Research in Developmental Disabilities 36 (2015) 579–586
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Physical activity levels of adolescents with and without intellectual disabilities during physical education and recess Chien-Yu Pan a,*, Chin-Wen Liu b, I Chiao Chung c, Po-Jen Hsu d a
National Kaohsiung Normal University, Taiwan, ROC Kaohsiung Municipal Cishan Junior High School, Taiwan, ROC c Tainan Municipal Madou Junior High School, Taiwan, ROC d The Affiliated School for Students with Hearing Impairments of National University of Tainan, Taiwan, ROC b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 September 2014 Accepted 24 October 2014 Available online 16 November 2014
To compare physical activity levels in adolescents with and without intellectual disabilities during physical education and recess. Forty adolescents diagnosed with intellectual disabilities (inclusive classrooms, n = 20; self-contained classrooms, n = 20) and 40 age-matched typically developing peers (general classrooms) participated. All participants wore an Actigraph GT1M accelerometer for 5 consecutive weekdays during school hours. Three groups of adolescents were similarly active during physical education; however, adolescents with intellectual disabilities in self-contained classrooms were less active during recess than did the other two groups. In addition, they spent less percentage of time in moderate-to-vigorous physical activity during recess than did the typically developing adolescents. An inclusive, structured, and supportive environment promotes physical activity engagement in adolescents with intellectual disabilities. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Physical activity Intellectual disability School setting Adolescents
1. Introduction The health benefits of regular physical activity are well established, and children and adolescents can gain substantial health benefits by engaging in moderate-to-vigorous physical activity (MVPA) for periods that add up to 60 min or more daily (US Department of Health and Human Services, 2008). However, national (Liou et al., 2005) and international (Eaton et al., 2010) data indicated that less than 40% of children and adolescents meet this guideline. Furthermore, the percentage of children and adolescents classified as being overweight and obese has increased (Liou & Chang, 2007; Troiano et al., 2007). To counter this problem, the Taiwan Ministry of Education has established guidelines for physical activity to promote healthy lifestyles for children and adolescents (Ministry of Education, 2007). The physical activity recommended by the Taiwan Ministry of Education is for exercise 3–5 times/week for 30 min each time to raise the heart rate to 130 beats per minute. Moreover, children and adolescents should engage in a minimum of 30 min of physical activity (Ministry of Education, 2007). Because the physical activity recommended by the Taiwan Ministry of Education may be not easily understood (i.e., 130 beats per minute; (Liou & Chiang, 2004) and physical activity can be carried out as part of active play and not regular exercise, emphasizing accumulating of moderate-intensity physical activity for 60 min or more daily could be a more practical approach to children and adolescents with intellectual disabilities.
* Corresponding author. No. 116, He-Ping First Road, Kaohsiung 802, Taiwan, ROC. E-mail address: [email protected] (C.-Y. Pan). http://dx.doi.org/10.1016/j.ridd.2014.10.042 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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C.-Y. Pan et al. / Research in Developmental Disabilities 36 (2015) 579–586
People with intellectual disabilities experienced considerably higher rates of morbidity (Krahn, Hammond, & Turner, 2006) and mortality (Gustavson, Umb-Carlsson, & Sonnander, 2005) than people in the general population. In terms of behavior and lifestyle, people with intellectual disabilities were more likely to engage in low levels of physical activity (Finlayson et al., 2009) and showed high rates of obesity (Melville et al., 2008). However, little is known about physical activity levels of children and adolescents with intellectual disabilities (Frey, Stanish, & Temple, 2008). The paucity of studies on this topic indicated that this research area was neglected, and only a few empirical studies measured objectively the physical activity levels of elementary school-aged children with intellectual disabilities. Foley, Bryan, and McCubbin (2008) used Actiwatch accelerometry to investigate physical activity levels of children with mild intellectual disabilities and of typically developing children under four conditions (inclusive physical education, inclusive recess, after school, and weekend), and their results indicated that physical activity levels of children with intellectual disabilities were substantially lower under all four conditions than those of typically developing children. Pitetti, Beets, and Combs (2009) evaluated physical activity by monitoring the heart rate in children with intellectual disabilities who were in a self-contained placement classroom during school (adapted physical education, classroom, and inclusive recess), and these researchers reported that children with intellectual disabilities could achieve recommended levels of daily MVPA for 60 min under regularly scheduled school settings. Lorenzi, Hovat, and Pellegrini (2000) monitored the physical activity of children with mild intellectual disabilities and of typically developing children during an inclusive recess setting by combining heart-rate measurement and Caltrac accelerometry and determined that children with intellectual disabilities were considerably more active than their peers without a disability. The aforementioned studies have obtained conflicting results when including children with intellectual disabilities, and literature searches have not yielded data on objectively measured physical activity levels in adolescents with intellectual disabilities. The decline in physical activity of typically developing children during the transition from adolescence to early adulthood is worrying. The reduction in or elimination of time dedicated to physical education and recess in Taiwan emphasizes the requirement for promoting opportunities for adolescents to participate in physical activity. However, because of Taiwan’s limited recreational market base and a small sports industry, few opportunities for physical activity are available outside of school for adolescents, and the physical activity opportunities for children and adolescents with intellectual disabilities are even rarer. Sun (2006) surveyed 142 adolescents with mild intellectual disabilities in general schools and reported that this population rarely engaged in physical activity during leisure time. Another survey indicated that 29.9% of adolescents with intellectual disabilities had regular physical activity habits, and that the main physical activity was walking (Lin et al., 2010). Only 8% of adolescents with intellectual disabilities met the national physical activity recommendation, which suggests exercising at least three times per week, 30 min each time. The potential lack of activity opportunities and perhaps walking is the main form of exercise for adolescents with intellectual disabilities are causes for concern, and indicates that school physical education and recess offer the primary opportunities for promoting physical activity in adolescents with intellectual disabilities. In Taiwan, students with disabilities who are able to benefit fully from mainstream settings are placed into general schools. Physical education curriculum for students with disabilities is aimed toward developing their physical and motor skills as well as promoting their interests in physical activities. Recess is an unstructured environment, and it occurred for all adolescents at the same time. The spaces and areas of the school accessible to students with and without disabilities are the same, and students’ physical activities are voluntary. Although the development of inclusive practices is being promoted, how physical activity could be provided most effectively to adolescents with intellectual disabilities remains to be established. To date, only one empirical study has measured objectively how inclusive or self-contained setting affects physical activity levels of elementary school-aged children with intellectual disabilities. Horvat and Franklin (2001) combined heart-rate monitoring and Tritrac-R3D accelerometry to compare the physical activity of children with mild intellectual disabilities across three conditions (classroom activity, inclusive recess with typically developing children, and non-inclusive recess), and determined that both recess groups demonstrated higher physical activity levels than the classroom group; no statistically significant differences were found between the two recess groups. Physical education and recess should be considered separate settings for increasing students’ physical activity levels in school because the goals and activities of these two periods are distinct. Little research has been conducted on physical activity levels in adolescents with intellectual disabilities in relation to the setting of physical activity during physical education and recess in general schools; however, such studies can help health professionals develop effective strategies to increase physical activity for adolescents with intellectual disabilities. Although no national consensus has been established on physical activity levels of students that should be promoted during physical education and recess, Taiwanese researchers could consider data collected in the USA and other countries that suggest that 50% of a student’s time in physical education (Centers for Disease Control and Prevention, 2011) and 40% of a student’s time in recess (Ridgers, Stratton, & Fairclough, 2005) should be devoted to MVPA. However, these studies have not fully explored physical activity levels related to adolescents with intellectual disabilities. This study was conducted to compare physical activity levels during physical education and recess in adolescents with intellectual disabilities (inclusive vs. self-contained classrooms) and typically developing adolescents. It was hypothesized that (a) adolescents with intellectual disabilities in self-contained placement classrooms were less active than adolescents with intellectual disabilities and typically developing adolescents in general classrooms during inclusive recess, and (b) activity levels of adolescents with intellectual disabilities in self-contained placement classrooms during adapted physical education classes were lower than adolescents with intellectual disabilities and typically developing adolescents in inclusive/general classrooms during inclusive/general physical education classes.
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2. Method 2.1. Participants and settings Forty adolescents with intellectual disabilities (10 females and 30 males) and 40 typically developing adolescents (10 females and 30 males), aged 12–17 years, from the same school in a city in southern Taiwan participated in this study. Twenty adolescents with intellectual disabilities were recruited from inclusive placement classrooms and 20 were recruited from self-contained placement classrooms. All adolescents with intellectual disabilities were diagnosed by trained physicians in public hospitals in early childhood and were assessed by qualified school district personnel when they transited into secondary school according to the guidelines of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text version (DSM-IV-TR; American Psychiatric Association, 2000). Severity ratings of intellectual disabilities were slight (Wechsler IQ 69–55, n = 21), medium (Wechsler IQ 54–40, n = 14), high (Wechsler IQ 39–25, n = 3), and total (Wechsler IQ 24 and below, n = 2). Four adolescents had secondary diagnoses such as hearing impairment (n = 2) and speech and language disorder (n = 2), and they were in self-contained placement classrooms. The following requirements were considered when selecting participants with intellectual disabilities: (a) adolescents with intellectual disabilities in inclusive placement classrooms had to participate in the school’s general physical education program 100% of the time, and spend at least 50% of the school day in inclusive placement classrooms, (b) adolescents with intellectual disabilities in self-contained placement classrooms had to participate in the school’s adapted physical education program and spend 100% of their time in self-contained placement classrooms, and (c) adolescents with intellectual disabilities had to be free of orthopedic impairments and were ambulant (i.e., able to walk). The comparison group consisted of age- (within six months) and gender-matched typically developing adolescents. According to their parents’ reports, the typically developing adolescents had no physical or mental disabilities. Informed parental consent and adolescent assent, together with approval from district and school administrations, were obtained for all participants before the study. The study was approved by the National Kaohsiung Normal University Institutional Review Board. Adolescents with intellectual disabilities in inclusive placement classrooms were from 11 inclusive classrooms and adolescents with intellectual disabilities in self-contained placement classrooms were from four self-contained classrooms. Adolescents with intellectual disabilities in inclusive classrooms were assigned to the resource room regularly for their particular subjects based on their needs, but completed their other studies in general classrooms during most of the school day. They were eligible for special-education services, which included resource-room assistance, integrated programs, speech therapy, occupational therapy, and physical therapy. For adolescents with intellectual disabilities in self-contained classrooms, each classroom had 8–15 adolescents, two certified special education teachers, and one paraeducator (i.e., teacher’s aide). The amount of support each adolescent received (e.g., attention from paraeducator) depended on the adolescent’s requirements, which were stipulated by their individualized educational plan. Adolescents with intellectual disabilities in the self-contained classrooms also had access to therapy services. The details of the participants included in this study are presented in Table 1. Physical education class for adolescents with intellectual disabilities in self-contained placement classrooms was led by a certified special-education instructor and was held in an outdoor sports field. The adapted physical education class (45 min) consisted of 8–15 adolescents from each self-contained special-education classroom and was assisted from one paraeducator. The adapted physical education curriculum included practicing motor skills (e.g., kicking, dribbling, throwing and catching) and fitness training (e.g., running around in circles) with minimal instruction (e.g., when adolescents were either standing or waiting for their turn to participate in an activity). General physical education class was led by a certified physical education instructor and was held in an outdoor sports field. The physical education class (45 min) consisted of 28 adolescents (including 1–3 adolescents with intellectual disabilities) with no paraeducator assisting. The physical education curriculum included basketball, volleyball, table-tennis, and badminton, and focused on constant movement (e.g., practicing skills, playing in games) and instruction of rules.
Table 1 Participant demographics.
Age (years) Height (cm) Weight (kg) BMI (kg/m2) Severity Slight Medium High Total
Adolescents with intellectual disabilities in inclusive placement classrooms (n = 20)
Adolescents with intellectual disabilities in self-contained placement classrooms (n = 20)
Typically developing adolescents in general classrooms (n = 40)
F
p
14.84 0.95 161.24 7.06 56.83 11.37 21.81 3.95
14.25 1.07 158.11 9.23 56.80 14.11 22.66 4.93
14.33 1.06 163.61 8.18 58.48 13.36 21.77 4.52
2.05 3.04 0.16 0.29
.14 .05 .85 .75
17 2 0 0
4 12 3 3
– – – –
Note. Mean SD; BMI = body mass index.
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The daily recess time lasted for 55 min for all adolescents, included three morning recesses (10 min each) and two afternoon recesses (10 and 15 min, respectively). All recess sessions had an inclusive and unstructured setting, and all adolescents were allowed to choose the activities in which they wished to participate. The inclusive recess occurred for all adolescents at the same time, and the space/areas of the school accessible to all adolescents were the same. No attempt was made to encourage or facilitate interactions among adolescents during recess, although they occasionally interacted when sharing equipment or playing games. The 10- to 15-min recesses involved free play in the school playground and sports ground. During recess, the classroom teachers or paraeducators observed the adolescents to ensure their safety but did not direct or suggest activities or encourage interactions between the adolescents with and without intellectual disabilities. 2.2. Measure Actigraph GT1M accelerometer (Fort Walton Beach, FL) was used for measuring daily physical activity objectively. The accelerometer is a small (38 mm 37 mm 18 mm) and lightweight (27 g) device that measures and records accelerations of 0.05–2.50 g and has a frequency response ranging from 0.25 to 2.50 Hz. The uniaxial Actigraph accelerometer has been used extensively and reported to be effective for objective measurement of physical activity in children and adolescents (Trost, Loprinzi, Moore, & Pfeiffer, 2011) and has been demonstrated to be reliable (Silva, Mota, Esliger, & Welk, 2010). Actigraph has also been used for adolescents with intellectual disabilities (Pan, 2006, 2007; Phillips & Holland, 2011). For this study, the accelerometers were programmed to collect data in 10-s intervals because children and adolescents are typically do not engage in long bouts of continuous activity, particularly when they do unstructured active play (US Department of Health and Human Services, 2008). The output was expressed as activity counts, which were used to determine the intensity of physical activity. To analyze the time an adolescent spent in MVPA, age-specific count cutoffs were used (Trost et al., 1998). To control for the disparities in monitoring physical education and recess lengths, the relative (percentage) time spent in counts per minute (CPM; total physical activity) and MVPA (%MVPA) were calculated and used in the subsequent analyses. 2.3. Procedures All participants were asked to wear an Actigraph GT1M accelerometer during school day for 5 school days (approximately 8 h per school day). The accelerometer was attached to a flexible belt that was fastened around the participants’ waist at the beginning of each school day, and the participants were asked to follow their regular daily routine; the accelerometers were removed at the end of each school day. Each participating classroom and physical education teacher was provided a diary to record the times when physical education and recess began and ended. After 5 school days, the accelerometers were collected, and data were uploaded for reduction and analysis. 2.4. Data analyses Descriptive statistical analyses were conducted for all physical activity variables in the three groups of adolescents during physical education and recess. The %MVPA during each recess period was calculated by adding the MVPA minutes for the sessions during the 5 days and then dividing the sum by the minutes of total monitoring (recorded) time during recess. Because physical education was offered only on two of the school days, the %MVPA during each physical education period when the adolescents were in physical education class was calculated by summing the MVPA minutes for the sessions on the two days and dividing the sum by the minutes of total monitoring (recorded) time during physical education. For the purpose of this study, one-way ANOVAs were used to examine the proportion of time for adolescent’s physical activity (i.e., CPM and %MVPA) during physical education and recess, respectively. In addition, the contribution of MVPA during physical education and recess, respectively, to daily recommended 60 min of MVPA across three groups of adolescents were also evaluated by one-way ANOVAs. Whenever a significant F ratio was obtained, a Scheffe post hoc test was applied to assess the comparisons of mean differences. All analyses were conducted using the Statistical Package for the Social Sciences version 18.0 (SPSS Inc., Chicago, IL), and the significance level was set at p < .05. 3. Results Data were analyzed first to test for possible confounds of participants’ gender and severity of disability on dependent variables. Independent t-test results revealed no significant differences for related to gender during physical education (CPM, t = 1.19, p = .24; %MVPA, t = 1.05, p = .30) and recess (CPM, t = 0.93, p = .38; %MVPA, t = 1.20, p = .24). ANOVA results indicated no significant differences related to severity of intellectual disabilities during physical education (CPM, F(3, 36) = 1.67, p = .19; %MVPA, F(3, 36) = 1.16, p = .34) and recess (CPM, F(3, 36) = 0.57, p = .64; %MVPA, F(3, 36) = 0.43, p = .73). Thus, participants’ gender and severity of disability were not used for subsequent analysis. A total of 30 physical education lessons in 15 classes (11 inclusive and 4 self-contained) were monitored. The average monitoring durations (recorded physical education times) were 43.23 1.53 min, 42.80 2.50 min, 43.05 2.91 min for adolescents with intellectual disabilities in inclusive classrooms, adolescents with intellectual disabilities in self-contained classrooms, and typically developing adolescents, respectively. The daily recess times monitored (recorded recess time) were
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41.33 13.47 min, 35.96 11.13 min, and 46.88 7.30 min for adolescents with intellectual disabilities in inclusive classrooms, adolescents with intellectual disabilities in self-contained classrooms, and typically developing adolescents, respectively. Means and standard deviations, expressed in minutes and the proportion of time spent in each physical activity variable during physical education and recess, and F-values of the proportion of time for adolescent’s physical activity levels during physical education and recess are presented in Table 2. As shown in Table 2, the participants in this study failed to achieve the recommended intensity of physical activity during physical education (50% of MVPA; Centers for Disease Control and Prevention, 2011) and recess (40% of MVPA; Ridgers et al., 2005). Results of the one-way ANOVAs indicated that there were significant group differences for CPM (F = 5.26, p = .007) and %MVPA (F = 4.67, p = .012) during inclusive recess and the contribution of MVPA during inclusive recess to daily recommended 60 min of MVPA (F = 5.85, p = .004). Total physical activity (i.e., CPM) was lower in adolescents with intellectual disabilities in self-contained classrooms than adolescents with intellectual disabilities ( 345.12) and typically developing adolescents ( 300.02) in general classrooms. The %MVPA during recess was lower in adolescents with intellectual disabilities in self-contained classrooms ( 12.41%) than typically developing adolescents in general classrooms. The contribution of MVPA during inclusive recess to daily recommended 60 min of MVPA was also lower in adolescents with intellectual disabilities in self-contained classrooms ( 12.77%) than typically developing adolescents in general classrooms. For physical education, there were no significant group differences for CPM (F = 1.25, p = .29) and %MVPA (F = 1.75, p = .18) and the contribution of MVPA during physical education to daily recommended 60 min of MVPA (F = 1.86, p = .16). 4. Discussion This investigation was conducted primary to measure objectively the physical activity levels of adolescents with intellectual disabilities in inclusive placement classrooms and those of adolescents in self-contained placement classrooms as compared with typically developing adolescents in general classrooms during physical education and recess. Physical activity was examined in distinct settings (i.e., physical education and recess) to obtain a partly exploratory view of physical activity in Taiwanese general-school adolescents with and without intellectual disabilities. The results indicate that the adolescents in the present study failed to achieve the recommended intensity of physical activity during physical education (50% of MVPA; Centers for Disease Control and Prevention, 2011) and recess (40% of MVPA; Ridgers et al., 2005). Three groups of adolescents were similarly active during their physical education classes; however, adolescents with intellectual disabilities in self-contained classrooms were less physically active than adolescents with intellectual disabilities in inclusive classrooms and typically developing adolescents during inclusive recess. Adolescents with intellectual disabilities in self-contained classrooms also spent less percentage of time in MVPA during inclusive recess than typically developing adolescents, and the contribution of MVPA during recess to daily recommended 60 min of MVPA was also lower for adolescents with intellectual disabilities in self-contained classrooms as compared to typically developing adolescents. Descriptive statistics (Table 2) showed that adolescents in the three groups were moderately active for 25–33% of physical education and 9–21% of recess time, well below the recommended 50% and 40% level, respectively. Faison-Hodge and Porretta (2004; 23%), Hsu and Pan (2006; 29%), and Pan (2007; 33%) reported similar physical activity levels for children and adolescent with and without intellectual disabilities during either inclusive or adapted physical education. This is a major concern related to secondary school-aged adolescents with and without disabilities. First, because the Taiwanese society strongly emphasized an exam-oriented educational system and graduation, engaging in physical activity after school Table 2 Physical activity, expressed in minutes and percentage of monitored length, within physical education and recess and F-values of the proportion of time for children’s physical activity levels at each setting. 1. Adolescents with intellectual disabilities in inclusive classrooms (n = 20) Minutes Physical education Counts 42476.30 (21926.58) 11.30 (7.25) MVPA Contributiona Recess Counts 32764.73 (29628.81) 8.41 (8.69) MVPA b Contribution –
2. Adolescents with intellectual disabilities in self-contained classrooms (n = 20)
3. Typically developing adolescents in general classrooms (n = 40)
%
Minutes
%
Minutes
%
971.88 (487.95) 25.81 (16.20) 18.84 (12.09)
40950.65 (27546.54) 10.89 (7.35)
942.42 (609.05) 25.34 (16.81) 18.14 (12.24)
50256.63 (23942.26) 14.35 (7.82)
1148.85 (538.35) 32.69 (17.49) 23.91 (13.03)
717.17 (511.92) 17.89 (15.49) 14.02 (14.48)
13504.72 (6176.26) 3.18 (1.83) –
372.05 (116.26) 8.96 (4.27) 5.29 (3.06)
33186.58 (21554.76) 10.84 (9.68) –
672.07 (387.47) 21.37 (17.59) 18.06 (16.14)
Note. Values reported as mean (standard deviation); MVPA = moderate-to-vigorous physical activity. * p < .05. ** p < .01. a (Physical education MVPA minutes/60) 100%. b (Recess MVPA minutes/60) 100%.
F
Post hoc
1.25
–
1.75 1.86
– –
5.26** *
4.67 5.85**
2 < 1, 3 2
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Physical activity levels of adolescents with and without intellectual disabilities during physical education and recess Chien-Yu Pan a,*, Chin-Wen Liu b, I Chiao Chung c, Po-Jen Hsu d a
National Kaohsiung Normal University, Taiwan, ROC Kaohsiung Municipal Cishan Junior High School, Taiwan, ROC c Tainan Municipal Madou Junior High School, Taiwan, ROC d The Affiliated School for Students with Hearing Impairments of National University of Tainan, Taiwan, ROC b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 September 2014 Accepted 24 October 2014 Available online 16 November 2014
To compare physical activity levels in adolescents with and without intellectual disabilities during physical education and recess. Forty adolescents diagnosed with intellectual disabilities (inclusive classrooms, n = 20; self-contained classrooms, n = 20) and 40 age-matched typically developing peers (general classrooms) participated. All participants wore an Actigraph GT1M accelerometer for 5 consecutive weekdays during school hours. Three groups of adolescents were similarly active during physical education; however, adolescents with intellectual disabilities in self-contained classrooms were less active during recess than did the other two groups. In addition, they spent less percentage of time in moderate-to-vigorous physical activity during recess than did the typically developing adolescents. An inclusive, structured, and supportive environment promotes physical activity engagement in adolescents with intellectual disabilities. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Physical activity Intellectual disability School setting Adolescents
1. Introduction The health benefits of regular physical activity are well established, and children and adolescents can gain substantial health benefits by engaging in moderate-to-vigorous physical activity (MVPA) for periods that add up to 60 min or more daily (US Department of Health and Human Services, 2008). However, national (Liou et al., 2005) and international (Eaton et al., 2010) data indicated that less than 40% of children and adolescents meet this guideline. Furthermore, the percentage of children and adolescents classified as being overweight and obese has increased (Liou & Chang, 2007; Troiano et al., 2007). To counter this problem, the Taiwan Ministry of Education has established guidelines for physical activity to promote healthy lifestyles for children and adolescents (Ministry of Education, 2007). The physical activity recommended by the Taiwan Ministry of Education is for exercise 3–5 times/week for 30 min each time to raise the heart rate to 130 beats per minute. Moreover, children and adolescents should engage in a minimum of 30 min of physical activity (Ministry of Education, 2007). Because the physical activity recommended by the Taiwan Ministry of Education may be not easily understood (i.e., 130 beats per minute; (Liou & Chiang, 2004) and physical activity can be carried out as part of active play and not regular exercise, emphasizing accumulating of moderate-intensity physical activity for 60 min or more daily could be a more practical approach to children and adolescents with intellectual disabilities.
* Corresponding author. No. 116, He-Ping First Road, Kaohsiung 802, Taiwan, ROC. E-mail address: [email protected] (C.-Y. Pan). http://dx.doi.org/10.1016/j.ridd.2014.10.042 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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People with intellectual disabilities experienced considerably higher rates of morbidity (Krahn, Hammond, & Turner, 2006) and mortality (Gustavson, Umb-Carlsson, & Sonnander, 2005) than people in the general population. In terms of behavior and lifestyle, people with intellectual disabilities were more likely to engage in low levels of physical activity (Finlayson et al., 2009) and showed high rates of obesity (Melville et al., 2008). However, little is known about physical activity levels of children and adolescents with intellectual disabilities (Frey, Stanish, & Temple, 2008). The paucity of studies on this topic indicated that this research area was neglected, and only a few empirical studies measured objectively the physical activity levels of elementary school-aged children with intellectual disabilities. Foley, Bryan, and McCubbin (2008) used Actiwatch accelerometry to investigate physical activity levels of children with mild intellectual disabilities and of typically developing children under four conditions (inclusive physical education, inclusive recess, after school, and weekend), and their results indicated that physical activity levels of children with intellectual disabilities were substantially lower under all four conditions than those of typically developing children. Pitetti, Beets, and Combs (2009) evaluated physical activity by monitoring the heart rate in children with intellectual disabilities who were in a self-contained placement classroom during school (adapted physical education, classroom, and inclusive recess), and these researchers reported that children with intellectual disabilities could achieve recommended levels of daily MVPA for 60 min under regularly scheduled school settings. Lorenzi, Hovat, and Pellegrini (2000) monitored the physical activity of children with mild intellectual disabilities and of typically developing children during an inclusive recess setting by combining heart-rate measurement and Caltrac accelerometry and determined that children with intellectual disabilities were considerably more active than their peers without a disability. The aforementioned studies have obtained conflicting results when including children with intellectual disabilities, and literature searches have not yielded data on objectively measured physical activity levels in adolescents with intellectual disabilities. The decline in physical activity of typically developing children during the transition from adolescence to early adulthood is worrying. The reduction in or elimination of time dedicated to physical education and recess in Taiwan emphasizes the requirement for promoting opportunities for adolescents to participate in physical activity. However, because of Taiwan’s limited recreational market base and a small sports industry, few opportunities for physical activity are available outside of school for adolescents, and the physical activity opportunities for children and adolescents with intellectual disabilities are even rarer. Sun (2006) surveyed 142 adolescents with mild intellectual disabilities in general schools and reported that this population rarely engaged in physical activity during leisure time. Another survey indicated that 29.9% of adolescents with intellectual disabilities had regular physical activity habits, and that the main physical activity was walking (Lin et al., 2010). Only 8% of adolescents with intellectual disabilities met the national physical activity recommendation, which suggests exercising at least three times per week, 30 min each time. The potential lack of activity opportunities and perhaps walking is the main form of exercise for adolescents with intellectual disabilities are causes for concern, and indicates that school physical education and recess offer the primary opportunities for promoting physical activity in adolescents with intellectual disabilities. In Taiwan, students with disabilities who are able to benefit fully from mainstream settings are placed into general schools. Physical education curriculum for students with disabilities is aimed toward developing their physical and motor skills as well as promoting their interests in physical activities. Recess is an unstructured environment, and it occurred for all adolescents at the same time. The spaces and areas of the school accessible to students with and without disabilities are the same, and students’ physical activities are voluntary. Although the development of inclusive practices is being promoted, how physical activity could be provided most effectively to adolescents with intellectual disabilities remains to be established. To date, only one empirical study has measured objectively how inclusive or self-contained setting affects physical activity levels of elementary school-aged children with intellectual disabilities. Horvat and Franklin (2001) combined heart-rate monitoring and Tritrac-R3D accelerometry to compare the physical activity of children with mild intellectual disabilities across three conditions (classroom activity, inclusive recess with typically developing children, and non-inclusive recess), and determined that both recess groups demonstrated higher physical activity levels than the classroom group; no statistically significant differences were found between the two recess groups. Physical education and recess should be considered separate settings for increasing students’ physical activity levels in school because the goals and activities of these two periods are distinct. Little research has been conducted on physical activity levels in adolescents with intellectual disabilities in relation to the setting of physical activity during physical education and recess in general schools; however, such studies can help health professionals develop effective strategies to increase physical activity for adolescents with intellectual disabilities. Although no national consensus has been established on physical activity levels of students that should be promoted during physical education and recess, Taiwanese researchers could consider data collected in the USA and other countries that suggest that 50% of a student’s time in physical education (Centers for Disease Control and Prevention, 2011) and 40% of a student’s time in recess (Ridgers, Stratton, & Fairclough, 2005) should be devoted to MVPA. However, these studies have not fully explored physical activity levels related to adolescents with intellectual disabilities. This study was conducted to compare physical activity levels during physical education and recess in adolescents with intellectual disabilities (inclusive vs. self-contained classrooms) and typically developing adolescents. It was hypothesized that (a) adolescents with intellectual disabilities in self-contained placement classrooms were less active than adolescents with intellectual disabilities and typically developing adolescents in general classrooms during inclusive recess, and (b) activity levels of adolescents with intellectual disabilities in self-contained placement classrooms during adapted physical education classes were lower than adolescents with intellectual disabilities and typically developing adolescents in inclusive/general classrooms during inclusive/general physical education classes.
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2. Method 2.1. Participants and settings Forty adolescents with intellectual disabilities (10 females and 30 males) and 40 typically developing adolescents (10 females and 30 males), aged 12–17 years, from the same school in a city in southern Taiwan participated in this study. Twenty adolescents with intellectual disabilities were recruited from inclusive placement classrooms and 20 were recruited from self-contained placement classrooms. All adolescents with intellectual disabilities were diagnosed by trained physicians in public hospitals in early childhood and were assessed by qualified school district personnel when they transited into secondary school according to the guidelines of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text version (DSM-IV-TR; American Psychiatric Association, 2000). Severity ratings of intellectual disabilities were slight (Wechsler IQ 69–55, n = 21), medium (Wechsler IQ 54–40, n = 14), high (Wechsler IQ 39–25, n = 3), and total (Wechsler IQ 24 and below, n = 2). Four adolescents had secondary diagnoses such as hearing impairment (n = 2) and speech and language disorder (n = 2), and they were in self-contained placement classrooms. The following requirements were considered when selecting participants with intellectual disabilities: (a) adolescents with intellectual disabilities in inclusive placement classrooms had to participate in the school’s general physical education program 100% of the time, and spend at least 50% of the school day in inclusive placement classrooms, (b) adolescents with intellectual disabilities in self-contained placement classrooms had to participate in the school’s adapted physical education program and spend 100% of their time in self-contained placement classrooms, and (c) adolescents with intellectual disabilities had to be free of orthopedic impairments and were ambulant (i.e., able to walk). The comparison group consisted of age- (within six months) and gender-matched typically developing adolescents. According to their parents’ reports, the typically developing adolescents had no physical or mental disabilities. Informed parental consent and adolescent assent, together with approval from district and school administrations, were obtained for all participants before the study. The study was approved by the National Kaohsiung Normal University Institutional Review Board. Adolescents with intellectual disabilities in inclusive placement classrooms were from 11 inclusive classrooms and adolescents with intellectual disabilities in self-contained placement classrooms were from four self-contained classrooms. Adolescents with intellectual disabilities in inclusive classrooms were assigned to the resource room regularly for their particular subjects based on their needs, but completed their other studies in general classrooms during most of the school day. They were eligible for special-education services, which included resource-room assistance, integrated programs, speech therapy, occupational therapy, and physical therapy. For adolescents with intellectual disabilities in self-contained classrooms, each classroom had 8–15 adolescents, two certified special education teachers, and one paraeducator (i.e., teacher’s aide). The amount of support each adolescent received (e.g., attention from paraeducator) depended on the adolescent’s requirements, which were stipulated by their individualized educational plan. Adolescents with intellectual disabilities in the self-contained classrooms also had access to therapy services. The details of the participants included in this study are presented in Table 1. Physical education class for adolescents with intellectual disabilities in self-contained placement classrooms was led by a certified special-education instructor and was held in an outdoor sports field. The adapted physical education class (45 min) consisted of 8–15 adolescents from each self-contained special-education classroom and was assisted from one paraeducator. The adapted physical education curriculum included practicing motor skills (e.g., kicking, dribbling, throwing and catching) and fitness training (e.g., running around in circles) with minimal instruction (e.g., when adolescents were either standing or waiting for their turn to participate in an activity). General physical education class was led by a certified physical education instructor and was held in an outdoor sports field. The physical education class (45 min) consisted of 28 adolescents (including 1–3 adolescents with intellectual disabilities) with no paraeducator assisting. The physical education curriculum included basketball, volleyball, table-tennis, and badminton, and focused on constant movement (e.g., practicing skills, playing in games) and instruction of rules.
Table 1 Participant demographics.
Age (years) Height (cm) Weight (kg) BMI (kg/m2) Severity Slight Medium High Total
Adolescents with intellectual disabilities in inclusive placement classrooms (n = 20)
Adolescents with intellectual disabilities in self-contained placement classrooms (n = 20)
Typically developing adolescents in general classrooms (n = 40)
F
p
14.84 0.95 161.24 7.06 56.83 11.37 21.81 3.95
14.25 1.07 158.11 9.23 56.80 14.11 22.66 4.93
14.33 1.06 163.61 8.18 58.48 13.36 21.77 4.52
2.05 3.04 0.16 0.29
.14 .05 .85 .75
17 2 0 0
4 12 3 3
– – – –
Note. Mean SD; BMI = body mass index.
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The daily recess time lasted for 55 min for all adolescents, included three morning recesses (10 min each) and two afternoon recesses (10 and 15 min, respectively). All recess sessions had an inclusive and unstructured setting, and all adolescents were allowed to choose the activities in which they wished to participate. The inclusive recess occurred for all adolescents at the same time, and the space/areas of the school accessible to all adolescents were the same. No attempt was made to encourage or facilitate interactions among adolescents during recess, although they occasionally interacted when sharing equipment or playing games. The 10- to 15-min recesses involved free play in the school playground and sports ground. During recess, the classroom teachers or paraeducators observed the adolescents to ensure their safety but did not direct or suggest activities or encourage interactions between the adolescents with and without intellectual disabilities. 2.2. Measure Actigraph GT1M accelerometer (Fort Walton Beach, FL) was used for measuring daily physical activity objectively. The accelerometer is a small (38 mm 37 mm 18 mm) and lightweight (27 g) device that measures and records accelerations of 0.05–2.50 g and has a frequency response ranging from 0.25 to 2.50 Hz. The uniaxial Actigraph accelerometer has been used extensively and reported to be effective for objective measurement of physical activity in children and adolescents (Trost, Loprinzi, Moore, & Pfeiffer, 2011) and has been demonstrated to be reliable (Silva, Mota, Esliger, & Welk, 2010). Actigraph has also been used for adolescents with intellectual disabilities (Pan, 2006, 2007; Phillips & Holland, 2011). For this study, the accelerometers were programmed to collect data in 10-s intervals because children and adolescents are typically do not engage in long bouts of continuous activity, particularly when they do unstructured active play (US Department of Health and Human Services, 2008). The output was expressed as activity counts, which were used to determine the intensity of physical activity. To analyze the time an adolescent spent in MVPA, age-specific count cutoffs were used (Trost et al., 1998). To control for the disparities in monitoring physical education and recess lengths, the relative (percentage) time spent in counts per minute (CPM; total physical activity) and MVPA (%MVPA) were calculated and used in the subsequent analyses. 2.3. Procedures All participants were asked to wear an Actigraph GT1M accelerometer during school day for 5 school days (approximately 8 h per school day). The accelerometer was attached to a flexible belt that was fastened around the participants’ waist at the beginning of each school day, and the participants were asked to follow their regular daily routine; the accelerometers were removed at the end of each school day. Each participating classroom and physical education teacher was provided a diary to record the times when physical education and recess began and ended. After 5 school days, the accelerometers were collected, and data were uploaded for reduction and analysis. 2.4. Data analyses Descriptive statistical analyses were conducted for all physical activity variables in the three groups of adolescents during physical education and recess. The %MVPA during each recess period was calculated by adding the MVPA minutes for the sessions during the 5 days and then dividing the sum by the minutes of total monitoring (recorded) time during recess. Because physical education was offered only on two of the school days, the %MVPA during each physical education period when the adolescents were in physical education class was calculated by summing the MVPA minutes for the sessions on the two days and dividing the sum by the minutes of total monitoring (recorded) time during physical education. For the purpose of this study, one-way ANOVAs were used to examine the proportion of time for adolescent’s physical activity (i.e., CPM and %MVPA) during physical education and recess, respectively. In addition, the contribution of MVPA during physical education and recess, respectively, to daily recommended 60 min of MVPA across three groups of adolescents were also evaluated by one-way ANOVAs. Whenever a significant F ratio was obtained, a Scheffe post hoc test was applied to assess the comparisons of mean differences. All analyses were conducted using the Statistical Package for the Social Sciences version 18.0 (SPSS Inc., Chicago, IL), and the significance level was set at p < .05. 3. Results Data were analyzed first to test for possible confounds of participants’ gender and severity of disability on dependent variables. Independent t-test results revealed no significant differences for related to gender during physical education (CPM, t = 1.19, p = .24; %MVPA, t = 1.05, p = .30) and recess (CPM, t = 0.93, p = .38; %MVPA, t = 1.20, p = .24). ANOVA results indicated no significant differences related to severity of intellectual disabilities during physical education (CPM, F(3, 36) = 1.67, p = .19; %MVPA, F(3, 36) = 1.16, p = .34) and recess (CPM, F(3, 36) = 0.57, p = .64; %MVPA, F(3, 36) = 0.43, p = .73). Thus, participants’ gender and severity of disability were not used for subsequent analysis. A total of 30 physical education lessons in 15 classes (11 inclusive and 4 self-contained) were monitored. The average monitoring durations (recorded physical education times) were 43.23 1.53 min, 42.80 2.50 min, 43.05 2.91 min for adolescents with intellectual disabilities in inclusive classrooms, adolescents with intellectual disabilities in self-contained classrooms, and typically developing adolescents, respectively. The daily recess times monitored (recorded recess time) were
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41.33 13.47 min, 35.96 11.13 min, and 46.88 7.30 min for adolescents with intellectual disabilities in inclusive classrooms, adolescents with intellectual disabilities in self-contained classrooms, and typically developing adolescents, respectively. Means and standard deviations, expressed in minutes and the proportion of time spent in each physical activity variable during physical education and recess, and F-values of the proportion of time for adolescent’s physical activity levels during physical education and recess are presented in Table 2. As shown in Table 2, the participants in this study failed to achieve the recommended intensity of physical activity during physical education (50% of MVPA; Centers for Disease Control and Prevention, 2011) and recess (40% of MVPA; Ridgers et al., 2005). Results of the one-way ANOVAs indicated that there were significant group differences for CPM (F = 5.26, p = .007) and %MVPA (F = 4.67, p = .012) during inclusive recess and the contribution of MVPA during inclusive recess to daily recommended 60 min of MVPA (F = 5.85, p = .004). Total physical activity (i.e., CPM) was lower in adolescents with intellectual disabilities in self-contained classrooms than adolescents with intellectual disabilities ( 345.12) and typically developing adolescents ( 300.02) in general classrooms. The %MVPA during recess was lower in adolescents with intellectual disabilities in self-contained classrooms ( 12.41%) than typically developing adolescents in general classrooms. The contribution of MVPA during inclusive recess to daily recommended 60 min of MVPA was also lower in adolescents with intellectual disabilities in self-contained classrooms ( 12.77%) than typically developing adolescents in general classrooms. For physical education, there were no significant group differences for CPM (F = 1.25, p = .29) and %MVPA (F = 1.75, p = .18) and the contribution of MVPA during physical education to daily recommended 60 min of MVPA (F = 1.86, p = .16). 4. Discussion This investigation was conducted primary to measure objectively the physical activity levels of adolescents with intellectual disabilities in inclusive placement classrooms and those of adolescents in self-contained placement classrooms as compared with typically developing adolescents in general classrooms during physical education and recess. Physical activity was examined in distinct settings (i.e., physical education and recess) to obtain a partly exploratory view of physical activity in Taiwanese general-school adolescents with and without intellectual disabilities. The results indicate that the adolescents in the present study failed to achieve the recommended intensity of physical activity during physical education (50% of MVPA; Centers for Disease Control and Prevention, 2011) and recess (40% of MVPA; Ridgers et al., 2005). Three groups of adolescents were similarly active during their physical education classes; however, adolescents with intellectual disabilities in self-contained classrooms were less physically active than adolescents with intellectual disabilities in inclusive classrooms and typically developing adolescents during inclusive recess. Adolescents with intellectual disabilities in self-contained classrooms also spent less percentage of time in MVPA during inclusive recess than typically developing adolescents, and the contribution of MVPA during recess to daily recommended 60 min of MVPA was also lower for adolescents with intellectual disabilities in self-contained classrooms as compared to typically developing adolescents. Descriptive statistics (Table 2) showed that adolescents in the three groups were moderately active for 25–33% of physical education and 9–21% of recess time, well below the recommended 50% and 40% level, respectively. Faison-Hodge and Porretta (2004; 23%), Hsu and Pan (2006; 29%), and Pan (2007; 33%) reported similar physical activity levels for children and adolescent with and without intellectual disabilities during either inclusive or adapted physical education. This is a major concern related to secondary school-aged adolescents with and without disabilities. First, because the Taiwanese society strongly emphasized an exam-oriented educational system and graduation, engaging in physical activity after school Table 2 Physical activity, expressed in minutes and percentage of monitored length, within physical education and recess and F-values of the proportion of time for children’s physical activity levels at each setting. 1. Adolescents with intellectual disabilities in inclusive classrooms (n = 20) Minutes Physical education Counts 42476.30 (21926.58) 11.30 (7.25) MVPA Contributiona Recess Counts 32764.73 (29628.81) 8.41 (8.69) MVPA b Contribution –
2. Adolescents with intellectual disabilities in self-contained classrooms (n = 20)
3. Typically developing adolescents in general classrooms (n = 40)
%
Minutes
%
Minutes
%
971.88 (487.95) 25.81 (16.20) 18.84 (12.09)
40950.65 (27546.54) 10.89 (7.35)
942.42 (609.05) 25.34 (16.81) 18.14 (12.24)
50256.63 (23942.26) 14.35 (7.82)
1148.85 (538.35) 32.69 (17.49) 23.91 (13.03)
717.17 (511.92) 17.89 (15.49) 14.02 (14.48)
13504.72 (6176.26) 3.18 (1.83) –
372.05 (116.26) 8.96 (4.27) 5.29 (3.06)
33186.58 (21554.76) 10.84 (9.68) –
672.07 (387.47) 21.37 (17.59) 18.06 (16.14)
Note. Values reported as mean (standard deviation); MVPA = moderate-to-vigorous physical activity. * p < .05. ** p < .01. a (Physical education MVPA minutes/60) 100%. b (Recess MVPA minutes/60) 100%.
F
Post hoc
1.25
–
1.75 1.86
– –
5.26** *
4.67 5.85**
2 < 1, 3 2
