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Running Head: BALANCE: HOPSCOTCH

Balance: Hopscotch

Karsen Walker

East Carolina University

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Running Head: BALANCE: HOPSCOTCH
I. Modality Category: Balance

II. Modality: Therapeutic Use of Play

III. Activity Name: Hopscotch Game

IV. Materials Needed:

1. *All participants must wear comfortable clothing along with closed-toed shoes.
2. *All participants must sign up prior to the start of the event.
3. *All participants are encouraged to bring friends.
4. Open room/space
5. Chalk (if outdoor)
6. Masking Tape (if indoor)
7. Color Tape for numbers (if indoor)
8. Bean Bag
9. First-Aid Kit
10. Water Bottles (1-24 pack)
11. Bluetooth Speaker

V. Treatment Population/Diagnosis: Children, ages 4-10, with Autism Spectrum

Disorder (ASD) – Level 1

VI. Description of Treatment Population/Diagnosis

Autism Spectrum Disorder (ASD) is a disorder that affects an individual’s

neurological and developmental abilities. This disorder begins in early childhood and
continues throughout a person’s lifetime (“Autism Spectrum Disorder,” 2019). Also
known as Asperger syndrome and pervasive developmental disorders, ASD affects an
individual’s physical coordination, cognitive functioning, social interactions,
behavior, and communication skills (“Autism Quick Facts,” 2016). ASD most
commonly has a wide range of symptoms because it is a spectrum disorder, and no
two people with this disorder have the same symptoms (“Autism Spectrum Disorder,”
2019). Signs are usually seen around the age of two and include: reduced eye contact,
lack of response to their name, sudden withdrawal, aggression, and lose language
skills. Although there is no cure, ASD can be treated to increase the individual’s
ability to function by reducing ASD symptoms. Treatments vary among individuals
but include early intervention through behavioral and communication therapies,
educational therapies, recreational therapy, and medications (“Autism Spectrum
Disorder,” 2018).

Although severity may be hard to determine, ASD classifies into three levels: Level
1, Level 2, and Level 3. The level of seriousness the doctor may assign allows for
therapists to provide the right treatment and support for each individual (Kandola,
2019).
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Level 1: the least severe diagnosis. Individuals may have difficulty to initiate
conversations, socialize, make friends, show inflexible behaviors, cope with changing
atmospheres, and need help with planning.
Level 2: need more support than those with level 1 diagnosis. Individuals have
trouble holding conversations and severe social anxiety. They are more likely to
respond to others inappropriately, speak in short sentences, and only discuss topics
that intrigue them. Level 2 individuals have inflexible behaviors that affect their daily
functioning and do not respond well to any changes that can cause them distress.
Level 3: the most severe diagnosis. Individuals with this have a significant deficiency
in their communication skills and react strongly to changes that cause them distress.
They will purposely avoid social interaction with others unless they need something
(Kandola, 2019).

This treatment intervention is appropriate for this population because it increases

balance, body control, movement, and communication skills. Also, this intervention
provides an enjoyable and balanced atmosphere for each individual. Lastly, this
treatment will allow each individual to socialize and meet new people throughout the
intervention.

 Physical Effects: Some individuals with ASD have physical effects on the
body. It is very common for an individual to have abnormal physical features
such as an asymmetrical face, wide-set eyes, hair growing in the wrong
direction, or a prominent forehead. These unique physical characteristics are
called dysmorphologies and can be used to easily identify if an individual has
developed ASD (Wright, 2012).

 Psychological Effects: This disorder can increase the commonality of mental

illness such as anxiety, obsessive-compulsive disorder (OCD), and depression.
Anxiety is common to individuals with ASD because they develop a
vulnerability to stress, have different brain structures and functions, and
history with social communication, which can lead to an anxiety disorder. An
individual may develop OCD because it is a type of anxiety disorder. OCD is
more common in people who are autistic because their DNA and
psychological tendencies can make them vulnerable to developing it. Lastly,
depression can develop when a person with autism become more introverted,
withdrawn, and isolated (“Mental Health and Autism,” n.d.).

 Social Effects: Individuals with ASD often have trouble developing proper
social skills. They have the desire to interact with individuals, but are unable
to engage with their friends properly or may even become overwhelmed with
new experiences. It is recommended for people with autism to build up social
skills by participating in community activities and having positive social
support (“Social Skills and Autism,” n.d.).

 Cognitive Effects: People with ASD tend to develop difficulties with their
cognitive ability. These include balance, regulating and controlling their
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Running Head: BALANCE: HOPSCOTCH
behavior, valuing others’ thoughts and feelings, and the ability to recognize
details. Although these effects can occur, most of the children can improve
these skills in a decent amount of time (Society for Research in Child
Development, 2010). This intervention allows the participants an opportunity
to enhance their cognitive capabilities.

VII. Recommended Group: One of the most important things for individuals with ASD
is repetition and social integration. Games like hopscotch allow just that. People with
ASD not only gain physical coordination such as balance control and midline
development but also enable participants to form proper social development and good
sportsmanship. With the help of adaptability, physical similarities, communication,
and shared interests, hopscotch can be played at any age. Typically, individuals are
put into a line and take turns going through the hopscotch pattern; the number of
players can vary from small to large groups, but for this particular game, it should
allow 2-8 participants. Also, the intervention primarily focuses on the effects of
hopscotch for children from ages 4-10. This age range allows the children to increase
their balance and orientation control, coordination, motor skills, and social exchanges
(Whittier, 2017). This game is adapted to the needs of each individual by adjusting
the size of the playing area, extending the number of tries/attempts, using color for
lines and numbers, and giving verbal clues and oral prompts. The only criteria needed
to participate is for individuals to be able to stand and follow directions to some
extent. If needed, players can hop twice in one square, hop on two feet, and step on
lines.

VIII. ICF Functional Outcome Area Classification

1. ICF Code d4553: Activities and Participation: Mobility: Walking and Moving:
Moving Around: Jumping
a. Moving up off the ground by bending and extending the legs, such as
jumping on one foot, hopping, skipping and jumping or diving into water.
2. ICF Code b2351: Body Functions: Sensory Functions and Pain: Hearing and
Vestibular Functions: Vestibular Functions: Vestibular Function of Balance
a. Sensory functions of the inner ear related to determining the balance of the
body.
3. ICF Code e325: Environmental Factors: Support and Relationships:
Acquaintances, Peers, Colleagues, Neighbours, and Community Members
a. Individuals who are familiar to each other as acquaintances, peer,
colleagues, neighbours, and community members, in situations of work,
school, recreation, or other aspects of life, and who share demographic
features such as, gender, religious creed or ethnicity or pursue common
interest.

IX. Treatment Goals/Objectives for Technique

GOAL: Participants will be able to increase their mobility for jumping/hopping.

OBJECTIVE:
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1. Successfully jump (ICF d4553) through hopscotch pattern on one foot 5 times
throughout the game.
2. After the intervention, participants will be able to jump (ICF d4553) through
the hopscotch pattern 3 out of the 5 times.
GOAL: Participants will be able to increase their balance.
OBJECTIVE:
1. Focus body on balance (ICF b2351) and orientation in order to jump through
hopscotch pattern on one foot 5 times during the game.
2. After the intervention, participants will have increased their balance (ICF
b2351) by 50%.
GOAL: Participants will be able to increase social participation.
OBJECTIVE:
1. During the game, participants must verbally communicate with others in order
to develop good sportsmanship by taking turns.
2. By the end of the game, participants will have increased their participation
with others by 100%.

X. Facilitation Process

1. Check indoor/outdoor space.

 If indoors, observe gymnasium/room for an open space.
 If outdoors, observe and find open space.
 Connect a phone Bluetooth to the speaker.
2. Set up hopscotch.
 If indoors, draw out hopscotch pattern and numbers with chalk or tape.
 If outdoors, draw out hopscotch pattern and numbers with tape.
 The pattern must consist of eight square numbered sections and a starting line.
 Place bean bag on starting line.
3. Before participants arrive, display water bottles for the participants convenience.
4. Greet participants and their guardians in order to provide a welcoming and
accepting experience.
5. Direct participants to the hopscotch set up.
6. Once all participants have arrived, begin frontloading for the game.
 Introduce staff member(s).
7. Elaborate the rules and expectations of the Hopscotch Game to the participants.
8. Explain adaptations to the participants.
 Size of squares are larger
 More than one attempt
 Colored lines and numbers
 Verbal clues and oral prompts
9. Ask participants if they have any questions or concerns regarding the game or
other information.
10. Allow participants to line up behind each other at the start line.
11. Select appropriate playlist and begin playing music at a low volume.
12. Hopscotch Game begins!
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Hopscotch Game
1. The first player stands behind the starting line and tosses his/her bean bag in square one.
2. They must then hop over the first square to the second square
3. Participant will continue hopping to the final square.
4. Once they reach final square, they must turn around and hop back to square two
5. Once at square two, participant must pause in their position and pick up the bean bag.
6. Next, they must hop in square one and out of the hopscotch pattern.
7. After the player has finished, the next player will repeat steps 1-6.
8. Once all players have tossed their bean bag into the first square, the play continues by
repeating steps 1-6 except the bean bag must be tossed into a higher number square.
9. Players will hop on one foot unless there is two squares side-by-side. If side-by-side, the
player must put one foot in each square.
10. If a player tosses the bean bag out of the square, into the wrong square, step on the line,
or lose balance while picking up the bean bag then they are out (Aiger, n.d.).

End of the Activity:

1. After the game has been implemented, participants are to gather together for the
processing questions.
2. Ask participants to pick up their belongings and throw away their empty water bottles.
3. Participants are to tell the facilitator when they are leaving.
4. Once everyone is gone begin the clean-up process.
5. Pick up the bean bags.
6. If facilitator used tape, pick it up and throw it away.
7. Disconnect speaker.
8. Collect materials used during implementation.
9. Make sure the spaced used is clear of any trash or equipment.

Comprehensive Programming Implications Section:

This facilitation process can be used for a larger, more complex, and comprehensive
program. This program provides participants with knowledge on jumping, balance, and
social interaction that can be used to increase balance coordination. The hopscotch game
will last for about an hour. It will start at 11:00 am and go until noon. But, the set-up and
arrival of facilitators will start 30 minutes before the start. Therapists can adjust the game
into more than one hopscotch game. If the implementation time was longer, therapists
could add individuals practice activities for participants jumping and keeping their
balance on one foot. For example, the therapists could add more activities such as
tightrope walking (with tape), become a flamingo, and jump the stream. While increasing
jumping on one foot, balance, and social participation, players are learning the
importance of their balance coordination and having fun. Therapists will also have to
measure the outcome of each player by observing their participation skills for each
activity.

Variations
No matter what their functional level may be, for a game such as hopscotch, there are a few
accommodations that can be made for any individual. Variations include, but aren’t limited to,
adaptations to hopscotch design, the length of the pattern, and the rules and location of the game.
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 Cognitive deficiencies: Based on this population, we could provide a video on the rules
of hopscotch for participants to watch before the game and a demonstration at the
beginning of the implementation.
 Language barriers: Being a children’s game, we could provide appropriate pictures for
the rules and low technical communication boards.
 Economic constraints: Because of some economic constraints within the participants, the
facilitator will provide the necessary materials needed to play hopscotch successfully.
 Lack of functional abilities: To increase functional abilities among each participant,
therapists will need to teach participants how to improve their potential capacity to play
the game.
 Lack of social skills: To increase functional abilities among each participant, therapists
will need to teach participants proper information that will help them with their
communication skills, getting along with others, good sportsmanship, asking for help,
and making friends.

XI. Contraindication and/or Precautions

Contraindication
 Be aware of excessive heat in the gym/open space/outside leading to
dehydration and exhaustion.
 Be sure that participants are staying hydrated to prevent the risk of
dehydration.
 Be aware of possible falls while and injuries.

Precaution
 Be aware of the participant’s wandering and self-injurious behavior.
 Be mindful of the potential that each participant might have poor safety
awareness and poor impulse control.
 Have a plan for individuals with communication deficits.
 Be sure to acknowledge that some individuals with ASD have a rigid
adherence to routines.
 Be aware that players may have comorbidities in addition to their current
disability.
 Be mindful that some participants may need assistance with jumping and
stability.

XII. Processing Questions

1. What part of the hopscotch game did you find most challenging?
2. Did you enjoy meeting new friends when you were playing this game?
3. Would you play this game with other friends or alone outside of today’s session?
4. What else could you add to the hopscotch game to make it more advanced?
5. Do you feel that after today’s intervention you have better control of your
movements and fear of falling?
6. Was it harder to balance on one foot during the beginning or end of the game?
7. How did it feel to increase your balance throughout the game?
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8. How did it feel to improve your mobility to jump/hop through the hopscotch
pattern?

XIII. Evidence-Based Abstract

Fard, A. N., Tabar, H. M. A., & Sheikh, M. (2015). Effect of a Selected Local Game
on Dynamic Balance of Educable Students with Down
Syndrome. International Journal of Sport Studies, 5(10), 1143–1148.
Retrieved from
https://pdfs.semanticscholar.org/8197/d987ce28088b8abaf7a5395044a010f8a
def.pdf

The purpose of this research article was to understand how a local game on
dynamic balance affects young male children with Down Syndrome (DS). The study
took place in Ghaemshahr County where 16 males, age 9 to 11 years old, with DS
participated. Researchers used a target convenience sampling method to select each
participant. Once selected, they were divided into two control and experimental
groups (8 individuals in each group) based on their dynamic balance scores. Their
age, weight, height, and IQ were collected from each student’s medical records and
used for the overall research. There were two ways participants were measured: heel
to toe walking test to assess dynamic balance and participation in a selected game for
eight weeks, three times per week. Hopscotch was chosen as the game for the
individuals because it provided a goal for maintaining balance and strengthening in
the leg muscles. Before the game, there was a 10-minute training session that
included stretching and walking, a 35-minute session for main exercises, and a 5-
minute cooldown stage. The experimental group played hopscotch for eight weeks,
three sessions per week. The control group was excluded from playing hopscotch and
participated in regular activities. This was to indicate a change between each group.
After the eight weeks, both groups were retested. The results showed that the
dynamic balance scored increased significantly for the experimental group rather than
the control group posttest(p<0.002). But, there wasn’t a significant difference
between the two groups in their dynamic balance scores pretest (p<0.745). Finally,
there was no change in their dynamic balance scores before and after the training
period (p=0.000).
In conclusion, the studies indicate that the hopscotch game improved dynamic
balance for the students with DS. With the support from corresponding evidence,
researched believe that the local game, hopscotch, should be included in the school’s
physical education program for students.
This study relates to recreational therapy because the results of this study
concluded that the hopscotch game could improve the balance of children as well as
their mobility for jumping. Therapists should include movement-related interventions
into their balance programs to help improve children’s ability to jump and balance
throughout the game on one foot. If wanting to facilitate this game with larger sample
sizes, therapists can split participants into two groups and have two different games.
Still, it is recommended to be facilitated with smaller sample sizes.
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XIV. Resources used for the Activity

How to play:
How to play hopscotch: Teach the kids this traditional game. (2017, July 3).
Retrieved December 5, 2019, from https://www.kidspot.com.au/things-to-
do/activity-articles/hopscotch/news-
story/4272569c82c29d6bd2a66080f43ec352.

Other Outdoor Activities for ASD:

Ostafi, R. (2019, June 28). 15 Fun Outdoor Activities for Children with Autism.
Retrieved December 5, 2019, from https://txsource.com/2016/07/28/15-fun-
outdoor-activities-for-children-with-autism/.

Other Balance Games:

Narvaes, A. (2017, March 15). 7 Fun Games to Improve Balance for Toddlers:
Mountain Kids. Retrieved December 5, 2019, from
https://mountainkidslouisville.com/blog/games-help-toddler-improve-
balance/.

Why Hopscotch Matters:

McCarthy, C. (1970, January 1). WHY HOPSCOTCH MATTERS. Retrieved
December 5, 2019, from http://movingsmartblog.blogspot.com/2012/06/why-
hopscotch-matters.html?m=1.
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References

Aiger, A. (n.d.). Fun Sports Games for Children. Retrieved December 3, 2019, from

https://howtoadult.com/366758-fun-sports-games-for-children.html.

Autism Quick Facts. (2016). Retrieved November 24, 2019, from https://www.myautism.org/all-

about-autism/autism-quick-facts/.

Autism spectrum disorder. (2018, January 6). Retrieved November 24, 2019, from

https://www.mayoclinic.org/diseases-conditions/autism-spectrum-disorder/diagnosis-

treatment/drc-20352934.

Autism Spectrum Disorder. (2019, October 2). Retrieved November 24, 2019, from

https://medlineplus.gov/autismspectrumdisorder.html.

Kandola, A. (2019, May 3). Levels of autism: Symptoms and criteria. Retrieved November 24,

2019, from https://www.medicalnewstoday.com/articles/325106.php#levels-of-autism.

Mental health and autism. (n.d.). Retrieved December 3, 2019, from

https://www.autism.org.uk/about/health/mental-health.aspx.

Social Skills and Autism. (n.d.). Retrieved December 3, 2019, from

https://www.autismspeaks.org/social-skills-and-autism.

Society for Research in Child Development. (2010, September 16). Cognitive skills in children

with autism vary and improve, study finds. ScienceDaily. Retrieved December 3, 2019

from www.sciencedaily.com/releases/2010/09/100915080429.htm

Whittier, K. (2017, January 12). Why Playing Hopscotch is Important. Retrieved December 3,

2019, from https://playandgrow.com/playing-hopscotch-important/.

Wright, J. (2012, August 1). Clinical research: Facial features can help diagnose autism:

Spectrum: Autism Research News. Retrieved December 2, 2019, from

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https://www.spectrumnews.org/news/clinical-research-facial-features-can-help-diagnose-

autism/.

XV. Submitted by: Karsen Walker