sustainability
Article
Physical Education and Development of Locomotion and Gross
Motor Skills of Children with Autism Spectrum Disorder
Adriana Kaplánová 1, * , Nikola Šišková 2 , Tatiana Grznárová 2
Citation: Kaplánová, A.; Šišková, N.;
Grznárová, T.; Vanderka, M. Physical
Education and Development of
Locomotion and Gross Motor Skills
of Children with Autism Spectrum
Disorder. Sustainability 2023, 15, 28.
https://doi.org/10.3390/su15010028
Academic Editors: Dario Novak,
Brigita Mieziene and
Branislav Antala
Received: 18 October 2022
Revised: 14 December 2022
Accepted: 17 December 2022
Published: 20 December 2022
Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Sustainability 2023, 15, 28. https://doi.org/10.3390/su15010028
and Marián Vanderka 2
1 Department of Sport Science in Educology and Humanities, Faculty of Physical Education and Sport,
Comenius University in Bratislava, 814 99 Bratislava, Slovakia
2 Department of Track and Field, Faculty of Physical Education and Sport, Comenius University in Bratislava,
814 99 Bratislava, Slovakia
* Correspondence: adriana.kaplanova@uniba.sk
Abstract: Movement abnormalities are a common problem in children with autism spectrum disorder
(ASD), which affect their fine and gross motor skills, locomotion, and eye movements, along with
their ability to conduct more complex movement types. The purpose of this study was to determine
whether regular exercises in physical education classes using the Test of Gross Motor Development
Second Edition (TGMD-2) improve locomotion, gross motor skills, and overall movement perfor-
mance in children with ASD and eliminate the occurrence of movement abnormalities. Twenty
children aged 5–10 years (M ± SD; 7.51 ± 1.58 years) who were diagnosed with ASD participated in
the research. The TGMD-2 training program was applied for a period of 8 weeks with a frequency
setting of two times a week and a duration of 30 min under the guidance of a physical education
teacher. Group A exercised according to TGMD-2 instructions, while Group B was the control group,
then vice versa. The rest period between exercises was 13 weeks. The research results indicate
that the use of exercises to develop the motor performance of children with ASD contributed to
the significant development of their locomotion and gross motor skills. In both groups A and B,
we noted an improvement in locomotion (p < 0.01) and gross motor skills (p < 0.01). The results
demonstrated a significant improvement in gains between the control and experimental periods in
groups A (p < 0.001) and B (p < 0.001). During the 13-week rest period between exercises, we found a
decrease in the level of motor performance in both groups of children with ASD (p < 0.01). In group
A, we found a decrease in motor performance (p < 0.01), locomotion (p < 0.01), and gross motor
skills (p < 0.01), and in group B, a significant deterioration of motor performance in terms of the total
TGMD-2 score (p < 0.05). Regular movement intervention is very important for children with ASD;
otherwise, their level of motor performance can drop significantly. Therefore, we recommend imple-
menting TGMD-2 exercises as part of the physical education of children with ASD and supporting
the routine and healthy habits of children.
Keywords: TGMD-2; movement abnormalities; adapted physical education; motor skills development
1. Introduction
Children with autism spectrum disorder (ASD) suffer from neurodevelopmental
disorders, which are characterized by certain limitations that manifest in several areas of
the children’s development and lives [1]. Deficits appear primarily in verbal and non-verbal
communication and interactions, and children with ASD have a reduced ability to adapt
and function among peers when there is a general disruption to the social relationships
in the classroom [2–5]. A deficit in social-emotional reciprocity makes it impossible for
children with ASD to judge the appropriate contact with peers, meaning there may be
abnormal contact establishment or difficulties with sharing emotions [6,7].
ASD is diagnosed in early childhood, usually around the fourth year of a child’s life,
and its occurrence was found to be four times as frequent in boys compared to girls [8,9].
https://www.mdpi.com/journal/sustainability
Sustainability 2023, 15, 28 2 of 10

It is at this age that movement abnormalities often occur in children with ASD, which
have been recorded in the areas of locomotion and motor skills, eye movements, or the
ability to conduct more complex movement types [10–13]. Children with ASD prefer
activities characteristic of a lower developmental stage and they create an intense and
gratuitous relationship with objects or sequences of certain movements with increasing
intensity, which when disturbed lead to mood changes and angry behavior [14–18]. Motor
abnormalities are observable in children with ASD in early childhood and they become
more significant with increasing age [19–22]. The most frequent movement abnormalities
of school-aged children with ASD include clumsy handling of objects and a ball and an
inability to catch the ball, dribble, throw it in the right direction, or roll the ball. Children
with ASD have difficulties in controlling their legs when kicking a ball, in locomotion skills
that include jumping related to the incorrect procedure when bending the knees, as well as
difficulties in balancing [23]. Therefore, many experts emphasize the importance of training
children with ASD in basic movement skills and adapting their physical education to suit
their needs [24–26].
According to experts, early movement interventions can improve the manipulation of
objects and increase the motor skills of children with ASD [27,28], and can also contribute
to enhancing locomotion and ball handling [29]. Individual exercise therapies are proving
to be a suitable adjunct to other targeted interventions as part of a comprehensive treatment
model [30]. Their advantage is in taking an individual approach that protects children with
ASD from having negative thoughts resulting from a misunderstanding of interactions and
communications between children [31].
Possibilities for developing the socialization of children with ASD have not yet been
sufficiently explored, but experts are investigating the benefits of group activities [32,33].
If the communication or social skills of children with ASD are reduced, there is a risk of
isolating these children from the group [34]. It is proven that sports or organized regular
physical activities provide a suitable environment for the development of a relationship
with peers. Physical education classes can thus become a suitable environment for helping
children with ASD to create a natural relationship with sports, build a healthy lifestyle
routine, and learn to socialize in society [35].
In addition, regular exercise with the use of TGMD-2 in physical education classes
can have a positive effect on children’s engagement in terms of performing individual
movement exercises since routine and immutability are among the main addictions of
children with ASD. Furthermore, a consistent environment and carrying out activities
among a group of children they know can deepen their sense of safety and security and
have a significant impact on their physical and mental health. Plus, the implementation of
proven series of physical education exercises among a stable group of peers can increase
the interest of children with ASD in their development of physical capabilities. Since
there is little research in Slovakia focused on physical activity and the elimination of
movement abnormalities of children with ASD in the area of locomotion or motor skills,
the Faculty of Physical Education and Sports of Comenius University in Bratislava, in
cooperation with the Academic Center for Autism Research, conducted research aimed at
monitoring the development of children with ASD’s motor performance. We assumes that
when implementing regular exercises using TGMD-2, we would note improvements in
locomotion, gross motor skills, and overall movement performance among children with
ASD and eliminate the occurrence of movement abnormalities.

2. Materials and Methods

2.1. Participants
The research group consisted of 20 participants aged 5–10 years (M ± SD;
7.51 ± 1.58 years), made up of 17 boys and 3 girls, who were diagnosed with ASD at
the Academic Center for Autism Research (ACVA) in Bratislava, Slovakia. Children com-
pleted a standardized examination using the ADOS-2 Autism Diagnostic Observation
Schedule scale [36]. The examination lasted 40–60 min and consisted of a series of precisely
Sustainability 2023, 15, 28 3 of 10

defined activities and conversations, during which the psychologist purposefully elicited
specific types of reactions from the child. Based on monitoring the child’s expressions in
interactions with the parent, deficits were evaluated in five main areas: language and com-
munication skills, mutual social interaction, play and creativity, stereotypical expressions,
and narrowly defined interests. With the aim of gaining a more detailed picture of the
children’s development and current behavior, a structured interview was conducted with
the parents or primary guardians using the ADI-R Autism Diagnostic Interview, lasting
90–150 min. The diagnosis covered three areas of problems: quality of communication,
quality of reciprocal social interactions, and limited, repetitive, and stereotypical patterns
of behavior in children with ASD. A thorough evaluation of the developmental history,
relevant information for differential diagnosis, and possible comorbidities was also part of
the diagnosis [37].
All parents or primary guardians of the subjects gave their informed consent for
a child’s inclusion before they participated in the study. The study was conducted in
accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics
Committee of the Faculty of Physical Education and Sports of Comenius University in
Bratislava, Slovakia (code 3/2019). The children were divided into two groups (A and B)
based on the average motor performance score achieved during the initial measurements.
There were nine boys and one girl in group A (6.78 ± 1.34 years) and eight boys and two
girls (8.25 ± 1.44 years) in group B. Group A, as an experimental group, exercised for eight
weeks with a frequency setting of two times a week and a duration of 30 min according to
the TGMD-2 instructions, while group B was the control group, then vice versa (crossover
study). The parents or primary guardians of the children were informed about and gave
consent for these conditions, that the children involved in our research did not perform
any other regular physical activity in their free time.

2.2. TGMD-2 Training Program

TGMD-2 is a training program that serves to identify children who are significantly
behind in terms of their motor skills compared to their peers. It contains 12 exercises
focused on changes in the level of motor performance, which are performed under the
guidance of a physical education teacher [38]. Movement skills are assessed based on
3–5 performance criteria. A child with ASD receives a rating of 0 if they do not perform the
requirements correctly, or 1 if they do. The highest achieved score for one sample group in
each exercise, taken from one or the other of the subtests, is shown in Table 1. We could use
the results of this assessment to monitor the children’s progress, evaluate the treatment,
and conduct further research on their locomotion and gross motor development. A more
detailed description of the exercise program is given in Table 2.

Table 1. Description of the TGMD-2 rater training program.

Locomotion Score Gross Motor Skills Score

1. Run 8 7. Striking a Stationary Ball 10
2. Gallop 8 8. Stationary Dribble 8
3. Hop 10 9. Catch 6
4. Lead 8 10. Kick 8
5. Horizontal Jump 6 11. Overhand Throw 8
6. Slide 8 12. Underhand Roll 8
∑ score 48 ∑ score 48
Sustainability 2023, 15, 28 4 of 10

Table 2. Study design and procedure.

1–4 weeks of the Training time Number of series Rest interval between exercises
Exercises
experiment (min) (n) (s)
1/2 days TGMD–2 (12 exercises) 30 3 30
5–8 weeks of the Training time Number of series Rest interval between exercises
Exercises
experiment (min) (n) (s)
1/2 days TGMD–2 (12 exercises) 30 5 20

2.3. Statistical Analyses

The statistical program 2IBM® SPSS® Statistics, version 26.0, for Windows (SPSS
Inc., Chicago, IL, USA) was used for statistical analysis. The normality of the distribu-
tion of the data was ascertained using the Shapiro–Wilk test. The differences between
input and output measurements in both experimental periods and in the rest period were
evaluated by Wilcoxon’s T-test. Increases during the entire experimental period were
evaluated by Friedman’s test. Differences between control and experimental groups were
assessed using Wilcoxon’s rank-sum test. The effect size was determined using Cohen’s
r: large effect—Cohen’s r ≥ 0.50, medium effect—0.30 ≤ Cohen’s r < 0.50, and small
effect—0.10 ≤ Cohen’s r < 0.30 [39].

3. Results
In Table 3, we present our evaluation of the motor performance of children with ASD
during the first period of exercise using the TGMD-2 training program at a frequency
setting of two times a week and a duration of 30 min for the experimental group A, and
the same evaluations of motor performance for control group B, where children with ASD
did not perform any physical leisure activity, nor regular physical activity. The maximum
number of points that children with ASD could obtain for individual exercises was 960,
of which 480 was for the locomotion subtest and 480 was for the gross motor subtest.
From the results, it is clear that in the first experimental group A, there were significant
improvements in the locomotion subtest (p < 0.01), in the gross motor subtest (p < 0.01),
and in the overall motor performance of children with ASD (p < 0.01).

Table 3. Evaluation of the motor performance of children with ASD during the first period of exercise
using the TGMD-2 training program.

Difference
Group Score (n) M SD p Z Cohen’s r
(%)
Input 370 37.00 21.57 0.005
A 31.98 −2.807 0.888
TGMD-2 Output 677 67.70 21.25 **
total Input 321 32.10 17.73 0.007
B 4.48 −2.689 0.851
Output 364 36.40 18.11 **
Input 182 18.20 10.68 0.005
A 33.13 −2.803 0.887
Locomotion Output 341 34.10 11.32 **
subtest Input 170 17.00 10.97 0.439
B 0.63 −0.774 0.245
Output 173 17.30 8.65 n.s.
Input 188 18.80 11.87 0.005
Gross A 30.83 −2.807 0.888
motor Output 336 33.60 10.74 **
skills Input 153 15.30 8.13
subtest 0.025
B 7.92 −2.245 0.710
Output 191 19.10 11.29 *
Notes: A—experimental group, B—control group, * p < 0.05, ** p < 0.01.
Sustainability 2023, 15, 28 5 of 10

In the second experimental period (October/November), group B performed exercises

using TGMD-2 instructions, and group A became the control group, without regular
physical activity. The results show that in the locomotion subtest (p < 0.01) and in the gross
motor subtest (p < 0.01), as well as in the total motor activity (p < 0.01), the experimental B
group of children with ASD improved significantly (Table 4).

Table 4. Evaluation of the motor performance of children with ASD during the second period of
exercise using the TGMD-2 training program.

Difference
Group Score (n) M SD p Z Cohen’s r
(%)
Input 310 31.00 19.61 0.005
B 32.08 −2.821 0.892
TGMD-2 Output 618 61.80 23.91 **
total
Input 528 52.80 18.74 0.444
A −2.08 −0.766 0.242
Output 508 50.80 17.22 n.s.

Input 161 16.10 10.40 0.005

B 31.46 −2.805 0.887
Locomotion Output 312 31.20 13.12 **
subtest
Input 258 25.80 8.77 0.261
A 2.71 −1.123 0.355
Output 271 27.10 8.22 n.s.

Gross Input 149 14.90 10.29 0.005

B 32.71 −2.814 0.891
motor Output 306 30.60 11.52 **
skills
subtest Input 270 27.00 8.77 0.011
A −6.86 −2.536 0.802
Output 237 23.70 9.90 *

Notes: A—experimental group, B—control group, * p < 0.05, ** p < 0.01.

Between the first experimental period (May/June) and the second (October/November),
there was a 13-week rest period in implementing the exercises. During the rest period, in
experimental group A, the motor performance of children with ASD decreased by 15.52%,
which points to the importance of developing the physical activity of children with ASD.
Meanwhile, in control group B, children with ASD’s motor performance improved by
5.63%, which was caused naturally since these children with ASD were in their period of
greatest motor development.
Friedman’s test showed that the gains in the motor performance of children with
ASD during the period from May to November in both groups A and B were signifi-
cant (p < 0.001). In group A, we noted significant differences in the motor performance
gains for children with ASD between the experimental (May/June) and the control (Oc-
tober/November) periods (p < 0.001), in the locomotion subtest (p < 0.001), and in the
gross motor skills subtest (p < 0.001) (see Figure 1). The average increase in the motor
performance of children with ASD in the experimental period was 30.7 ± 7.59 based on
the total score, and in the control period, the average decrease was −2 ± 6.31. In the
experimental period, the average increase in the locomotion subtest was 15.9 167 ± 6.55,
and in the control period, it was 1.3 ± 4.88. In the experimental period, the gross motor
skills score increased by 14.8 ± 6.10, and in the control period, the average decrease was
−3.3 ± 3.72.
Sustainability 2023, 15, 28 6 of 10

Figure 1. Differences in gains in motor performance between the experimental and control periods in
group A.

In group B, we noted significant differences in the motor performance gains of children

with ASD between the experimental (May–June) and control (October-November) periods
(p < 0.001), as well as in the locomotion subtest (p < 0.001) and the gross motor skills
subtest (p < 0.001) (see Figures 1 and 2). The average increases in motor performance of
children with ASD in terms of the total score were 30.8 ± 7.47 in the experimental period
and 4.3 ± 3.72 in the control period. For the locomotion subtest, they were 15.1 ± 6.88
in the experimental period and 0.3 ± 4.63 in the control period, and for the gross motor
skills subtest, they were 15.7 ± 2.76 in the experimental period and 3.8 ± 3.92 in the
control period.

Figure 2. Differences in gains in motor performance between the experimental and control periods in
group B.

Overall, movement intervention in the form of an 8-week program of TGMD-2 exer-

cises with a frequency of 30 min twice a week significantly increased the locomotion, gross
motor skills, and overall motor performance of children with ASD.

4. Discussion
This study presents findings on the implementation of 12 exercises through TGMD-2
in children with ASD under the guidance of a trained physical education teacher. The
results show a significant improvement in motor performance, specifically locomotion and
gross motor skills, in children with ASD between the ages of 5 and 10 in both experimental
periods, which is in line with the research findings of other experts [27–29]. Children with
ASD improved in their ball and object handling, learned to dribble, caught the ball, threw
the ball in the right direction, and also rolled it. After the implementation of exercises
Sustainability 2023, 15, 28 7 of 10

according to TGMD-2, children’s leg control improved when kicking a ball. We also noted
improvements in their jumping, and difficulties with balancing decreased, which is in
line with the findings of previous authors to have used TGMD-2 for the development of
locomotion and gross motor skills [22,40]. Physical activity can stimulate the cerebral cortex
of children with ASD, and at the same time, contribute to an increased supply of oxygen
and nutrients, which helps to maintain or restore the normal functioning of the nervous
system. Movement interventions to combat mental health problems, such as autism, have
been shown to have a positive impact, but it is important to set certain standards so that
physical activity for children with ASD is consistently effective [41].
Leading children with ASD in the performance of regular physical activity—with
a frequency set of two times a week for 30 min each time over eight weeks—appears to
be effective, which is consistent with the findings of another study (n = 60) that showed
a relationship between physical exercise and improving symptoms or reducing deficits
caused by comorbidities associated with ASD [42]. Our findings are also consistent with
another study to have focused on the application of exercise programs using TGMD-2 in
children with ASD, lasting for 30 min three times a week, in which 14 training sessions were
applied (less than in our battery of exercises) with similar findings in favor of the motor
development of children with ASD [43]. Similarly, another study aimed at evaluating
the effects of creative yoga over the same period of eight weeks (n = 24), which also
demonstrated improvements in gross motor skills in children with ASD, as well as reduced
errors when carrying out training-specific yoga exercises [44]. The same training mesocycle
in the form of swimming training (technical and game) resulted in improvements in
gross motor skills, as well as improvements in stereotypical autistic behavior and emotion
regulation in children with ASD [45].
There is also growing evidence of the positive effect of interventions using music,
dance, theater, and martial arts for addressing multisystem disorders in autism. Improve-
ments in social communication skills have been demonstrated after the implementation of
music and moderate to large improvements in children’s motor skills and cognition after
martial arts therapy [46]. Even virtual training and physical exercises, when implemented
for nine weeks, have the potential to effectively strengthen executive functions and the
self-regulation of children with ASD [47]. In addition, we showed that movement load
improves motor skills even in healthy children (p = 0.012). Healthy children had a 35.15%
higher total score in the exit measurements than at the beginning of the experiment, which
is a similar result to that in our research with autistic children [48].
The motor skills of children with ASD and their imitation skills are interconnected
and related to early social communication skills at the preschool age [49]. This evidence
suggests that motor skills and intellect are highly interconnected in children with ASD. In
addition, basic movement skills are part of the developmental process of children with ASD
and form the basis for more advanced movement patterns, which appear to be effective
to developing, especially when at school, and can eliminate delays in the development
of locomotion and gross motor skills [22,40]. Furthermore, it is beneficial, in general,
for us to increase children’s interest in physical activities and sports and to build their
natural relationship with a healthy lifestyle [40]. Our findings should support educators’,
psychologists’, therapists’, doctors’ and other professionals’ interest in the issue and fuel
their efforts to eliminate movement delays. Systematic assessment of basic movement
skills can also provide a basis for developing a diagnosis of movement delay in children
with ASD [23,40]. Moreover, it can provide valuable information for the development of
movement elements suitable for implementation in physical education classes for children
with ASD, which proves to be helpful in terms of peer group stability and the development
of socialization and communication skills among such children with ASD.

5. Limitations
A limitation of this study was the size of the research sample compared to research
from other countries, as Slovakia is a country with a small population. Furthermore, it was
Sustainability 2023, 15, 28 8 of 10

limited by the varying severity of the children’s autism and mental disability, along with
gender imbalances in the individual groups. Plus, the findings may not be generalizable to
other countries, especially considering that physical education classes vary in their nature
and scope internationally. Moreover, although the parents or primary guardians of the
children with ASD were informed that children should not perform other physical activity,
even during the rest period, this factor was not monitored or verified by research tools.
In the future, it would be interesting to conduct similar studies with different movement
loads, volumes, and times of use for children, with a better division into individual groups.
It would also be interesting to compare the progress of the development of locomotion and
gross motor skills in children with ASD in individual developmental periods, i.e., preschool
age and infant school age, during which motor development is the most intensive.

6. Conclusions
Our findings suggest that a training intervention using TGMD-2 may have a positive
effect on the improvement of the locomotion, gross motor skills, and motor performance of
children with ASD. Such a regular exercise program may offer a suitable tool for improving
the motor level of children with ASD after the eighth week of its implementation at a
frequency of two times per week for 30 min each time. Moreover, after a 13-week rest
period, in the case of experimental group A, we recorded a significant decrease in the
motor performance of children with ASD. This result indicates that regular movement
intervention is very important for children with ASD; otherwise, their level of motor
performance drops significantly. Therefore, we recommend implementing regular exercises
according to the TGMD-2 instructions as part of the physical education for children with
ASD and supporting their routine and healthy habits.

Author Contributions: Conceptualization, A.K., N.Š. and M.V.; methodology, A.K., N.Š. and M.V.;
software, T.G.; validation, T.G.; formal analysis, A.K. and N.Š.; investigation, N.Š.; resources, A.K.;
data curation, A.K.; writing—original draft preparation, A.K.; writing—review and editing, A.K.;
visualization, A.K. and T.G.; supervision, M.V.; project administration, N.Š. and T.G.; funding
acquisition, M.V. All authors have read and agreed to the published version of the manuscript.
Funding: This research was funded by [The Scientific Grant Agency of the Ministry of Education,
Science, Research and Sport of the Slovak Republic (VEGA)] grant number [1/0608/20 with the title
“The influence of movement activities on the cognitive, social and motor skills of children with autism"].
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of the Ethics
Commission of the Faculty of Physical Education and Sport of Comenius University in Bratislava
(protocol code 3/2019 and date of approval 15 May 2019).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Acknowledgments: We greatly appreciate the cooperation of the Academic Center for Autism
Research (ACVA) in Bratislava in Slovakia.
Conflicts of Interest: The authors declare no conflict of interest.

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