“Do I prefer educating fitness professionals about autism and neurodiversity, or Board Certified Behavior Analysts® (BCBA®s) and Registered Behavior Technicians® (RBT®s) about exercise science?”
Rather than a theoretical musing, I’ve wobbled back and forth on this professional preference for nearly a decade. Not that there’s a definitive answer here, as fitness, in particular resistance-based training, can have profoundly beneficial impacts not only for the Autism Spectrum Disorder (ASD) and neurodivergent population, but across a range of environments.
While very few professionals (and parents) would argue against the importance of fitness, statistical evidence across the ASD population strongly demonstrates higher rates of strength and motor deficits along with greater rates of inactivity among adolescents, teens, and adults on the autism spectrum. Additionally, accessibility to comprehensive, evidence-supported, and effective fitness programming is insufficient to broadly impact the issue.
Unlike nutrition and sleep, physical activity (or lack thereof) can easily go unaccounted for, to the point where one day a parent “realizes” that their 30-year old son is “inactive” and has “gained weight,” “become sedentary,” or has difficulty with daily tasks. Sometimes it even takes a medical professional to point this out. The detrimental effects of physical inactivity are widely known, yet because they are cumulative in nature, may be largely ignored until an acute physical or medical issue arises.
To the opposite, or beneficial side, are the myriad physical, emotional, and cognitive benefits experienced by those who consistently participate in resistance training programming. Additionally, this type of physical activity is highly generalizable to activities of daily living (ADLs) and scalable from all three dimensions of capability: physical, adaptive, and cognitive.
There is evidence to suggest that well-designed and strategically implemented fitness programs can have beneficial effects on many of the areas of development most relevant to the field and practice of behavior analysis; independence, initiation, self-regulation, and task engagement, with, arguably, confidence and resilience being additional skills.
Rather than exercise being relegated to a supplemental, tertiary, or extracurricular program, I propose that it can serve as a catalyst for increased program effectiveness when utilized with a rigorous best practices approach, providing behavior therapists with an underappreciated yet necessary modality for growth and development.
The Premise of Fitness and Establishing Operational Definitions
The term “fitness” is vague, as there are myriad conceptions, definitions, and practices associated with physical activity. There are general and specific aspects of fitness, so for the purposes of this article I’ll focus on a definition that is most congruent with our aim:
Fitness is the aggregate skill set of strength, motor planning, and stamina sufficient to safely and independently complete daily tasks and maintain physical quality of life.
This definition focuses on physical attributes that can generalize across a range of situations, environments, and challenges. General physical aptitude enables our bodies to perform without pain or compensation. Think of carrying grocery bags, walking up/down a steep flight of steps, or searching for a Spongebob ball that rolled under the bed. All of these are physical tasks that require strength, mobility, and motor skills, all of which are often, and erroneously, considered intact.
General fitness for everyday thriving requires a basic understanding of exercise science and programming. Essentially, we need to know which types of exercises do what and how much (and how well) they need to be performed. Similar to behavioral models, there is a minimum response required for efficacy. So below I am including operational definitions that would fall under the umbrella of “need-to-know” for general fitness programming:
- Programming: The combination or sequence of different exercises and/or modalities.
- Volume: Total number of sets and repetitions (or time) of a given exercise or program.
- Training effect: The specific adaptation of a muscle, group of muscles, or systemically due to a stimulus.
- Motor control: the ability to perform a movement safely and effectively through a full range of motion without compensatory movement.
It helps to consider exercises and different modalities as “tools in the toolbox.” First, it serves to categorize and operationally define activities, and can lead to making informed decisions about programming and goal setting towards specific outcomes/training effects.
Articles and/or media advocating physical activity will often espouse the viewpoint that “any exercise is good when done consistently,” and while this is partially, albeit superficially, true, it lacks the reality that not all exercise or physical activity lead to the same outcomes. A cardio kickboxing class is nowhere near as effective as building general strength as free weight or machine-based training. This is not a comparison of “better or worse,” rather the physiological implication of different modalities.
Protein from a Carrot
Having a basic knowledge of different exercise modalities, along with their purpose and limitations, leads us to make decisions about “what to do for what”. Suppose your friend wants to “tone and strengthen” their upper body and decides to enroll in a Zumba class because they enjoy group exercise and a high energy atmosphere. Despite their effort, the desired “toning and strengthening” isn’t appearing as anticipated. The modality (Zumba) is an insufficient stimulus for the desired training effect.
Your doctor tells you to add more protein to your diet, and you remark “I like carrots a lot, I’ll eat more carrots.” The issue is that carrots have practically zero usable protein, and so adding more will not satisfy the requirement of more protein. Similarly, exercise protocols, even when general fitness is the goal, still need to follow an evidence-based structure for progress to occur.
While having a primary or secondary reinforcer driving the motivation to engage in some sort of consistent physical activity, the consistency itself does not override the specific qualities of the exercise itself. Even within what we refer to as “general” fitness, there are still particular benefits/effects depending on the activity in question.
On Fitness for Neurodivergent Populations
Narrowing the discussion, many behavior therapists work mainly, or exclusively with the autism and/or neurodivergent populations. Fitness is easily the most overlooked aspect of programming (I use this phrase in lieu of therapy or intervention, though it often encompasses both) for the ASD population, particularly for adolescents, teens, and adults.
While a greater emphasis is being placed (particularly in contemporary social media) on “health and wellness” for the neurodivergent population, the majority of articles, videos, and posts focus on nutrition and sleep, with exercise being conspicuously absent.
My take on this is there are several contributing factors.
- Everyone has to eat and sleep. While these are certainly areas of challenge for many ASD individuals, they must still be addressed. They are fundamental to life and automatically command a market for information.
- Exercise is misunderstood. Consider the previous sections in this article aimed at operationally defining and, to a small degree, demystifying general physical activity.
- Lack of exercise has cumulative rather than immediate consequences. While the medical, socio-emotional, and cognitive detriments of a sedentary lifestyle are well studied, they don’t show up all at once on a random Thursday.
- A cultural norm of inactivity. Most adults in the US are insufficiently physically active. This leads to less of a consideration and implementation of fitness programming for clients/patients/students.
- The technical/programming aspect. Even with sufficient motivation, the “how to” aspect of implementing appropriate and effective exercises programs in clinical and/or educational settings creates a challenge. From my own observational experience, programs will often default to something that is “easy, low cost, and/or requires limited additional education” such as chair yoga, dance sessions, or walks.
Why Behavior Therapists are Optimal Candidates for Fitness Programming
Considering the prerequisite training, experience, and motivation to provide behavioral, educational, and life skill programming for the ASD and neurodivergent population, behavior therapists and RBTs are prime candidates for implementing exercise programming. Additionally, there is mutual benefit as the integration of fitness programming can enhance clinical programs offerings and lead to greater skill acquisition in other areas of performance, several of which are frequent targets for therapists. These range from executive functioning skills to activities of daily living (ADLs) to self-regulation. Fitness can even be utilized as an independent leisure skill:
“Zack, you finished up and can choose 3 exercises to do from your fitness board.”
With respect to long-term planning for an active lifestyle, including fitness becoming a preferred activity, behavior therapists are in a unique position to provide programming and reinforcement around engaging in exercise. Fitness can be used as a primary/target activity or as enhancement to primary behavioral and educational programs.
One of the well-espoused benefits of consistent fitness participation is an increase in positive affect and self-regulation. Clearly, these are two well-trodden areas of behavioral performance in the ABA world, yet the advantages provided through incorporating exercise are seldom incorporated into clinical or home-based ABA practices.
The lack of fitness integration is likely due to compartmentalization; integrating a meaningful, effective fitness program requires an interdisciplinary model. This, if done correctly, does require the expenditure of resources; time, money, energy. However, ABA practitioners are in a unique position to incorporate exercise given that many of the fundamental concepts and practices of behavior analysis apply to fitness programming, including structure, scalability, baseline skill assessment, and programming based on observable actions.
On the Essentials of Programming, What Works Best, and Why
Referring back to specific modalities, strength or resistance-based exercises will have the best carryover or generalization to activities of daily living. Strength training is becoming less stigmatized and broadly adopted beyond its bodybuilding origins. There are still vast misconceptions regarding strength training, including the notion that hypertrophy, or muscle growth, will be both immediate and extreme, or that resistance training does not also have a beneficial impact on cardiovascular functioning.
Given the common physical deficits associated with ASD; low muscle tone, core stability, and motor planning, strength training has a uniquely qualified and empirically valid potential for reducing these challenges while enhancing independence and self-regulation at the same time.
Programming essentials in resistance training include primary, “compound” movement patterns, namely squatting, pushing, pulling, hinging/lifting things up, and carrying. From these basics, there are multiple exercises and variations that target the movement pattern and associated muscles. Equally important is the scalability of these exercises. For example, we often have our life skill athlete squat to a box as a target for depth, or provide a mirror prompt for arm extension on an overhead press.
The “Someone Else Will Do it” Fallacy
While an interdisciplinary model featuring multiple practitioners can be advantageous, the issue with fitness is far too few qualified practitioners. While physical therapists often incorporate aspects of resistance training/strength exercises, these tend to be with younger individuals and/or those who receive PT services.
As individuals age out of OT/PT, there is seldom continued development of strengthening and enhancing gross motor skills. Again, physical fitness is a cumulative process, not based on a single session but the culmination of ongoing practice. Behavior therapists who are already providing therapeutic and educational services for the ASD/ND population can provide continued access to individualized fitness programming that also meets the adaptive/behavioral and cognitive needs of their learners.
Consider the Crossover
Perhaps one or a combination of points in this article has swayed your consideration of fitness (strength, motor planning, and safety) as a life skill. As a life skill, exercise may occur more in line with practices that BCBAs and RBTs regularly implement. As with any outcome-driven programming, adherence to best practices, assessing baseline, and addressing current ability levels with specific goals.
Age and skill-appropriate fitness programming becomes a conduit to improved physical, emotional, and cognitive wellbeing. While there is often a brief, perfunctory “nod” to exercise as “important,” systematically introducing resistance-based fitness programming into clinical and educational settings can have profound benefits in the short- and long-term, developing stronger, more capable bodies and positive attitudes towards exercise.