Children and youth with autism spectrum disorder (ASD) display lower levels of physical activity (PA) compared to their typically developing (TD) peers.1–3 Additionally, several studies4–6 have shown that children and youth with ASD participate in significantly fewer regular activities, including both organized sports and self- or family-organized activities. Given the rising prevalence of ASD among children and youth worldwide,7,8 coupled with low PA levels, it is crucial to understand the complex factors hindering and facilitating PA to effectively promote PA in this population.
ASD is a neurodevelopmental condition, characterized by core characteristics in 2 areas, social communication and restrictive, repetitive sensory-motor behaviors.9 The condition is characterized as a spectrum, indicating significant variation in factors such as functioning and support needs.10 The global prevalence is estimated to be 1% to 2%.11 In addition to the general benefits from PA, including physical fitness and mental health,12–14 studies have shown positive effects of PA on several factors closely related to the core characteristics of ASD, including social-emotional behaviors such as social interaction skills and motor control,15–18 and some have shown reductions in stereotypic behaviors.15,17,19
A plethora of approaches to understanding the complex factors affecting PA behavior exist, and theoretical models exploring how individual and social-environmental factors interrelate, such as socioecological models.20,21 Socioecological models have been used to understand PA behavior in the general population,22,23 in diverse populations with disabilities,24,25 and with ASD.26,27 In the context of health behavior, such as PA, McLeroy et al21 proposed an adapted socioecological model, depicting 5 levels of influence: (1) intrapersonal factors, both modifiable (eg, attitudes and motivation) and nonmodifiable (eg, age and gender); (2) interpersonal factors, which are formal and informal social networks, social support systems, and groups (eg, family, friends, and public acceptance); (3) institutional factors, which are formal and informal contexts within social institutions (eg, physical education [PE] curriculum or content); (4) community factors, which are the relationships between and among organizations and informal networks (eg, PA programs and facilities); and (5) public policy, including local, state, and national laws, policies, and priorities. Additionally, Sallis et al,28 and Spence and Lee29 proposed a sixth level of influence, physical ecology which pertains to the physical environment (eg, climate) when studying PA behavior. Previous research has explored many levels of influence in this population,26,27 but few reviews have explored all levels of influence,2,30–32 including physical ecology.
Research on PA participation among children and youth with ASD has grown in popularity, and literature reviews that systematically map the research done in this area are needed. Utilizing a socioecological model to examine barriers and facilitators for PA provides the possibility of comprehensively investigating the complex interplay between individual and social-environmental factors. Liang et al2 examined PA levels of children and adolescents with ASD, identifying factors of influence on 4 out of 5 levels, not including physical ecology. The review only included studies that quantitatively measured PA levels, excluding most qualitative studies exploring individual experiences. Similarly, the reviews by Krieger et al,31 Hickingbotham et al,30 and Askari et al32 mapped barriers and facilitators for PA, identifying factors located at the intrapersonal and interpersonal levels, and to a lesser extent the community level. Interestingly, at the intrapersonal level, Askari et al32 was the only review to discuss the findings in relation to the core characteristics of ASD, while Hickingbotham et al,30 who also included other psychiatric disorders in their review, identified only intrapersonal factors. However, to our knowledge, no previous scoping review has comprehensively examined barriers and facilitators for PA among children and youth with ASD. Considering this, the current scoping review aimed to thoroughly identify and synthesize barriers and facilitators for PA among children and youth with ASD across the socioecological model’s levels of influence.
Methods
The comprehensive nature of scoping reviews helped us to thoroughly and systematically map the existing literature regarding barriers and facilitators for PA in children and youth with ASD, regardless of the study design and the methodological quality of included studies. Scoping reviews usually do not assess the quality of the existing literature but can identify gaps in the literature.33 This review was guided by the framework for conducting scoping reviews by Arksey and O’Malley33 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews protocol (Supplementary Material S1 [available online]).34
Data Sources and Searches
The following 5 sources were searched: Web of Science, Scopus, ERIC (ProQuest), SPORTDiscus (EBSCO), and MEDLINE (Ovid). The search string was developed in close cooperation between all authors, with Jensen and Solhaug being research librarians experienced in performing systematic review studies. The search strategies for each source are provided in Supplementary Material S2 (available online). Then, a manual search of reference lists was performed.
Inclusion Criteria
To be included in this review, the research had to be (1) an original empirical study; hence, literature reviews, abstracts, commentaries, and studies developing/validating new instruments were excluded; (2) published in English; (3) focused on 6- to 21-year-old (school age) children and youth with ASD; (4) on the topic of experienced or perceived barriers and facilitators for PA (including self- or family-organized PA, PE, organized sports, etc); and (5) published in peer-reviewed journals. The methodological approach was not utilized as an exclusion criterion, and quantitative, qualitative, and mixed methods studies were included.
Data Selection
The initial search was conducted on February 3, 2022, an updated search was performed on April 9, 2024, and after the removal of duplicates, all items were screened independently and blinded based on title and abstract by Jensen and Solhaug using a specialized software, Rayyan (Rayyan Systems, Inc).35 Rayyan does not provide automatic screening and was used only to systematize the independent screening. Conflicts between the initial reviewers were independently reviewed and settled by Okkenhaug, who screened the full text of the remaining studies based on the inclusion criteria. This screening process was followed by a joint discussion between all authors in cases of uncertainty, and then final agreement was reached on which of the studies to include.
Data Extraction and Framework Synthesis
The data extraction and analysis were guided by the framework synthesis method, as this is a systematic and flexible approach to studying the complexities of influences affecting PA.36 The framework consists of 5 overlapping steps37: familiarization, framework selection, indexing, charting, and mapping and interpretation. The framework synthesis was performed by Okkenhaug.
The familiarization stage leading up to the planning of this scoping review gave the researchers specific knowledge about the research field and its complexities per both its methodological approaches and usage of theoretical frameworks. To capture these complexities, the need for a concrete framework to synthesize the reviewed literature became apparent. Through this familiarization, the socioecological model was identified and chosen as the synthesizing framework.
Indexing consisted of 2 separate processes: (1) extracting descriptive characteristics of the included studies using a standardized form, this included author names, title, year of publication, journal, country of origin, aim, methods, sample (N) including female participants, age of participants, study perspective (first person or proxy), diagnosis, theoretical perspective, and philosophical underpinning; and (2) barriers and facilitators were indexed through a codebook approach. The codebook was based on the socioecological model and developed by Okkenhaug. Initially, it included the 5 levels from McLeroy et al’s21 socioecological model and the additional physical ecology as categories for both barriers and facilitators. This initially led to deductive indexing. During the initial full-text readthrough, the codebook was further inductively developed to include subcategories grounded in the included material. All the studies, regardless of methodological approach, were indexed through coding, and text and tables regarding barriers and facilitators for PA included in the “Results” section were indexed. All indexing was done in NVivo (version 1.6.1, Lumivero), and full PDFs of the included studies were uploaded into the software. An external researcher blindly indexed 10% of the included studies using the codebook with the possibility to add new codes, and this was followed by a discussion with Okkenhaugr. Overall, the indexing showed coherent results, and the categories were interpreted similarly. The discussion centered around whether factors belonged on the intrapersonal or interpersonal levels of influence, and how the same factors are experienced as both barriers and facilitators. This is further reflected in the discussion.
After indexing, all the excerpts were inspected within each subcategory and charted based on what the specific excerpt was about. This helped to reduce the data material and start the mapping and interpretation of content within each subcategory. In this process, some subcategories were renamed to better describe the content. These subcategories together with the socioecological model guided the presentation of results.
Through mapping and interpreting, we addressed the aim of this review: to collate the findings into a whole. This was done by looking at findings across categories, how a barrier or facilitator at 1 level affected other level barriers or facilitators, and how the same factor can be perceived both as a barrier and as a facilitator. This process also led to the differentiation between barriers and facilitators unique for children and youth with ASD and that were similar across populations, identified as general barriers and facilitators. The outcomes of this process guided the writing-up and structuring of both the results and the discussion.
Results
The search identified 751 studies, excluding duplicates. Following the screening of titles and abstracts, 680 studies were eliminated, resulting in a first sample of 71 studies. See Figure 1 for a flowchart of the selection process. Following a full-text screening, 53 studies were considered eligible for inclusion. Reasons for exclusion at this stage were not exploring barriers or facilitators for PA, wrong study population, wrong publication type, and an additional duplicate. The reference lists of all the included studies were checked for additional relevant studies, and 1 additional study was included.
—Study selection process. PA indicates physical activity; WoS, Web of Science.
Citation: Journal of Physical Activity and Health 21, 10; 10.1123/jpah.2024-0075
Characteristics of Included Studies
Table 1 summarizes the included studies. Fifty-four studies met the inclusion criteria, including 15 quantitative, 35 qualitative, and 4 mixed methods studies (ie, integrating quantitative and qualitative data38). Additionally, most studies combining methods did so within the same tradition (either qualitative or quantitative) and were thus not categorized as mixed methods. All studies were published between 2008 and 2024, with only one study published before 2010, and 35 over the last 5 years (2019–2024). Thirty-two studies were conducted in North America, 11 in Europe, 1 in both Europe and North America, 7 in Asia, 2 in Australia, and 1 in South America. No substantial differences regarding levels of influence were identified between places of origin. Twenty-six studies utilized theoretical frameworks in developing their approaches or in analyzing their data. Of these, the most used framework was different variants of the socioecological model (9 studies). The respondents in 15 of the studies were children or youth with ASD who gave first-person accounts, 23 involved proxies (parents, coaches, instructors, teachers, and health care professionals), and 16 studies included both first-person and proxy accounts.
Descriptive Statistics of Included Studies
| Study number | Authors | Origin | Method | Sample (N) | Female ASD | Age | Theoretical perspective |
|---|---|---|---|---|---|---|---|
| 1 | Arkesteyn et al52 | Belgium | Qualitative (interview) | C/Y ASD: 17 | 6 | 14.4 (1.6) | Socioecological |
| 2 | Arnell et al61 | Sweden | Qualitative (focus group) | Stakeholders: 17 | n/a | n/a | Socioecological |
| 3 | Arnell et al39 | Sweden | Qualitative (interview) | C/Y ASD: 24 | 7 | 12–16 | n/a |
| 4 | Arnell et al58 | Sweden | Qualitative (interview) | Parents: 28 | 12 | 12–16 | n/a |
| 5 | Ayvazoglu et al64 | The United States | Qualitative (interview) | C/Y ASD: 6 Parents: 6 | 2 | 4–13 (7.5) | Systems theory |
| 6 | Blagrave and Colombo-Dougovito75 | The United States | Qualitative (interview) | Parents: 13 | n/a | 4–16 (11.2) | n/a |
| 7 | Blagrave et al78 | The United States, the United Kingdom | Qualitative (interview) | Y/A ASD: 23 | 9 | 18–75 (40.45 [17.79]) | n/a |
| 8 | Blagrave69 | The United States | Qualitative (drawing, observation, interview) | C/Y ASD: 10 | 1 | 10–14 (11.9) | Socioecological |
| 9 | Blagrave and Kemper80 | The United States | Qualitative (Preference Picture Scale, interview) | C/Y ASD: 8 Parents: 8 | 3 | 9–14 (11.75) | n/a |
| 10 | Boucher et al50 | Canada | Mixed methods (interview, questionnaire) | C/Y ASD: 14 Caregivers: 14 | 1 | 8–16 (12.23 [2.51]) | n/a |
| 11 | Bremer et al68 | Canada | Quantitative (questionnaire) | Parents: 202 | 41 | 6–13 (9.4 [2.1]) | ICF |
| 12 | Brewster and Coleyshaw65 | The United Kingdom | Qualitative (focus group) | C/Y ASD: 20 | 6 | 8–17 | n/a |
| 13 | Brown et al89 | Canada | Quantitative (questionnaire) | Parents: 201 | 39 | 4–17 (9.42 [3.32]) | Multiprocess action control framework |
| 14 | Columna et al50 | The United States | Qualitative (interview) | Parents: 9 | 0 | 6–14 (10 [2.60]) | n/a |
| 15 | Durmus and Sarol88 | Turkey | Qualitative (interview) | Parents: 16 | 2 | 8–14 (9.31) | Planned behavior theory |
| 16 | Esenturk84 | Turkey | Qualitative (interview) | Parents: 10 | 5 | 9–16 (12.1) | n/a |
| 17 | Fiscella et al91 | The United States | Quantitative (questionnaire) | Parents: 494 ASD, 14,450 TD | 106 | 12.44 (3.13) | Socioecological |
| 18 | Garcia et al62 | The United States | Mixed (questionnaire, interview) | C/Y ASD: 9 Instructor: 1 | 0 | 16.87 (1.36) | n/a |
| 19 | Graham et al57 | Canada | Mixed (questionnaire, focus group) | C/Y ASD: 5 Parents: 5 | n/a | 8–10 (9.2) | n/a |
| 20 | Gregor et al76 | Canada | Qualitative (interview) | Parents: 10 | 1 | 11–19 (14.7) | n/a |
| 21 | Gurkan and Kocak47 | Turkey | Qualitative (interview) | Parents: 11 | 2 | 7–16 (11.54) | Leisure facilitators and hierarchical leisure constraints theory |
| 22 | Gurkan and Kocak44 | Turkey | Qualitative (interview) | Parents: 17 | n/a | 10–19 | Socioecological |
| 23 | Hamm and Yun55 | The United States | Quantitative (questionnaire) | C/Y ASD: 143 | 51 | 18–35 (25 [4.51]) | Self-determination theory |
| 24 | Healy et al40 | The United States | Quantitative (questionnaire) | Y/A ASD: 253 | 103 | 18–50 (30.84 [7.26]) | n/a |
| 25 | Healy and Garcia41 | Ireland | Quantitative (questionnaire) | C/Y ASD: 55 C/Y TD: 55 Parents: 110 | 8 | 9 | Youth Physical Activity Promotion model |
| 26 | Healy et al90 | The United States | Qualitative (interview, text analysis) | Parents: 13 | 4 | 6–16 (9.38 [3.07]) | Social-cognitive theory |
| 27 | Healy et al66 | Ireland | Qualitative (interview) | C/Y ASD: 12 | 1 | 9–13 (11) | n/a |
| 28 | Hillier et al42 | The United States | Quantitative (questionnaire) | Y/A ASD: 30 TD: 30 | 3 | 18–27 (22) | Theory of planned behavior |
| 29 | Hilton et al59 | The United States | Quantitative (interview) | C/Y ASD: 52 C/Y TD: 53 Parents: 105 | 8 | 6–12 (9.54) | n/a |
| 30 | Jachyra et al49 | Canada | Qualitative (interview, digital stories) | C/Y ASD: 10 | 0 | 12–18 (14.7) | Critical social science approach |
| 31 | Kimber et al74 | The United Kingdom | Qualitative (interview) | Coaches: 10 | n/a | n/a | n/a |
| 32 | Lamb et al67 | The United Kingdom | Qualitative (interview, photovoice) | C/Y ASD: 5 | 1 | 12–16 (1.4) | Bourdieu’s reflexive sociology |
| 33 | Lawson et al82 | The United States | Qualitative (interview) | C/Y ASD: 14 Parents: 14 | 2 | 6–18 (9.14) | n/a |
| 34 | Lee et al83 | The United States | Qualitative (interview, text analysis) | Parents: 5 | n/a | 7–14 | Position theory |
| 35 | May et al63 | Australia | Qualitative (interview, motor control testing) | C/Y ASD: 13 Parents: 9 | n/a | 4–11 (5.8 [1.9]) | n/a |
| 36 | Memari et al43 | Iran | Quantitative (questionnaire, activity log) | Parents: 83 | 31 | 6–15 (9.8 [1.8]) | n/a |
| 37 | Must et al79 | The United States | Quantitative (questionnaire) | Parents: 53 ASD, 58 TD | 9 | 3–11 (6.6 [2.1]) | Socioecological |
| 38 | Obrusnikova and Cavalier27 | The United States | Qualitative (interview, photovoice, activity log, accelerometer) | C/Y ASD: 14 | 2 | 8–14 (10.64 [1.65]) | Socioecological |
| 39 | Obrusnikova and Miccinello46 | The United States | Mixed (questionnaire, focus group) | Parents: 103, 11 for focus group | 15 | 5–21 (12 [3.81]) | Socioecological |
| 40 | Oliveira et al87 | Brazil | Quantitative (questionnaire, motor testing) | C/Y ASD: 30 Parents: 30 | 10 | 5–10 (6.7 [1.38]) | n/a |
| 41 | Oriel et al51 | The United States | Quantitative (questionnaire) | Teachers: 121 | n/a | 3–18 | n/a |
| 42 | Pan et al48 | Taiwan | Quantitative (questionnaire, accelerometer) | C/Y ASD: 25 C/Y TD: 75 | 0 | 14.26 (±0.89) | Self-determination theory |
| 43 | Parsons et al54 | The United Kingdom | Qualitative (interview) | C/Y ASD: 3 A ASD: 3 Parents: 4 Stakeholders: 5 | 1 | FP: 10–24 (16.8) P: 9–17 (11.8) | Theoretical domains framework and capability opportunity motivation, behavior model of behavior |
| 44 | Pushkarenko et al73 | Canada | Qualitative (interview) | Parents: 6 | n/a | 7–10 (8.2) | Socioecological |
| 45 | Rios and Benson45 | Canada | Qualitative (interview) | Caregivers: 17 | 3 | 5–9 (7.12 [1.17]) | n/a |
| 46 | Rosso86 | Australia | Qualitative (weekly reports, debrief sessions, meeting notes) | C/Y ASD: 20 C/Y TD: 4 Instructors: 17 | 6 | 13–19 (15.33) | Community development and sport theory |
| 47 | Ryan et al77 | Canada | Quantitative (questionnaire) | Parents: 120 ASD, 289 other ID | 26 | 11–23 (17.20 [3.05]) | n/a |
| 48 | Salters et al56 | Canada | Qualitative (interview) | Instructors: 9 | n/a | n/a | n/a |
| 49 | Sarol et al70 | Turkey | Qualitative (interview) | C/Y ASD: 1 Parents: 1 Coach: 1 | n/a | 14 | Expectancy-value theory |
| 50 | Seguin and Fletcher71 | Canada | Qualitative (interview, field observations) | C/Y ASD: 1 TD sibling: 1 Parents: 2 Instructor: 1 | 1 | 9 | n/a |
| 51 | Stanish et al60 | The United States | Quantitative (interview) | C/Y ASD: 35 C/Y TD: 60 | 6 | 13–21 (15.9) | n/a |
| 52 | Verret et al72 | France | Qualitative (interview) | C/Y ASD: 4 Teacher: 1 | n/a | 14 | Interest theory |
| 53 | Wright et al85 | Canada | Qualitative (interview) | C/Y ASD: 4 TD siblings: 4 Parents: 4 Instructors 6 | 1 | 6–14 (11) | n/a |
| 54 | Yessick et al81 | The United States | Qualitative (scrapbook interview, field notes) | C/Y ASD: 4 | n/a | 11–12 (11.5) | n/a |
Abbreviations: A ASD, adult with ASD; ASD, autism spectrum disorders; C/Y ASD, children and youth with ASD; ID, intellectual disability; FP, first person; ICF, International Classification of Functioning, Disability, and Health; P, parent; n/a, not applicable; Y/A ASD, youth and adults with ASD; TD, typically developed.
Barriers and Facilitators for PA
In line with our aim, the included studies were collated based on the socioecological model,21 and both barriers and facilitators were found on all levels of the model. Overall, the analytical process led to substantially more barriers than facilitators coded, and barriers were identified in 53 of the included studies, and facilitators in 45. As it was previously shown that children and youth with ASD are less physically active than their TD peers,1,2 this was not surprising. It was, however, interesting how the same aspects could be perceived as both facilitators and barriers, “but it depends on ... . ”39 Plus, substantially more barriers and facilitators were identified at the intrapersonal and interpersonal levels of influence than the 4 other levels, with public policy factors being the least-covered category. Syntheses of the findings can be found in Table 2.
Barriers and Facilitators for PA
| Barriers | Study numbera | Facilitators | Study numbera |
|---|---|---|---|
| Intrapersonal barriers | Intrapersonal facilitators | ||
| Motivation | 1, 2, 3, 4, 5, 10, 12, 14, 18, 19, 21, 22, 24, 27, 28, 29, 30, 35, 36, 38, 39, 41, 42, 43, 45, 48, 51 | Motivation | 1, 3, 4, 8, 10, 11, 12, 14, 18, 19, 22, 23, 30, 32, 38, 43, 44, 49, 50, 51, 52 |
| Inadequate motor competence | 1, 3, 4, 10, 11, 20, 21, 22, 27, 29, 32, 37, 38, 39, 40, 41, 45, 46, 48, 51 | Predictability and structure | 1, 3, 4, 12, 18, 30, 31, 39, 43, 45, 48, 54 |
| Overstimulating environment | 2, 3, 4, 6, 7, 8, 9, 10, 14, 19, 20, 27, 31, 32, 35, 37, 41, 43, 44, 45, 54 | Demonstrating motor skills | 3, 11, 15, 22, 27, 32, 40, 45, 49, 50 |
| Risk behavior | 5, 6, 9, 10, 12, 14, 20, 22, 31, 33, 34, 35, 37, 39, 41, 43 | Social competence | 3, 22, 30, 48 |
| Social competence | 1, 4, 5, 6, 10, 12, 20, 22, 31, 32, 35, 39, 41, 45, 47, 48 | ||
| Unpredictability | 3, 4, 5, 9, 12, 16, 19, 20, 31, 43, 45, 53 | ||
| Preference | 1, 4, 10, 14, 28, 34, 35, 38, 43, 51 | ||
| Interpersonal barriers | Interpersonal facilitators | ||
| Family support | 1, 2, 4, 5, 9, 12, 13, 14, 15, 16, 20, 21, 22, 24, 26, 30, 33, 34, 36, 37, 38, 39, 43, 45, 48, 49, 53 | Family support | 1, 4, 5, 6, 7, 8, 9, 10, 13, 14, 15, 19, 20, 22, 26, 30, 31, 34, 35, 38, 39, 44, 45, 47, 49, 51 |
| Bullying and exclusion | 1, 3, 5, 6, 8, 10, 12, 14, 15, 20, 21, 22, 25, 27, 30, 34, 37, 38, 39, 44, 45, 47, 54 | Inclusion | 1, 3, 6, 7, 8, 10, 14, 15, 18, 19, 21, 22, 27, 30, 38, 43, 44, 45, 48, 49, 50, 51, 54 |
| Teacher/coach relationship | 1, 2, 4, 7, 9, 14, 15, 18, 20, 27, 30, 31, 37, 41, 44, 46, 47, 48 | Teacher/coach relationship | 1, 2, 3, 4, 8, 10, 15, 20, 31, 33, 44, 46, 47, 48, 49, 50, 52, 53, 54 |
| Social participation | 1, 3, 4, 9, 10, 27, 31, 32, 45, 46, 48, 51 | ||
| Institutional barriers | Institutional facilitators | ||
| Physical education | 1, 2, 3, 4, 5, 14, 16, 18, 20, 22, 30, 32, 34, 39, 41, 43, 46, 52, 53 | Physical education | 2, 10, 18, 22, 32, 38 |
| Public support | 2, 7, 14, 20, 22, 43, 45 | School support | 11, 15, 39, 43, 45 |
| Community barriers | Community facilitators | ||
| Unavailable programs | 1, 2, 3, 4, 5, 6, 9, 10, 12, 14, 15, 20, 21, 22, 28, 29, 30, 33, 35, 36, 37, 38, 39, 43, 44, 45, 46, 47, 48, 53 | Inclusive programs | 3, 5, 6, 14, 15, 20, 21, 22, 26, 31, 35, 38, 39, 43, 44, 45, 47, 53 |
| Inaccessible facilities | 1, 6, 7, 14, 21, 22, 33, 38, 39, 43, 46 | Accessible facilities | 1, 6, 7, 17, 21, 22, 38, 39 |
| Public policy barriers | Public policy facilitators | ||
| Down-prioritizing PA | 2, 4, 14, 15, 16, 20, 22, 30, 45 | Prioritizing PA | 22 |
| Physical barriers | Physical facilitators | ||
| Climate | 1, 3, 4, 8, 10, 14, 18, 20, 22, 38, 39, 51 | Climate | 18, 19, 38, 39 |
| Surroundings | 1, 3, 8, 38 |
Abbreviation: PA, physical activity.
aSee Table 1.
Intrapersonal Factors
Motivational barriers were the most diverse and complex category of intrapersonal barriers. The participants described aspects of motivation generally as barriers for PA,27,39–54 and more concretely, feelings of not belonging,48,49,55 incompetence,39,45,48,56 lack of autonomy,39,54,57 challenges with self-regulation,39,58,59 and low self-esteem.39,44,45,54,56,60–63 Experiencing feelings of unsafety was highlighted in several of the included studies.53,60,64–66 The emphasis on feeling unsafe shows the importance of teachers and coaches working to support their students and athletes to reduce anxiety levels and feelings of vulnerability. Conversely, motivation was also perceived as an important facilitator through descriptions of enjoyment with PA,27,39,44,49,52–54,57,58,60,67–72 feelings of safety,62,65 self-esteem,54,73 feeling competent,44,55,71,72 experiencing belongingness,49 experiencing the activity as meaningful,39,44,50,58,60 and the freedom of choice or autonomy.39,52,54,55
ASD is characterized by core characteristics in 2 areas, social communication and restrictive, repetitive sensory-motor behaviors,9 and at the intrapersonal level, all of the remaining intrapersonal categories found in Table 2 can be connected to these core characteristics. Pertaining to social communication, we found barriers related to deficits in social-emotional reciprocity9 presented as social competence barriers and facilitators,45,52,53,74 which included challenges with understanding social norms46,51,56,64,67,75–77 and social withdrawal.56,64,65 Interestingly, developing social understanding was perceived both as a facilitator and as a barrier, a barrier to understanding specifically. At the same time, PA could give opportunities for social learning and further participation in social interactions.44,56,71 Additionally, some studies45,56,77 showed that both parents and the children and youth themselves perceived social skills as being the most important skill set for participation, and hence more important to develop than, for instance, motor skills.
Deficits in nonverbal communicative behaviors9 manifested as challenges with understanding nonverbal and verbal cues44,45,58,65,67,74 within the category of social competence, especially for nonverbal individuals.44 Regarding deficits in developing, maintaining, and understanding relationships,9 factors related to adjusting to others and how social codes and demands change were experienced as barriers for PA.63,65,75 Interestingly, PA could help to develop reciprocal relationships,44,56,71 and choosing whom to participate with could facilitate PA.39 It should be acknowledged that solving or addressing these barriers and facilitators required social support and knowledge from parents/caregivers, coaches and teachers, friends, pupils, or other athletes,40,48,78 (ie, other levels of influence in the socioecological model).
Considering the core symptoms within the second area,9 experiences of overstimulating environments in the sense of noise, people, lightning, and temperature were identified as barriers in several studies39,45,51,53,54,57,58,61,66,67,73–76,78–81 in addition to tactile stimuli like sweating and getting dirt on you,50,63,66,69,78 which was connected to symptoms of hyperreactivity. Similarly, behaviors described as risk behaviors, consisting of a lack of awareness of surroundings and risks,44,46,53,80,82 risk of eloping,46,50,74,75,82 and unsafe behaviors for oneself and others44,46,50,51,53,54,63–65,75,76,79,82,83 were related to symptoms of hyporeactivity. Some general attempts to overcome these barriers through “disability-friendly” programs or “autistic-friendly hours”78 have been made at community and institutional levels. Unfortunately, this led to a lack of individual adaptations in some cases, and as ASD is a heterogeneous diagnosis, these measures did not have the desired effects. Additionally, Kimber et al74 found that for some individuals, communication difficulties enhanced these barriers. Taken together, this pointed to the need for coaches, teachers, support staff, and similar to have sufficient knowledge about ASD and to know the individual.
Another core symptom is related to the insistence on sameness and inflexible adherence to routines.9 Within our material, this manifested as barriers connected to unpredictability, and more specifically challenges with transitions54,64 and rigid thinking concerning structure and predictability when participating in PA.39,45,54,57,58,65,74,76,80,84,85 Interestingly, several studies,39,45,46,49,52,54,56,58,65,74,81 highlighted that when PA was organized in a predictable way it facilitated participation and that PA could contribute to routines, a predictable everyday life, and even promote healthy behaviors.62 This, in turn, was shown to add to the care demands on parents or caregivers.58,65 Restrictive fixed interests are also a symptom within this area,9 manifested by a preference for other activities not transferable to PA,27,42,50,52–54,58,60,63,83 although some studies showed that this in some cases can be incorporated into the PA, and via that, be used to facilitate PA.27,46 For some individuals, PA was their preferred activity,53,54 contributing to PA participation.
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition,9 in line with previous research, does also include some associated features of ASD relevant when discussing PA, namely motor abnormalities or delays. Findings from our included studies showed that children and youth experienced inadequate motor competence, including delays in motor development and low motor competence,27,39,44,46,47,51–53,56,58,59,66,68,76,79,86,87 challenges with developing motor skills,45,60,67 and clumsiness45,56 as barriers to PA. Conversely, studies also showed that participating in PA could help develop these competences, and through that further facilitate PA.39,44,45,67,68,70,71,87,88
Taken together, these findings suggest that children and youth with ASD experience barriers to PA that can be connected to the core symptoms of their diagnosis, which could lead to an argument that PA is not suitable for children and youth with autism. However, several studies showed how the same barriers can be “flipped” to become facilitators through adaptions made in the environment (ie, other levels of influence in the analytical model),40,61,73,76 emphasizing that PA is suitable for children and youth with ASD when adapted to their needs.
Interpersonal Factors
Regarding the interpersonal barriers and facilitators, parent and family support dominated the included studies. Considering barriers, parents being inactive or not prioritizing PA,44,49,89 not being able to provide direct support, such as transportation or being present,27,40,46,49,50,52,54,58,64,70,80,84,85,88 and being gatekeepers for trying new activities27,45,50,65,80,84,88 were prominent. Also, the family economy was highlighted as a potential barrier.43–45,47,50,56,58,64,70,76,82,84,88 Most of these barriers could be flipped around, and having physically active parents, parents prioritizing PA as a part of family life, and viewing PA as important also for their child with ASD could facilitate PA.44,49,50,69,70,88,89 Similarly, the parents’ or extended family’s direct support was deemed crucial for PA in several studies,27,45,46,49,52,53,57,58,60,63,64,70,73,75,77,78,80,88 and could be connected to the previously mentioned themes of structure, predictability, and providing safety for the child or youth. The parents who managed to obtain financial support, access PA programs, and master their life situations seemed to be the most proactive and were to a larger degree able to contribute to their child’s PA.44,53,58,70,73,74,78,80
Regarding the social aspects of PA, bullying and exclusion were experienced by children and youth in several of the included studies, including both peer-bullying and not being asked to join activities,39,41,46,47,49,50,52,53,64–66,69,76,79,83 experiencing a general intolerance toward individuals with ASD and a lack of understanding among adults.44,47,50,64,73,88 Especially, nonverbal individuals experienced other people not being willing to include them,45,74 and in some cases, simply having the diagnosis was grounds for being excluded from PA.66,75 Simultaneously, arenas for PA could be important for building friendship in this population,47,56,57,66 and having a conscious group of friends to do PA with seemed an important facilitator.27,39,44,52–54,57,60,66,70,71,73–75,78,81
The included studies showed several issues regarding teachers and coaches’ competences, including for teaching or coaching (eg, pedagogy and adapting activity),52,58,62,66,76,77,79,80,86,88 about ASD,49–51,61,73,74,78,86,88 and dealing with exclusion and bullying,73,74 leading to difficulties with inclusion and developing the teacher-student or coach-athlete relationship.56,77 It seemed crucial for teachers and coaches to develop the relationship by getting to know the individual and building trust.52,53,56,58,69–72,74,76,77,81,82,85,88 To achieve this, several studies39,52,53,71,73,74,81,85,88 highlighted personal characteristics such as understanding, competence, humor, communication, and role-modeling as aids in promoting participation and enjoyment in PA.
Considering social participation, individuals with ASD experienced challenges with understanding both verbal and nonverbal communication and communicating their own needs,39,45,52,86 leading to difficulties understanding instructions, feedback, etcetera. Similarly, 5 studies highlighted challenges with understanding social codes and demands and how these change between settings.39,52,56,58,67 Furthermore, challenges with adjusting to others in team or group activities led to clear preferences around whom to be active with, which in turn could lead to barriers to participating in organized forms of PA or preferring solitary activities.39,53,58,60,67,74,80
Institutional Factors
Regarding the institutional factors, most findings were related to PE. Barriers to participating in PE were related to PE being perceived as loud, chaotic, or competitive with little room for adaptation in line with the parents’ or children’s wishes,39,49,52,54,58,67,72 being actively excluded,44,46,50,51,61,83,84 low teacher competence in adapting and inclusion,39,44,50,58,64,76 and low teacher-to-student ratios.51,61,62,85,86 On the other hand, having PE as a mandatory subject was reported to be positive27,44,53,61 and appeared to also predict out-of-school participation in PA,46,68 especially when teachers were competent in adapting PE with the aim of participation for all.62,67,72 Also on the institutional level, a lack of information on why and how to do PA was described as a barrier,54,76,78 together with a lack of support from school and too much time spent in school and on homework.44,45,50,61 Further, different kinds of support during school hours were perceived as positive for PA, such as having educational assistants to support the student45 and general support and recommendations for PA from teachers.54,88
Community Factors
Similar to PE, competitive environments with rigid performance standards appeared to be a potential barrier to participation in organized sports.39,49,54,58,63,73,75,76 An additional challenge for children and youth with ASD was that the availability of adapted programs was low, participation was expensive, and there were long waitlists.27,39,42–44,46,47,49,50,52–54,58,59,61,64,65,73,75,76,79,82,85,88 As previously stated, coaches lacked competence in adapting and including children and youth with ASD, and low staff-to-participant ratios further inhibited participation.44–47,49,50,53,54,56,58,61,64,73,75,76,80,85,86,88 Regarding facilitators, having available and inclusive PA programs,27,46,47,63,70,74,75,77,85,88 with competent coaches willing to adapt and include children and youth with ASD,39,44,47,63,73,76,77,85,88 and a physically and socially supportive environment were essential.54,77,90
PA facilities and their structure could constitute an additional barrier for PA, by not being open, not allowing children and youth with ASD access or enforcing strict rules for behavior,27,44,47,50,75 location and equipment being perceived as unsafe,46,75 and lighting and noise contributing to overstimulation.52,54,78,82,86 Some parents also reported avoiding PA in public spaces to avoid public embarrassment,50,64,75 leading to not having access to PA facilities. Parents in several studies27,44,46,47,52,75,78,91 highlighted the importance of having available and safe PA facilities in their neighborhood as an important facilitator.
Public Policy Factors
This was the least-covered category, with only 9 studies showing results at this level of the socioecological model. Considering barriers, both caregivers and stakeholders (teachers, support staff, health care workers, etc) expressed that public policy providers did not give enough importance to PA and did not prioritize it.45,58,61,84,88 In practical terms, this could lead to more importance and time given to other subjects in school and to different forms of therapy.44,49 This also included public funding and financial support for behavioral therapy and educational matters, which were more available than funding for PA.44,45,49,76,88 On the other hand, parents in Gurkan and Kocak44 expressed increased public prioritization for PA, which further facilitated increased PA in their families and for their children with autism.
Physical Factors
Considering the physical factors, both climate and the weather constituted the most frequently mentioned barrier and facilitator. Barriers included temperature (ie, “too hot” or “too cold”) and varying weather conditions, bugs or animals, or allergies.27,39,44,46,50,52,53,58,60,62,69,76 At the same time as the weather could inhibit PA, good weather conditions, a comfortable temperature, or no insects could facilitate PA in some cases.27,46,57,62 Additionally, the surroundings could inhibit PA if there were too many distractions, such as cars, other people, noises, and the location in itself.27,39,52,69 Calmer or quieter surroundings and available equipment were on the other hand reported to facilitate PA.27,52
Discussion
The first study identified in this scoping review was published in 2008,59 and with 35 (65%) of the 54 included studies published after 2019, the field of study can be characterized as growing popularity. The included studies utilized a variety of methodological and theoretical approaches, with findings being somewhat consistent. The primary study perspective in 23 (42.6%) studies came only from proxies (parents, teachers, coaches, etc), whereas 31 (57.4%) included either only the perspectives of children and youth or the perspectives of both proxies and the children and youth with ASD themselves. This contrasts with what previous reviews on children and youth with disabilities had found24,92 and shows that the research field is shifting to include the perspectives of children and youth to a significant degree. One reason for this shift might be an increased focus on children’s and youths’ rights to be heard in matters affecting their everyday lives,93,94 resulting in a shift moving professionals and researchers toward incorporating first-person perspectives in their work and research.
The synthesis of studies based on the perspectives included also showed that the emphasis on different forms of barriers and facilitators differed between different perspectives. Like Shields et al,24 we found that the children and youth with ASD mostly identified both barriers and facilitators on intra- and interpersonal levels, while parents and support staff additionally identified factors on institutional, community, and public policy levels. The exception was community-level factors where children and youth in our included studies reported similarly to proxies, which could be explained by the individuals’ feelings of exclusion when not being welcomed into a PA program.
Furthermore, although both the children and youth and proxies reported similar numbers of intrapersonal level barriers, the content of the barriers varied. The children and youth themselves highlighted motivational barriers, while parents to a larger degree highlighted the barriers that can be connected to the core characteristics of ASD. This difference is interesting for several reasons: First, the children and youth themselves might not experience the characteristics of their diagnosis as limiting to the same extent that their parents do, which could indicate that parents or others around the children and youth can underestimate them and their possibilities, contributing to barriers. Second, this could indicate that the group of children and youth with ASD studied differs when proxies are invited to participate and when the children and youth themselves are invited. For example, nonverbal individuals were rarely included themselves, but their parents/caregivers, teachers, or coaches were. This points to within-group differences in who on the autism spectrum is being heard from.95 At the same time, it is important to acknowledge the parents’ role in voicing their children’s views or needs. In line with this, it is important to also acknowledge the large heterogeneity within the autism spectrum, with factors influencing one individual’s PA participation that might not influence another’s. This was also shown in how proxies expressed family support both as an important barrier and as a facilitator, while children and youth themselves to a lesser degree highlighted the role of the family. Two of the included and recently published studies53,80 utilized diverse qualitative methods to ensure the inclusion of individuals with complex communication needs and intellectual disabilities, showing possibilities for hearing the voices of diverse groups in research.
Interestingly, at the community level, first-person and proxy accounts viewed barriers similarly per experiences of unavailable PA programs. However, when looking at facilitators, the proxies highlighted inclusive or adapted PA programs, and this was to a much lesser degree covered by the children and youth themselves. This could indicate that parents stress the accessibility of adapted or specialized programs, whereas the children and youth themselves might prefer participating on the same grounds as their peers. Taken together, one could argue that children and adults experience the world differently,96 and hence perceive both different and similar barriers and facilitators. This underlines the importance of including the perspectives of both the children and youth with ASD and proxies such as parents, teachers, and coaches to further understand the complex factors influencing PA participation.
Some previous research on TD children and youth had shown boys to have higher levels of PA participation23,97 and PA levels98 compared to girls. Interestingly, the number of barriers and facilitators and the levels of influence were similar for boys and girls when reported,40,60,79 and only 2 of the included studies indicated that boys were more physically active.43,87 One reason for the lack of gender differences could be the skewed gender ratio in individuals diagnosed with ASD, with a proposed ratio of 4 boys to every 1 girl,99 the proportion reflected in the included studies.
The complexities of PA behavior are highlighted through several findings; first, as shown in Figure 2, some factors are perceived as both facilitators and barriers, often dependent on the quality of interaction. An example of such a factor is parent support for PA. This underscores the complexity, contextuality, and subjectivity of the PA experiences as well as the heterogeneity within the autism spectrum. Further, what level of influence a factor is located at is not always apparent. For example, experiencing unpredictability as a barrier to participation could be interpreted as an intrapersonal factor, but it can also be interpreted as an interpersonal factor related to how PA is organized, or the pedagogical approaches of the coach or teacher. Similarly, family finance can be understood as an interpersonal factor, and an issue concerning the availability of PA through the institutional, community, or public policy levels of influence.
—Socioecological model, adapted from McLeroy et al.21 PA indicates physical activity.
Citation: Journal of Physical Activity and Health 21, 10; 10.1123/jpah.2024-0075
Throughout our conceptual mapping and interpretation, 2 main categories of barriers and facilitators across the socioecological model’s levels of influence were identified: the factors unique to children and youth with ASD, and factors influencing children and youth in general. Unique to children and youth with ASD were all the intrapersonal factors except motivation, which was related to the diagnosis. While acknowledging the unique challenges children and youth with ASD experience, most of the identified barriers and facilitators for PA were the same as previous studies had identified for TD children and youth, and children and youth with other disabilities.14,24,97,100–103 This points to some more general challenges PA providers face with regard to the support of inclusive PA environments and overreaching goals such as “participation for all.”
Different aspects of motivation have repeatedly been shown to be associated with PA,24,97,100,103,104 indicating similar needs to feel competent, experience belongingness, safety, and moreover, a feeling of self-esteem from performing activities. Interestingly, feelings of unsafety as a barrier for PA among children and youth with ASD could be related to the preference or need for predictability and structure connected to the core characteristic of insistence on sameness and inflexible adherence to routines.9 Increased knowledge of the individual athletes with ASD needs might help teachers and coaches in their efforts to support inclusive PA environments and thus help facilitate feelings of safety. Family support dominated the interpersonal factors in the included studies; similarly, Martins et al105 and Bloemen et al103 found positive associations between having physically active parents and child or youth PA. This also included family finances and possibilities to support PA, which was identified as a potentially stronger barrier for children and youth with disabilities.103
With difficulties in social competence leading to social withdrawal in some cases, it is interesting how developing social skills and participating with friends were important facilitators also for this population, in line with findings from TD children and youth.100–102,106 This contributes to the knowledge about the importance of belongingness, and how this is important for the drive to participate in PA in this population as well. The additional risk of bullying highlighted in the included studies points to this potentially being a strong barrier to participation in organized forms of PA for this population, which further indicates the importance of working actively with inclusion and anti-bullying in PA arenas.
The importance of a good teacher-student or coach-athlete relationship is prominent across the literature100,107 and supported in the included studies. Within this also lays the importance of getting to know the individual, which was obviously highlighted in the included studies. This also includes general knowledge about ASD, as the heterogeneity of the diagnosis predicts individual differences in the expression of ASD. Also related is the teacher’s or coach’s role in contributing to structure and predictability and using understandable (eg, adapted) communication.
PE and sport were previously shown to be characterized by normative performance standards100,103,107 and competitive environments,22 which could both facilitate PA and function as a barrier. These issues were prominent in the included studies and were highlighted only as barriers. This contributes to our understanding of how traditional sports or of PE providers themselves might reduce barriers to participation for some groups, in this case, children and youth with ASD. This might be partly explained by how the normative performance standards might inhibit the possibilities for inclusion or willingness to adapt for participation for all. In line with this, it is important to remember that this also constitutes a barrier for TD children and youth and shows how sports organizations’ goals of participation for all, etcetera, might not cohere with normative performance standards.
Thus, the active exclusion of children and youth with disabilities in general,103,107 and in this case, ASD, constitutes another big challenge for schools, sport organizers, and other PA organizers. Knowing that children and youth with ASD and other disabilities achieve less PA than their TD peers (who also achieve less than recommended PA) and participate in fewer activities constitutes a large problem. When the organized forms of PA are not available in the same manner, the possibilities for increasing PA levels also appear to be limited. This might find support on another level of the socioecological model, the public policy level, but as the included studies showed, parents and stakeholders reported little public support for PA. Instead, the parents experienced more support for other kinds of therapy (eg, behavioral or speech), whereas funding for PA participation was scarce. This further led to the need for increased financial resources to participate in cases where parents needed to cover the costs for assistants or other support staff for PA or sports.
Limitations and Strengths
This scoping review had both limitations and strengths. The systematic and broad search for all relevant peer-reviewed studies published in academic journals was a strength of this research. We also applied rigorous review methods and did not exclude studies based on time of publication or methodological approach. Also, as this review was restricted to published studies, publication bias cannot be discounted. Due to the large number of studies found and included, we did not search the gray literature. Moreover, there is a possibility that our search and selection processes led to us missing relevant studies. Still, as discussed in the “Methods” section, the current scoping review followed a structured search protocol in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews protocol.34 Finally, we did not complete a quality assessment of the included studies since this is not recommended with scoping reviews.33
The choice to utilize a framework synthesis method36,37 to structure the analysis of included studies might be considered a strength that helps move an analysis from only synthesizing to an integrated discussion. On the other hand, the choice of a predefined theoretical framework can contribute to confirmation bias, leading to findings not “fitting” the theoretical model being overlooked. To avoid this, the choice of a framework that included all levels of influence was important to capture more of the whole picture. Furthermore, describing how the analysis was performed was important to enhance transparency. When compiling research findings from different studies, it is important to remember that children and youth with ASD are as heterogeneous as other children and youth and that grouping results can lead to important distinctions and dimensions being lost. Conversely, it can be argued that regardless of methodological approach, theoretical framework, level of functioning, and country of origin, the included studies showed markedly similar findings.
Implications
This scoping review has highlighted both unique and general barriers and facilitators for PA among children and youth with ASD. From this comprehensive synthesis, we make the following recommendations to enhance PA in this population, and these recommendations might also be used to inform the development of future interventions:
- 1.To be able to respond to the diverse needs of individuals with autism, teachers, and coaches should set aside time to get to know the individual and their needs. In line with this, it is important to enhance teachers’ and coaches’ knowledge about inclusive pedagogy, specific conditions, such as ASD, and developing relationships with diverse groups of students or athletes. This also implies that teachers or coaches must have the time and resources available to prioritize this, which needs to be supported at institutional, community, and public policy levels.
- 2.PA providers should prioritize providing safety through predictability, structure, and an inclusive environment. Moreover, building inclusive PA environments free of bullying and exclusion should be prioritized. This would involve working with policy makers, PA providers, teachers, coaches, and peers both at schools and in sports.
- 3.Enhancing the availability of diverse PAs, both competitive and noncompetitive, is important to further enhance PA participation.
- 4.To enhance PA participation, political prioritizing is needed, including economic support for PA as leisure and to ensure PE or adapted PE participation. Support should also be directed toward parents, like further enhancing stakeholders’ knowledge about PA and autism.
Conclusions
This comprehensive scoping review showed the complexity of factors contributing to barriers and facilitators for PA among children and youth with ASD, and how the perspectives included frame what type of facilitators and barriers are identified in the studies. ASD-specific barriers and facilitators must be viewed in light of the heterogenous diagnosis, requiring that teachers, coaches, and caretakers know each individual with ASD in order to facilitate PA. With social skills being reported as the most important skill set, findings in this review highlighted social support as a key to promoting PA. General barriers and facilitators included normative performance standards in PE and organized sports. A competitive environment seemed to function as a barrier for many children and youth with ASD and TD children and youth alike, highlighting the importance of making a variety of PAs available. The synthesis of ASD-specific and general barriers and facilitators highlights the need for both individual adaptations and more general measures that facilitate PA, not only for children and youth with ASD. To facilitate PA for children and youth with ASD, specific measures should be taken at interpersonal, institutional, community, and especially public policy levels of influence. Future research might elaborate on the motivational aspects of the intrapersonal level of influence to identify measures to enhance individual motivation. Also, the included studies were prominently from high-income countries, and research from other parts of the world is needed.
Acknowledgment
The authors would like to express their gratitude to Ingar Mehus and Terese Wilhelmsen for their valuable comments in developing this article.
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