International Journal of Developmental Disabilities

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/yjdd20

Physical activity, sedentary behaviour and quality

of life in children with autism: insights from
Romania and Greece

Ruxandra Folostina, Claudia Iuliana Iacob & Christine K. Syriopoulou-Delli

To cite this article: Ruxandra Folostina, Claudia Iuliana Iacob & Christine K. Syriopoulou-Delli
(2023) Physical activity, sedentary behaviour and quality of life in children with autism: insights
from Romania and Greece, International Journal of Developmental Disabilities, 69:3, 432-441,
DOI: 10.1080/20473869.2023.2204574

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Published online: 17 May 2023.

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Physical activity, sedentary behaviour
and quality of life in children with autism:
insights from Romania and Greece
Ruxandra Folostina1 , Claudia Iuliana Iacob2 and Christine K.
Syriopoulou-Delli3
1
Department of Special Education, University of Bucharest, Bucharest, Romania; 2Department of Applied
Psychology and Psychotherapy, University of Bucharest, Bucharest, Romania; 3School of Social Sciences,
Humanities, and Arts, University of Macedonia, Thessaloniki, Greece

Background: The COVID-19 pandemic has accentuated sedentarism in children, including those with aut-
ism. Given the importance of the topic for long-term health, this study aimed to explore the post-pandemic
relationship between physical activity, sedentary behaviours and quality of life (QOL) in children with autism
from Romania and Greece.
Methods: An online questionnaire collected information regarding physical activity levels in children and their
parents, children’s sedentary behaviours and QOL from 83 Romanian parents (m1age ¼ 40.1; sd1age ¼ 6.37)
and 42 Greek parents (m2age ¼ 39.5; sd2age ¼ 5.45) between March and July 2022.
Results: Most Greek children (95%) had 2 or 3 weekly hours of physical education at school/kindergarten,
while only 64% of Romanian children had the same level of physical education. Romanian parents reported
being more active (v2weekdays¼ 33.7, df ¼ 3, p < .001; (v2leisure¼ 41.8, df ¼ 2, p < .001) than the Greek coun-
terparts. Contrary to expectations, the parents’ physical activity did not correlate with the child’s physical
activity. Sedentary behaviour time was significantly higher in Greek than Romanian children during working
days and the weekends. Sedentary behaviour during weekdays predicted the child’ QOL.
Conclusions: This exploratory study offers insight into Romanian and Greek children’s patterns of physical
and sedentary activities. The results stress the need to increase physical activity and decrease sedentary
behaviours in children with autism from Romania and Greece. The practical implications and limits of this
exploratory approach were further discussed.
Keywords: sedentary behaviour; physical activity; quality of life; screen time; autism; family caregiving

Background require energy expenditure. Daily PA involves a series

The importance of physical activity (PA) cannot be over-
looked at any age. The benefits of PA are well known for
all children, including those with disabilities. For
example, PA programs favour participation and promote
the inclusion of children with autism (Hortal-Quesada and
Sanchis-Sanchis 2022). Although the participation of chil-
dren with disabilities in physical activities has multiple
benefits, studies have reported decreasing PA and increas-
ing levels of sedentary behaviour (SB) in the last years
(Brazendale et al. 2020), especially during the COVID-19
pandemic (Yuan et al. 2022).
The Health Organization (2020) defines PA as any
bodily movement produced by skeletal muscles that
Correspondence to: Claudia Iuliana Iacob, Department of Applied
Psychology and Psychotherapy, Faculty Faculty of Psychology and
Educational Sciences, University of Bucharest, Panduri Avenue, No. 90,
Sector 5, Bucharest, Romania. Email: claudia-iuliana.iacob@fpse.unibuc.ro
of activities varying in intensity, from behaviours consid-
ered sedentary (e.g. sitting, lying) to moderate and vigor-
ous PA (MVPA; e.g. running, swimming) (Department
of Health 2019). World Health Organization (2020)
guidelines on PA and SB recommend that children and
adolescents perform at least 60 min per day of MVPA,
primarily aerobic PA, across the week. Moreover, child-
ren’s routines should include vigorous aerobic activities
at least three days a week (World Health Organization
2020). On the other hand, SB is any activity conducted
in a sitting or reclining position (Pate et al. 2008). The
most prevalent sedentary activities are screen-time based,
but reading, sitting and socialising, as well as sitting in
classes are also considered SBs (Biddle et al. 2010).
Physical activity is essential for optimising quality
of life (QOL) throughout childhood and adulthood
(Folta et al. 2022, Memari et al. 2015). This construct

# The British Society of Developmental Disabilities 2023

DOI 10.1080/20473869.2023.2204574 International Journal of Developmental Disabilities 2023 VOL. 69 NO. 3 432
 Ruxandra Folostina et al. Physical activity, sedentary behaviour and quality of life in children with autism
has been positively linked to QOL in individuals with
autism (Sarol and Çimen 2015), intellectual disability
€
(Ozkan and Kale 2021), and physical disabilities (Mann
et al. 2016). QOL for children with disabilities can be
conceptualised as their satisfaction level in primary
environments: home, community, and school (Diener
et al. 1999, Ikeda et al. 2014).
Cross-sectional studies show that SB is inversely
related to QOL in typically developing children and
adolescents. More screen usage is associated with worse
ratings in a variety of QOL domains, including phys-
ical, psychosocial, mental, emotional, and school
domains (Omorou et al. 2016). However, little is known
about this relationship among children with autism.
QOL, physical activity and sedentary
behaviour in children with autism
Autism spectrum disorder is a developmental disability
usually diagnosed in the first three years of life. It
affects primarily social interaction and communication
but also interest in various activities, motor skills, and
learning (American Psychiatric Association 2022).
Children with autism often have difficulties engaging in
age-appropriate physical activities, leaving them vulner-
able to negative QOL changes.
Evidence has shown that PA positively impacts
social and communication skills in children and adoles-
cents with autism (Huang et al. 2020), reduces behav-
ioural problems (Sorensen and Zarrett 2014), leading to
better QOL. Some studies even reported that motor per-
formance and independence skills predict QOL in chil-
dren with autism (Ozboke et al. 2021).
Although the benefits of physical activities are indis-
putable, studies claim that children and adolescents with
autism have higher SB and lower weekly PA levels than
their typically developing peers (Jones et al. 2017). The
consequences of this SB and the lack of PA have been
associated with increased weight gain and screen time
(e.g. television, video games, and computers) (Healy
et al. 2019, McCoy et al. 2016). In addition, adolescents
with autism are less physically active during the week-
days compared to the weekends due to a more structured
program during school days (Stanish et al. 2017). On
average, it is estimated that children with autism spend
more time engaged in SBs than typically developing
children. The intervals range from 26 to 430 min/day for
the first group compared to 72 to 318 min/day for typic-
ally developing children (Jones et al. 2017). Other
studies also reveal that children with disabilities are
more sedentary than other children (Must et al. 2014,
Ryan et al. 2015), which raises concerns for their socio-
emotional and physical health. The psychosocial impli-
cations include low self-esteem, less social acceptance,
greater dependence on others for daily living and higher
rates of obesity (McCoy and Morgan 2020). As such,
PA matters when addressing multiple health issues and
International Journal of Developmental Disabilities
enhancing the well-being of young people with autism
(Hamm and Yun 2019).
Barriers to optimising physical activity and
reducing sedentary behaviours in children
with autism
Several categories of barriers to encouraging PA and
reducing SB in children with autism have been docu-
mented and connected with QOL: the restrictions asso-
ciated with the COVID-19 pandemic (Yuan et al.
2022), community-based barriers (e.g. accessibility of
suitable places, the cost of structured physical activ-
ities), family-related barriers (e.g. the parents’ level of
PA), and disorder-related barriers (e.g. poor motor
skills, lack of motivation, skill generalisation deficits)
(Cuesta-Gomez et al. 2022).
The COVID-19 pandemic and associated health
restrictions limited the possibilities for physical activities.
Moreover, while many virtual dynamic activities were
available during the pandemic, children with disabilities
were less engaged, preferring in-person physical activities
for which parents had to assist them (Esent€urk 2021).
Regarding community-based barriers, 32% of parents sig-
nalled a lack of opportunity, and 22% reported high costs
as obstacles. These barriers were associated with more
video game time on weekdays and weekends (Must et al.
2015). At the same time, schools provide mandatory
physical education (PE) classes, so children with autism
who are not home-schooled or have serious health restric-
tions should benefit from them (Individuals With
Disabilities Education Act, 20 U.S.C. § 1401 2004).
Unfortunately, schools do not cover the minimum neces-
sary level of PA for children (World Health Organization
2020) and engaging special needs students can be chal-
lenging for teachers (Marron et al. 2021).
Parents’ regular participation in PA is another major
contributor to children’s interest in physical activities
(Ku et al. 2020a, 2020b). In addition, families who
practice regular physical activities tend to foster similar
practices for their children with disabilities. On the con-
trary, inactive parents, daily work demands, time pres-
sure, and family finances encourage SBs.
Disorder-related barriers must also be accounted for.
Children with autism are mainly visually oriented and,
thus, may prefer the screens’ stimulation and engage-
ment in such SB (Mazurek et al. 2012). The difficulties
in social motivation were associated with less enjoyment
in physical activities than their typically developing
peers (Stanish et al. 2015). Data on autism severity and
PA are mixed, but age was consistently inversely corre-
lated with physical activities (Arkesteyn et al. 2022).
QOL and sedentary behaviours in Romanian
and Greek children with autism
Although SBs have increased significantly in recent years,
there are disparities across countries due to cultural
2023 VOL. 69 NO. 3 433
Ruxandra Folostina et al. Physical activity, sedentary behaviour and quality of life in children with autism
differences and lifestyles. Researchers and policymakers
are interested in cross-cultural disparities in lifestyle and
physical activities in connection to obesity and SB to dis-
cover intervention measures. As a result, the current study
focuses on two different countries in terms of lifestyle.
Greece is a country with a Mediterranean lifestyle, but a
recent study on sedentary lifestyles in the EU confirms that
sedentary lifestyles are more prevalent in Mediterranean
countries compared with northern countries. Romanian
adults also engage a lot in SBs, although they have a differ-
ent lifestyle from the Mediterranean countries (European
Commission 2022). Since the adults’ lifestyle is correlated
with their children’s lifestyle, we expect Romanian chil-
dren to be less sedentary than Greek children.
Most studies regarding the relationship between QOL
and PA, SBs of children with autism were conducted in
the Anglo-Saxon area and less so in Eastern European
countries. The studies in Romania and Greece investi-
gated the use of games or physical education (i.e. PE)
classes in optimising cognitive performance in children
with developmental disabilities (Mocanu and Udrea,
2021, Bechar and Grosu 2016, Varsamis and Agaliotis
2015). However, during the COVID-19 pandemic, some
papers drew attention to sedentarism and its long-term
negative consequences (Magklara et al. 2023, Folostina
and Iacob 2021). The educational systems in both coun-
tries are organised similarly. Students with special educa-
tional need can study in special schools or be integrated
into mainstream schools (with or without a support
teacher). Weekly PE classes are mandatory, so children
with autism should attend. So far, no studies have been
identified targeting post-pandemic physical activities, sed-
entary behaviours, and QOL in ASD samples from these
countries and the current investigation will fill in this gap.
Considering the theme’s importance for these child-
ren’s physical and emotional health, this study aimed to
explore the relationship between children’s PA, sedentary
behaviours and QOL in two samples from Romania and
Greece. We are interested to see what cross-country dif-
ferences exist regarding parents’ PA levels on the one
hand and child PA, SB, and QOL levels on the other
hand. Based on previous studies, we expect parents’ PA
levels to positively correlate with children’s PA levels
and their QOL. In terms of between-country differences,
we anticipate Greek children to be more sedentary than
Romanian children, mirroring their parents’ sedentary
lifestyle, as shown by the European Commission reports
(2022). Other differences are hard to anticipate given the
scarce literature in these countries; hence need for the cur-
rent exploratory approach. Lastly, we expect SBs will pre-
dict the child’s QOL.
Methods
Participants and design
This cross-sectional design study is based on two con-
venience samples of parents of children with autism.
434 International Journal of Developmental Disabilities 2023
Sample one included 83 Romanian parents (90%
females; m1age ¼ 40.1; sd1age ¼ 6.37) and sample two
forty-two Greek parents (95% females; m2age ¼ 39.5;
sd2age ¼ 5.45). Sample one participants cared for chil-
dren between 3 and 17 years (mage ¼ 9.88, SDage ¼
3.56), and sample two was for children between 6 and
15 years (mage ¼ 9.14, SD ¼ 2.88). Information regard-
ing additional sociodemographic characteristics of both
samples can be consulted in Table 1.
Instruments
Children’s quality of life was assessed with the Kid and
Kiddo – KINDLR health-related quality of life question-
naire (Ravens-Sieberer and Bullinger 2000), a 24-item
instrument scored on a 5-point Likert scale from 0 (never)
to 4 (all the time), filled out by parents. The questionnaire
includes six dimensions: physical well-being, emotional
well-being, self-esteem, family, friends and daily func-
tioning. An example of an item is: “During the past week,
he/she played with friends.”. The English version of the
questionnaire was translated and back-translated into
Romanian and Greek languages before administration.
The Cronbach alpha coefficients of internal consistency
had good values: aRomania ¼ .85, aGreece ¼ .90.
Children’s screen time and sedentary behaviours
were evaluated with the Sedentary Behaviour
Questionnaire (SBQ; Rosenberg et al. 2010), the adapted
version for children and adolescents proposed by Dahlgren
et al. (2021). This instrument investigates the amount of
time spent on weekdays, respectively on weekends
engaged in the following behaviours: navigating on the
smartphone and/or table, watching TV, playing computer/-
video games, sitting while listening to music, sitting and
talking on the phone, doing homework at the desk, sitting
and reading, playing a musical instrument, doing arts and
crafts, sitting in a car, bus, train or other motorised
vehicles. Given the wide range of SBs it encompasses, this
instrument was considered suitable for the purposes of the
current research. An example of an item is: “How much
time does he/she send on the following during a normal
weekday, from the time he/she wakes up until goes to bed?
1. On the smartphone and/or tablet.” The answering
options were none, 15 min, 30 min, one hour, 2 h, 3 h, 4 h,
5 h, 6 h or more per day. During the data analysis phase,
the answers were converted from hours to minutes for ease
of interpretation (e.g. 300 min instead of 5 h). Summed
scores of each item were calculated separately for week-
days and weekend engagement in daily SBs. The
Cronbach alpha coefficients of internal consistency had
good values: aRomania ¼ .83, aGreece ¼ .87.
Physical activity information was collected using six
questions from Dahlgren et al. (2021) questionnaire on
PA: (1) how many times does the child attend PE
classes at school weekly (answering options: does not
have PE classes on the schedule, zero, 1 h, 2 h, 3 h); (2)
how many times per week is the child engaged in
VOL. 69 NO. 3
 Ruxandra Folostina et al. Physical activity, sedentary behaviour and quality of life in children with autism

Table 1. Sociodemographic characteristics of study samples.

Variable Romanian sample (N ¼ 83) Greek sample (N ¼ 42) v2 (p-value)

Parent relationship status .08
Married 88% 81%
In a romantic relationship 3.6% 4.8%
Unpaired (e.g. single, divorced, widowed) 8.4% 14.2%
Parent education level .02
Secondary/vocational school 15.6% 19%
High-school 21.7% 4.9%
Faculty-level education 44.6% 57.1%
Master’s degree or higher 18.1% 19%
Financial situation .07
Below average 7.3% 0%
Average 80.7% 95.2%
Comfortable 12% 4.8%
Living environment <.001
Rural 16.9% 0%
Small urban (<100.000 inhabitants) 27.7% 9.5%
Big urban (>100.000 inhabitants) 55.4% 90.5%
Child gender .85
Female 20.5% 19%
Male 79.5% 81%
Child age category .58
Preschool (3–6 years) 19.3% 23.8%
School-age (7–11 years) 48.2% 52.4%
Teenager (12–17 years) 32.5% 23.8%
Child IQ <.001
< 85 84% 23.8%
85–115 12% 71.4%
>115 4% 4.8%
Child speech development <.001
Non-verbal 13.3% 33.3%
Monosilabic speech/single words 39.8% 57.1%
Talks in sentences 47% 9.5%
Child BMI .14
Underweight 52.1% 54.8%
Normal weight 39.7% 45.2%
Overweight 8.2% 0
Note. IQ ¼ intelligence quotient, BMI ¼ body mass index.

organised sports/activities outside school (answering
options: none, once a week, 1-2 h/week, 2-3 h/week, 3-
4 h/week, 4-5 h/week, 5-6 h/week); (3) how physically
active is the child after school on weekdays (answering
options: mostly sedentary, less than 30 min, 30-60 min,
1-2 h, 2-3 h, more than 3 h); (4) how physically active
is the child on weekends (same answering options as
the previous question); (5) what is your daily activity
level during working weekdays (answering options:
sedentary most of the time, sedentary for about half a
day, active for more than half a day); (6) what is your
usual PA level during leisure time (answering options:
sedentary most of the time, active about 30 min/day,
active about 60 min/day or more). The first four ques-
tions address the child’s behaviour, and the last two
refer to the parents’ behaviour.
Sociodemographic and health-related information
was collected with a form designed by the authors.
Participants filled out relevant information about them-
selves and their children: age, gender, parent relationship
status, education level, financial situation, living environ-
ment, child diagnosis, IQ, speech level, and BMI.
Procedure
The instruments used in this study were translated and
back-translated into Romanian and Greek languages by
PhD level researchers in special education. Afterwards,
an online Google form was distributed to special
schools and rehabilitation centres, asking teachers to
pass the form to the parents of their students. The data
were collected between March and July 2022 when
children physically returned to school; only parents
completed the measures. Participation was anonymous
and voluntary, and no reward was offered. Potential
participants read and signed informed consent before
completing the measures. They could withdraw from
the study at any point without consequences and contact
a researcher for supplementary information. The study
was analysed and approved by the Research Ethics
Committee of the University of Bucharest (notice no.
58/17.09.2021).
Data analysis
The data were analysed using Jamovi software, version
2.3.21 (The jamovi project 2022). We reported standard
descriptive statistics, frequencies and Pearson correla-
tions for each sample and Kendall’s coefficient of rank
correlation for ordinal variables associated with con-
tinuous ones (Zimmerman and Zumbo 1993). We com-
puted an independent-sample chi-square test to identify
between-country differences in nominal and ordinal var-
iables. In addition, we used a series of student t-tests

International Journal of Developmental Disabilities 2023 VOL. 69 NO. 3 435

Ruxandra Folostina et al. Physical activity, sedentary behaviour and quality of life in children with autism

with Cohen’s d-effect sizes (Cohen 1988) to explore

10

0.11 0.16 .10 .59 –

between-group differences in the quality of life, screen

–
time and SBs of children with autism. Since multiple
comparisons were conducted on the same data, type I

.14 .23
8

.41 0.17 –
error increases, leading to false-positive results. To

–
diminish this error, we used the Bonferroni correction
and established the significant p-value at .005. Finally,

39.5 (5.45) 9.14 (2.88) 18.2 (3.67) 30.3 (9.82) 403 (178) 439 (195)
0.23

.02
we performed a multiple linear regression analysis with

–
two predictors entered in the same step, to see whether
SBs during weekdays and weekends will predict QOL

.87

0.21

0.01
.42

.14
5

–
in children from both countries. We chose this model
because the variables are continuous and normally
distributed.

.53

.41

.32
.03

.20

.12
4

–
Results

Greece
Preliminary analyses

0.16

0.21
.38
.14

.24

.17

.08
Preliminary between-country differences in sociodemo-

–
graphic information showed that both samples are simi-
lar regarding the parents’ relational and financial status

0.19

0.03

0.11
and the children’s age, gender and weight. On the other

.17
.30
.04

.22

.11
2

–
hand, compared to Greek participants, more Romanian
participants lived in rural or small urban areas, and their

0.36
0.15
0.09

0.06

0.17
.46
children had an IQ below 85, with sentence-level devel-
.02

.13

.03
1
–
oped speech (see Table 1).
The main descriptive statistics and correlations
10

.06 .16 .54 –

among the primary variables were rendered in Table 2
for each sample. In both countries, a positive correl-
9

–
ation was found between QOL and the time spent

.11 .22
8

0.04 .51 –
engaging in SBs on weekdays and weekends. On the
other hand, children’s age did not correlate with SB, as
7

previous studies showed. Only Greek parents’ PA dur-

40.1 (6.37) 9.88 (3.56) 19.2 (4.72) 38.6 (12.1) 232 (211) 217 (222)
ing leisure time correlated with a child’s QOL.

Note. sb ¼ Kendall’s tau – b correlation coefficients.  p < .05;  p < .01,  p < .001.
.04

.15

.10
6

Romanian parents’ level of PA during leisure time was

associated with the child’s PA during weekdays. The
.83

correlations were small.

0.01
.08

.13

.14
5

On average, children in Romania spend 232 min

Correlations and descriptive statistics for main variables.

engaged in sedentary activities during an ordinary

.43

.46

working day and 217 min on weekends. For Greek chil-

.19

.21
.14

.05
4

dren, the same averages increased to 403 and 439 min,

Romania

respectively.
0.04

0.11

0.13
.04
.12

.06

.03
3

Physical activity levels: between-group

differences
Regarding the frequency of PA, over 95% of Greek chil-
.40

0.05

0.13

0.07
.03
.10

.02

.11

dren had at least two weekly hours of PE during school

2

hours, while only 64% of Romanian children benefitted

from the same level of PE. Moreover, 19.3% of
.52

.29
.23
.05

.19

.02

.02

.05

.14

Romanian participants reported that their children do not

1
–

have PE classes in the schedule or attend zero PE

classes. The chi-square test indicated these differences
during weekends (sb)
9. child PA level during

are statistically significant (v2 ¼ 15.7, df ¼ 4, p ¼ .003).

7. parent PA level

8. parent PA level
during working

10. child PA level

Approximately half the children in each investigated

weekdays (sb)
during leisure
daily SB on

6. daily SB on
parent age

country did not report any organised PA outside the

weekends
weekdays
child BMI
child age

days (sb)

time (sb)

Mean (SD)

school during weekdays (v2 ¼ 6.57, df ¼ 7, p ¼ .47).

Table 2.

Variable

QOL

About 62% of Greek parents considered their children

primarily sedentary or having less than 30 min/day of
1.
2.
3.
4.
5.

436 International Journal of Developmental Disabilities 2023 VOL. 69 NO. 3

 Ruxandra Folostina et al. Physical activity, sedentary behaviour and quality of life in children with autism
PA after school hours, compared to 31.3% Romanian
children. They were more physically active after school,
with 30.1% having more than one hour of activity,
compared to 4.8% of Greek children. Between-country
differences are significant (v2 ¼ 16.5, df ¼ 5, p ¼ .006).
On weekends, the level of PA increased, as 76,2% of
Greek children had between 30 min and 2 h of activity.
Approximately 46.3% of Romanian children had the
same level of PA. These differences are statistically sig-
nificant (v2 ¼ 30.4, df ¼ 5, p < .001).
Most parents in both countries were active on week-
days for over half a day. Also, they spent at least
30 min a day physically active during their leisure time.
However, the overall between-country differences were
significant, rendering Romanian parents more active
than their Greek counterparts (v2weekdays¼ 33.7, df ¼ 3,
p < .001; (v2leisure¼ 41.8, df ¼ 2, p < .001). For details,
please consult Figure 1.
Quality of life and sedentary behaviours:
between-group differences
The overall quality of life (i.e. QOL) was higher for
Romanian children than for Greek children [t(123) ¼
3.81, p < .001, d ¼ .72]. Concerning each QOL dimen-
sion, emotional, family, friends and school-related QOL
were similar for both groups. All the results are pre-
sented in Table 3. Weekday and weekend SBs were sig-
nificantly higher in Greek children, as their parents
reported. The magnitude of effect sizes was medium to
large for the investigated variables.
Sedentary behaviours as QOL predictors in
children with autism
The general prediction model was significant (F(2,122) ¼
5.12, p ¼ .007, R2 ¼ .07), explaining 7% of the total
QOL's variance. However, only SBs during weekdays
were a significant predictor (b ¼ .43, p ¼ .017).
Interestingly, the child’s SB during weekends was not a
significant predictor for QOL (see Table 4).
Discussion
This study aimed to investigate the post-pandemic rela-
tionship between PA levels, SB and QOL in children
with autism from Romania and Greece. An exploratory,
cross-sectional approach was used. The results will be
discussed taking into consideration cross-country differ-
ences, the relationship between SB and QOL, and prac-
tical implications.
Physical activity and sedentary behaviour in
children with autism: cross-country
differences
Regarding the PA levels, the data showed that almost all
Greek children participate in 2-3 weekly hours of PE at
school. Instead, only 64% of Romanian children had the
same level of participation. Even if in both countries PE
International Journal of Developmental Disabilities
classes are mandatory for all students, Romanian stu-
dents with disabilities usually do not attend such classes
because teachers cannot handle them appropriately, so
they skip these classes unofficially. This phenomenon is
not documented in empirical quantitative studies on
Romania. However, similar challenges were recently
reported in other European countries (Marron et al.
2021). Future studies should probe to see if there are dif-
ferences between PE classes in schools and those offered
by potential rehabilitation centres where some children
may benefit from additional services. One would expect
the specialised services to be more efficient in engaging
children with autism in PE.
In the current sample, about half the children did not
have organised physical activities after school.
Nevertheless, Romanian children were more active than
their Greek counterparts. Several factors can explain this
difference. First, most Greek participants live in big
urban cities, as opposed to approximately 55% of
Romanian participants. Living in big cities may hinder
the opportunities for PA, as shown by previous meta-
data (Sandercock et al. 2010). Living expenses are
higher in big cities and this may be a barrier to engaging
children in PAs after school (Must et al. 2015). Second,
most Greek children were nonverbal or had single-word
speech, which can make it harder for them to attend PAs
with other children and socially withdraw in screen-
based activities. Third, sedentary activities may be con-
sidered a break after a long school day. Parents might
use screen time and sedentary activities to improve their
children’s well-being (Stiller et al. 2019). However, this
behaviour pattern is not healthy in the long term
(Anokye et al. 2012). Another possible explanation
might have to do with the increasing caregiving burden
parents deal with and can highlight the need for formal
and informal (family) support for these parents.
During the weekend, the children’s level of PA
increased in both investigated countries, a phenomenon
related to parents’ concern for encouraging PA in their
children when the time allows. Concurrently, children
in both countries spend almost as much time in SBs on
weekends as on school days. That is around 200 min for
Romanian children and double for Greek children. This
significant cross-country difference can be explained by
authentic parenting variability in raising children with
autism in each country. International reports show that
Mediterranean countries, such as Greece, report more
sedentary behaviours than other countries (European
Commission 2022). Parents are generally aware of
excessive screen time’s adverse effects; some may have
mixed feelings declaring poor management of such
behaviours, especially when children prefer spending
time this way. On the other hand, some parents may
prefer to engage in SBs or extended screen time (Wong
et al. 2019), modelling the child’s behaviour. Another
explanation may be related to the measuring instrument
2023 VOL. 69 NO. 3 437
Ruxandra Folostina et al. Physical activity, sedentary behaviour and quality of life in children with autism

Figure 1. Frequencies of PE classes and physical activity levels on weekdays and weekends.
Note. 1. Does not have PE classes on the schedule, zero, one, two, three. 2. None, once a week, 1–2 hours/week, 2–3 hours/week, 3–4 hours/week,
4–5 hours/week, 5–6 hours/week. 3. and 4. Mostly sedentary, less than 30 minutes, 30–60 minutes, 1–2 hours, 2–3 hours, more than 3 hours. 5.
Sedentary most of the time, sedentary for about half a day, active for more than half a day. 6. Sedentary most of the time, active about 30 minutes/day,
active about 60 minutes/day or more.

Table 3. Group differences between Romanian and Greek children.

Romania Greece
M SD M SD t(123) p Cohen’s d
Overall QOL 38.6 12.1 30.3 9.82 3.81 <.001 .72
Physical QOL 5.33 2.33 3.24 2.48 4.63 <.001 .87
Emotional QOL 5.99 2.49 4.81 2.35 2.54 .01 .48
Self-esteem QOL 7.20 3.88 3.81 2.88 5.01 <.001 .94
Family-related QOL 9.05 2.66 8.86 1.22 .44 .65 .08
Friends-related QOL 6.41 3.60 5.86 1.51 .95 .34 .18
School-related QOL 4.58 3.22 3.76 2.32 1.45 .14 .27
Weekdays sedentary behaviour 232 211 403 178 4.51 <.001 0.85
Weekends sedentary behaviour 217 222 439 195 5.48 <.001 0.99
significant comparisons; a Bonferroni-adjusted significance level of .005 was used to diminish type I error due to multiple comparisons
testing on the same data.

Table 4. Predictors of child QOL.

95% CI for B
Model 1 B Lower limit Upper limit SE B b
Intercept 31.72 28.26 35.18 1.74
Child sedentary behaviour weekdays .02 .004 .04 .009 .43
Child sedentary behaviour weekends 0.009 0.02 .007 .009 0.19
Note. p ¼ .017.

because the scores were obtained by summing up the
time spent in multiple SBs. Finally, parents’ memory
may be skewed towards remembering extreme values
and, thus, overreporting the phenomenon. However,
previous research papers reported similar values (Jones
et al. 2017).
Contrary to expectations, in this sample, the parents’
activity level was not associated with the child’s QOL or
PA. However, small correlations were found between
Greek parents’ PA during leisure time and the child’s
QOL. One might argue that when parents have free time
during weekends, they engage in dynamic interactions
with children, raising their QOL. This is consistent with
raising children’s physical activities during weekends.
However, these results cannot be robustly interpreted
since multiple cofound variables were not controlled,
and the study has a cross-sectional design. Future studies
might clarify these aspects.
Children’s sedentary behaviours and QOL
Concerning the relationship between children’s QOL,
their SBs and sociodemographic information, several

438 International Journal of Developmental Disabilities 2023 VOL. 69 NO. 3

 Ruxandra Folostina et al. Physical activity, sedentary behaviour and quality of life in children with autism
findings need to be discussed. Contrary to previous
findings, child age did not correlate with SBs in the
current sample. A possible explanation is that children
included in this study go to school/kindergarten and
have a structured program for most of the day.
As expected, the correlation was positive for both
samples regarding the relationship between SBs and
children’s QOL. This is probably due to the short-term
calming effects that SBs have. Our measure of QOL
did not emphasise health-related aspects but behavioural
indicators of a child’s well-being and satisfaction. As
such, screen time and other static activities (such as arts
and crafts, listening to music or desk activities) were
associated with higher QOL scores. In addition, some
sedentary activities include hobbies (e.g. arts and
crafts), which may increase emotional well-being. Since
children prefer them, it is recommended that parents
and teachers try to combine these activities with
dynamic ones to avoid long-term negative consequen-
ces. For example, children might be encouraged to
dance or stand up while listening to music. If they like
arts and crafts, parents might place the necessary tools
in different parts of the room, motivating the child to
move around. If children spend much time at the desk,
they may be stimulated to sit on a gym ball, a desk
bicycle or another device that enables lower body
movements. These devices can also accommodate the
sensory needs of children with ASD and their prefer-
ence for solitary activities (Locke et al. 2016).
Child SB on weekdays significantly predicted QOL.
Children enjoy their sedentary activities during week-
days after school because they can provide relaxation
moments and distance from the overstimulating activ-
ities throughout the day (Slobodin et al. 2019). Also,
when discussing the negative impact of SBs, it is neces-
sary to separate screen time overuse from sedentary
hobbies that optimise fine motor skills or attention (e.g.
arts and crafts). Therefore, parents must balance group
or individual physical and static regulatory activities.
Practical implications
Most results are consistent with previous findings and
support the necessity for better PA-facilitating policies in
children with autism. The development of adapted PA
programs, as well as better-trained teachers, could be a
solution. Such programs should focus on developing
physical/motor skills (e.g. walking, running, climbing,
throwing) and sports-based skills (e.g. dance, swim-
ming). Enhancing individual and group skills using such
activities is recommended (The National Consortium for
Physical Education for Individuals with Disabilities,
n.d.). For children with autism, individual activities may
be more suitable at the beginning, as their communica-
tion difficulties might impair verbal instruction under-
standing (Wilson 2002). Also, group PE classes can be
overstimulating, and children may need additional time
International Journal of Developmental Disabilities
to habituate (Healy et al. 2016). However, researchers
have reported successful group programs that could be
implemented in schools along with proper teacher train-
ing (Adorno et al. 2022, Haghighi et al. 2022).
Turning the lenses towards community-based facili-
tators of PAs, local governments should encourage the
development of cost-free programs that could assist
parents in providing a healthier lifestyle for their chil-
dren. Taking into consideration that the caregiving bur-
den may act as a barrier for parents in diminishing the
SBs of their children, it is advisable to transition from
child-centred care to integrated family-centred care
(Kokorelias et al. 2019). This transition may be difficult
in collectivistic societies, such as Romania and Greece
(Hofstede-insights 2019), where parents are not used to
being taken care of, and their primary focus is the
child’s needs.
Limitations
The current investigation has documented PA in chil-
dren with autism and their parents and their relationship
with demographic characteristics, child QOL and SBs
in two samples from Romania and Greece. Overall, the
results were consistent with the existing evidence, and
recommendations for improving QOL were provided.
However, the findings are based on convenience sam-
ples and cannot be generalised. Furthermore, the cross-
sectional design allows only for correlational analyses
between the variables. Finally, the data was obtained
from self-report measures completed by parents and are
subject to potential desirability bias (Althubaiti 2016).
Nevertheless, the participation was anonymous and vol-
untary, no rewards were offered, and the participants
did not meet the research team. All these elements
diminish the probability of high desirability bias.
Measuring children’s QOL by their parents’ perception
does not reveal the children’s direct experience. At the
same time, considering the children’s diagnoses, their
perception is indirectly accessible to others.
From a methodological standpoint, the following
shortcomings can be highlighted: (1) the level of PA
was not assessed using a scale, but several survey ques-
tions; this approach was anticipated to increase the
response rate of participants, but it limited the complex-
ity of statistical analyses; (2) the psychometric proper-
ties of the adapted version of the SBQ (Rosenberg
et al. 2010) for the pediatric population (Dahlgren et al.
2021) were not published so far, which raises questions
regarding the instrument’s validity; even so, the results
obtained were mostly in line with previous literature
and the internal consistency coefficients values were
good; (3) although countries had socio-demographic
differences, these were not controlled in the subsequent
statistical tests, due to low subsample sizes.
2023 VOL. 69 NO. 3 439
Ruxandra Folostina et al. Physical activity, sedentary behaviour and quality of life in children with autism
The study was approved by the Research Ethics
Committee of the University of Bucharest (notice no.
58/17.09.2021).
Disclosure statement
No potential conflict of interest was reported by the
authors.
Funding
This work was funded by the ERAMUSþ Project
“Autism Play Therapy for Movement” (622353-EPP-1-
2020-1-EN-SPO-SSCP).
ORCID
Ruxandra Folostina http://orcid.org/0000-0002-
5543-2471
Claudia Iuliana Iacob http://orcid.org/0000-0001-
9508-4881
Christine K. Syriopoulou-Delli http://orci-
d.org/0000-0003-1490-8899
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