633562

research-article2016
AUT0010.1177/1362361316633562AutismPan et al.

Original Article
Autism

The impacts of physical activity 1­–13

© The Author(s) 2016
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DOI: 10.1177/1362361316633562

cognitive outcomes in children aut.sagepub.com

with autism spectrum disorder

Chien-Yu Pan1, Chia-Hua Chu1, Chia-Liang Tsai2,

Ming-Chih Sung1, Chu-Yang Huang1 and Wei-Ya Ma1

Abstract
This study examined the effects of a 12-week physical activity intervention on the motor skill proficiency and executive
function of 22 boys (aged 9.08 ± 1.75 years) with autism spectrum disorder. In Phase I of the 12 weeks, 11 boys with
autism spectrum disorder (Group A) received the intervention, whereas the other 11 boys with autism spectrum
disorder (Group B) did not (true control, no intervention). The arrangement was reversed in Phase II, which lasted an
additional 12 weeks. The Bruininks–Oseretsky Test of Motor Proficiency, Second Edition, and the Wisconsin Card Sorting
Test were conducted three times for each participant (Group A, primary grouping: baseline (T1), post-assessment (T2),
and follow-up assessment (T3); Group B, control grouping: T1−T2; intervention condition, T2−T3). The main findings
were that both groups of children with autism spectrum disorder significantly exhibited improvements in motor skill
proficiency (the total motor composite and two motor-area composites) and executive function (three indices of the
Wisconsin Card Sorting Test) after 12 weeks of physical activity intervention. In addition, the effectiveness appeared to
have been sustained for at least 12 weeks in Group A. The findings provide supporting evidence that physical activity
interventions involving table tennis training may be a viable therapeutic option for treating children with autism spectrum
disorder.

Keywords
autism spectrum disorder, executive function, motor skill proficiency, physical activity intervention

Introduction
Children with autism spectrum disorder (ASD) experience
challenges in social communication and interactions and
exhibit a restricted pattern of behavior and interests
(American Psychiatric Association (APA), 2013).
Identifiers for ASD-related motor skill impairment are
lacking in the Diagnostic and Statistical Manual of Mental
Disorders (APA, 2013); however, the International
Classification of Functioning, Disability and Health lists
motor skill deficits as an ASD-associated symptom (World
Health Organization, 2001). Impaired or delayed motor
skills (e.g. movement skills, motor coordination, and gross
and fine motor skills) have been reported in numerous
studies on children with ASD (Fournier et al., 2010; Green
et al., 2009; Lloyd et al., 2013; Staples and Reid, 2010).
Traditional interventions are primarily focused on core
challenges in the social, communicative, and behavioral
domains. However, a frequently overlooked area in the
early intervention literature for children with ASD is motor
skills. Motor skills, including locomotor (e.g. running,
hopping, and jumping), object control (e.g. catching,
throwing, and striking), gross motor (e.g. coordination,
balance, and agility), and fine motor skills (e.g. precision,
integration, and manual dexterity), are necessary for
engaging in physical activities related to the development
1National Kaohsiung Normal University, Taiwan
2National Cheng Kung University, Taiwan
Corresponding author:
Chien-Yu Pan, Department of Physical Education, National Kaohsiung
Normal University, No. 116, He-Ping First Road, Kaohsiung 802,
Taiwan.
Email: chpan@nknucc.nknu.edu.tw

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2 Autism
of healthy lifestyles; however, participation in physical
activities is necessary for promoting the development of
these skills as well. Therefore, developing proficient motor
skills may be even more critical for children with ASD
because it empowers them with the opportunity to engage
in physically active activities with peers, enabling them to
derive the developmental benefits of physical activities.
A range of motor skill impairments has been identified
in studies on people with ASD, and these include gross
motor, fine motor, postural control, and imitation or praxis
impairments (Bhat et al., 2011). There is no one-size-fits-
all approach to motor skill assessment (Staples et al.,
2012); however, researchers and pediatric clinicians com-
monly assess gross and fine motor skill performance using
standardized measures such as the Bruininks–Oseretsky
Test of Motor Proficiency, Second Edition (BOS-2; Pan,
2014; Wuang et al., 2010), the Movement Assessment
Battery for Children (Ament et al., 2015; Whyatt and
Craig, 2012), or the Test of Gross Motor Development
(MacDonald et al., 2013; Staples and Reid, 2010) in chil-
dren with ASD. The most comprehensive study directly
measured the motor skills of 25 school-aged children with
ASD compared with three typically developing (TD) com-
parison groups, each individually matched according to (1)
chronological age, (2) movement skill performance, and
(3) mental age (Staples and Reid, 2010). That cross-
sectional study found that children with ASD exhibited
significantly poorer locomotor and object control scores
compared with TD children in the chronological- and men-
tal-age-matched groups; however, no significant differ-
ences emerged between the children with ASD with a
mean age of 11.15 years and TD children with a mean age
of 5.87 years. The significant motor delays experienced by
school-age children with ASD indicate the need for creat-
ing motor skill interventions in order to minimize motor
delays and promote optimal overall development.
In addition to the motor skill deficits reported in numer-
ous studies on children with ASD, executive dysfunction
has consistently been observed in people diagnosed with
ASD (Robinson et al., 2009; Sachse et al., 2013). Executive
function constitutes a set of cognitive processes that com-
prise distinct yet highly interrelated components such as
cognitive flexibility, inhibitory control, and working mem-
ory (McClelland et al., 2014). Because executive function
is involved in the regulation of both thought and action, the
behavioral manifestations of executive function can be
assessed (Becker et al., 2014), including difficulty switch-
ing between tasks, difficulty initiating new nonroutine
actions, and a lack of impulse control (Rajendran and
Mitchell, 2007). Low cognitive and behavioral flexibility
is a specific executive function impairment in many chil-
dren with ASD (Reed et al., 2013), and this difficulty is
correlated with core symptom presentation (Reed et al.,
2013) and adaptive behaviors in ASD (Pugliese et al.,
2015). Problems with flexibility and initiation are linked to
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decreased independence and poor outcomes in adulthood
(Hume et al., 2009). Other long-term effects of executive
function deficits have been found in middle-childhood
girls with attention-deficit hyperactivity disorder; specifi-
cally, impaired global executive function predicted a
higher number of suspensions and expulsions from school.
Because executive function contributes to success in
school and employment and enables people to inhibit inap-
propriate behaviors as well as manage stress and barriers
related to activities in daily life, assessing and developing
interventions that target executive function impairments
early in life to prevent long-term difficulties across a range
of important functional domains is critical.
Evidence supports the beneficial effects of physical
activity on executive function and suggests that effects
might be particularly large for children (Gapin et al.,
2011). The rationale is that exercise-induced neural plas-
ticity is not merely restricted to areas of the brain serving
motor function and may therefore translate into enhanced
executive function (Verburgh et al., 2014). However, few
studies have explored physical activity as a means of
improving executive function of children with ASD. To
date, data on the effects of physical activity intervention
addressing executive function for children with ASD are
promising. Hilton et al. (2014) conducted a single-group
pretest–posttest design in a group of seven children diag-
nosed with ASD (aged 6–14 years) and reported improved
motor skill proficiency and executive function following
10 weeks of an exergaming program; significant improve-
ments were noted in working memory, metacognition, and
the motor skill areas of strength and agility. Because motor
skill and executive function deficits, in addition to core
symptoms in children with ASD, may contribute to low
rates of physical activity participation by presenting a
greater challenge for such children, interventions directly
targeting motor skill proficiency and executive function in
children with ASD may be helpful.
Studies have indicated that physical activity interven-
tions can be effective for improving motor skills in children
with ASD (aged 4–18  years) (Bremer et al., 2015;
MacDonald et al., 2012; Wuang et al., 2010). A recent study
on optimal outcomes for young children with ASD aged
14–33 months indicated that motor skills were a significant
predictor of calibrated autism severity (i.e. a severity
marker less influenced by verbal intelligent quotient (IQ;
Gotham et al., 2009)) at that age, implying that young chil-
dren with superior motor skills demonstrated fewer social
communicative skill deficits (MacDonald et al., 2014).
Therefore, physical activity interventions can potentially
improve the overall development of young children with
ASD, in addition to their motor skills. Bass et al. (2009)
indicated that 12-week therapeutic horseback riding was
effective in improving sensory skills and social responsive-
ness in children with ASD ranging from 5 to 10 years. Pan
(2010) reported that a 10-week aquatic exercise regimen
Pan et al. 3
improved aquatic skills and has social improvement poten-
tial for children with ASD (aged 6–9 years). Anderson-
Hanley et al. (2011) found significant improvements in the
measures of attention and working memory and significant
decreases in repetitive behaviors in 12 children aged 10–
18 years with a diagnosis of an ASD immediately after they
participated in a 20-min exergaming intervention. Chan
et al. (2013) investigated the efficacy of a 4-week (60 min
per session, twice per week) mind–body exercise, nei yang
gong, in 20 children with ASD aged 6–17 years, and found
positive enhancements in self-control and reductions in
typical autistic symptoms and daily emotional and behavio-
ral problems. Although the mentioned data support the
positive effects of these novel interventions, whether the
treatment efficacies can be sustained or cumulate remains
largely inconclusive.
Numerous studies have been published on the value of
employing moderate to vigorous aerobic exercise in exec-
utive function improvement in TD children (Crova et al.,
2014; Diamond and Lee, 2011; Verburgh et al., 2014);
however, the effects of using alternative forms of physical
activity intervention have only begun to be studied. Pesce
(2012) indicated that whether and how the qualitative
aspects of physical activity intervention (e.g. open-skill
exercise or a combination of complex skills) affect short-
and long-term physical and cognitive performance must be
examined. Recent evidence suggests that ASD-associated
motor skill deficits may not be pervasive, but are apparent
in activities requiring complex, interceptive actions or core
balance abilities (Whyatt and Craig, 2012), or in skills
necessitating the coupling of visual and temporal feedback
(Ament et al., 2015). Therefore, the purpose of this study
was twofold: (1) to evaluate the effects of a 12-week phys-
ical activity intervention through table tennis exercise on
motor skill proficiency and executive function in two
groups (A and B) of children with ASD and (2) to examine
the possible sustained intervention effects in improving
motor skill proficiency and executive function of primary-
grouping (i.e. Group A) children with ASD. We employed
a physical activity intervention through table tennis exer-
cise because it merges motor skill training (i.e. locomotor
and object control skills) with executive function training
(more details are in physical activity intervention session),
and the characteristics of this type of exercise are expected
to affect response selection and execution in children with
ASD (e.g. the training of visual information in a table ten-
nis task as perceived by the player, and the manipulation of
the temporal and spatial characteristics of ball flight). The
research questions asked were as follows:
1. Does motor skill proficiency assessed using the
BOT-2 (Bruininks and Bruininks, 2005) improve
after participation in the physical activity interven-
tion through table tennis exercise in two groups of
children with ASD?
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2. Does executive function measured using the com-
puter version of the Wisconsin Card Sorting Test
(WCST; Heaton and PAR Staff, 2003) improve
after participation in the physical activity interven-
tion through table tennis exercise in two groups of
children with ASD?
3. Does the intervention effect sustained for at least
12 weeks in primary-grouping children with ASD
(i.e. Group A)?
We hypothesized that (1) physical activity intervention
through table tennis exercise would improve both motor
skill proficiency and executive function in both groups of
children with ASD, and (2) the intervention effect would
sustain for at least 12 weeks in primary-grouping children
with ASD. To date, no study has examined these physical
and cognitive measures concurrently in a realistic and
dynamic environment (i.e. table tennis setting) in ASD;
therefore, our study was partly exploratory.
Method
Study design
Ethical approval was received from a university research
ethics committee for human behavioral sciences. All par-
ents and children provided informed consent before the
study began. Before intervention, all children were
screened for eligibility and paired on the basis of age, dis-
ability type, and comorbidity and then they were randomly
split into Group A (n = 11; primary grouping: baseline
(T1), post-assessment (T2), and follow-up assessment
(T3)) and Group B (n = 11; control grouping: T1−T2; inter-
vention condition, T2−T3). This enabled testing the effec-
tiveness of the intervention (Group A children with ASD
receiving the first phase of a 12-week intervention, and
Group B children with ASD acting as the control) in addi-
tion to the effectiveness of a second phase of a 12-week
intervention in Group B children with ASD as well as the
potential sustainment of treatment effectiveness in Group
A children with ASD.
Regardless of group assignment, all participants
received the intervention for the same number of sessions
and hours. Each participant also attended three assess-
ments, where we assessed motor skill proficiency and
executive function: once at study enrollment to serve as
the baseline (T1), a second time after 12 weeks of physical
activity intervention or regular treatment (T2), and a third
time after another 12 weeks (T3). Assessments 1 and 2 rep-
resented the pre- and post-assessment, respectively, of the
experimental (Group A) and control (Group B) groups.
Assessment 3 served as the 12-week follow-up for Group
A and the posttest for Group B following the intervention.
The progression of the participants throughout the trial is
depicted in Figure 1.
4 Autism

Figure 1.  Participant flow diagram describing the progress through the enrollment, allocation, follow-up, and data analysis.

Participants Autism Behavior Checklist (ABC; Krug et al., 2008) and

The participant inclusion criteria were as follows: (1) cur-
rent age between 6 and 12 years, (2) a diagnosis of ASD
based on Diagnostic and Statistical Manual of Mental
Disorders, 4th edition, text revision (DSM-IV-TR) criteria
at a high-functioning level, (3) the ability to follow direc-
tions and perform requested motor skill proficiency and
executive function measures, and (4) no history of reading
disabilities according to parents. We recruited participants
through an autism society by promoting the study at local
ASD support group meetings, from the local clinical
center, and through word of mouth in a large urban city
with a high level of socioeconomic deprivation in a devel-
oping Asian country. A multidisciplinary team from a
developmental clinic at a hospital in that Asian country
evaluated and determined the ASD diagnosis, and written
confirmation of ASD diagnosis had to be provided. In
addition to a formal diagnosis by the physicians, we col-
lected parent ratings, which we confirmed through paren-
tal reports using the traditional Chinese version of the
Social Responsiveness Scale, Second Edition (SRS-2;
Constantino and Gruber, 2012) to screen for autistic traits
and autism and/or Asperger behaviors. The ABC Chinese
version manual documents good reliability (test–retest
reliability, 0.89; Cronbach’s alpha, 0.95) for the measure
as a whole as well as content, construct, and criterion-
related validity. The Chinese version of the SRS-2 used in
this study was a version obtained from the publisher. We
did not use the Autism Diagnostic Interview–Revised
(Lord et al., 1994) and the Autism Diagnostic Observation
Schedule (Lord et al., 2002) because these instruments
were unavailable in Chinese-language versions for
research. However, it is believed that expert clinicians of
the multidisciplinary team are reliable and accurate in
diagnosing high-functioning ASD.
Parents enrolled 22 children with ASD, aged
6–12 years, in our study. The children were randomly
assigned to one of two groups on the basis of age, disabil-
ity type, and comorbidity. We collected information for
each child from the parents, including records on

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Pan et al. 5

Table 1.  Participant descriptive characteristics.

Group A (n = 11) Group B (n = 11) t p

  M ± SD M ± SD
Age (years) 9.68 ± 1.61 8.49 ± 1.76 1.64 0.17
Height (cm) 137.88 ± 12.25 134.55 ± 12.99 0.62 0.54
Weight (kg) 35.93 ± 11.45 32.00 ± 12.47 0.77 0.45
BMI (kg/m2) 18.56 ± 3.73 17.02 ± 3.66 0.98 0.34
ABCT total raw score 13.45 ± 6.39 14.09 ± 7.23 −0.22 0.83
SRS-2 total raw score 113.82 ± 19.34 111.64 ± 19.33 0.27 0.79
Type of ASD (n, %)
 Autism  6  6  
  Asperger’s syndrome  5  5  
Co-existing symptoms (n, %)
 None  8  8  
 ADHD  3  3  
Medication (n, %)
 None  8  8  
 Yes  3  3  

BMI: body mass index; ABCT: Autism Behavior Checklist–Taiwan version; SRS-2: Social Responsiveness Scale-2–Chinese version; ASD: autism
spectrum disorder; ADHD: attention-deficit hyperactivity disorder; M: mean; SD: standard deviation.

after-school therapy, comorbidity, and medication usage.
All but one regularly received after-school group therapy,
speech therapy, occupational therapy, and physical ther-
apy. After-school group therapy involved speaking freely
in a group, providing feedback to others, learning each
other’s manners of interacting, and requesting support;
speech therapy involved language comprehension, expres-
sion, and communication training; occupational therapy
consisted of sensory motor integration and general skill
building for participating in activities of daily living, play
and school; and physical therapy included a passive range
of motion exercises, postural control activities, balance
training, sensory processing and organization skills, and
neurodevelopment training. The descriptive characteris-
tics are listed in Table 1.
Physical activity intervention
Despite differences in the intervention arrangement, both
groups undertook 12 weeks of physical training for 24 ses-
sions (two sessions per week, 70 min per session) in a mul-
tipurpose room at the university. Each intervention session
was conducted by the primary investigator, assisted by a
trained undergraduate and graduate research assistants; the
instructor-to-child ratio for both groups ranged from 1:2 to
1:1, depending on attendance. The primary researcher
trained one primary coach and five research assistants and
provided a written treatment protocol for administering the
intervention. The primary coach was an elite national table
tennis player for 5 years, with 5 years of experience teach-
ing table tennis exercise to children with and without dis-
abilities. All research assistants, majoring in physical
education, special education, or adapted physical educa-
tion, had experience with children with ASD.
Each intervention session was conducted with an iden-
tical format, consisting of five activities: warm-up (5 min),
motor skills (20 min), particular type of motor skill train-
ing that was expected to relate to executive function
(20 min), group games (20 min), and cool-down (5 min).
The second and third activities were the two main ses-
sions of the intervention involving specific components
that are designed to increase the child’s motor skills and
executive function. Motor skill training included techni-
cal skills specific to table tennis (e.g. basic forehand and
backhand push strokes, serves, and returns) and body
movement skills related to table tennis exercise (e.g. hand
bounce, racquet bounce, footwork movement, body con-
trol, balance training, and hand-eye coordination). The
first 4 weeks involved focusing on only simple table ten-
nis ball skills followed by 8 weeks wherein simple table
tennis ball skills were repeated and more complex table
tennis ball exercises and ball games were added.
Participants did not learn the rules of the game in the cur-
rent intervention because they had not yet mastered the
necessary skills to play a regulation table tennis match.
The particular type of training that was expected to relate
to executive function consisted of the manipulation of the
task (e.g. the colors, direction, interval, and speed of the
balls) and the social environment (e.g. peers and coaches).
An example of how to execute the components of the
treatment approach is described as follows: the coach or
automatic ball projection machine tossed balls of two
colors (white and orange); the participants hit the balls
according to the indicated color in a random order.

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6 Autism

Table 2.  Physical activity training program protocol.

Activity Length (min) Content Goal

1. Warm-up  5 Slowly jog around, stretch each major muscle Warm-up and stretching
group
2. Motor skills 20 Table tennis technical skills (forehand and Individually learn and practice the
  backhand counterstroke/serve/return/block/ skill
attack, etc.), locomotor skills (footwork 1-to-2 to 1-to-1 instructor-to-child
movement, e.g., one-, two-, and cross-step), ratio
and object control skills (ball- and racquet-
handling drills, etc.)
3. Motor skills  + executive 20 Individually learn particular task and practice Each child would prepare to
function training (i.e. specific skills assumed to be related to respond by processing actual
inhibitory control and executive function (e.g. white and orange balls visual information, planning his
attention) projected randomly from a specified direction, response, and then programming
and the child was taught to hit only the the appropriate action or inhibition
orange ball so that the child could inhibit their response
movement programming when a white one 1-to-2 to 1-to-1 instructor-to-child
was projected, and vice versa) ratio
4. Group games 20 Cooperative games/activities (table tennis Social interaction and
  balancing shuttle-run, etc.) sportsmanship development
  Fun and challenging activities (running, wind Integrating previously learned skills
sprints, jumping rope, line jumps, etc.) Fitness training
5. Cool-down  5 Slow walk/job/stretch, make comments and Review, reward, and help with
announcements transition

The participants were required to read aloud the number
of balls from 1 to 10 and hit the indicated number (or
color) of balls, concurrently ignoring the color (or num-
ber) of the balls. The primary coach guided the transitions
between the five activities. The activities, content, and
goals of the intervention are listed in Table 2. We mainly
adopted the training protocols from previous studies (Pan
et al., 2015; Tsai et al., 2012); a more detailed training
manual is available on request from the primary researcher.
Procedures
All measurements were conducted in the gym, with a
parent or caregiver present. At the initial assessment, all
parents completed a supplemental information form
providing demographic data and a brief developmental
history of their child.
Anthropometric measurements. Height and weight were
measured to the nearest 0.1 kg and 0.1 cm, respectively,
using a bioelectrical impedance analyzer (MF-BIA8,
InBody 720, Biospace).
Motor skill proficiency.  The BOT-2 (Bruininks and Bruin-
inks, 2005) measures an array of motor skills in people
aged 4–21 years. It uses a composite structure organized
around the muscle groups and limbs involved in move-
ments. The following four motor-area composites exist,
and each composite comprises two subscales, each com-
posed of five to nine items: (1) fine manual control (fine
motor precision and integration), (2) manual coordination
(manual dexterity and upper-limb coordination), (3) body
coordination (bilateral coordination and balance), and (4)
strength and agility (running speed and agility and
strength). Each composite generates gender- and age-spe-
cific standard subscale scores; the four composite scores
were combined to obtain a total motor composite score.
The BOT-2 was chosen for this study because it is one
of the most widely used performance-based measures
(Bhat et al., 2011) and provides norms for the age group of
children included in this study (Bruininks and Bruininks,
2005). Its validity and reliability were demonstrated in an
evaluation of children with development coordination dis-
orders, mild intellectual disabilities, and high-functioning
autism or Asperger disorder (Bruininks and Bruininks,
2005). Bruininks and Bruininks (2005) established strong
internal subtest consistency reliability (r = 0.70–0.80),
internal composite consistency reliability (r = 0.80–0.90),
test–retest reliability (r = 0.69–0.80), and interrater relia-
bility (r = 0.92–0.99) for the BOT-2 manual.
Executive function.  The computer version of the WCST was
used to assess executive function (Heaton and PAR Staff,
2003). The WCST is a measure of abstract reasoning abil-
ity necessitating the ability to shift strategies (Heaton
et al., 1993). The WCST comprises 4 stimulus cards and
128 response cards. The stimulus cards display one red tri-
angle, two green stars, three yellow crosses, or four blue
circles. The 128 response cards contain images combining
various shapes (triangles, stars, crosses, and circles), colors
(red, blue, yellow, and green), and numbers (one, two,
three, or four). In the computer version of the WCST,

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Pan et al. 7
the cards are displayed on a screen. The four stimulus
cards are identical to the card version, except that the par-
ticipants had to choose a response card that matches one of
the four key cards on the basis of its potential characteris-
tics. The basic concept of the WCST is that participants
match response cards to key cards according to a nonspeci-
fied matching rule, which changes each time 10 (of a max-
imum of 128) response cards have been sorted correctly.
We used this computerized WCST version to reduce the
complexity of WCST administration and to increase the
efficiency of data collection. We used six raw scores from
the WCST indices for analysis: total correct (i.e. an indica-
tor of overall performance), perseverative responses (i.e.
number of responses that were perseverative, regardless of
whether they were correct), perseverative errors (i.e. num-
ber of errors made after a rule change, reflecting tendency
toward perseveration), conceptual-level response (i.e. con-
secutive number of correct responses in series of three or
more, providing insight into the correct sorting principles),
categories completed (i.e. an indicator of correct set shift-
ing), and non-perseverative errors (i.e. the number of
errors that were not perseverative, reflecting efficiency in
incorrect set shifting). The first 5 indices reflect concep-
tual formation and flexibility, and the final index repre-
sents unsuccessful problem solving with an ineffective
sorting strategy (Polgár et al., 2010).
Data analysis
To assess the effects of the physical activity intervention,
analysis of variance (ANOVA) and analysis of covariance
(ANCOVA) with a 2 (time: T1 vs T2) × 2 (group: A vs B)
mixed-model factorial design were conducted for the
BOT-2 and executive function outcomes, respectively. A
potential confounding variable (i.e. child age) was used as
a covariate for the raw scores of the executive function
outcomes because it was considered as an important
developmental factor. Age was not used as a covariate
because age-specific standard scores were used for the
BOT-2 measures. The least significant difference post hoc
test was performed if differences in group or time were
deemed significant. We conducted a follow-up by testing
for simple main effects, with significant interaction
effects. The effect size was computed and reported as a η2
value for ANOVA and ANCOVA evaluations. Next, paired
t tests were performed to examine the physical activity
intervention effect in Group B (T2 vs T3) and the poten-
tial for a sustained physical activity intervention effect in
Group A (T2 vs T3). The effect size was computed and
reported as a Cohen’s d for paired t tests. All statistical
analyses were conducted using SPSS (version 18.0) for
Windows (SPSS Inc., Chicago, IL, USA). To control for
possible type I error inflation caused by multiple com-
parisons in repeated-measures ANOVA, ANCOVA, and
paired t tests, the alpha level was set at p < 0.01.
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Intervention consistency
To ensure quality in program implementation, the physical
activity intervention was implemented as prescribed and
supervised by the primary researcher for each session. If
the instructor did not implement the instructional sequence
of each component of the intervention as intended, the pri-
mary researcher intervened to assist the instructor. If any
participant engaged in off-task behavior during the pro-
gram, the instructor managed the behavior, and the primary
researcher assisted the instructor when required.
Additionally, anecdotal information (e.g. conversations and
e-mail correspondence) was collected informally from
instructors when the primary researcher was contacted by
instructors to discuss the intervention program. Furthermore,
each instructor completed a self-report checklist of their
compliance with the teaching steps after each session for
assessing whether each component of the intervention was
implemented precisely and consistently among the partici-
pants. By the end of the study, the instructors had com-
pleted 100% of the checklist forms, and all of them
responded “yes” to the steps for each component session.
Results
There was no significant difference in the participation
rate between Group A (90.53% ± 6.48%) in Phase I of the
12 weeks and Group B (88.26% ± 6.93%) in Phase II of
the 12 weeks (t = 0.80, p = 0.44).
Effects of physical activity intervention on motor
skill proficiency
The results for motor skill proficiency performance are
listed in Table 3. We found no differences between groups
at the study entry (T1) on all demographic (Table 1) and
outcome variables of motor skill proficiency (Table 3).
Phase I (T1−T2).  The ANOVA analysis revealed a signifi-
cant main effect of time on three motor-area composites (i.e.
manual coordination: F = 23.90, p < 0.01, η2 = 0.46; body
coordination: F = 42.95, p < 0.01, η2 = 0.57; strength and
agility: F = 63.57, p < 0.01, η2 = 0.61) and the total motor
composite (F = 28.95, p < 0.01, η2 = 0.45) (Table 4). These
scores post-intervention (T2) were significantly higher than
those pre-intervention (T1). No significant group differ-
ences were found for any of the BOT-2 composite scores.
We observed a significant interaction effect for the total
motor composite (F = 15.31, p < 0.01, η2 = 0.24) and three
BOT-2 composites (manual coordination: F = 8.52, p < 0.01,
η2 = 0.16; body coordination: F = 11.96, p < 0.01, η2 = 0.16;
strength and agility: F = 15.31, p < 0.01, η2 = 0.20).
As shown in Figure 2, a follow-up of the simple main
effects revealed that Group A exhibited improved total
motor composite after the physical activity intervention
8 Autism

Table 3.  Motor skill proficiency and executive function by group at three assessments.

T1 Group A (n = 11) Group B (n = 11)

  t p T1 T2 T3 T1 T2 T3
BOT-2
 FMC −0.22 0.83 47.00 ± 11.64 45.18 ± 17.43 58.55 ± 12.60 48.36 ± 16.94 45.91 ± 18.89 54.64 ± 17.70
 MC 0.59 0.56 47.27 ± 10.56 57.00 ± 11.83 55.00 ± 11.23 44.64 ± 10.48 47.09 ± 11.32 53.00 ± 11.40
 BC 0.49 0.63 49.91 ± 9.62 59.91 ± 10.63 55.73 ± 10.98 47.91 ± 9.42 51.00 ± 8.75 58.73 ± 10.58
 SA 0.25 0.80 54.36 ± 5.99 67.64 ± 9.71 66.27 ± 9.47 53.36 ± 11.75 57.00 ± 9.71 66.27 ± 8.33
 TMC 0.43 0.67 49.73 ± 8.39 60.09 ± 10.11 63.64 ± 10.95 48.48 ± 8.51 49.82 ± 5.86 61.55 ± 8.61
WCST
  TC (+) 0.43 0.67 71.64 ± 10.51 80.73 ± 9.37 79.73 ± 8.97 70.00 ± 7.17 70.09 ± 6.12 76.00 ± 5.42
  PR (−) 1.37 0.19 27.00 ± 15.50 16.36 ± 12.58 18.64 ± 12.81 19.55 ± 9.26 17.27 ± 8.44 13.82 ± 9.50
  PE (−) 1.06 0.30 24.36 ± 17.81 18.18 ± 12.73 12.91 ± 11.55 17.82 ± 10.31 13.63 ± 10.28 9.00 ± 9.77
  NPE (−) −0.21 0.84 15.64 ± 8.95 13.45 ± 8.63 9.18 ± 7.55 16.36 ± 7.55 18.27 ± 14.95 7.00 ± 3.61
  CLR (+) −0.14 0.89 55.36 ± 23.19 76.55 ± 10.42 63.27 ± 15.02 56.45 ± 9.83 58.00 ± 11.48 70.09 ± 7.42
  CC (+) −1.94 0.07 4.09 ± 2.26 5.18 ± 1.60 4.91 ± 2.02 5.55 ± 1.04 5.41 ± 1.26 6.00 ± 0.00

BOT-2: Bruininks–Oseretsky Test of Motor Proficiency, Second Edition; FMC: fine motor control; MC: manual coordination; BC: body coordina-
tion; SA: strength and agility; WCST: Wisconsin Card Sorting Test; TMC: total motor composite; TC: total correct; PR: perseverative responses;
PE: perseverative errors; NPE: non-perseverative errors; CLR: conceptual-level response; CC: categories completed; (+): higher scores represent
better performance; (−): lower scores represent better performance.

Table 4.  Summary of analyses from two-way (group × time) ANOVA (BOT-2) and ANCOVA controlling for age (WCST) with
repeated measures on one factor (time).

Group (G) A B Time (T) T1 T2 Statistically significant

interactions (p < 0.01)
BOT-2
 FMC NS 46.09 ± 4.30 47.14 ± 4.30 NS 47.68 ± 3.10 45.55 ± 3.88 NS
 MC NS 52.14 ± 3.22 45.86 ± 3.22 p < 0.01 45.96 ± 2.24 52.05 ± 2.47 p < 0.01
 BC NS 54.91 ± 2.82 49.46 ± 2.82 p < 0.01 48.91 ± 2.03 55.46 ± 2.08 p < 0.01
 SA NS 61.00 ± 2.77 55.18 ± 2.77 p < 0.01 53.86 ± 1.99 62.32 ± 2.07 p < 0.01
 TMC NS 54.91 ± 2.39 49.00 ± 2.39 p < 0.01 48.96 ± 1.80 54.96 ± 1.76 p < 0.01
WCST
  TC (+) NS 75.65 ± 2.56 70.57 ± 2.56 NS 70.82 ± 1.93 75.41 ± 1.71 p < 0.01
  PR (−) NS 21.99 ± 3.68 18.10 ± 3.68 NS 23.27 ± 2.79 16.82 ± 2.33 p < 0.01
  PE (−) NS 21.51 ± 3.92 15.49 ± 3.92 NS 21.09 ± 3.16 15.91 ± 2.53 NS
  NPE (−) NS 14.94 ± 2.85 16.92 ± 2.85 NS 16.00 ± 1.81 15.86 ± 2.64 NS
  CLR (+) NS 64.67 ± 4.22 58.51 ± 4.22 NS 55.91 ± 3.71 67.27 ± 2.36 p < 0.01
  CC (+) NS 4.47 ± 0.41 5.75 ± 0.41 NS 4.82 ± 0.36 5.41 ± 0.27 NS

BOT-2: Bruininks–Oseretsky Test of Motor Proficiency, Second Edition; FMC: fine motor control; MC: manual coordination; BC: body coordina-
tion; SA: strength and agility; WCST: Wisconsin Card Sorting Test; TMC: total motor composite; TC: total correct; PR: perseverative responses;
PE: perseverative errors; NPE: non-perseverative errors; CLR: conceptual-level response; CC: categories completed; NS: not significant; (+): higher
scores represent better performance; (−): lower scores represent better performance.

(T2) compared with Group B (+10.27, F = 8.50, p < 0.01,
η2 = 0.30). Group A had a significantly higher score after
the intervention (T2) compared with T1 (manual coordina-
tion: +9.73, F = 15.86, p < 0.01, η2 = 0.49; body coordina-
tion: +10.00, F = 47.41, p < 0.01, η2 = 0.21; strength and
agility: +13.27, F = 50.44, p < 0.01, η2 = 0.43; total motor
composite: +10.36, F = 29.06, p < 0.01, η2 = 0.25). We
found a significant improvement in Group B for manual
coordination (+2.46, F = 24.80, p < 0.01, η2 = 0.12) and
strength and agility (+3.64, F = 13.16, p < 0.01, η2 = 0.03)
at T2 compared with T1.
Phase II (T2−T3). For Group B, the comparison between
T2 and T3 (i.e. intervention condition) revealed signifi-
cant differences for manual coordination (+5.91,
t = 4.21, p < 0.01, Cohen’s d = 0.52), body coordination
(+7.73, t = 5.56, p < 0.01, Cohen’s d = 0.80), strength
and agility (+9.27, t = 5.07, p < 0.01, Cohen’s d = 1.02),
and the total motor composite (+11.73, t = 5.58, p < 0.01,
Cohen’s d = 1.59), indicating a greater improvement in
scores after the physical activity intervention. For Group
A, the comparison between T2 and T3 (i.e. follow-up
assessment) revealed no significant difference in any of

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Pan et al. 9

Figure 2.  The BOT-2 standard score of two groups of children with ASD before (T1) and after (T2) intervention.
MC: manual coordination; BC: body coordination; SA: strength and agility; TMC: total motor composite.
**p < 0.01.

the BOT-2 composite scores, suggesting that interven-
tion effects were sustained.
Effects of physical activity intervention on
executive function
The results for executive function are listed in Table 3. No
differences were noted between groups at the study entry
(T1) on all demographic (Table 1) and executive function
outcome variables (Table 3).
Phase I (T1−T2).  Our ANCOVA results revealed that none
of the WCST indices exhibited any significant main effects
of group. There were no significant main effects of time on
all indices of WCST (Table 4). We noted interactions in
group-by-time differences for the total correct (F = 19.84,
p < 0.01, η2 = 0.48), perseverative responses (F = 14.21,
p < 0.01, η2 = 0.41), and the conceptual-level response
(F = 19.98, p < 0.01, η2 = 0.43).
A follow-up of the simple main effect revealed that
Group A performed higher in the total correct (+10.64,
F = 9.93, p < 0.01, η2 = 0.33) and conceptual-level response
(+18.55, F = 15.73, p < 0.01, η2 = 0.44) compared with
Group B after the intervention (Figure 3). For within-
group differences between T1 and T2, Group A had a sig-
nificantly higher score for the total correct (+9.09,
F = 26.98, p < 0.01, η2 = 0.19) as well as for the concep-
tual-level response (+21.18, F = 21.19, p < 0.01, η2 = 0.28),
but a significantly lower score for the perseverative
response (−10.64, F = 61.44, p < 0.01, η2 = 0.14), whereas
the performance of Group B was similar both at T1 and
after the intervention period (T2).
Phase II (T2−T3).  We found a significant improvement in
the total correct (+5.91, t = 5.94, p < 0.01, Cohen’s
d = 1.02) and conceptual-level response (+12.09, t = 4.55,
p < 0.01, Cohen’s d = 1.25) at T3 compared with T2 (i.e.
intervention condition) for Group B. No significant differ-
ence was noted for any of the WCST scores between T2
and T3 (i.e. follow-up assessment) for Group A, suggest-
ing that intervention effects were sustained.
Discussion
We recruited 22 children with ASD in two periods of a
physical activity intervention, during which the motor skill
proficiency and executive function performance increased
after training. For the first period (T1−T2), 11 children
with ASD received the intervention (Group A), and the
other 11 children with ASD served as the control (Group
B). We found significant interaction effects and noted that
the intervention induced improvements in the experimen-
tal group (Group A) compared with the control group,
which did not receive the intervention (Group B); in the
total motor composite and three motor-area composites
(i.e. manual coordination, body coordination, and strength
and agility); as well as in three indices of the WCST per-
formance (i.e. total correct, perseverative response, and
conceptual-level response). For the second period (T2−T3),
we observed improvements in a comparison between T2
and T3 scores in Group B for the total motor composite
and three motor-area composites (i.e. manual coordina-
tion, body coordination, and strength and agility) as well
as for two of the WCST performance indices (i.e. total cor-
rect and conceptual-level response). In addition, the

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10 Autism
Figure 3.  The WCST raw score of two groups of children with ASD before (T1) and after (T2) intervention.
TC: total correct; PR: perseverative responses; CLR: conceptual-level response.
**p < 0.01.
intervention effect appeared to be sustained for at least
12 weeks for Group A. These results are encouraging
because the motor skill impairment in ASD acts as a bar-
rier to social interactions and community integration when
diagnosed children engage in physical activities with
peers. Furthermore, the positive impact of the current
physical activity intervention on executive function may
provide additional cognitive control for students coping
with the restricted behaviors of ASD. Because of the sim-
plicity and effectiveness of this physical exercise, it can be
considered an alternative or complementary intervention
for improving motor skill proficiency and executive func-
tion in children with ASD.
Several studies on children with ASD (Bass et al., 2009;
Bremer et al., 2015; MacDonald et al., 2012; Pan, 2010;
Wuang et al., 2010) have found improvements in motor
skills following long-term physical activity intervention.
The cumulative effects from a series of training steps that
are goal directed, structured, progressive, and interrelated
may account for significant improvements in motor skills.
For instance, once a child learned to return the ball (basic
forehand and backhand return), we introduced dynamic
tasks that were more challenging, such as continually
returning a ball delivered at various speeds, and from dif-
ferent directions by either the coach or an automatic ball
projection machine. After mastering these tasks, the child
was more able to utilize body feedback to understand the
outcome of movements (feedback), anticipate upcoming
events (feedforward), and plan alternative strategies. The
child was also encouraged to rely on self-evaluations of
performance. Adjusting the speed and direction allowed
patterns of manual coordination and body coordination
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skills that were more mature to emerge from the enhanced
use of feedback. Likewise, the ability to control the trunk
and shift bodyweight led to improvements in running abil-
ity as well as strength and agility in the children. The sig-
nificant enhancements in motor skills following the
intervention may be relevant for the overall functioning of
children with ASD. MacDonald et al. (2013, 2014) have
found that motor skills significantly predicted the social
communicative skills of children with ASD; in other
words, children with superior motor skills were more
likely to have greater social communication skills. If the
motor skills of young children with ASD are improved
through early intervention, they may have greater opportu-
nities for social communicative interactions (e.g. playing
with peers and siblings) throughout childhood.
The potential benefits of physical exercise in promot-
ing increased executive function in our study are consist-
ent with the findings reported in recent empirical studies
on regular aerobic activity and open-skill exercise in chil-
dren with and without disabilities (Chang et al., 2014;
Guiney and Machado, 2013; Hilton et al., 2014; Pan et al.,
2015; Tsai et al., 2012). For instance, Hilton et al. (2014)
adopted a single-group pretest–posttest research design
and found improvements in the working memory and
metacognition (i.e. the ability to initiate, plan, organize,
and sustain future-oriented problem solving in working
memory) of seven children with ASD according to the
parent-reported Behavior Rating Inventory of Executive
Function after 10 weeks of exergaming (i.e. Makoto arena
training). In addition, Tsai et al. (2012) reported a signifi-
cant increase in the inhibitory function of 16 children with
developmental coordination disorder after 10 weeks of
Pan et al. 11
soccer training compared with no-exercise control groups
composed of children with and without developmental
coordination disorder. Pan et al. (2015) adopted a between-
subject experimental design and reported a significant
increase in the Stroop Color-Word condition (i.e. the
selective attention or inhibition of a dominant response),
WCST total correct, perseverative errors, and other cate-
gories completed in 15 children with attention-deficit
hyperactivity disorder after 12 weeks of table tennis train-
ing. The effectiveness of open-skill exercise training may
be related to the concurrent emphasis on physical as well
as cognitive training and psychological activation from
social interactions with peers during physical activity,
which tends to be focused on executive function. Similarly,
the table tennis exercise adopted in this study was devel-
oped on the basis of the principles of constraint-induced
movement therapy (Bonnier et al., 2006), and the children
were guided to practice with repetitions and experiment
with varied strategies and tasks to undercover their latent
motor potential. This may explain the distinctive effects
of the table tennis exercise in enhancing attention and
concentration in the children.
According to a review of relevant literature, this study
is the first to explore the effect of a chronic open-skill
physical activity intervention on motor skill and execu-
tive function parameters in a sample of children with
ASD. Because of the improvements observed in three
WCST performance indices (i.e. total correct, persevera-
tive responses, and conceptual-level response) for Group
A in the comparison between T1 and T2 scores, in addi-
tion to two WCST performance indices (i.e. total correct
and conceptual-level response) for Group B in the com-
parison between T2 and T3 scores, the current physical
activity intervention may serve as a valuable addition to
other forms of therapy for children with ASD with execu-
tive function impairments. Although significant improve-
ments in executive function were limited to three indices
in Group A, we noted similar gains for the remaining
three indices, but they did not reach a level of signifi-
cance compared with improvements in the control group.
A larger sample or a longer intervention duration may
yield improvements in the other indices of executive
function. It is also possible that a larger effect could be
observed if ASD-diagnosed participants were to demon-
strate a greater degree of executive function impairment
at the baseline. Nevertheless, our findings directly imply
that children with ASD may derive advantages in flexi-
bility performance after participating in a physical activ-
ity intervention through table tennis exercise. In our
study, we considered the WCST indices to reflect flexi-
bility in reasoning and executive functioning. Lopez
et al. (2005) noted that the ability to shift rules during a
card-sorting task is correlated with restricted behavioral
patterns in people with ASD. Greater inflexibility in
behaviors among people with ASD acts as the foundation
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for underlying deficits (Geurts et al., 2009). The enhanced
flexibility induced by the current physical activity inter-
vention may lead to improvements in early repetitive and
inflexible behaviors associated with ASD. Cognitive fac-
tors are inevitably involved in movement control, espe-
cially in the sporting context, necessitating greater
accuracy in decision making and quicker action anticipa-
tion by players (Chen et al., 2015). Table tennis players
must gauge the speed of a moving ball with precision as
well as the timing for passing the ball. This physical
activity intervention appeared to motivate the children
and was both quick and easy to implement. It may be use-
ful as a support for traditional therapy, with the potential
for greater improvements in motor skill and executive
function performance, which are critical for daily activity
participation in children with ASD.
One important limitation of our study was the small
sample, although it represents an improvement over the
past predominant reliance on case studies. It would be ben-
eficial for future studies to adopt a randomized design with
a larger sample. Another limitation of this study was the
use of the BOT-2 and WCST tests, which limited our abil-
ity to assess other motor skills and executive functions. By
considering only one measure each for motor skills and
executive functions, we did not assess or control for the
full range of children’s motor skills and executive func-
tions. Including measures of brain activity that are more
direct (e.g. electroencephalograms or functional magnetic
resonance imaging) would further support the scientific
rigor of the findings and strengthen their generalizability.
Moreover, the specific components of the current physical
activity intervention that yielded the primary benefits have
yet to be clarified (e.g. motor skill training vs motor skills
and executive function training). A follow-up study could
conduct a comparison of traditional table tennis exercise
with the current intervention program, which could sepa-
rate the factors contributing to the motor and cognitive
effects. Furthermore, we lacked a quantitative measure-
ment for exertion or exercise intensity, which has been
linked to the effect magnitude in certain cases. Future stud-
ies could quantify exertion according to intensity, perhaps
by measuring the heart rate and energy expenditure (e.g.
using an accelerometer). Finally, investigating additional
outcomes such as improved social skills may yield useful
findings. As noted, Bass et al. (2009) found improved
social functioning in 19 children with ASD after a 12-week
horseback riding intervention, and Pan (2010) found
improvements in social behaviors in 16 children with ASD
after 10 weeks of aquatic group exercise. Examining the
potential benefits of the current physical activity training
in the social domain for ASD may be beneficial because it
is possible to control several variables in table tennis exer-
cise that can moderate outcomes (e.g. social environment:
individual vs collaborative vs competitive play).
MacDonald et al. (2013, 2014) found that object control
12 Autism
motor skills as well as fine and gross motor skills predicted
calibrated autism severity significantly, implying that
social and motor skills should be considered in early inter-
ventions focused on the phenotypic characteristics of
ASD, because motor skills can hinder success in early
interventions. This implication underscores the need for
additional well-designed comparative studies that clarify
the role of potential factors. Such additional information
might guide the development of interventions that are
more refined, perhaps enabling greater precision in tailor-
ing interventions to meet the needs of individual patients
(e.g. emphasizing social behavioral changes or cognitive
and motor skill performance as required).
Our study provides initial evidence that 12 weeks of
physical activity intervention through table tennis exercise
exerted a positive effect in enhancing motor skill profi-
ciency and executive function in children with ASD. These
motor skill and executive function enhancements further
elucidate the potential application of table tennis training
as a complementary intervention for rehabilitating motor
skill disturbances and for increasing executive function in
children with ASD or other motor skill and executive func-
tion problems. Additional research should be conducted to
replicate and extend these findings for identifying the
physical activity components potentially influencing
motor skill and executive function outcomes and for exam-
ining the applied utility of physical activity intervention
through table tennis exercise for ASD populations.
Acknowledgements
The authors gratefully thank all the children who participated in
this study, parents of children for their supports, and research assis-
tants who helped with data collection and other contributions.
Funding
This research was supported by MOST 103-2410-H-017-
026-MY3.
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