EXERCISE & SPORTS SCIENCE AUSTRALIA
Submission to the Select Committee on Autism
July 2020
1.0 About Exercise & Sports Science Australia
Exercise & Sports Science Australia (ESSA) is the peak professional association for exercise and sports professionals
in Australia, representing over 8,000 members, including university qualified Accredited Exercise Physiologists
(AEP), Accredited Sports Scientists (ASpS), Accredited High Performance Managers (AHPM) and Accredited Exercise Scientists (AES).
1.1 AEPs and the National Disability Insurance Scheme
AEPs are university qualified allied health professionals who provide clinical exercise interventions aimed at
primary and secondary prevention; managing sub-acute and chronic disease or injury; and assist in restoring
optimal physical function, health and wellness. Clinical exercise interventions, as delivered by AEPs, provide a range of physical, mental and psychosocial benefits to people w ith a disability. AEPs develop a range of exercise
based activit ies that empower NDIS participants and support them to achieve goals in the areas of daily living,
social inclusion and functional w ell-being.
AEPs can currently register under the ‘Exercise Physiology and Personal Well Being Activit ies’ and “Therapeutic
Supports“ registration groups and deliver supports in both the ‘Improved Health and Wellbeing’ and ’Improved
Daily Living’ categories of participant plans. The COAG Disability Reform Council’s Quarterly Report revealed that
as of June 2019, 2,557 approved providers are registered under the Exercise Physiology and Personal Well Being
Activit ies’ registration group (NDIA, 2019).
1.2 AESs and the National Disability Insurance Scheme
AESs are university qualified professionals with high level training in exercise and sports science. AES apply the
science of exercise to design and deliver physical activity and exercise-based interventions to improve health,
fitness, w ell-being, performance and assist in the prevention of injury and chronic condit ions. AES can register as personal trainers in the ‘Exercise Physiology and Personal Well Being Activit ies’ registration group. AES are also
often engaged in the NDIS as therapy assistants, delivering exercise-based interventions that have been prescribed
by a health professional qualified in clinical exercise prescription. Some NDIS providers engage AESs to support people w ith disability to engage in community sports and recreation opportunities under social & community
participation funding categories.
2.0 Summary of Recommendations
Recommendation 1: Clinical exercise interventions, as prescribed by an Accredited Exercise Physiologist, should
be acknow ledged and promoted as services that can support people w ith Autism Spectrum Disorder (ASD).
Recommendation 2: Develop clear referral pathways to support parents, teachers, community sports coaches,
play groups, and other therapists to access AEPs.
Recommendation 3: Develop and deliver a training program for teachers working in local schools, to assist them
in identifying w hen it would be appropriate to refer a child with ASD to an AEP.
Recommendation 4: Employ AES/AEPs in special schools to increase the safe delivery of physical activity programs and positively impact on the health and wellbeing outcomes of children w ith ASD and other disabilit ies.
Recommendation 5: Increase the number of sessions available to people w ith disability under the Chronic
Disease Management plans.
Recommendation 6: The NOIA should employ planners who have qualifications and/ or experience in health, human
services and support planners to develop a stronger understanding of the complex needs associated with particular
disabilit ies, including ASD.
Recommendation 7: Ensure NOIA Planners receive ongoing education about the role and value of allied health
professions, including AEPs.
Recommendation 8: Introduce measures to better support parents/ carers of people with ASD in their caring role.
Recommendation 9: The Australian Government needs to invest in t he development of National Autism Strategy
that aligns w ith the next phase of the National Disability Strategy.
Recommendation 10: Clinical exercise interventions, as prescribed by an Accredited Exercise Physiologist, should
be acknow ledged and promoted as services that can support people w ith ASD to engage more confidently in recreational and community activities.
3.0 ESSA’s Submission to the Select Committee on Autism
ESSA welcomes the opportunity to provide feedback to the Select Committee on Autism.
ESSA’s submission primarily responds to the following Terms of Reference:
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International best practice with regards to diagnosis, support services and education, effectiveness, cost and required intensity.
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The interaction between services provided by the Commonwealth, state and local governments, including:
o health and mental health,
o education,
o employment,
o justice, and
o housing.
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The adequacy and efficacy of the National Disability Insurance Scheme (NDIS) for autistic people.
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The development of a National Autism Strategy and its interaction with the next phase of the National Disability Strategy.
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The social inclusion and participation of autistic people within the economy and community. 4.0 Response to Terms of Reference
4.1 International best practice with regards to diagnosis, support services and education, effectiveness,
cost and required intensity.
ESSA recommends that clinical exercise interventions, as prescribed by an Accredited Exercise Physiologist, should
be acknowledged and promoted as services that can support people with Autism Spectrum Disorder (ASD) to
achieve improvements in the areas of:
- motor, manipulative and locomotor skills
- cognitive functioning
- behavioural stereotypy
- aggressive behaviours
- socioemotional functioning
- physical condition and skill related fitness To support this recommendation ESSA has conducted a broad screen of peer reviewed literature to demonstrate
the intervening effects of Accredited Exercise Scientists (AES’s) and Accredited Exercise Physiologists (AEP’s) into
the population inclusive of the spectrum of persons associated with Autism Spectrum Disorder (ASD).
4.1.1 Literature review
Method/inclusion criteria The assessment of study inclusion criteria was as follows:
- Empirical studies using qualitative or quantitative methods including cross-sectional, prospective and retrospective cohort, and case-control designs. Date restrictions 1990-2020. Original, peer-reviewed
journal articles were included; systematic reviews and meta-analyses, theses, media releases,
dissertations, books and book chapters, conference papers and presentations and papers were not
excluded from the review.
- English-language articles. Keywords: Autism, ASD, exercise physiology, physical activity, physiologist, systematic review, RCT, meta analyses
Literature Review Results
In addition to the success of the standard treatments of Autism Spectrum Disorder (ASD), it is noted that within the last two decades the interest in the potentially beneficial effects of physical exercise has grown.
Comparing typically developing children with children with ASD, (Pan, 2008) concludes that, overall, the latter
group shows less activity. Also (Hildebrandt, Chorus, and Stubbe (2010) stated that people with ASD constitute a
special risk group because of their sedentary lifestyle, and associated increased risks of heart disease, diabetes and obesity (World Health Organization, 2002). In 2019 the World Health Organisation noted:
- Interventions for people with ASD need to be accompanied by broader actions for making physical, social and attitudinal environments more accessible, inclusive and supportive.
- Worldwide, people with ASD are often subject to stigma, discrimination and human rights violations. Globally, access to services and support for people with ASD is inadequate.
People with ASD typically experience challenges in the domain of motor skills. Here, limited motor coordination,
deficiencies in fine and gross motor functioning (Pan et al., 2009, Emck et al., 2011), and repetit ive, stereotypical
movements, are common. Examples of the latter symptoms are hand w aving when excited or
extraordinary postures in stressful situations (Vandereijcken et al., 2008). Additional challenges include
maintaining balance and motion planning are also seen (Vernazza-Martin et al., 2005).
Since physical activity has proven to be an effective means to prevent problems in the general population, it is
likely to also be effective in the ASD population. (Pitetti, Rendoff, Grover, and Beets (2007) indeed showed that a walking programme not only improved physical condition but also reduced the Body Mass Index (BMI) often
adolescents with severe autism.
Importantly, in addition to improving balance and flexibility (Yilmaz, Yanardag, Birkan, & Bum in, 2004), aerobic
exercise has also shown to reduce the stereotypical behavioural patterns of children with ASD (Elliot et al., 1994, Yilmaz et al., 2004), and their self-stimulation behaviours (Powers, Thibadeau, & Rose, 1992).
Results of a meta-analysis-a method for synthesizing research showed physical activity interventions to have a
moderate or large effect on a variety of outcomes, including for the development of manipulative skills,
locomotor skills, skill-related fitness, social functioning, and muscular strength and endurance. The authors
conclude that physical activity’s standing as an evidence-based strategy for youth with ASD is reinforced (Healy,
Hopper, et al., 2018).
The study “The Effects of Structured Physical Activity Program on Social Interaction and Communication for
Children with Autism“ examined the effects of a 12-week structured physical activity program on social
interaction and communication in children with ASD. After the 12-week physical activity program, the results
showed an overall improvement on social interaction and communication skills for the experimental group
compared with the control group. (Zhao, Chen. 2018).
The publication, “A Meta-Analytic Review of the Efficacy of Physical Exercise Interventions on Cognition in
Individuals with Autism Spectrum Disorder and ADHD“, specifically demonstrated that exercise benefited 76.30 %
of ASD individuals by enhancing their on-task behaviour and performance on simple learning task. The publication
shows evidence that exercise interventions mostly only account for a small variance on cognitive improvements,
supporting the consensus in the literature that the relationship between exercise and cognition is complex and is
moderated by many other factors such as individual differences (e.g., Chang et al. 2012a; Tomporowski et
al. 2008). Nonetheless, it should be noted that the application of exercise interventions with individuals with ASD
and/or ADHD should not be underestimated, as it is likely to be particularly useful in addressing areas of their
cognitive function in which they typically do not perform well, for example, inhibition (Beran, Speelman, 2016).
One such factor that may contribute to reductions in stereotypy (the most common reported improvement in the
reviewed studies) is the possibility that the physical stimulation obtained via exercise may be similar to that
obtained via stereotypy for some children (Lang, et al., 2010)
The preliminary study “Choosing an Appropriate Physical Exercise to Reduce Stereotypic Behavior in Children with
Autism Spectrum Disorders: A Non-randomized Crossover Study“ confirmed the positive influence of physical
exercise on stereotypic behaviour in children with ASD. It also provided initial evidence that physical exercise
should be matched with stereotypic behaviour in children with ASD to deliver significant behavioural benefits.
Additional research should be conducted to replicate and extend these findings to examine the sustainability of
this benefit for children with ASD (Tse, Pang, Lee, 2018).
Other studies reported positive effects on social behaviour (Pan, 2010), communication skills (Hameury et al., 2010), academic engagement (Nicholson, Keh le, Bray, & van Heest, 2011), and sensory skills (Bass, Duchowny, &
Llabre, 2009).
In summary, a global screening of the relevant literature suggests that physical exercise is a sensible approach to
addressing a variety of problems associated with ASD. (Jones, et al., 2017).
4.1.2 NDIS Case studies
ESSA would like to share three case studies shared by AEPs providing therapy supports to people with ASD under
the NDIS. These case studies demonstrate that the benefits associated with engaging people with ASD in physical
activity, as identified in the literature, are also reflected in practice.
Case Study A
A 16-year-old NDIS participant diagnosed with autism, moderate intellectual disability, anxiety, OCD, ADHD, low
muscle tone engaged an AEP. The aims of working with the AEP were to improve strength, stamina and mobility
as well as enhancing the ability to independently complete activities of daily living. Following a comprehensive
assessment, the AEP developed a 12-week individualised exercise program that was specifically designed for the
teenager. Over the 12 weeks the physical condition of the 16-year-old participant improved significantly including
general strength and endurance as well as improved mobility and fine motor skills. By the end of the period he was
able to complete activities of daily such as shaving, brushing his teeth, sustained gripping of a knife and fork and
making his bed. At the end of the program, the participant was ready to be transitioned to a community setting
(i.e. gym) to continue on an exercise program with the support of a disability worker.
Case Study B
A 9-year-old NDIS participant with a diagnosis of Autism Spectrum Disorder (level 2) and low muscle tone was
referred to an AEP. Prior to engagement with the AEP the participant experienced poor coordination, balance and
strength (particularly endurance). This was demonstrated through her inability to ride a bike, catch a ball/balloon
from 3m away and engage in swimming lessons. Following a comprehensive assessment, the AEP worked with the
participant and carers to set several goals to work towards. Some of these were general goals such as play safely
on the school playground and participate in a team sporting activity in the next 12 months with her peers outside
of school. Other goals were more specific such as reducing her frequency of injuries, catching a tennis ball
consecutively x 10 with two hands, Hop on one-foot x 10, balance on either foot for 20 seconds,, ride a bike with
supervision short distances and swim 1 x lap of swimming pool 25m with close supervision. The AEP then develop
an individually designed program that incorporated a hydrotherapy program focused on swimming skills, and
/and-based activities to focus on strength, balance, coordination and endurance. Over time the young girl
transitioned into mainstream swimming lessons, safely navigating common playgroup equipment and
participation in a Sporting Skills Group, including soccer, football, tennis and basketball. The engagement with
other children helped to build social skills in addition to physical outcomes. By the end of the 12 months the
participant had commenced ballet lessons, moved up 2 levels in swimming lessons, completed cross country at
school, was able to safely ride her bike short distances and perform skills such as consistently catching a small ball.
Case Study(
An NDIS participant with a diagnosis on autism engaged an AEP to assist with improve general physical condition
and reduce fatigue with the aim of enjoying recreational activities in the community and at school. She admitted
to struggling to ‘keep up’ in certain recreational activities due to a lack of strength, coordination. Following a
comprehensive assessment, the AEP developed a 7-week exercise program aimed at increasing fitness; The
program included two gym-based sessions a week, with each session including a focus on coordination, motor
sequencing, agility, or balance. In addition to the face-to-face gym sessions, the participant was also prescribed a daily home exercises program including daily step count goals. By the end of the 7 weeks the participant showed
improvements in aerobic/anaerobic capacity, strength, power, balance, coordination, agility and mobility.
Recommendation 1: Clinical exercise interventions, as prescribed by an Accredited Exercise Physiologist, should
be acknowledged and promoted as services that can support people with Autism Spectrum Disorder.
4.2 The interaction between services provided by the Commonwealth, state and local governments, including health and mental health, education, employment, justice, and housing
4.2.1 Interface between health and education
ESSA notes that despite the growing body of literature demonstrating the benefits of physical activity for people with ASD, there is very limited awareness amongst the health and disability sectors about the AEP profession and the valuable role AEPs play in supporting people with ASD to achieve positive outcomes.
ESSA suggests that benefits of engaging an AEPs, particularly for children with ASD, should be promoted more broadly. ESSA maintains that there is a particular need for awareness of the AEP profession to be promoted amongst families of children with ASD, NDIS planners and Local Area Coordinators, education systems and community sporting groups.
AEPs supporting children with ASD, have reported posit ive outcomes when working closely with families, teachers and sporting coaches and other therapists to identify and implement strategies to support children with ASD to achieve goals at home, school and in the community. These goals are often developed following a comprehensive
assessment from an AEP (including a full movement-based assessment) and typically relate to functional gains in
strength, balance, stability, coordination and social engagement in physical activity/sport.
ESSA notes that there are currently no consistent referral pathways to support children with ASD and their
families to connect w ith an AEP. Ideally, parents, teachers, community sports coaches, play groups, other
therapists should have clear referral pathways to follow to support access to an AEP. ESSA notes that a successful
referral pathw ay would need to be supported by an education program for teachers working in local schools, to assist them in identifying when it would be appropriate to refer a child w ith ASD to an AEP.
ESSA also recommends the education sector consider the employment of AES/ AEPs in special schools to increase
the safe delivery of physical activity programs and positively impact on the health and wellbeing outcomes of
children with ASD and other disabilities.
Recommendation 2: Develop clear referral pathways to support parents, teachers, community sports coaches,
play groups, other therapists’ access AEPs.
Recommendation 3: Develop and deliver a training program for teachers working in local schools, to assist them
in identifying w hen it would be appropriate to refer a child with ASD to an AEP
Recommendation 4: Employ AES/AEPs in special schools to increase the safe delivery of physical activity
programs and positively impact on the health and wellbeing outcomes of children w ith ASD and other disabilit ies.
4.2.2 The interface between the NDIS and Health
ESSA has received reports from members that NOIA planner planners commonly advise participants to use other
health services (i.e. Medicare Chronic Disease Management (COM) Plans (item code10953) and Private Health
Insurers) before recommending exercise physiology services within the NDIS. ESSA suggests that this advice is
detrimental to the health, wellbeing, function and mobility of people w ith ASD.
AEPs working with people with ASD and chronic condit ion report that their clients often need to see three or
more allied health professionals to manage their chronic condition. If these individuals were to spread their
maximum five COM services across the required allied health practitioners (e.g. speech therapist, dietician and
exercise physiologist), the ability to make significant changes to the health and well being is limited to potentially
only one session per practitioner.
Recommendation 5: Increase the number of sessions available to people with disability under the Chronic
Disease Management plans.
4.3 The adequacy and efficacy of the National Disability Insurance Scheme (NDIS) for autistic people
4.3.1 NOIA Planners
ESSA suggests the quality of an NDIS planning experience can be life changing for individuals with ASD and their
family/carers. A positive planning experience can improve the quality of life of both participants and their
family/carers. Whilst a negative planning experience can be distressing for all involved and lead unnecessary to
gaps in care.
AEPs working in the NDIS have expressed concern about the inconsistences in planning decisions, noting that some
participants receive a generous plan w ith adequate funding for therapy, whilst others w ith similar conditions and
circumstances receive very little funding. These types of concerns are reflected in the recent Tune Review of the
National Disability Insurance Scheme Act 2013.
ESSA considers it essential that planners have qualifications and/or experience in health, human services or
disability. ESSA suggests that a lack of relevant qualifications and experience in these areas significantly impacts
on the ability of planners to understand and address the complex needs of participants, particularly when it
comes to the complex interface between health and disability.
ESSA suggests that NOIA planners be supported to develop a strong understanding of the complex needs
associated w ith particular disabilities, including ASD. This may require training and development of NOIA
planners in specialist knowledge areas. Specialist knowledge should encompass an understanding of certain
disabilit ies across the lifespan. ESSA members have reported occasions where funding requests have been
inappropriately declined by NOIA planners on the basis that a child with ASD has grown up and “should” be
developing independence and self-management skills.
ESSA notes there are advances in disability related research every year and NOIA planners should be subject to
ongoing professional development to ensure they stay up to date with best practice and innovative evidence
based interventions for people w ith a disability.
ESSA strongly recommends that all planners be educated about the role and value of allied health professions available under the NDIS. ESSA would welcome the opportunity to provide the NOIA with education and resources on the role and value of exercise physiology.
Recommendation 6: The NOIA should employ planners that have qualifications and/or experience in health, human services and support planners to develop a strong understanding of the complex needs associated with particular
disabilit ies, including ASD.
Recommendation 7: Ensure NOIA Planners receive ongoing education about the role and value of allied health
professions, including AEPs.
4.3.2 Supporting Families/informal carers
ESSA members working with people with ASD report that access to carer support/respite is often lacking and this can impact on the therapy outcomes that can be achieved with a child. For example, it is not uncommon for an AEP to prescribe a home-based exercise program for a child with ASD. These home-based programs often require
child’s parent/carer to support the child to engage in physical activity at home in between AEP sessions. Where parents/carers of children with ASD are a lready at capacity in their caring role it can be difficult for them to schedule in t ime for therapy and home exercise programs. In some circumstances this means the child with ASD is not receiving the support they require, and in some circumstances, they start to full even further behind their
peers.
Recommendation 8: Introduce measures to better support parents/carers of people with ASD in their caring role.
4.3 The development of a National Autism Strategy and its interaction with the next phase of the National
Disability Strategy
ESSA supports the development of a National Autism Strategy and recommends this strategy align with the next
phase of the National Disabi lity Strategy. ESSA notes that there are key elements of the current National Disability Strategy 2010-2020 that should be carried forward and reflected in a National Autism Strategy. For example, Policy Direction 1 under the Health and Wellbeing outcome.
Policy Direction 1: All health service providers (including hospitals, general practices, specialist services, allied
health, dental health, mental health, population health programs and ambulance services) have the
capabilities to meet the needs of people with disability.
ESSA suggests that a National Autism Strategy should maintain a strong focus on training and community
awareness programs aimed at upskilling allied health professionals and key stakeholders involved in supporting
people with ASD. This training should raise awareness of evidence based best practice and an interdisciplinary
approach to care and support. It should also identify opportunities to improve access to appropriate support
services.
Recommendation 9: The Australian Government to invest in the development of National Autism Strategy that
aligns w ith the next phase of the National Disability Strategy.
4.5 The social inclusion and participation of autistic people within the economy and community
The literature review and case studies presented in section 4.1 this submission demonstrates how physical
activity and the engagement of an AEP can support people w ith ASD to improve their socioemotional functioning
and engage more confidently in recreational activities.
Recommendation 10: Clinical exercise interventions, as prescribed by an Accredited Exercise Physiologist, should
be acknowledged and promoted as services that can support people w ith Autism Spectrum Disorder to engage
more confidently in recreational and community activit ies.
5.0 Contact ESSA
Thank you for the opportunity to provide feedback to the Select Committee Inquiry into Autism.
Please contact our Policy and Advocacy Team on or for
further detail or any questions regarding the content of this submission.
6.0 References
Bass, M.M., Duchowny, C.A., & Llabre, M.M. (2009). The effect of therapeutic horseback riding on social functioning in children with autism. Journal of Autism and Developmental Disorders, 39(9), 1261-1267. https:// doi .org/10.1007 /s10803-009-0734-3 Chang, Y.-K., Labban, J., Gapin, J., & Etnier, J. (2012a). The effects of acute exercise on cognitive performance: A meta-analysis. Brain Research, 1453, 87-101. DOl:10.1016/j.brainres.2012.02.068 Elliott, R.O., Dobbin, A.R., Rose, G.D., & Soper, H.V. (1994). Vigorous, aerobic exercise versus general motor training activit ies: effects on maladaptive and stereotypic behaviours of adults with both autism and mental retardation. Journal of Autism & Developmental Disorders, 24(5), 565-576. DOI: 10.1007/ BF02172138. Emck, C., Bosscher, R., Wieringen, P.C.V., Doreleijers, T., & Beek, P.J. (2010). Gross motor performance and physical fitness in children with psychiatric disorders. Developmental Medicine & Child Neurology, 53(2), 150-155. https://doi.org/10.1111/j.1469-8749.2010.03806.x Hameury, L., Delavous, P., Teste, B., Leroy, C., Gaboriau, C., & Berthier, A. (2010). Equitherapie et autismeEquine assisted therapy and autism. Annales Medico-psychologiques, revue psychiatrique, 168(9), 655-659. https://doi.org/10.1016/j.amp.2009.12.019 Healy, S., Nacario, A., Braithwaite, R. E., & Hopper, C. (2018). The effect of physical activity interventions on youth with autism spectrum disorder: A meta-analysis. Autism research: official journal of the International Society for Autism Research, 11(6), 818- 833. https://doi.org/10.1002/aur.1955 Hildebrandt, V.H., Chorus, A.M.J, & Stubbe, J.H. (2010). Trendrapport Bew egen en Gezondheid 2008/ 2009. TNO, Leiden. https://repository.tudelft.nl/view/tno/uuid:0e2c3bb4-04fa-4698-8972-36d7d764639d Jones, R. A., Downing, K., Rinehart, N. J., Barnett, L. M., May, T., McGillivray, J. A., Papadopoulos, N. V., Skouteris, H., Timperio, A., & Hinkley, T. (2017). Physical activity, sedentary behavior and their correlates in children with Autism Spectrum Disorder: A systematic review. PloS one, 12(2), e0172482. https:// doi .org/10.13 71/journal. pone .0172482 Lang, R., Koegel, L.K., Ashbaugh, K., Regester, A., Ence, W., & Smith, W. (2010). Physical exercise and individuals with autism spectrum disorders: A systematic review. Research in Autism Spectrum Disorders, 4(4), 565
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Powers, S., Thibadeau, S., & Rose, K. (1992). Antecedent exercise and its effects on self-stimulation. Behavioural Interventions, 7(1), 15-22. https://doi.org/10.1002/bin.2360070103 Tan, B. W., Pooley, J. A., & Speelman, C. P. (2016). A Meta-Analytic Review of the Efficacy of Physical Exercise Interventions on Cognition in Individuals with Autism Spectrum Disorder and ADHD. Journal of autism and developmental disorders, 46(9), 3126- 3143. https://doi.org/10.1007 /s10803-016-2854-x Tomporowski, P. D., Lambourne, K., & Okumura, M . S. (2011). Physical activity interventions and children’s mental function: An introduction and overview. Preventive Medicine, 52(Supplement), S3-S9. doi:10.1016/j.ypmed.2011.01.028. Tse, C., Pang, C. L., & Lee, P. H. (2018). Choosing an Appropriate Physical Exercise to Reduce Stereotypic Behavior in Children with Autism Spectrum Disorders: A Non-randomized Crossover Study. Journal of autism and developmental disorders, 48(5), 1666-1672. https://doi.org/10.1007 /s10803-017-3419-3 Tune D. Review of the National Disability Insurance Scheme Act 2013: Removing red tape and implementing the NDIS participant service guarantee [Internet]. 2020 December [cited 2020 Jan 23).Available from https://www.dss.gov.au/sites/default/files/documents/01 2020/ndis-act-review-final-accessibility-and prepared-publishingl.pdf Vandereijcken, W., Hoogduin, C.A.L., & Emmelkamp, P.M .G. (2008). Handboek Psychopathologie Deel 1: Basisbegrippen. Bohn Stafleu Van Loghum, Houten. https://books.google.com.au/books?hl=en&lr=&id=QbRgcXldUdUC&oi=fnd&pg=PA1&ots=kADa7skZOs&si g=gUIFjKID8ihA-Ha7 uFR9GVgSGQ&redir esc=y#v=onepage&g&f=false Vernazza-Martin, S., Martin, N., Nernazza, A., Lepellec-Muller, A., Rufo, M ., Massion, J., & Assaiante, C. (2005). Goal directed locomotion and balance control in autistic children. Journal of Autism and Developmental Disorders, 35, 91-102. https://doi.org/10.1007 /s10803-004-1037-3 World Health Organization (2019). Autism spectrum disorders. Retrieved July 15, 2019, from https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders . Yilmaz, 1., Yanardag, M., Birkan, B., & Bum in, G. (2004). Effects of swimming training on physical fitness and water orientation in autism. Pediatrics International, 46(5), 624-626. DOI: 10.1111/ j .1442-200x.2004.01938.x Zhao, M ., & Chen, S. (2018). The effects of structured physical activity program on social interaction and communication for children with autism. BioMed Research International, 2018, 13. http:/ldx.doi.org/10.1155/2018/1825046
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