Play, dreams and imitation in childhood. London: Routledge & Kegan
Paul.
Pitetti, K.H., Rendoff, A.D., Grover, T. & Beets, M.W. (2007). The Efficacy of a 9-month
treadmill walking program on the exercise capacity and weight reduction for
adolescents with severe autism. Journal of Autism and Developmental Disorders, 37,
997-1006. doi: 10.1007/s10803-006-0238-3
Positive Gaming (2014). The Benefits of exergaming. Retrieved from:
http://www.positivegaming.com/positivegaming/benefits/exergaming-benefits.
Preissler, M. A. (2006). Play and Autism: Facilitating symbolic understanding. In D. Singer,
R.M. Golinkoff, & K. Hirsh-Pasek (Eds.), Play=Learning: How play motivates and
enhances children’s cognitive and social-emotional growth (pp. 231-250). New York,
NY: Oxford University Press.
Putnam, C. & Chong, L. (2008). Software and technologies designed for people with Autism:
What do users want? In ASSETS '08: Proceedings of the 10
th
International ACM
SIGACCESS Conference on Computers and Accessibility. New York: ACM, 3-10.
Rayner, C., Denholm, C., & Sigafoos, J. (2009). Video-based intervention for individuals with
Autism: Key questions that remain unanswered. Research in Autism Spectrum
Disorders, 3, 291-303.
171

Rimmer, J.H. (2006). Use of the ICF in identifying factors that impact participation in
physical activity/rehabilitation among people with disabilities. Disability and
Rehabilitation, 28, 1087-1095. doi: 10.1080/09638280500493860
Rimmer, J.H., Braddock, D. & Pitetti, K.H. (1996). Research on physical activity and
disability: an emerging priority. Medicine and Science in Sports and Exercise, 28,
1366-1372.
Rimmer, J.H., Yamaki, K., Davis, B.D., Wang, E., & Vogel, L.C. (2011). Obesity and
overweight prevalence among adolescents with disabilities. Preventing Chronic
Disease, 8(2), A41.
Rouard, M. & Simon, J. (1977). Children’s play spaces: From sandbox to adventure
playground. (L. Geiser, Trans.). Woodstock, NY: Overlook Press.
Rowland, T.W. (2007). Promoting physical activity for children’s health: Rationale and
strategies. Sports Medicine, 37, 929-936.
Rutter M. (1970). Autistic children: infancy to adulthood. Seminars in Psychiatry 2, 435–50.
Ryan, R.M., Frederick, C.M., Lepes, D., Rubio, N., & Sheldon, K. (1997). Intrinsic
motivation and exercise adherence. International Journal of Sport Psychology 28,
335–354.
Sainsbury, C. (2000). Martian in the playground. London: The Book Factory.
Sallis, J.F., Prochaska, J.J., & Taylor, W.C. (2000). A review of correlates of physical activity
of children and adolescents. Medicine and Science in Sports and Exercise, 32, 963–
975.
Sallis, J.F., Prochaska, J.J., Taylor, W.C., Hill, J.O., & Geraci, J.C., 1999. Correlates of
physical activity in a national sample of girls and boys in Grades 4 through 12. Health
Psychology, 18(4), 410-415.
Salvy, S. J., Bowker, J. W., Roemmich, J. N., Romero, N., Kieffer, E., Paluch, R., et al.
172

(2008). Peer influence on children's physical activity: An experience sampling study.
Journal of Pediatric Psychology, 33(1), 39-49.
Salvy, S. J., Roemmich, J. N., Bowker, J. C., Romero, N. D., Stadler, P. J., & Epstein, L. H.
(2008). Effect of peers and friends on youth physical activity and motivation to be
physically active. Journal of Pediatric Psychology, 34(2), 217-225.
doi:10.1093/jpepsy/jsn071.
Sandt, D.D.R. & Frey, G.C. (2005). Comparison of physical activity levels between children
with and without Autistic Spectrum Disorders. Adapted Physical Activity Quarterly,
22, 146-159.
Scarlett, W.G., Naudeau, S., Salonius-Pasternak, D. & Ponte, I. (2005). Children’s play.
Thousand Oaks, CA: Sage Publications.
Shattuck, P.T., Orsmond, G.I., Wagner, M., & Cooper, B. (2011). Participation in social
activities among adolescents with an Autism Spectrum Disorder. PLoS ONE, 6(11),
e276176.
Schneider, M. & Cooper, D.M. (2011). Enjoyment of exercise moderates the impact of a
school-based physical activity intervention. International Journal of Behavioral
Nutrition and Physical Activity, 8, 64.
Schopler, E. & Mesibov, G.B. (Eds.). (1983). Autism in adolescents and adults. New York:
Plenum Press.
Sicile-Kira, C. (2004). Autism Spectrum Disorders: The Complete guide to understanding
Autism. New York: The Berkley Publishing Group.
Sigman, M., & Ruskin, E. (1999). Continuity and change in the social competence of children
with autism, Down syndrome, and developmental delays. Monographs of the Society
for Research in Child Development, 64, 1–114.
Sinclair, J., Hingston, P., & Masek, M. (2007). Considerations for the design of exergames. In
173

GRAPHITE '07: Proceedings of the 5th International Conference on Computer
Graphics and Interactive Techniques in Australia and Southeast Asia, pp. 289-295.
Sit, C.H.P., Lam, J.W.K., & McKenzie, T.L. (2010). Direct observation of children’s
preferences and activity levels during interactive and on-line electronic games. Journal
of Physical Activity & Health, 7(4), 484-489.
Spruijt-Metz, D. & Hsu, Y-W. (2012). Active voice: Taking measure of physical activity,
sedentary behavior and metabolic health in youth. Sports Medicine Bulletin, January.
Retrieved from: http://www.multibriefs.com/briefs/acsm/active1-10.htm.
Staiano, A.E., Abraham, A.A., & Calvert, S.L. (2012). Motivating effects of cooperative
exergame play for overweight and obese adolescents. Journal of Diabetes Science and
Technology, 6(4), 812-19.
Staiano, A. & Calvert, S. (2010, June). Wii Tennis play as physical activity in low-income
African American adolescents. Paper presented at the Annual Meeting of the
International Communication Association, Suntec City, Singapore.
Stice, E., Shaw, H., & Marti, C.N., 2006. A meta-analytic review of obesity prevention
programs for children and adolescents: The skinny on interventions that work.
Psychology Bulletin, 132(5), 667-691.
Straker, L.M., Abbott, R.A., Piek, J.P., Pollock, C.M., Davies, P.S., & Smith, A.J. (2009).
Rationale, design, and methods for a randomized and controlled trial to investigate
whether home access to electronic games decreases children’s physical activity. BMC
Public Health, 9, 212. doi: 10.1186/1471-2458-9-212
Strauss, B. (2001). Social facilitation in motor tasks: a review of research and theory.
Psychology of Sport and Exercise, 3, 237-256. doi:10.1016/S1469-0292(01)00019-x.
174

Summerbell, C.D., Waters, E., Edmunds, L., Kelly, S.A.M., Brown, T., & Campbell, K.J.,
2005. Interventions for preventing obesity in children. Cochrane Database of
Systematic Reviews 3, CD001871.
Toppo, g. (2012, May 31). Video games help autistic students in classrooms. USA TODAY.
Retrieved from: http://usatoday30.usatoday.com/news/health/story/2012-05-31/video-
games-autism-students/55319452/1.
Treiber, F.A., Baranowski, T., Braden, D.S., Strong, W.B., Levy, M., & Knox, W., 1991.
Social support for exercise: Relationship to physical activity in young adults.
Preventive Medicine, 20(6), 737-750.
Tremblay, M.S., LeBlanc, A.G., Kho, M.E., Saunders, T.J., Larouche, R., Colley, R.C.,
Goldfield, G., & Gorber, S.C. (2011). Systematic review of sedentary behavior and
health indicators in school-aged children and youth. International Journal of
Behavioral Nutrition and Physical Activity, 8, 98.
Troiano, R.P., Berrigan, D., Dodd, K.W., Masse, L.C., Tilert, T., & McDowell, M. (2008).
Physical activity in the United States measured by accelerometer. Medicine and
Science in Sports and Exercise, 40(1), 181-188.
Tyler, C.V., Schramm, S.C., Karafa, M., Tang, A.S., & Jain, A.K. (2011). Chronic disease
risks in young adults with Autism Spectrum Disorder: Forewarned is forearmed.
American Journal on Intellectual and Developmental Disabilities, 116(5), 371–380.
USDHHS (2004). National initiative on physical fitness for children and youth with
disabilities. Retrieved from: http://www.hhs.gov/od/physicalfitness.html.
USDHHS. (2007). The Surgeon General's call to action to prevent and decrease overweight
and obesity. Retrieved from: http://www.surgeongeneral.gov/topics/obesity/index.htm
175

van Sluijs, E.M., McMinn, A.M., & Griffin, S.J. (2008). Effectiveness of interventions to
promote physical activity in children and adolescents: systematic review of controlled
trials. British Journal of Sports Medicine, 42(8), 653-7.
Volkmar, F.R., & Klin, A. (1995). Social development in autism: Historical and clinical
perspectives. In S. Baron-Cohen, H. Tager-Flusberg, & D. J. Cohen (Eds.),
Understanding other minds: Perspectives from autism (pp. 40–55). New York: Oxford
University Press.
Vygotsky, L. S. (1967). Play and its role in the mental development of the child. Soviet
Psychology, 5(3), 6-18.
Werner, J.M., Aziz-Zadeh, L., & Cermak, A.C. (2011). Praxis and imitation in children with
Autism Spectrum Disorder. NDTA Network, Sept/Oct, 10-15.
Westland, C. & Knight, J. (1982). Playing living learning: A Worldwide perspective on
children’s opportunities to play. State College, PA: Venture Publishing.
Wetherby, A.M., & Prutting, C.A. (1984). Profiles of communicative and cognitive-social
abilities in autistic children. Journal of Speech and Hearing Research, 27, 364–377.
Wilcock, A. A. (2003). Occupational science: The study of humans as occupational beings. In
P. Kramer, J. Hinojosa & C. B. Royeen (Eds.), Perspectives in Human Occupation:
Participation in Life (pp. 156-177). Philadelphia: Lippincott, Williams & Wilkins.
Wilcock, A.A. (2005). Occupational science: Bridging occupation and health. Canadian
Journal of Occupational Therapy, 72(1), 5-12.
Wilmot, E.G., Edwardson, C.L., Achana, F.A., Davies, M.J., Gorely, T., Gray, L.J., Khunti,
K., Yates, T., & Biddle, S.J.H. (2012). Sedentary time in adults and the association
with diabetes, cardiovascular disease and death: systematic review and meta-analysis.
Diabetologia, 55(11), 2895. doi: 10.1007/s00125-012-2677-z.
176

Wolfberg, P.J. (1999). Play and imagination in children with autism. New York: Teachers
College Press, Columbia University.
Wolfberg, P.J. (2009). Play and imagination in children with Autism (2nd ed.). New York:
Teachers College Press.
Wolfberg, P.J. & Schuler, A. L. (1999). Fostering peer interaction, imaginative play and
spontaneous language in children with autism. Child Language Teaching and Therapy,
15, 41-52.
Wood, W. (1995). Weaving the warp and weft of occupational therapy: An art and science for
all times. American Journal of Occupational Therapy, 49(1), 44-52.
Wuang, Y-P., & Su, Chwen-Y. (2009). Reliability and responsiveness of the Bruininks-
Oseretsky test of Motor Proficiency – Second Edition in children with intellectual
disability. Research in Developmental Disabilities, 30(5), 847-855.
Yerxa, E. J. (1993). Occupational science: A new source of power for participants in
occupational therapy. Occupational Science: Australia, 1, 161A-164.
Zajonc, R.B. (1965). Social facilitation. Science, 149, 269–274
Zemke, R. & Clark, F. (Eds.). (1996). Occupational Science: The evolving discipline.
Philadelphia, F.A. Davis.
177

Appendix
A. Exergaming studies literature review charts .....................................................................178

B. IRB Documents
Study 1 ...................................................................................................................................197
Study 2 ...................................................................................................................................200
Study 3 ...................................................................................................................................208

C. Measures
BOT-2 Body Coordination Test Form ...................................................................................222
Enjoyment Form (Study 2) ....................................................................................................223
Enjoyment Form (Study 3) ....................................................................................................224
Alternate Enjoyment Form (Study 3) ....................................................................................225
Field Notes Form ...................................................................................................................226
Physical Activity & Demographic Questionnaire..................................................................227
RPE Form (Study 2)...............................................................................................................230
RPE Form (Study 3)...............................................................................................................231
Videogame Survey .................................................................................................................233
178

APPENDIX A. Exergaming Literature Review

Exergaming Studies Literature Review
Objective
To conduct a systematic review of outcomes studies measuring the health- and fitness-related
effects of active video game play (exergaming) in children and adolescents.
Method
Keyword searches were conducted once per month for thirty-six months (between December
2009 and December 2013) using PubMed, OvidSP MEDLINE, CINAHL, and Google Scholar. To be
included in this review, studies must have met all of the following criteria:
(a) Study participants were, on average, 18 years of age or younger, or separate
results were reported for a subgroup of participants 18 years or younger.

(b) Methodology included use of an active video or computer game system, such as
the Nintendo Wii, Sony Playstation EyeToy, Konami Dance Dance Revolution,
etc., or the addition of a videogame component to standard exercise equipment.

(c) Reported outcomes included at least one measure of cardiorespiratory fitness or
activity level such as heart rate, energy expenditure, or accelerometer counts, or an
anthropometric measure such as body mass index.

(c) The study was peer-reviewed, and published in or translated to English.

The following key-word search terms were used: “computer game(s),” “exergame(s),”
“exergaming,” “game system(s),” “gaming,” “new generation,” “video game(s),” “videogame(s),”
and “virtual reality.” Each of the preceding terms was used in combination with each of the
following terms in the search: “active,” “activity level,” “cardiovascular,” “exercise,” “fitness,”
“obesity,” “overweight,” “physical activity,” and “weight loss.” All years were included in the
search, although active videogames have only been available to the public since 2000, so all studies
included in this review were published between 2001 and 2013.
179

The reference lists from relevant articles were evaluated to identify additional appropriate
studies, and primary studies described in earlier review papers were also examined. All studies were
evaluated using a published Levels of Evidence rating system (Gutman, 2008); see Table 1.
Results
Searches yielding 2271 articles initially, including duplicates and articles about TSVGs. 45
unique studies meeting inclusion criteria were located, critically evaluated, and summarized using the
American Occupational Therapy Association Levels of Evidence Rating System (Tables 2 and 3).
Conclusion
While it appears that exergames do increase energy expenditure, heart rate, and activity level
compared to traditional videogames, the level of physical activity is often less than that experienced
by children engaged in typical sports and games. However, for youth who are primarily sedentary,
exergaming may increase physical activity and assist in weight management. With improving
technology and continued research, exergaming may be an effective way to counteract increasing
rates of childhood obesity by increasing engagement in physical activity and improving
cardiovascular health and fitness.
180

Table 1. American Occupational Therapy Association Levels of Evidence Rating System.
Level of Evidence Rigor of Research Design
I Systematic reviews, meta-analyses, or randomized controlled trials
(RCTs)
II 2-group non-randomized controlled trials (e.g., cohort designs, case
control studies, or 2-group pre/posttest designs)
III 1-group nonrandomized noncontrolled trial (e.g., 1-group pre/or posttest
designs)
IV Single-subject design, descriptive studies, case series, or case reports
V Expert opinions
Note: Reprinted with permission from S. A. Gutman (2008). State of the Journal. American Journal of
Occupational Therapy, 62, p. 619-622. Copyright 2008 by the American Occupational Therapy
Association.

Table 2. Studies measuring immediate physiologic or activity level changes in youth (age 18 or under) using videogame, computer game, or virtual
reality programs.
Study Design Participants Procedure Outcome Measures Level of
Evidence
Outcome
Bailey & McInnis
(2011)
Single group, repeated
measures design, with
baseline (rest).
39 children, average
age 11.5±2.0 years
Participants played each of 6
EG, and walked on a treadmill
for 10-15 minutes
-EE (indirect calorimetry)
-Enjoyment Rating (10-point
analog scale)
III +
Brown et al. (2008) Single group, repeated
measures design, with
baseline (rest).
17 children, average
range 11.06±0.40 years
Participants played a TSVG,
walked on a treadmill, and
played each of 3 EGs for 15
min. each.
- EE (VO
2
/VO
2
max)
- HR
III +
Crommett (2009) Single group, repeated
measures design, no baseline.
48 children, average
age 8.6±3.6 years
Participants played EG for 30
min., and participated in 30
min. of traditional Physical
Education class.
- HR

III +
de Vries et al. (2008) Single group, repeated
measures design, no baseline
12 children, age range
7-13 years
Participants played each of 6
EGs for 5 min. each.
- Activity counts (accelerometry)
- EE (IPE method)
- HR
III ?
Epstein et al. (2007) Between groups (overweight
vs. non-overweight) repeated
measures design, with
baseline (rest).

18 overweight children
17 non-overweight
children
Average age 10.8±1.4
years
Participants engaged in 6
conditions: dancing with
music; dancing with video;
playing 2 EGs; riding
stationary bicycle; riding
bicycle while watching video.

- Activity counts (accelerometry)
- Enjoyment rating (self-report
Likert scale)
- Relative reinforcing value of
game (measured by specialized
computer program)
III +

182

Exner et al. (2009) Single group, quasi-
experimental design with
control group (playing alone
vs. with a partner vs. no
intervention control group)
and baseline (rest).
74 children &
adolescents, age range
12-18 years
Participants engaged for 25
min. in one of 5 conditions:
playing traditional court tennis
alone or with partner, playing
the EG alone or with partner,
or no intervention.
- Activity counts (accelerometry)
- Enjoyment rating (self-report
Likert scale)
II +

Fogel et al. (2010) Single group, repeated
measures design, no baseline.
4 children, average age
9 years
Participants engaged in regular
PE class and PE class that
incorporate 10 EG stations
-Activity counts

III +
Gasperetti et al.
(2011)
Single group, repeated
measures design, no baseline.
10 children &
adolescents with visual
impairment, age range
10-16 years
Participants were randomized
to play each of 3 EGs on 3
consecutive nights for 10 min.
each.
- HR III +
Graf et al. (2009) Single group, repeated
measures design, with
baseline (rest).

23 children, average
age 11.5±1.5 years
Participants played 3 EGs for
15 min. each, and walked on
treadmill at 3 different speeds
(6 min. each).
- BP
- EE (VO
2
/VO
2
max)
- HR
- Large- and small-artery elasticity
- RPE
II +

Graves et al. (2008a) Single group, repeated
measures design, with
baseline (rest).
13 adolescents, average
age 15.1±1.4 years
Participants played a TSVG,
and 3 EGs for 15 min. each.
- EE (VO
2
/VO
2
max)
- HR
- Activity counts (accelerometry)
III +

Graves et al. (2007,
2008b)
Single group, repeated
measures design, with
baseline (rest).
11 adolescents, average
age 14.6±0.5 years
Participants played 3 EGs for
15 min. each.
- EE (IPE method) III +
183

Graves et al. (2010) Between groups
(adolescent/young
adult/adult), repeated
measures design, no baseline.
14 adolescents, age
range 11-17 years
15 young adults
13 Adults
Participants played a TSVG, 4
EGs, and performed treadmill
walking/jogging for 10 min.
each.
- EE (VO
2
/VO
2
max)
- Enjoyment (PACES)
- HR
II +
Haddock et al. (2009) Single group, repeated
measures design, with
baseline (rest).

20 overweight children,
average age 10.9±2.2
years
Participants rode stationary
bicycle for 20 min., with and
without videogame play
- EE
- RPE
III +
Haddock et al. (2010) Single group, repeated
measures design with
baseline (rest).

37 children and
adolescents, average
age 12.4±1.0 years
Participants played their choice
of EG for 20 min.
- EE (VO
2
/VO
2
max)
- HR
III +
Kemble et al. (2007) Single group, repeated
measures design, with
baseline (rest).

30 adolescent boys,
average age 13.0±1.0
years
Participants played both a
TSVG and an EG.

- EE (VO
2
/VO
2
max)
- HR
- Physiological arousal (HR
variability, questionnaire)
III +

Lanningham-Foster et
al. (2006)
Between groups
(overweight/non-
overweight), repeated
measures design, with
baseline (rest).
10 overweight children
15 non-overweight
children
Average age 9.7±1.6
years
Participants played a TSVG, 2
EGs, and walked on treadmill
for 15 min. each.
- EE (VO
2
/VO
2
max)

III +

Lanningham-Foster et
al. (2009)
Between groups
(children/adults), repeated
measures design, with
baseline (rest).
22 children, average
age 12.10±1.70 years
20 adults, average age
33.5±10.7 years
Participants engaged in 10 min.
of each condition: resting,
sitting watching TV, standing
watching TV, playing a TSVG,
playing an EG.
- EE (IPE method)
- Activity counts (accelerometry)

III +

184

Maddison et al.
(2011)
Two groups, randomized
controlled trials, with
baseline
322 overweight/obese
children, age range 10-
14 years
One group of participants play
EG; control played TSVG.
Assessment collected at
baseline, 12 weeks, 24 weeks
-BMI
-Waist circumference
-EE (VO
2
max)
I +
Maddison et al.
(2007)
Single group, repeated
measures design, with
baseline (rest).

21 children, average
age 12.4±1.1 years
Participants played a TSVG,
and 5 EGs.

- EE (VO
2
/VO
2
max)
- HR
- Activity counts and motion
(accelerometry)
III +

Mellecker &
McManus (2008)
Single group, repeated
measures design, with
baseline (rest).

18 children, average
age 9.6±1.7 years
Participants played 2 EGs and
a TSVG for 5 min. each.
- EE (IPE method)
- HR
III +

Mellecker et al.
(2009)
Single group, repeated
measures design, with
baseline (rest).

29 children, average
age 9.60 years
Participants played a TSVG for
5 min., walked on treadmill 3
min., and walked on treadmill
while playing a computer game
5 min.
- EE (IPE method)
- HR
III +
Mills et al. (2013) Single group, repeated
measures design, with
baseline (rest)
15 children, average
age age 10.1±.7 years
Participants played EG and
participated in a graded
exercise test

-HR
-EE
-FMD
-PA enjoyment scale (PACES)
III +
185

Penko & Barkley
(2010)
Between groups
(overweight/non-
overweight), repeated
measures design, with
baseline (rest).

13 overweight children
11 non-overweight
children
Age range 8-12 years
Participants played a TSVG, an
EG, and treadmill walking for
10 min. each.

- EE (VO
2
/VO
2
max)
- HR
- Rating of “liking” (using visual
scale)
- RPE
- Relative reinforcing value (using
computer simulation task)
II ?

Porcari et al. (2009) Between groups (boys/girls),
repeated measures design,
with baseline (rest).

7 adolescent boys,
average age 16.7±1.5
years
7 adolescent girls,
average age 17.4±0.79
years
Participants rode an exercise
bike both with and without
videogame enhancement for 20
min.

- EE (VO
2
/VO
2
max)
- Exercise enjoyment
(questionnaire)
- Exercise Induced Feeling
Inventory
- HR
- RPE
III +

Ridley & Olds (2001) Single group, repeated
measures design, with
baseline (rest).

10 children, average
age 12.5±0.5 years
Participants playing each of 4
arcade games, 2 of which were
EGs, for 5 mins. or more each
game.
- EE (VO
2
/VO
2
max)
- HR
- Activity counts (accelerometry)
IV +

Schipper et al. (2009) Between groups
(children/young adults),
repeated measures design,
with baseline (rest).
10 children
10 young adults
Participants each played three
EGs.
- Level of enjoyment
-METS
- RPE
IV +

Siegel et al. (2008) Single group, repeated
measures design, with
baseline (rest).
17 overweight children,
average age 10.1±1.9
years
Participants rode a stationary
bicycle alone and while playing
an EG.
- EE (VO
2
/VO
2
max)
- HR
- RPE
III +

186

Staiano et al. (2010) Between groups (videogame
play alone/with a peer)
design, with TSVG control
group.
71 low-income African
American adolescents,
average age 14.39±1.67
years
Participants were randomly
assigned to one of three
conditions: exergaming with
peer, exergaming alone,
playing TSVG for 25 min.
- Activity counts (accelerometry)
- EE (IPE method)
- METS
II +
Straker & Abbott
(2007)
Single group, repeated
measures design, with
baseline (rest).
20 children, age range
9-12 years
Participants played each of five
types of videogames, ranging
from TSVGs to EGs, for a
minimum of five min. each
game.
- EE (VO
2
/VO
2
max)
- HR

III +

Tan et al. (2002) Single group, repeated
measures design, with
baseline (rest).

40 adolescents, average
age 17.5±0.7 years
Participants played an EG and
walked on a treadmill at
maximum intensity for
approximately 10 min. each.
- Dance duration at peak difficulty
- EE (VO
2
/VO
2
max)
- HR
- RPE
IV ?

Unnithan et al. (2006) Between groups
(overweight/non-
overweight), repeated
measures design, with
baseline (rest).

10 overweight
adolescents, average
age 13.5±3.3 years
12 non-overweight
adolescents, average
age 12.3 ±1.5 years
Participants played an EG for
12 min., and participated in a
treadmill walking test at
maximum intensity to
determine VO
2peak
.
- EE (VO
2
/VO
2
max)
- HR

III +

Wetzsteon et al.
(2009)
Between groups
(overweight/non-
overweight), repeated
measures design, with
baseline (rest).

23 overweight children,
average age 11.9 years
43 non-overweight
children, average age
12.2 years
Participants played an EG,
performed walking, running,
and tuck jump tests.
- EE (VO
2
/VO
2
max)
- Ground reaction forces
- HR

III ?

187

White et al. (2010) Single group, repeated
measures design, with
baseline (rest).
26 male children,
average age 11.4±0.8
years
Participants performed a range
of activities including: TSVG,
five different EGs, and a
walking/running fitness test
over the course of three
sessions.
- EE (IPE method)
- HR
- METS
III +
Wittman (2010) Single group, repeated
measures design, with
baseline (rest).

25 children, age range
9-12 years
Participants played traditional
capture the flag and kickball
for 20 min. each, and 2 EGs for
20 min. each.
- Activity enjoyment (rating scale)
- HR
- RPE
- Steps taken (pedometry)
IV ?

Abbreviations: BP = blood pressure, EE = energy expenditure, Exergame(s) = EG(s), HR = heart rate, IPE = Individual prediction equation of energy expenditure calculated
using HR, age, gender, and body mass. METS = metabolic equivalents, TSVG = traditional seated videogame, RPE = rating of perceived exertion, VO
2
/VO
2
max = oxygen
consumption using indirect calorimetry; min.=min..
a
Level of Evidence: methodological rigor as assessed by five-component rating scale (Gutman, 2008) described in Method section; see Table 1.
b
Outcome: +, exergaming caused a greater positive effect in all or most outcome measures when compared to rest and TSVG play; 0, no effect; ?, unclear; beneficial for some
but not all outcomes or participants.
188

Table 3. Intervention studies using videogame, computer game, or virtual reality programs to enhance physical fitness in children (age 18 or under).
Study Design Participants Intervention

Outcome Measures Level of
Evidence

Outcome
Adkins et al.
(2013)
Two groups
(intervention and control
group), repeated
measures design, no
baseline
88 children, age
range 7-10 years
44 children, age
8.1 ± 1.3
Participated in running club twice a week
for 7 weeks, then EG for 7 weeks
-Activity counts
(accelerometry)
-BMI
III ?
Maloney et al.
(2008)
RCT wait-list design.

60 children,
average age
7.5±0.5 years

40 participants were provided exergaming
systems in-home for 10 weeks; 20 of these
received five weekly 1:1 coaching
sessions.

After 10 weeks, all 60 participants
received the exergaming system for use in-
home.

Measurements were recorded at baseline
(week 0), week 10, and week 28 (post-
intervention).

- BP
- BMI
- Activity counts
(accelerometry)
- Sedentary screentime
(questionnaire)

I ?

McDonough
(2009)
Single group, repeated
measures design, with
baseline (rest).

20 adolescent
girls, age range
16-18 years
During the 8-week observational study,
participants were asked to self-select
among 8 types of exercise equipment,
including a dance EG and traditional
equipment such as a treadmill, recumbent
bicycle, etc.

- EE (IPE method)
- Number of min. of use

III ?

McDougall &
Duncan (2008)
Single group, repeated
measures design, with
baseline (rest).

12 children, age
range 8-11 years
1 week intervention using Sony EyeToy
system daily for 24 mins/day.
- HR
- Steps walked (pedometer)
III +

Murphy et al.
(2009)

RCT, pre-post test
design. Participants
randomized to either a
12 week intervention
(n=23), or delayed
treatment control group
(n=12).

35 overweight
children with
endothelial
dysfunction,
average age
10.21±1.67 years

During the 12 week in-home intervention,
participants were instructed to play the EG
5 times per week, following a progressive
exercise protocol (time increased from 10-
30 mins per session).

- Aerobic fitness (graded
exercise test, VO
2peak
)
- Blood chemistry
(cholesterol, triglycerides,
insulin, glucose, markers
of NO productions,
inflammation)
- BMI
I +

189

- Endothelial dysfunction
(electrocardiogram, flow-
mediated dilation, mean
arterial pressure,
ultrasound scan)
- Weight

Ni Mhurchu et
al. (2008)
Pilot RCT, participants
were randomized to
receive an exergaming
upgrade package for
their PlayStation2
systems (n=10), or no
intervention (control
group, n=10).

20 children,
average age
12±1.5 years
During the 12 week in-home intervention,
participants were instructed to substitute
exergaming for TSVGs.

Activity counts and motion were recorded
at baseline (week 0), week 6, and week 12
(post-intervention).

- Activity counts and
motion (accelerometry,
daily activity log, PAC-Q)

I ?

Paw et al.
(2008)
Pilot RCT, 12 week
intervention. Participants
randomized into home
group (n=14) or multi-
player group (n=13).

27 children,
average age
10.6±0.8 years
Home group participants received an in-
home EG system and were instructed to
play as often as desired, while the
multiplayer group received both the in-
home system and a weekly class at a
fitness center during which participants
played the EGs together.

Outcomes measures were recorded at
baseline (week 0), week 6, and week 12
(post-intervention).

- Aerobic fitness (20m
shuttle test)
- BMI
- Perceived competence in
sports (CBSK-M)
- Physical activity level &
sedentary behavior
(questionnaire)
- Skinfold thickness

I ?
Palmeira et al.
(2008) (cited
in Foley &
Maddison,
2010)

2-arm quasi-
experimental design with
control group. 4-week
intervention.

15 overweight
children, average
age 13.60 years
Half the participants (intervention group)
received exergaming intervention, controls
received no intervention.

- Activity counts
(accelerometry)

II +

Pettit et al.
(2005)
RCT, 8-week alternative
treatments design. All
participants participated
in a 3 hour per day, 3
day per week fitness and
nutrition program.

20 obese
adolescents,
average age
15.7±0.9 years
Exergaming group participants (n=10)
were randomized to play the EG 1 hour out
of the 3-hr session, while the control group
(n=10) spent 1 hour in vigorous physical
activity.

Both groups spent 2 hours per session
learning about nutrition, engaging in
physical activity, and motivation/self-
- Body fat percentage

- BMI
- Weight

I ?
190

esteem training.

Southard &
Southard
(2006)

RCT, 4-week
intervention. Study in
progress, full results not
yet available. Results on
partial sample (n=77)
reported after week 1.

5 underweight
children

68 normal
weight children

16 children at-
risk for
overweight

31 overweight
children

Age range 9-11
years

All participants wore pedometers for 4
weeks, Intervention group participants
(n=38, 22 underweight or normal weight,
16 at-risk or overweight) were randomized
to play an EG, which requires children to
accumulate “ergs,” (energy expended
while walking) in order to play the game.

Control group participants (n=39, 24
underweight or normal weight, 15 at-risk
or overweight) received no intervention.

Steps walked were recorded at week 0
(baseline) and week 1 (partial
intervention).

- Steps walked (pedometer)

I

?

Widman et al.
(2006)
Single group, pre-post
test design.

4 adolescent
boys with spina
bifida, average
age 17.5±0.9
years

4 adolescent girls
with spina bifida,
average age
15.5±0.6 years

16-week intervention. All participants used
a device which combines a traditional
hand-crank exercise machine with a
videogame, in-home for 16 weeks

- HR
- Maximum work capacity
-RPE
- EE (VO
2
/VO
2
max)
III +

Abbreviations: BP = blood pressure, EE = energy expenditure, EG(s) = EGs(s), HR = heart rate, IPE = Individual prediction equation of energy expenditure calculated using HR, age,
gender, and body mass. METS = metabolic equivalents, TSVG = traditional seated videogame, RPE = rating of perceived exertion, VO
2
/VO
2
max = oxygen consumption using indirect
calorimetry.

a
Level of Evidence: methodological rigor as assessed by five-component rating scale (Gutman, 2008) described in Method section; see Table 1.
b
Outcome: +, intervention was beneficial; 0, no effect; ?, unclear; beneficial for some but not all outcomes or participants.

References
Adkins, M., Brown, G.A., Heelan, K., Ansorge, C., Shaw, B.S. & Shaw, I. (2013). Can dance
exergaming contribute to improving physical activity levels in elementary school children?
African Journal for Physical, Health Education, Recreation and Dance, 19(3), 576-585.
Bailey, B.W. & McInnis, K. (2011). Energy cost of exergaming: A comparison of the energy cost of 6
forms of exergaming. Archives of Pediatric and Adolescent Medicine, 165(7), 597-602.
Brown, G.A., Holoubeck, M., Nylander, B., Watanabe, N., Janulewicz, P., Costello, M., … Abbey, B.
(2008). Energy costs of physically active video gaming: Wii boxing, Wii tennis, and Dance
Dance Revolution. Medicine and Science in Sports and Exercise, 40, S46. doi:
10.1249/01.mss.0000322956.60097.f0
Crommett, A. (2009). DDR activity compared to traditional P.E. activities: A heart rate study. Medicine
and Science in Sports and Exercise, 41, 13-14. doi: 10.1249/01.mss.0000353299.79959.da
de Vries, S.I., Simons, M., & Jongert, T.W.A. (2008). Energy expenditure of active computer-games.
Medicine and Science in Sports and Exercise, 40, S198. doi:
10.1249/01.mss.0000322317.24933.01
Epstein, L.H., Beecher, M.D., Graf, J.L., & Roemmich, J.N. (2007). Choice of interactive dance and
bicycle games in overweight and nonoverweight youth. Annals of Behavioral Medicine, 33, 124-
131. doi: 10.1007/BF02879893
Exner, A., Papatheodorou, G., Baker, C.M., Verdaguer, A., Hluchan, C.M., & Calvert, S.L. (2009,
April). Solitary versus social gross motor videogame play: Energy expenditure among low-
income African American adolescents. Poster presented at the biennial meeting of the Society for
Research in Child Development, Denver, CO.
Fogel, V.A., Miltenberger, R.G., Graves, R., & Koehler, S. (2010). The Effects of exergaming on
physical activity among inactive children in a physical education classroom. Journal of Applied
Behavior Analysis, 43, 591-600.
192

Gasperetti, B.A., Foley, J.T., Yang, S.P., Columna, L., & Lieberman, L. (2011, March). Comparison of
three exergames played by youth with visual impairments. Program to be presented at the
American Alliance for Health, Physical Education, Recreation and Dance National Convention
and Exposition, San Diego, California. Retrieved from:
http://aahperd.confex.com/aahperd/2011/preliminaryprogram/abstract_16161.htm.
Graf, D.L., Pratt, L.V., Hester, C.N., & Short, K.R. (2009). Playing active video games increases energy
expenditure in children. Pediatrics, 124, 534-540. doi: 10.1542/peds.2008-2851
Graves, L.E.F., Ridgers, N.D., & Stratton, G. (2008a). The contribution of upper limb and total body
movement to adolescents’ energy expenditure whilst playing Nintendo Wii. European Journal of
Applied Physiology, 104, 617-623. doi: 10.1007/s00421-008-0813-8
Graves, L.E.F., Ridgers, N.D., Williams, K., Stratton, G., Atkinson, G., &Cable, N.T. (2010). The
Physiological cost and enjoyment of Wii Fit in adolescents, young adults, and older adults.
Journal of Physical Activity and Health, 7, 393-401.
Graves, L., Gareth, S., Ridgers, N.D., & Cable, N.T. (2008b). Energy expenditure in adolescents playing
new generation computer games. British Journal of Sports Medicine, 42, 592-594.
Graves, L., Stratton, G., Ridgers, N.D., & Cable, N.T. (2007). Comparison of energy expenditure in
adolescents when playing new generation and sedentary computer games: Cross sectional study.
BMJ, 335, 1282-1284. doi: 10.1136/bmj.39415.632951.80
Gutman, S.A. (2008). State of the Journal. American Journal of Occupational Therapy, 62, 619-622.
Haddock, B.L., Siegel, S.R., & Wikin, L.D. (2009). The Addition of a video game to stationary cycling:
The impact on energy expenditure in overweight children. Open Sports Sciences Journal, 1, 42-
46. doi: 10.2174/1875399X00902010042
Haddock, B.L., Siegel, S.R., & Wikin, L.D. (2010). Energy expenditure of middle school children while
playing Wii Sports games. Californian Journal of Health Promotion, 8, 32-39.
193

Kemble, C.D., Mahar, M.T., Rowe, D.A., Murray, N.P., & Cooper, N. (2007). Energy expenditure
during rest, traditional video game play, and interactive video game play in adolescent boys.
Medicine and Science in Sports and Exercise, 39, S88. doi:
10.1249/01.mss.0000273257.98503.27
Lanningham-Foster, L., Jensen, T.B., Foster, R.C., Redmond, A.B., Walker, B.A., Heinz, D., & Levine,
J.A. (2006). Energy expenditure of sedentary screen time compared with active screen time for
children. Pediatrics, 118, e1831-e1835. doi: 10.1542/peds.2006-1087
Lanningham-Foster, L., Foster, R.C., McCrady, S.K., Jensen, T.B., Mitre, N., & Levine, J.A. (2009).
Activity-promoting video games and increased energy expenditure. The Journal of Pediatrics,
154, 819-823. doi: 10.1016/j.jpeds.2009.01.009
Maddison, R., Foley, L., Ni Mhurchu, C., Jiang, Y., Jull, A., Prapavessis, H., Hohepa, M., & Rodgers,
A. (2011). Effects of active video games on body composition: A randomized controlled trial.
American Journal of Clinical Nutrition, 94, 156-63.
Maddison, R., Ni Mhurchu, C., Jull, A., Jiang, Y., Prapavessis, H., & Rodgers, A. (2007). Energy
expended playing video console games: An opportunity to increase children’s physical activity?
Pediatric Exercise Science, 19, 334-343.
Maloney, A.E., Bethea, T.C., Kelsey, K.S., Marks, J.T., Paez, S., Rosenberg., A.M., … Sikich, L.
(2008). A Pilot of a video game (DDR) to promote physical activity and decrease sedentary
screen time. Obesity, 16, 2074-2080. doi: 10.1038/oby.2008.295
McDonogh, S.L. (2009). Comparison of an inter-active dance video game and traditional exercise
equipment relative to use preferences and energy expenditure in adolescent females ages 16-18.
Medicine and Science in Sports and Exercise, 41, 12-13. doi:
10.1249/01.mss.0000353296.57088.68
McDougall, J. & Duncan, M.J. (2008). Children, video games and physical activity: An exploratory
study. International Journal of Disability and Human Development, 7, 89-94.
194

Mellecker, R.R. & McManus, A.M. (2008). Energy expenditure and cardiovascular responses to seated
and active gaming in children. Archives of Pediatric and Adolescent Medicine, 162, 886-891.
Mellecker, R.R., McManus, A.M., Lanningham-Foster, L.M. & Levine, J.A. (2009). The feasibility of
ambulatory screen time in children. International Journal of Pediatric Obesity, 4, 106-111. doi:
10.1080/17477160802315002
Mills, A., Rosenberg, M., Stratton, G., Carter, H., Spence, A., Pugh, C., Green, D., Naylor, L. (2013).
The effect of exergaming on vascular function in children. The Journal of Pediatrics, 163(3),
806-810.
Murphy, E.C-S., Carson, L., Neal., W., Baylis, C., Donley, D., & Yeater, R. (2009). Effects of an
exercise intervention using Dance Dance Revolution on endothelial function and other risk
factors in overweight children. International Journal of Pediatric Obesity, 4, 205-214.
Ni Mhurchu, C., Maddison, R., Jiang, Y., Jull, A., Prapavessis, H., & Rodgers, A. (2008). Couch
potatoes to jumping beans: A pilot study of the effect of active video games on physical activity
in children. International Journal of Behavioral Nutrition and Physical Activity, 5, doi:
10.1186/1479-5868-5-8
Paw, M.J.M.C.A., Wietske, M.J., Vaessen, E.P.G., Titze, S., & van Mechelen, W. (2008). The
motivation of children to play an active video game. Journal of Science and Medicine in Sport,
11, 163-166. doi: 10.1016/j.jsams.2007.06.001
Penko, A.L. & Barkley, J.E. (2010). Motivation and physiologic responses of playing a physically
interactive video game relative to a sedentary alternative in children. Annals of Behavioral
Medicine, 39, 162-169. doi: 10.1007/s12160-010-9164-x
Porcari, J.P., Hellenbrand, N., Foster, C., Gibson, M., & Doberstein, S. (2009). The physiological and
psychological effects of a video game-enhance Cateye Gamebike. Medicine and Science in
Sports and Exercise, 41, 12. doi: 10.1249/01.mss.0000353294.49465.a2
195

Ridley, K., & Olds, T. (2001). Video center games: Energy cost and children’s behaviors. Pediatric
Exercise Science, 13, 413-421.
Schipper, P., Aansorgh, B., Thijssen, D.H., De Groot, P.C., Groothius, J.T., & Hopman, M.T. (2009).
Activity levels while playing new generation video games. Medicine and Science in Sports and
Exercise, 41, 13. doi: 10.1249/01.mss.0000353298.02831.74
Siegel, S.R., Haddock, B.L., Wilkin, L.D., & Brock, J.A. (2008). Energy expenditure in overweight
youth using active video games versus straight stationary bike protocol. Medicine and Science in
Sports and Exercise, 40, S460. doi: 10.1249/01.mss.0000322957.67721.b2
Southard, D.R. & Southard, B.H. (2006). Promoting physical activity in children with MetaKenkoh.
Clinical and Investigative Medicine, 29, 293-297.
Staiano, A. & Calvert, S. (2010, June). Wii Tennis play as physical activity in low-income African
American adolescents. Paper presented at the Annual Meeting of the International
Communication Association, Suntec City, Singapore.
Straker, L. & Abbott, R. (2007). Effect of screen-based media on energy expenditure and heart rate in 9-
to 12-year-old children. Pediatric Exercise Science, 19, 459-471.
Tan, B., Aziz, A.R., Chua, K., & Teh, K.C. (2002). Aerobic demands of dance simulation game.
International Journal of Sports Medicine, 23, 125-129. doi: 10.1055/s-2002-20132
Unnithan, V.B., Houser, W., & Fernhall, B. (2006). Evaluation of the energy cost of playing a dance
simulation video game in overweight and non-overweight children and adolescents.
International Journal of Sports Medicine, 27, 804-809. doi: 10.1055/s-2005-872964
Wetzsteon, R.J., Swanson, K.S., Pickett, K., Golner, S., Stovitz, S.D., & Petit, M.A. (2006). Energy
expenditure and ground reaction forces of an active video game, Dance Dance Revolution, in
healthy weight and overweight children. Medicine and Science in Sports and Exercise, 38, S255.
White, K., Schofield, G., & Kilding, A.E. (2010). Energy expended by boys playing active video games.
Journal of Science and Medicine in Sport, 14(2), 130-4. doi: 10.1016/j.jsams.2010.07.005.
196

Widman, L.M., McDonald, C.M., & Abresch, R.T. (2006). Effectiveness of an upper extremity exercise
device integrated with computer gaming for aerobic training in adolescents with spinal cord
dysfunction. The Journal of Spinal Cord Medicine, 29, 363-370.
Wittman, G. (2010). Video gaming increases physical activity. Journal of Extension, 48(2), 1-4.
Available from: http://www.joe.org/joe/2010april/tt6.php.

197

APPENDIX B. IRB Documents
Study 1

Proposal #HS-10-00696
University of Southern California Health Sciences Campus
Institutional Review Board
LAC+USC Medical Center, General Hospital Suite 4700
1200 North State Street, Los Angeles, CA 90033
(323) 223-2340 phone
(323) 224-8389 fax
irb@usc.edu

Date: Feb 01, 2011, 12:01pm
To: Amanda Foran
OCCUPATIONAL SCIENCE AND OCCUPATIONAL THERAPY (DIVISION 7)

From: Health Sciences Institutional Review Board
General Hospital, Suite 4700
1200 North State Street
Los Angeles, CA 90033
(323) 223-2340

TITLE OF PROPOSAL:
Survey of at-home videogame use for LAUSD school children and adolescents with special
needs. (Videogame survey)

Action
Date:
2/1/2011 Action Taken: Approve
Committee: Institutional Review Board Chairman
Note: Your iStar application and attachments were reviewed by the expedited mechanism on
February 1, 2011.

The project was APPROVED.

The materials submitted and considered for review of this project included:
1. Revised iStar Application, dated 1/27/11
198

2. Response to contingencies from 1/26/11
3. Videogame Survey
4. Email Invitation Script
5. Letter of Support from LAUSD
6. Revised Cover Letter Template
7. Teacher Letter

Based on the information submitted for review, this study is exempt from 45 CFR 46
according to §46.101(b) as category 2.

As a research which is considered exempt according to §46.101(b) this project is not
subject to requirements for continuing review. You are authorized to conduct this
research as approved.

The HIPAA Privacy Rule will not apply to this research. The investigator certifies that
he/she is not accessing, using or obtaining protected (i.e., identifiable) health information
held by: a) a health care provider (e.g., physician or other health care practitioner,
hospital, clinic, nursing home); b) health plan (e.g., group health plan, insurance
company, (HMO); or c) health care clearinghouse (e.g., billing service) that is governed
by the HIPAA privacy federal regulations.

Proposal #HS-10-00618
University of Southern California Health Sciences Campus
Institutional Review Board
LAC+USC Medical Center, General Hospital Suite 4700
1200 North State Street, Los Angeles, CA 90033
(323) 223-2340 phone
(323) 224-8389 fax
irb@usc.edu

Date: Nov 10, 2010, 10:21am
To: Amanda Foran
OCCUPATIONAL SCIENCE AND OCCUPATIONAL THERAPY (DIVISION 7)

From: Health Sciences Institutional Review Board
General Hospital, Suite 4700
199

1200 North State Street
Los Angeles, CA 90033
(323) 223-2340

TITLE OF PROPOSAL:
Survey of at-home videogame use for children and adolescents with Autism Spectrum
Disorders. (Videogame Survey - IAN)

Action
Date:
11/10/2010 Action Taken: Approve
Committee: Institutional Review Board Chairman
Note: Your iStar application and attachments were reviewed by the expedited mechanism on
November 10, 2010.

The project was APPROVED.

The materials submitted and considered for review of this project included:
1. iStar Application, dated 11/3/10
2. Videogame Survey (English and Spanish)
3. Recruitment Letter (English and Spanish)

Based on the information submitted for review, this study is exempt from 45 CFR 46
according to §46.101(b) as category 2.

As a research which is considered exempt according to §46.101(b) this project is not
subject to requirements for continuing review. You are authorized to conduct this
research as approved.

The HIPAA Privacy Rule will not apply to this research. The investigator certifies that
he/she is not accessing, using or obtaining protected (i.e., identifiable) health information
held by: a) a health care provider (e.g., physician or other health care practitioner,
hospital, clinic, nursing home); b) health plan (e.g., group health plan, insurance
company, (HMO); or c) health care clearinghouse (e.g., billing service) that is governed
by the HIPAA privacy federal regulations.

200

Study 2

Proposal #HS-11-00113
University of Southern California Health Sciences Campus
Institutional Review Board
LAC+USC Medical Center, General Hospital Suite 4700
1200 North State Street, Los Angeles, CA 90033
(323) 223-2340 phone
(323) 224-8389 fax
irb@usc.edu
Date: Mar 28, 2012, 01:58pm
To: Amanda Foran
OCCUPATIONAL SCIENCE AND OCCUPATIONAL THERAPY (DIVISION 7)

From: Health Sciences Institutional Review Board
General Hospital Suite 4700
1200 North State Street
Los Angeles, CA 90033
(323) 223-2340

TITLE OF PROPOSAL:
Case studies on the feasibility of exergaming to enhance physical activity in youth with autism spectrum
disorders
Continuing Review: HS-11-00113-CR001 (Continuing review - Exergaming feasibility in ASD)

Action
Date:
3/26/2012 Action Taken: Approved
Committee: Institutional Review Board Vice Chairman
Note: Your iStar Continuing Review Application received by the IRB on 3/19/2012 was
reviewed by Dr. Robert Larsen on 3/26/2012. The Continuing Review was submitted for
expedited review according to 45 CFR 46.110(b) under Research Categories 6 and 7.
The Continuing Review was APPROVED.

The IRB reviewed this study and because the study has no funding and the risk to
participants is minimal, the IRB has applied the USC Human Research Protection
201

Program Flexibility Policy under an Exempt Category.

This study is not subject to the federal regulations at 45 CFR 46. You are authorized to
conduct this research as approved. This project is not subject to requirements for
continuing review.

Subject protections and ethical standards expected of exempt research will apply to new
exempt categories.

202

INFORMED CONSENT

STUDY TITLE: Case studies on the feasibility of exergaming to
enhance physical activity in youth with autism spectrum
disorders

PRINCIPAL INVESTIGATOR: Amanda C Foran, MS OTR/L

DEPARTMENT: Division of Occupational Science and
Occupational Therapy

TELEPHONE NUMBER: 360 259 0089

______________________________________________________________________

We invite you and your child to take part in a research study. Please take as much time as you
need to read the consent form. You may want to discuss it with your family, friends, or your
personal doctor. You may find some of the language difficult to understand. If so, please ask
questions. If you decide to participate, you will be asked to sign this form on behalf of your
child.

WHY IS THIS STUDY BEING DONE?

This study is about active videogame systems and physical activity. We hope to learn about
how much exercise a child can get from playing active videogames and how easily a child can
play them. We would also like to find out what we can do to help make playing videogames
easier for children with Autism Spectrum Disorders. The special videogame system used in
this study may be easier for your child to understand than traditional videogames because
he/she will be able to see himself/herself on the screen creating the movements. Your child is
invited as a possible participant because he/she can follow simple instructions and may be
interested in playing videogames. About 10 children will take part in the study.

WHAT IS INVOLVED IN THE STUDY?

If you decide to take part, this is what will happen:

You will be asked to complete a questionnaire about your child, including their age, gender,
physical activity level, and other information. You will be asked to fill out a checklist about your
child’s language ability. You will also be asked to look over the “Child Assent” form (attached to
this packet), and indicate whether or not you think your child would understand the information
on the form.

If you allow your child to participate, he/she will be asked to complete 6 sessions (45-60
minutes each) either in your home or at a USC facility. The sessions will be scheduled at your
convenience over the course of 3-6 weeks. During each session, your child will wear a heart
rate monitor on a soft strap around the chest, and an activity monitor around his/her waist.
Your child will also be videotaped so that researchers can look back and see how much your
child was moving and how much help he/she needed while playing.

203

With help from the researchers, your child will learn how to play a videogame that requires
body movements, such as jumping and swinging his/her arms. We will ask your child to tell us
how tiring the game was, and how much he/she liked the game after each session. At the first
and last session, your child will be given a series of simple movement tests which require
him/her to do things like walk a straight line on a piece of tape on the floor, walk heel-to-toe, or
balance on one leg.

WHAT ARE THE POSSIBLE RISKS AND DISCOMFORTS?

Possible risks and discomforts your child could experience during this study include:

1. Minor discomfort while wearing the heart rate monitor band or activity monitor during
videogame play.
2. He/She may become anxious or excited during or after videogame play due to
increased physical activity level and participation in a new activity. We will monitor your
child for signs of distress, and consult with you on appropriate calming methods prior to
your child’s participation.
3. There is a possible risk of falling although the balance beam that your child will walk on
is not raised off the floor. Your child will be carefully supervised.

There may be other risks/discomforts associated with participating in this study that we do not
know at this time.

WILL YOUR CHILD’S INFORMATION BE KEPT PRIVATE?

We will keep your child’s records for this study confidential as far as permitted by law.
However, if we are required to do so by law, we will disclose confidential information about
your child. The University of Southern California’s Institutional Review Board (IRB) may review
your child’s records. The IRB is a research review board that reviews and monitors research
studies to protect the rights and welfare of research participants. We may publish the
information from this study in journals or present it at meetings. If we do, we will not use your
child’s name or any information that would identify your child.

We will remove your child’s name and other information that may identify him/her from our
research data. We will store the data in a locked filing cabinet or password-protected
computer system in our research office on the campus of the University of Southern California
to prevent access by unauthorized personnel. Some videos of your child performing the
balance tests or playing the videogames will be taken during this study. Pictures or videos may
be used in presentations or publications. Sufficient portions of the face will be obscured to hide
the identity of your child, unless you indicate below that it is okay to show his/her full face.

You and your child have the right to view video-recordings and results of motor assessments
for up to one year after conclusion of the study. After one year, all video-recordings and
assessment data will be destroyed or securely stored in a locked filing cabinet or password-
protected computer system in our research office on the campus of the University of Southern
California to prevent access by unauthorized personnel.

WHAT ARE THE POSSIBLE BENEFITS OF TAKING PART IN THIS STUDY?

The possible benefits to your child for taking part in this study may include:
204

1. He/She may find it fun to play these videogames.
2. Because many children with special needs tend to be sedentary for much of the day,
participation in the study will provide your child with an opportunity to get moving and
have fun, as a break from typical daily routine.

The knowledge obtained from your child’s participation may provide your family with ideas on
how to incorporate both physical activity and technology into the daily life of your child. Results
of this study can also serve to inform future research using videogames as a way to promote
physical activity for children with special needs.

WHAT OTHER OPTIONS ARE THERE?

An alternative would be to not participate in this study.

ARE THERE ANY PAYMENTS TO YOU OR YOUR CHILD FOR TAKING PART IN THE
STUDY?

If your child completes at least one session, your family will be provided with a $20 gift card to
a local supermarket or sporting goods store. In addition, we will also give you a thank-you
letter and certificate of participation, in acknowledgment of your participation in the project.

WHAT ARE YOUR CHILD’S RIGHTS AS A PARTICIPANT, AND WHAT WILL HAPPEN IF
YOU DECIDE NOT TO ALLOW YOUR CHILD TO PARTICIPATE?

Your child’s participation in this study is voluntary. Your decision whether or not to allow your
child to take part will not affect your current or future relationship with USC. You are not giving
up any legal claims or rights. If you do decide to allow your child to take part in this study, you
are free to change your mind and stop your child from being in the study at any time.

CAN YOUR CHILD BE REMOVED FROM THE STUDY?

Your child may be removed from this study without your consent for any of the following
reasons:

1. Your child is unable to follow instructions despite support from researchers, and
accommodations for your child’s individual special needs.
2. Your child appears uncomfortable or becomes increasingly agitated with participation in
the study.
3. Your child is unavailable to complete all 6 sessions of the study due to medical issues,
your family’s schedule, or unwillingness to participate.

WHOM DO YOU CALL IF YOU HAVE QUESTIONS OR CONCERNS?

You may contact Amanda C Foran, MS OTR/L at (360) 259-0089 with any questions,
concerns, or complaints about the research or your child’s participation in this study. If you feel
your child has been hurt by taking part in this study, please contact Sharon Cermak, Ed.D at
(323) 442-2850. If you are unable to contact the research team, please contact the USC
Institutional Review Board (IRB) Office at 323-223-2340 between the hours of 8:00 AM and
4:00 PM. (Fax: 323-224-8389 or email at irb@usc.edu).
205

If you have any questions about your child’s rights as a research participant, or want to talk to
someone independent of the research team, you may contact the Institutional Review Board
Office at the numbers above or write to the Health Sciences Institutional Review Board at
LAC+USC Medical Center, General Hospital Suite 4700, 1200 North State Street, Los
Angeles, CA 90033.

You will get a copy of this consent form.

AGREEMENT:

I have read (or someone has read to me) the information provided above. I have been given a
chance to ask questions by contacting the researchers in person and by phone if needed. All
my questions have been answered. By signing this form, I am agreeing to allow my child to
take part in this study.

Name of Parent Signature Date Signed
(and Time*)

______________________________
Name of Child Participant

Please review the “Child Assent Form” attached to this packet, and indicate whether or not you
think your child can understand the information on the form (please check and initial one):

YES, my child will be able to understand the information ____

NO, my child will not be able to understand the information but I am allowing him/her to
participate in the study _____

In some cases, the researchers may wish to use a videorecording of your child for academic
presentations or publications. (please check and initial one):

____ I agree to allow my child’s full face to be shown in academic presentations or publications
as necessary.

____ I prefer that a portion of my child’s face be obscured in all academic presentations or
publications so that he/she cannot be identified.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

206

RESEARCHER USE ONLY:

In reviewing this form, I believe that the parent of the potential child participant understands the
information described in this informed consent and freely consents to participate. I have made
myself available to answer questions from the parents regarding this form.

Name of Person Obtaining Informed
Consent
Signature Date Signed
(and Time*)

207

University of Southern California
Division of Occupational Science and Occupational Therapy

ASSENT TO BE IN RESEARCH

Exergaming Case Studies

1. My name is _________.

2. We are asking you to help us with a project because we are trying to learn more about how much
exercise you get and how much fun you have when you play videogames.

3. If you decide to be in this project, we will help you learn how to play a new videogame and watch you
playing it so we can see how much exercise you are getting. We will ask you to wear a band around
your chest and another around your hips so the computer knows how hard your body is working. We
will also ask you to try balancing on one foot and walking on a straight line, so we can see how your
body moves.

4. Sometimes things happen when you play videogames or practice balancing. You could become tired or
frustrated when playing the videogame. You may also feel uncomfortable wearing the band around
your chest or hips. Or other things might happen that we don’t know about yet. A helper will be there to
be sure you don’t get hurt or scared.

5. People also have good things happen to them when they are part of projects like this. You will learn
how to use a fun new game, you can tell your friends that you got to play with college students during
classtime. If you do most of the sessions, your family will get a gift card to thank you for playing with us.

6. Your parent(s ) said it was ok to play videogames with us and do the balance tests. But if you don't
want to do it, you can just tell us “no.” It’s up to you. If you say yes now, but change your mind later,
that’s okay too. All you have to do is tell us.

8. You can ask me any questions that you have about this project. If you have a question later that you
didn’t think of now, you can ask your parents to call me at (323) 442-2850, or you can ask me next time
we see each other.

9. Putting your name at the bottom means that you have decided to be in this project. You and your
parents will be given a copy of this form after you have signed it.

____________________________________
Name of Subject

____________________________________ ____________________
Signature of Subject [please put your name here] Date

___________________________________
Name and Title of Person Obtaining Assent

___________________________________ ____________________
Signature of Person Obtaining Assent Date (must be same as Subject’s)
208

Study 3

Proposal #HS-12-00508
University of Southern California Health Sciences Campus
Institutional Review Board
LAC+USC Medical Center, General Hospital Suite 4700
1200 North State Street, Los Angeles, CA 90033
(323) 223-2340 phone
(323) 224-8389 fax
irb@usc.edu
Date: Jul 29, 2013, 08:37am
To: Amanda Foran
OCCUPATIONAL SCIENCE AND OCCUPATIONAL THERAPY (DIVISION 7)

From: Health Sciences Institutional Review Board
General Hospital Suite 4700
1200 North State Street
Los Angeles, CA 90033
(323) 223-2340

TITLE OF PROPOSAL: The effect of exergaming on physical activity and enjoyment in youth and
young adults with Autism Spectrum Disorder and typical development - Continuing Review: HS-12-
00508-CR001 (Fall 2013 continuation)

Action Date: 7/27/2013 Action Taken: Approved
Committee: Institutional Review Board Vice-Chair
Note: Your iStar Continuing Review Application received by the IRB on 7/19/2013 was
reviewed by Dr. Deirdre Anglin on 7/27/2013. The Continuing Review qualifies for
expedited review as categories 4, 6 and 7. The Continuing Review was APPROVED.

The IRB edited Informed Consent for ASD Subjects dated 07/22/13 was APPROVED.
The IRB edited Informed Consent for NT Mentors dated 07/22/13 was APPROVED.
The Adult Assent document dated 9/11/12 was APPROVED.

APPROVAL FOR YOUR STUDY IS VALID FROM 7/27/2013 UNTIL 7/26/2014.

209

Notes to PI:

1. Please submit a current copy of the Towson IRB Approval letter with your next
submission to the IRB.

2. The IRB has modified the Informed Consents for ASD Subjects and NT Mentors
and have version dated the documents 07/22/13. They have been saved using the
Microsoft Word track changes feature so that the modifications made by the IRB may
be easily identified. The informed consents are located at the “Documents” tab in the
iStar study and in the iStar application under item 29. The IRB has placed an
“Approval Stamp” on a copy of the consents (after using the accept changes feature)
and placed them at the top of the “Documents” tab under the Approved Consent
Forms (With IRB Approval Stamp). These are considered the APPROVED informed
consents. You must utilize a copy of the Approved informed consents that bears the
IRB Approval Stamp. If you agree and accept these documents you may proceed with
your study utilizing the documents.

If additional changes need to be made to the informed consent, you must make the
changes on the IRB Approved copy of the informed consent. Your additions and/or
deletions must be identified by using the track changes feature in Microsoft Word.
The changes need to be submitted to the IRB using the amendment procedure in
iStar.

Informed consent must be obtained by the investigator or person authorized to obtain
informed consent from all research subjects or their legally authorized representatives.
You must ensure that all project personnel involved in the process of consent/assent are
trained properly and are fully aware of their responsibilities relative to the obtainment of
informed consent/assent according to the IRB guidelines and applicable federal
regulations.

The IRB office has stamped the approved informed consent for use in this research
project. It should be photocopied, as appropriate. You may not use this informed
consent document to consent new subjects after the expiration date. The study subject
must sign and date the informed consent document. The person obtaining informed
consent must also sign the study consent form at the time consent is obtained. One copy
of the informed consent should be given to the study subject, one copy placed in the
hospital medical record, and the investigator should retain one copy.

Informed consent is obtained in the research participant’s language. If the participant
speaks Spanish and the informed consent document has been translated into Spanish,
you must utilize the Spanish informed consent document, the Spanish Experimental
Subject's Bill of Rights, and the Spanish HIPAA Authorization form. For participants
who speak other languages, you must have a translator verbally translate the English
informed consent document into those languages for the participants. The English
informed consent serves as a summary. The translator, the person obtaining informed
consent and the witness sign the English informed consent document. The participant
and witness sign the Short Form informed consent document, which must be in the
participant’s language. The IRB has translated the Short Form consent into multiple
languages, which are available on the IRB website. In addition, the participant signs the
210

Experimental Subject's Bill of Rights in the participant’s language. The IRB has
translated the Experimental Subject's Bill of Rights into multiple languages which are
also available on the IRB website (http://www.usc.edu/admin/provost/oprs/hsirb/forms).

As the Principal Investigator you are required to ensure that this research and the actions
of all project personnel involved in conducting the study will conform with the research
project and it's modifications approved by the IRB; HHS regulations (45CFR46); FDA
regulations (21CFR50,56); International Conference on Harmonization Good Clinical
Practice Consolidated Guideline; IRB Policies and Procedures and applicable state laws.
Failure to comply may result in suspension or termination of your research project,
notification of appropriate governmental agencies by the IRB, and/or suspension of your
freedom to present or publish results. Any proposed changes in the research project
must be submitted, reviewed and approved by the IRB before the change can be
implemented. The only exception is a change necessary to eliminate apparent immediate
hazards to the research subjects. In such a case, the IRB should be promptly informed of
the change following its implementation for IRB review. You must inform the IRB
immediately if you become aware of any violations of HHS regulations (45CFR46),
FDA regulations (21CFR50,56), applicable state laws or IRB Policies and Procedures
for the protection of human subjects. You are required to notify the IRB office in the
event of any action by the sponsor, funding agency or FDA, including warnings,
suspension or termination of your participation in this trial. You must maintain all
required research records and recognize the IRB is authorized to inspect these records.

APPROVAL FOR YOUR STUDY WILL EXPIRE AT THE END OF THE DAY (i.e.,
MIDNIGHT) ON 7/26/2014. IRB approval is valid for a maximum period of one year
with continuing review by the IRB required at least annually in order to maintain
approval status. You must not enter subjects on the study if IRB approval expires. In
this case you must immediately request IRB permission to continue study
treatments/interventions on currently enrolled subjects by sending a message in iStar.
Attachments:
Rev. NT Informed Consent (IRB edits) 7-22-13.doc.docx
Rev. ASD Informed Consent (IRB edits) 7-22-13.doc.docx

Approved ICs and HIPAA forms: view

211

University of Southern California
Division of Occupational Science and Occupational Therapy

CONSENT TO BE IN RESEARCH (MODIFIED)

The effect of exergaming on physical activity and enjoyment in youth and young adults
with Autism Spectrum Disorder and typical development

1. My name is _________.

2. We are asking you to help us with a project because we are trying to learn more about how much
exercise people get and how much fun they have when they play videogames.

3. If you decide to be in this project, we will help you learn how to play a new videogame and watch you
playing it so we can see how much exercise you are getting. We will ask you to wear a band around
your chest and another around your hips so the computer knows how hard your body is working. We
will also ask you to try balancing on one foot and walking on a straight line, so we can see how your
body moves. You will come in for 8 sessions that each last about 30 to 60 minutes. We will also ask
you some questions about yourself and how much you exercise.

4. Sometimes things happen when you play videogames or practice balancing. You could become tired or
frustrated when playing the videogame or uncomfortable answering certain questions. You may also
feel uncomfortable wearing the band around your chest or hips. Or other things might happen that we
don’t know about yet. A helper will be there to be sure you don’t get hurt or scared.

5. People also have good things happen to them when they are part of projects like this. You will learn
how to use a fun new game, and can make friends with others who are in the study playing with you.

6. You will also get a gift card for helping out with this study, and you can use it to buy sporting goods or
other fun equipment.

7. Your parent/guardian said it was ok to play videogames with us and do the balance tests. But if you
don't want to do it, you can just tell us “no.” It’s up to you. If you say yes now, but change your mind
later, that’s okay too. All you have to do is tell us.

8. You can ask me any questions that you have about this project. If you have a question later that you
didn’t think of now, you can ask your family to call me at (360) 259-0089, or you can ask me next time
we see each other.

9. Putting your name on the next page means that you have decided to be in this project. You and your
parents will be given a copy of this form after you have signed it.

__________________________________
Name of Participant

____________________________________ ____________________
Signature of Participant
[please put your name here] Date

___________________________________
Name of Person Obtaining Assent

___________________________________ ____________________
Signature of Person Obtaining Assent Date (must be same as Participant’s)
212

INFORMED CONSENT

STUDY TITLE: The effect of exergaming on physical activity and
enjoyment in youth and young adults with Autism
Spectrum Disorder and typical development

PRINCIPAL INVESTIGATOR: Amanda C Foran, PhD (c), OTR/L

DEPARTMENT: Division of Occupational Science and
Occupational Therapy

TELEPHONE NUMBER: (360) 259-0089 or (301) 604-4235
______________________________________________________________________

We invite you to take part in a research study. Please take as much time as you need to read
the consent form. You may want to discuss it with your family, friends, or your personal doctor.
You may find some of the language difficult to understand. If so, please ask questions. If you
decide to participate, you will be asked to sign this form.

***Please note: If you have a Guardian, he/she must read this form and review the questions at
the end of this form and sign on your behalf.

WHY IS THIS STUDY BEING DONE?

This study is about active videogame systems and physical activity. We hope to learn about
how much exercise people can get from playing active videogames and how much fun it is to
play them. We would also like to find out what we can do to help make playing active
videogames easier for individuals on the Autism Spectrum (ASD). You are invited as a
possible participant because you are a young adult on the Autism Spectrum and may be
interested in playing videogames. About 40 young adults on the Autism Spectrum will take part
in the study, as well as 40 neurotypical “mentor” students.

WHAT IS INVOLVED IN THE STUDY?

If you decide to take part, this is what will happen:

You will be asked to complete a questionnaire about your age, gender, physical activity level,
and other basic personal information. For example, you will be asked to rate how often you
engage in physical activity, whether or not you currently play videogames, and how much you
enjoy such activities. You will also be asked to provide verification of your diagnosis (paper
copy of an IEP, physician diagnosis, or other formal documentation). If you decide to
participate, you will be asked to complete 8 sessions (30-60 minutes each) at the Towson
University Center for Adults with Autism. The sessions will be scheduled during twice-monthly
evening group meeting times, over the course of one semester (Summer or Fall 2013). At the
first session, your weight, height, and waist measurement will be obtained. During each
session, you will wear a heart rate monitor on a soft strap around the chest, and an activity
monitor on a belt around your waist. You will also be videotaped so that researchers can look
back and see how much you were moving and how much fun you were having while playing.

213

With help from the researchers, you will learn how to play a videogame that requires body
movements such as jumping and swinging your arms. At some sessions you will play the
game alone, and some sessions you will play with a neurotypical partner. We will ask you to
tell us how tiring the game was, and how much you liked the game after each session. At the
first and last session, you will be given a series of simple movement tests which require you to
do things like walk a straight line on a piece of tape on the floor and balance on one leg.

In some cases, the researchers may wish to use a video recording of you for academic
presentations or publications. You will be asked to indicate your agreement to allow videos of
you to be shown, and you have the option to request that your face is obscured in this video.
Should you decide that you’d rather not have your video used for academic purposes, you may
decline and still participate in the study.

WHAT ARE THE POSSIBLE RISKS AND DISCOMFORTS?

Possible risks and discomforts you could experience during this study include:

4. Minor discomfort while wearing the heart rate monitor band or activity monitor during
videogame play.
5. You may become anxious or excited during or after videogame play due to increased
physical activity level and participation in a new activity. We will monitor you for signs of
distress, and consult with you on appropriate calming methods prior to your
participation.
6. There is a possible risk of falling, although the balance beam that you will walk on is not
raised off the floor. You will be carefully supervised during all movement activities for
safety.
7. There is a small risk that people who are not connected with this study will learn your
identity or personal information.
8. There is a possibility that you may feel uneasy or embarrassed completing the
questionnaires.

There may be other risks/discomforts associated with participating in this study that we do not
know at this time.

WILL YOUR INFORMATION BE KEPT PRIVATE?

We will keep your records for this study confidential as far as permitted by law. However, if we
are required to do so by law, we will disclose confidential information about you to appropriate
authorities. The Center for Adults with Autism, the University of Southern California’s
Institutional Review Board (IRB), and the Towson University IRB may review your records. The
IRB is a research review board that reviews and monitors research studies to protect the rights
and welfare of research participants. We may publish the information from this study in
journals or present it at meetings. If we do, we will not use your name or any information that
would identify you.

We will remove your name and other information that may identify you from our research data.
We will store the data in a locked filing cabinet or fingerprint- and password-protected
computer system in our research office to prevent access by unauthorized personnel. Some
videos of you performing the balance tests or playing the videogames will be taken during this
study. Pictures or videos may be used in presentations or publications. Sufficient portions of
214

your face will be obscured to hide your identity, unless you indicate below that it is okay to
show your full face.

You have the right to view video-recordings and results of motor assessments for up to one
year after conclusion of the study. After one year, all video-recordings and assessment data
will be destroyed or securely stored in a locked filing cabinet or fingerprint- and password-
protected computer system in our research office to prevent access by unauthorized
personnel.

WHAT ARE THE POSSIBLE BENEFITS OF TAKING PART IN THIS STUDY?

The possible benefits for taking part in this study may include:

3. You may find it fun to play these videogames.
4. Because many individuals with special needs tend to be sedentary for much of the day,
participation in the study will provide you with an opportunity to get moving and have
fun, as a break from typical daily routine.
5. This study may contribute to the advancement of knowledge in the fields of ASD and
physical activity research, which could potentially lead to know treatments or therapies.

The knowledge obtained from your participation may provide you with ideas on how to
incorporate both physical activity and technology into daily life. Results of this study can also
serve to inform future research using videogames as a way to promote physical activity for
children with special needs.

WHAT OTHER OPTIONS ARE THERE?

An alternative would be to not participate in this study.

ARE THERE ANY PAYMENTS TO YOU FOR TAKING PART IN THE STUDY?

As compensation for your time, you will be provided with a gift card at the last session ($10 per
session completed, up to $80.00). You will be invited to an end of study celebration party with
food, drinks, and a chance to meet with the other participants and researchers to discuss the
study and watch videos of you and other participants playing the exergames. In addition, we
will also give you a thank-you letter and certificate of participation, in acknowledgment of your
participation in the project.

WHAT HAPPENS IF YOU GET INJURED OR NEED EMERGENCY CARE?

If you are injured as a direct result of research procedures, you will receive medical treatment.
You or your insurance/health plan/government programs will be responsible for the cost of the
medical care. Health care facilities do not provide any other form of compensation for injury.

WHAT ARE YOUR RIGHTS AS A PARTICIPANT, AND WHAT WILL HAPPEN IF YOU
DECIDE NOT TO PARTICIPATE?

Your participation in this study is voluntary. Your decision whether or not to take part will not
affect your current or future relationship with the University of Southern California or Towson
215

University. You are not giving up any legal claims or rights. If you do decide to take part in this
study, you are free to change your mind and stop being in the study at any time.

CAN YOU BE REMOVED FROM THE STUDY?

You may be removed from this study without your consent for any of the following reasons:

4. You are unable to follow instructions despite support from researchers, and
accommodations for your individual special needs.
5. You appear uncomfortable or become increasingly agitated with participation in the
study.
6. You are unavailable to complete all 8 sessions of the study due to medical issues, your
personal schedule, or unwillingness to participate.

WHOM DO YOU CALL IF YOU HAVE QUESTIONS OR CONCERNS?

You may contact Amanda C Foran, Ph.D.(c), OTR/L at (360) 259-0089 with any questions,
concerns, or complaints about the research or your participation in this study. If you feel you
have been hurt by taking part in this study, please contact Sharon Cermak, Ed.D at (323) 442-
2850. If you have questions, concerns, or complaints about the research and are unable to
contact the research team, please contact the USC Institutional Review Board (IRB) Office at
323-223-2340 between the hours of 11:00 AM and 7:00 PM Eastern Standard Time. (Fax:
323-224-8389 or email at irb@usc.edu). You may also contact Debi Gartland, PhD, Chair of
the Towson University Institutional Review Board at 410-704-2236.

If you have any questions about your rights as a research participant, or want to talk to
someone independent of the research team, you may contact the Institutional Review Board
Office at the numbers above or write to the Health Sciences Institutional Review Board at
LAC+USC Medical Center, General Hospital Suite 4700, 1200 North State Street, Los
Angeles, CA 90033. You will get a copy of this consent form.

AGREEMENT:

I have read (or someone has read to me) the information provided above. I have been given a
chance to ask questions by contacting the researchers in person and by phone if needed. All
my questions have been answered. By signing this form, I confirm that I am at least 18 years
old, and I am agreeing to take part in this study.

Name of Participant Signature Date Signed
(and Time*)
In some cases, the researchers may wish to use a video recording of you for academic
presentations or publications. (please check and initial one):

 I agree to allow my full face to be shown in academic presentations or publications as
necessary.____(initials)

216

 I prefer that a portion of my face be obscured in all academic presentations or
publications so that I cannot be identified.____(initials)

***Please note: If you have a guardian, you will need their permission to participate in this
study. They may sign below to indicate their approval of your participation.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

RESEARCHER USE ONLY:

I have personally explained the research to the research participant and/or the participant’s
guardian and answered all questions. I believe that the potential participant understands the
information described in this informed consent and freely consents to participate.

Name of Person Obtaining Informed
Consent
Signature Date Signed
(and Time*)

Guardians, please review both this form and the “Modified Assent Form” attached to
this packet, and indicate whether or not you think your son/daughter can understand
the information on this form (please check and initial one):

 YES, the potential participant will be able to understand the information on this
consent form and will be providing consent for him/herself____ (initials)

 *NO, the potential participant for whom I serve as guardian will not be able to
understand the information but I am allowing him/her to participate in the study
(and I have signed the form on the page below indicating my agreement).
_____(initials) *In this case, the potential participant will be asked to complete
the Modified Consent Form with researcher assistance.

Name of Guardian Signature Date Signed
(and Time*)

217

INFORMED CONSENT

STUDY TITLE: The effect of exergaming on physical activity and
enjoyment in youth and young adults with Autism
Spectrum Disorder and typical development

PRINCIPAL INVESTIGATOR: Amanda C Foran, PhD (c), OTR/L

DEPARTMENT: Division of Occupational Science and
Occupational Therapy

TELEPHONE NUMBER: (360) 259-0089 or (301) 604-4235
______________________________________________________________________

We invite you to take part in a research study. Please take as much time as you need to read
the consent form. You may want to discuss it with your family, friends, or your personal doctor.
You may find some of the language difficult to understand. If so, please ask questions. If you
decide to participate, you will be asked to sign this form.

WHY IS THIS STUDY BEING DONE?

This study is about active videogame systems and physical activity. We hope to learn about
how much exercise people can get from playing active videogames and how much fun it is to
play them. We would also like to find out what we can do to help make playing active
videogames easier for individuals with Autism Spectrum Disorders (ASD). You are invited as a
possible participant because you are a young adult and may be interested in playing
videogames. About 40 young adults with ASD will take part in the study, as well as 40
neurotypical “mentor” students (you!).

WHAT IS INVOLVED IN THE STUDY?

If you decide to take part, this is what will happen:

You will be asked to complete a questionnaire about your age, gender, physical activity level,
and other basic personal information. For example, you will be asked to rate how often you
engage in physical activity, whether or not you currently play videogames, and how much you
enjoy such activities. If you decide to participate, you will be asked to complete 11 sessions
(30-60 minutes each) at the Towson University Center for Adults with Autism. The sessions will
be scheduled during twice-monthly evening group meeting times, over the course of one
semester (Summer of Fall 2013). At the first session, your weight, height, and waist
measurement will be obtained. During each session, you will wear a heart rate monitor on a
soft strap around the chest, and an activity monitor on a belt around your waist. You will also
be videotaped so that researchers can look back and see how much you were moving and
how much fun you were having while playing.

With help from the researchers, you will learn how to play a videogame that requires body
movements such as jumping and swinging your arms. At some sessions you will play the
game alone, and some sessions you will either play with a partner who has ASD or another
“mentor” student. We will ask you to tell us how tiring the game was, and how much you liked
the game after each session. At the first and last session, you will be given a series of simple
218

movement tests which require you to do things like walk a straight line on a piece of tape on
the floor and balance on one leg.

In some cases, the researchers may wish to use a video recording of you for academic
presentations or publications. You will be asked to indicate your agreement to allow videos of
you to be shown, and you have the option to request that your face is obscured in this video.
Should you decide that you’d rather not have your video used for academic purposes, you may
decline and still participate in the study.

WHAT ARE THE POSSIBLE RISKS AND DISCOMFORTS?

Possible risks and discomforts you could experience during this study include:

9. Minor discomfort while wearing the heart rate monitor band or activity monitor during
videogame play.
10. There is a possible risk of falling, although the balance beam that you will walk on is not
raised off the floor. You will be carefully supervised during all movement activities for
safety.
11. There is a small risk that people who are not connected with this study will learn your
identity or personal information.
12. There is a possibility that you may feel uneasy or embarrassed completing the
questionnaires.

There may be other risks/discomforts associated with participating in this study that we do not
know at this time.

WILL YOUR INFORMATION BE KEPT PRIVATE?

We will keep your records for this study confidential as far as permitted by law. However, if we
are required to do so by law, we will disclose confidential information about you to the
appropriate authorities. The Center for Adults with Autism, the University of Southern
California’s Institutional Review Board (IRB), and the Towson University IRB may review your
records. The IRB is a research review board that reviews and monitors research studies to
protect the rights and welfare of research participants. We may publish the information from
this study in journals or present it at meetings. If we do, we will not use your name or any
information that would identify you.

We will remove your name and other information that may identify you from our research data.
We will store the data in a locked filing cabinet or fingerprint and password-protected computer
system in our research office to prevent access by unauthorized personnel. Some videos of
you performing the balance tests or playing the videogames will be taken during this study.
Pictures or videos may be used in presentations or publications. Sufficient portions of your
face will be obscured to hide your identity, unless you indicate below that it is okay to show
your full face.

You have the right to view video-recordings and results of motor assessments for up to one
year after conclusion of the study. After one year, all video-recordings and assessment data
will be destroyed or securely stored in a locked filing cabinet or fingerprint and password-
protected computer system in our research office to prevent access by unauthorized
personnel.
219

WHAT ARE THE POSSIBLE BENEFITS OF TAKING PART IN THIS STUDY?

The possible benefits for taking part in this study may include:

6. You may find it fun to play these videogames.
7. Participation in the study will provide you with an opportunity to get moving and be
active with other students and young adults with special needs.
8. This study may contribute to the advancement of knowledge in the fields of ASD and
physical activity research, which could potentially lead to know treatments or therapies.

The knowledge obtained from your participation may provide you with ideas on how to
incorporate both physical activity and technology into daily life. Results of this study can also
serve to inform future research using videogames as a way to promote physical activity for
individuals with special needs.

WHAT OTHER OPTIONS ARE THERE?

An alternative would be to not participate in this study.

ARE THERE ANY PAYMENTS TO YOU FOR TAKING PART IN THE STUDY?

As compensation for your time, you will be provided with a gift card at the last session ($10 per
session completed, up to $110.00). You will be invited to an end of study celebration party
with food, drinks, and a chance to meet with the other participants and researchers to discuss
the study and watch videos of you and other participants playing the exergames. In addition,
we will also give you a thank-you letter and certificate of participation, in acknowledgment of
your participation in the project.

WHAT HAPPENS IF YOU GET INJURED ON NEED EMERGENCY CARE?

If you are injured as a direct result of research procedures, you will receive medical treatment.
You or your insurance/health plan/government programs will be responsible for the cost of the
medical care. Health care facilities do not provide any other form of compensation for injury.

WHAT ARE YOUR RIGHTS AS A PARTICIPANT, AND WHAT WILL HAPPEN IF YOU
DECIDE NOT TO PARTICIPATE?

Your participation in this study is voluntary. Your decision whether or not to take part will not
affect your current or future relationship with the University of Southern California or Towson
University. You are not giving up any legal claims or rights. If you do decide to take part in this
study, you are free to change your mind and stop being in the study at any time.

CAN YOU BE REMOVED FROM THE STUDY?

You may be removed from this study without your consent for any of the following reasons:

7. You are unable to follow instructions despite support from researchers.
8. You are uncomfortable or become increasingly agitated with participation in the study.
220

9. You are unavailable to complete all 10 sessions of the study due to medical issues, your
personal schedule, or unwillingness to participate.

WHOM DO YOU CALL IF YOU HAVE QUESTIONS OR CONCERNS?

You may contact Amanda C Foran, Ph.D.(c), OTR/L at (360) 259-0089 with any questions,
concerns, or complaints about the research or your participation in this study.

If you feel you have been hurt by taking part in this study, please contact Sharon Cermak,
Ed.D at (323) 442-2850. If you have questions, concerns, or complaints about the research
and are unable to contact the research team, please contact the USC Institutional Review
Board (IRB) Office at 323-223-2340 between the hours of 11:00 AM and 7:00 PM Eastern
Standard Time. (Fax: 323-224-8389 or email at irb@usc.edu). You may also contact Debi
Gartland, PhD, Chair of the Towson University Institutional Review Board at 410-704-2236.

If you have any questions about your rights as a research participant, or want to talk to
someone independent of the research team, you may contact the Institutional Review Board
Office at the numbers above or write to the Health Sciences Institutional Review Board at
LAC+USC Medical Center, General Hospital Suite 4700, 1200 North State Street, Los
Angeles, CA 90033.

You will get a copy of this consent form.
221

AGREEMENT:

I have read (or someone has read to me) the information provided above. I have been given a
chance to ask questions by contacting the researchers in person and by phone if needed. All
my questions have been answered. By signing this form, I confirm that I am at least 18 years
old, and I am agreeing to take part in this study.

Name of Participant Signature Date Signed
(and Time*)

In some cases, the researchers may wish to use a video recording of you for academic
presentations or publications. (please check and initial one):

 I agree to allow my full face to be shown in academic presentations or publications as
necessary. ____(initials)

 I prefer that a portion of my face be obscured in all academic presentations or
publications so that I cannot be identified. ____(initials)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

RESEARCHER USE ONLY:

I have personally explained the research to the research participant and/or the participant’s
guardian and answered all questions. I believe that the potential participant understands the
information described in this informed consent and freely consents to participate.

Name of Person Obtaining Informed
Consent
Signature Date Signed
(and Time*)

222

APPENDIX C. Measures
BOT-2 Body Coordination Test Form
Balance and Bilateral Coordination Tests Date: ______________ Subject ID#______________

Enjoyment Form (Study 2)

BAD OK GREAT

Enjoyment Form 1 (Study 3)
I would rather play
this game than any
other game
Not at all true Sometimes true Often true Always True
I wish we did not have
to play this game
Not at all true Sometimes true Often true Always True
I think playing this
game is fun
Not at all true Sometimes true Often true Always True
Even when I don’t feel
well I still want to play
this game
Not at all true Sometimes true Often true Always True
Playing this game
helps me to relax
after I have been
working hard all day
Not at all true Sometimes true Often true Always True

225

Alternate Enjoyment Form 2 (Study 3)

VERY BAD OK GOOD VERY HAPPY
226

Field Notes Form (Study 2)
Subject: Date: Session #:
Game Title:

Time Started_______ Time Stopped_______
Enjoyment: Lo Med Hi
RPE: Lo Med Hi
Impressions:

Game Title:

Time Started_______ Time Stopped_______
Enjoyment: Lo Med Hi
RPE: Lo Med Hi
Impressions:

Game Title:

Time Started_______ Time Stopped_______
Enjoyment: Lo Med Hi
RPE: Lo Med Hi
Impressions:

227

Physical Activity & Demographic Questionnaire
ID #______________

□ Non-ASD □ ASD (Form of verification? _______________________________ Initials____ Date____)

Exergaming Study Questionnaire
Please answer the following questions. Each item has one answer unless otherwise indicated.

YOUR INFORMATION:

1. What is your age? ____ years, ____ months
2. What is your gender? Male □ Female □

3. What is your height? ____ feet, ____ inches

4. What is your weight? ____ lbs

5. What is your waist circumference? _____ inches

6. What is your race/ethnic background?
□ American Indian or Alaska Native
□ Asian
□ Black or African American
□ Hispanic or Latino/a
□ Native Hawaiian or Other Pacific Islander
□ White

7. Have you been told that you have any of the following? (please check all that apply):

Yes No
□ Attention Deficit Hyperactivity Disorder (ADD or ADHD) □ □
□ Developmental Coordination Disorder/ Dyspraxia/ Motor Planning □ □
□ Developmental Delay □ □
□ Learning Disability □ □
□ Mental Retardation or Intellectual Disability □ □
228

□ Sensory Integration Disorder □ □
□ Other: _______________________

MOTOR SKILLS AND PHYSICAL ACTIVITY

8. Compared to other individuals not on the Autism Spectrum of the same age and gender as
you, how would you rate your motor skills?

Gross motor skills (e.g. sports, swimming, playing, running)
□ Much better than others
□ Somewhat better than others
□ About the same as others
□ Somewhat worse than others
□ Much worse than others

Fine motor skills (e.g. handwriting, cutting, coloring)
□ Much better than others
□ Somewhat better than others
□ About the same as others
□ Somewhat worse than others
□ Much worse than others

9. Compared to other individuals of the same age and gender not on the Autism Spectrum, how
would you rate your daily physical activity level?
□ Very inactive
□ Inactive
□ Typical of other children his/her age in terms of physical activity
□ Active
□ Very active

229

10. Compared to other individuals of the same age and gender, how much do you enjoy
physical activity?
□ Much less than others
□ Somewhat less than others
□ About the same as others
□ Somewhat more than others
□ Much more than others

11. When you have a choice about how to spend recreational time, you:
□ Almost always choose quiet recreation (e.g. TV, reading, playing videogames or cards)
□ Usually choose quiet recreation
□ Are just as likely to choose quiet as active recreation
□ Usually choose active recreation (e.g. bicycling, dancing, swimming, sports)
□ Almost always choose active recreation

12. Additional comments regarding your motor abilities or physical activity level:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

230

Rating of Perceived Exertion Form (Study 2)

RESTING QUIETLY WALKING or LIGHT PLAY RUNNING or PLAYING SPORTS

231

Rating of Perceived Exertion Form (Study 3)
9 10
So tired, I can’t go anymore
7 8
Really tired
5 6
Tired
3 2
A little tired
232

1 2
Not tired at all

233

Videogame Survey
Your Age: _____ Your gender: _____ ID #_________________
-GENERAL QUESTIONS-

1. Which game systems do you currently have in your home? (circle all that apply)

Nintendo 64 Nintendo
Gameboy

Nintendo
GameCube
Nintendo DS Nintendo Wii
Sony
Playstation
Sony Playstation
2

Sony Playstation
3
EyeToy for
Playstation
Sony PSX
Sony PSP Playstation Move Microsoft Xbox Microsoft Xbox
360
Dance Pad for “Dance Dance
Revolution”

Kinect for Xbox
360
VTech V.Smile Computer None of the
above
Other (please list):
__________________________

2. Do you play videogames? (circle one)

YES

NO (*if no, STOP. You are done!)

-TRADITIONAL SEATED VIDEOGAMES (player sits while playing and uses a hand-held controller)-

3. On average, how many hours per day do you spend playing traditional seated videogames or computer
games?

Hours (check one): ___0-½ ___1 ___1 ½ ___ 2 ___ 2 ½ ___3 ___3 ½ ___4 or more

4. When you play traditional seated videogames/computer games, do you usually play alone, or with a
partner? (circle one)

Alone With a partner (circle which: friend, sibling,
parent, other)

Combination of alone and with a partner
(circle which: friend, sibling, parent, other)
234

-ACTIVE VIDEOGAMES (player moves around while playing)-

5. On average, how many hours per day do you spend playing active videogames requiring standing or
large body movements?

Hours (check one): ___0-½ ___1 ___1 ½ ___ 2 ___ 2 ½ ___3 ___3 ½ ___4 or more

6. When you play active videogames, do you usually play alone, or with a partner? (circle one)

Alone With a partner (circle which: friend, sibling,
parent, other)
Combination of alone and with a partner
(circle which: friend, sibling, parent, other)

7. If you play active videogames please list the names of your 3 favorite games:

____________________ ____________________ ____________________

Abstract (if available)

Abstract Background: Technology has been used successfully to enhance social engagement for individuals with Autism Spectrum Disorders (ASD), yet the majority of screen‐based media are sedentary and solitary activities. Young adults with ASD are at risk for overweight/obesity and sedentary behavior. Exergaming is an emerging physically active occupation that may benefit individuals with ASD who are often drawn to technology, and who may have limited opportunities for physical activity in the community. In pilot studies, subjects reported enjoying exergaming more than playing traditional seated videogames, and they consistently achieved moderate‐to‐vigorous physical activity levels while exergaming. Typically developing individuals tend to work harder and enjoy physical activities more when playing with a partner. However, individuals with ASD are known to have limitations in conventional social interaction skills. ❧ Method: We measured the physiological and psychological responses of young adults with and without ASD to videogame play under varying conditions. We sought to describe the relationship of exergaming to physical activity levels in this group, and to determine if exergame playing condition (alone versus with a peer playing partner) influenced physical activity level and/or enjoyment. We used a two diagnostic group (ASD and neuro‐typical) by two playing status (alone and with partner) by three game type (boxing exergame, tennis exergame, traditional seated videogame) repeated‐measures crossover design with randomized conditions. ❧ Results: Participants experienced high levels of enjoyment and perceived exertion while exergaming. For individuals on the Autism Spectrum, perceived exertion was mediated by enjoyment during partner play. That is, subjects on the Autism Spectrum reported significantly lower perceived exertion and greater enjoyment when playing the most physically challenging games with the greatest intensity, as measured by heart rate, energy expenditure, and activity counts. ❧ Conclusion: For some young adults with ASD, exergaming with a partner contributes to greater enjoyment and higher‐intensity gameplay as compared to playing alone and playing TSVGs. Exergaming represents a cost‐effective, socially relevant, and accessible way to incorporate physical activity into the daily lives of young adults with Autism Spectrum, many of whom are at risk for sedentary lifestyle and overweight/obesity. Incorporating a social component into physical activities may further enhance the health‐promoting effects for individuals with ASD, who have previously been characterized as uninterested or unable to interact socially.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Social and motor skills in autism spectrum disorder & developmental coordination disorder: functional & structural neurobiology

PDF

Behavioral and neural influences of interoception and alexithymia on emotional empathy in autism spectrum disorder

PDF

Barriers to accessing support services in employment and health care for adults with autism spectrum disorders: a qualitative study

PDF

Core, social and moral disgust processing in youth with autism spectrum disorder (ASD)

PDF

The acute relationship between affective states and physiological stress response, and the moderating role of moderate-to-vigorous physical activity

PDF

Effects of preferred physical activity on stereotypical behaviors in children with autism spectrum disorder: adapting from in-person to telehealth

PDF

Developmental trajectories of sensory patterns in young children with and without autism spectrum disorder: a longitudinal population-based study from infancy to school age

Asset Metadata

Creator Foran, Amanda Colleen (author)

Core Title Social interaction moderates enjoyment and perception of physical activity during exergame play in young adults with autism spectrum disorders

School School of Dentistry

Degree Doctor of Philosophy

Degree Program Occupational Science

Publication Date 02/27/2015

Defense Date 05/15/2014

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag autism,engagement,enjoyment,Exercise,fitness,OAI-PMH Harvest,partner,physical activity,Play,social interaction,Technology

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Cermak, Sharon A. (committee chair), Blanche, Erna (committee member), Spruijt-Metz, Donna (committee member)

Creator Email aforan@towson.edu,aforan@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-465734

Unique identifier UC11286787

Identifier etd-ForanAmand-2852.pdf (filename),usctheses-c3-465734 (legacy record id)

Legacy Identifier etd-ForanAmand-2852.pdf

Dmrecord 465734

Document Type Dissertation

Format application/pdf (imt)

Rights Foran, Amanda Colleen

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA