A review of research on physical exercise with people with severe and profound developmental disabilities

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Research in Developmental Disabilities, Vol. 19, No. 6, pp. 477– 492, 1998 Copyright © 1998 Elsevier Science Ltd Printed in the USA. All rights reserved 0891-4222/98 $19.00 1 .00

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A Review of Research on Physical Exercise with People with Severe and Profound Developmental Disabilities Giulio E. Lancioni University of Leiden

Mark F. O’Reilly University College Dublin

During the last two decades, a significant amount of research has examined physical exercise with people with severe and profound developmental disabilities. The research has followed three main objectives: 1) finding strategies for allowing the people to engage in physical exercise fairly independent; 2) improving the people’s physical fitness; and 3) reducing the people’s deviant behavior. This paper reviews the studies related to the aforementioned objectives and comments on the main findings and on the practicality and acceptability of physical exercise. © 1998 Elsevier Science Ltd

During the last two decades, large emphasis has been placed on the importance of physical exercise for people with normal functioning, people with emotional complaints (e.g., depression and stress) or learning problems, and people with

Address correspondence to G. E. Lancioni, Department of Psychology, University of Leiden, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands.

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severe and profound developmental disabilities (Allen, 1980; Allison, Faith, & Franklin, 1995; Basile, Motta, & Allison, 1995; Brown, 1991; Brown & Lawton, 1986; Brown & Siegel, 1988; Cramer, Nieman, & Lee, 1991; Fernhall, Tymeson, Millar, & Burkett, 1989; MacMahon & Gross, 1987). Three main objectives have constituted the basis of the research efforts with people with severe and profound developmental disabilities: 1) finding strategies for allowing these people (known to be rather sedentary) to engage in physical exercise fairly independently; 2) improving the people’s physical fitness and possibly their achievement or performance; and 3) reducing the people’s behavioral problems such as self-stimulatory and self-injurious stereotypies and possibly enhancing their constructive engagement (Brown & Chamove, 1993; GablerHalle, Halle, & Chung, 1993; O’Conner & Cuvo, 1989; Reid, Phillips, & Green, 1991; Rousey & Eyman, 1995; Schurrer, Weltman, & Brammell, 1985; Uslan, Russell, & Weiner, 1988). The ways in which researchers have pursued these objectives have varied quite significantly. The exercise presented to the subjects has taken different forms (e.g., walking, jogging, and fitness routines) with different intensities and different duration levels. Large variations have also appeared with regard to the implementation of the exercise and, particularly, to the amount of staff involvement during the exercise (Allen & Iwata, 1980; Combs & Jansma, 1990; Croce, 1990; Dishman, 1991; Smith & Iwata, 1997; Whitaker & Saleem, 1994). This paper is an attempt to review the groups of studies concerning the aforementioned three objectives. The first aim of the paper is to provide a general picture of the research work performed, in particular, of the different forms (intensities) of exercise used and of the duration of the exercise. A second aim of the paper is to comment on: a) the findings reported; b) the practicality of different exercise arrangements (implementation strategies); and c) the level of acceptability of various exercise conditions, their friendliness, or possible aversiveness for the subjects. Table 1 lists the various groups of studies, the number and age of subjects involved in the studies (if subjects with mild and moderate developmental disabilities were included, these are not reported in the table), the form of exercise, the number of sessions per day and their length, and the findings. The findings were classified as Positive, Negative, and Mixed. Positive findings mean a successful increase in the level of independent exercise for the first group of studies; an improvement in physical fitness (and possibly in performance) for the second group of studies; and a reduction of deviant behavior (and possibly an increase in constructive behavior) for the last group of studies. Negative findings mean that the objectives of independent exercise, improvement in physical fitness or reduction in deviant behavior were not achieved. Mixed findings mean that the aforementioned objectives were obtained with only some persons.

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Table 1 Studies Divided by Groups (and Subgroups) with Number and Age of Subjects, Type of Exercise, Number of Sessions per Day, Length of Sessions, and Findings

Groups I

II

Studies Allen & Iwata (1980) Caouette & Reid (1985) Bennett et al. (1989) Caouette & Reid (1991) Ellis et al. (1992) Lancioni et al. (1994) Lancioni et al. (1997) Beasley (1982) Tomporowski & Ellis (1984) Tomporowski & Ellis (1985) Ellis et al (1989) Combs & Jansma (1990) Croce (1990) King & Mace (1990) Merriman et al. (1996)

IIIa

IIIb

Watters & Watters (1980) Kern et al. (1982) Allison et al. (1991) Powers et al. (1992) Rosenthal-Malek & Mitchell (1997) Baumeister & MacLean (1984) Jansma & Combs (1987) Bachman & Sluyter (1988)

No. Age Ss. (years)

? — Simple Routines 6 22–30 Pedaling 2 24,26 Pedaling 13 18–34 Pedaling 1 10 Walking 2 23,18 Walking 2 24,18 Walking ? — Jogging ? — Var. Fitness Activities 19 15–38 Var. Fitness Activities 1 26 Jogging & Treadmill 3 — Var. Fitness Activities 3 24–30 Var. Fitness Activities 1 44 Var. Fitness Activities ? — Var. Fitness Activities 2 12,12 Jogging 2 5,7 Jogging 1 24 Jogging 1 8 Roller Skating 1 16 Jogging 2 ? 2

McGimsey & Favell (1988) IIIc(**) Bachman & Fuqua (1983) Kern et al. (1984) Larson & Miltenberger (1992) Morrissey et al. (1992) Elliott et al. (1994)

9 4 1 6 ? 3

Celiberti et al. (1997) Lancioni et al. (1984) Tarnowski & Drabman (1985) Whitaker & Saleem (1994)

1 3 1 1

IIId

Exercise

23,19 Jogging —

Var. Fitness Activities 53,29 Var. Fitness Activities 12–25 Jogging 6–16 Jogging 11 Jogging 22–49 Jogging — Calisthenics 23–28 Var. Fitness Activities 6 Jogging 11–17 Daily Activity 5 Walking 47 Walking

No. Length sessions (min) Findings 1 1 1 1 1 — 2 1 1 1

15 15 15 15 19 21 21–31 30 180

Mixed (*) Mixed Positive Mixed Negative Positive Positive Positive(*) Positive(*)

180 Positive(*)

1

20 Positive

1

60 Positive

1

60 Positive

1

—

1 1 1–2 1 1 1

Negative

40–45 Positive(*) 8–10 5–20 20 10 20

Mixed Positive Positive Positive Positive

1

60 Positive

1

60 Positive(*)

1

45 Positive

2 1 1–2 1 1 1

45 — 15 5–15 15 20

1 4–11 1 1

6 15–20 15 60

Mixed Mixed Positive Negative Positive(*) Mixed Positive Positive Positive Positive

? 5 The number of subjects with severe and profound developmental disabilities is not known. — 5 No specific information is available. (*) 5 The findings concern all subjects included in the study and not only those with severe and profound developmental disabilities. (**) 5 The table specifies only the vigorous form of exercise. If this was effective, the findings were labelled “positive.”

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GROUPS OF STUDIES I. Studies Aimed at Finding Strategies for Increasing Independent Physical Exercise Seven studies have been designed to increase the level of independent exercise of persons with severe and profound developmental disabilities (Allen & Iwata, 1980; Bennett, Eisenman, French, Henderson, & Shultz, 1989; Caouette & Reid, 1985, 1991; Ellis, Cress, & Spellman, 1992; Lancioni, Oliva, & O’Reilly, 1997; Lancioni, Oliva, & Signorino, 1994). The studies by Bennett et al. (1989), Caouette and Reid (1985, 1991), and Lancioni et al. (1994, 1997) have combined the use of technical instruments with reinforcement strategies for establishing pedaling or walking plus object manipulation. The studies by Allen and Iwata (1980) and Ellis et al. (1992) have used self-instruction plus reinforcement packages for promoting simple exercise routines and walking. In the study by Ellis et al. (1992), a child with the Prader-Willi syndrome was required to walk a certain number of laps on a course of about 47 m. At the beginning of each lap, the child had to take a baton from a basket. This baton was then to be placed in a baton rack at the end of the lap. The child was to continue with the exercise (with the laps) until the last baton had been taken from the basket. At the end of the exercise, the child was to report to the supervisor to obtain token reinforcers. Although the procedure seemed to be effective in bringing the child to walk as many laps as programed (through the batons), the number of laps did not really increase over the level observed during the last baseline sessions. Moreover, the child seemed to slow down her pace over sessions, using an increasing amount of time to walk the same distance. Caouette and Reid (1985, 1991) adopted a bicycle ergometer as a means of exercise. In their first study, the authors tested the effects of visual stimulation and music tailored to the subjects’ pedaling behavior. The six persons with severe developmental disabilities involved in the study received extensive visual stimulation through flashing lights, music, or a combination of the two if they pedaled at the rate of 120% of the baseline level. The 120% rate was chosen arbitrarily. It was considered adequate for a comfortable exercise intensity that could be sustained for sessions of 15 min once a day. An increase in the pedaling behavior of all six subjects was noted. Yet, it was concluded that the reinforcement contingencies had a clear effect for only four of them. The music was considered more effective than the visual stimulation. Lancioni et al. (1997) used a mobile robot as a tool for promoting ambulation and object manipulation in persons who needed physical support and guidance given their blindness, deafness, motor disabilities, and low functioning levels. The robot was programed to move at a very gentle pace so the two adults involved could hold firmly on the robot’s handle and move with it in a comfortable way. Walking periods of about 4 –5 min were interspersed with brief breaks during which the persons sat and received vibratory (reinforcing)

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stimulation. Both persons learned to use the robot and achieved robot-assisted ambulation times of more than 30 min per session without signs of tiredness. II. Studies Aimed at Improving Physical Fitness and Performance Eight studies have examined physical exercise for improving physical fitness or both physical fitness and general performance (Beasley, 1982; Combs & Jansma, 1990; Croce, 1990; Ellis, MacLean, & Gazdag, 1989; King & Mace, 1990; Merriman, Barnett, & Jarry, 1996; Tomporowski & Ellis, 1984, 1985). For example, Tomporowski and Ellis (1984) investigated the effects of exercise on physical fitness and mental and adaptive functioning in 20 institutionalized subjects. The subjects’ level of developmental disability varied from moderate to profound with an average IQ score of nearly 27. The subjects were exposed to 139 exercise sessions. Each session lasted about 3 hr involving 30 min of light calisthenics and flexibility exercise, 1 hr of activity with various types of equipment (e.g., treadmill and stationary bicycles), 1 hr of walking and running outdoors, as well as periods of swimming and bicycling interspersed with the aforementioned forms of exercise. The results indicated that the subjects had a clear improvement in physical fitness. They showed a better performance on the treadmill and an enhanced running ability. Most subjects also had a clear reduction in body weight. The program had no effects on the subjects’ intelligence scores. Thus, the hypothesis that improved physical fitness would influence mental ability was not supported. Some modest changes observed in the subjects’ general behavior could not be related to the exercise program because comparison groups, which did not receive the exercise program, showed similar changes. The study by Ellis et al. (1989) was aimed at checking whether the use of 20-min exercise sessions (initially jogging, then moving on a treadmill) would produce improvements in physical fitness and problem behavior in a man with severe developmental disabilities. The heart-rate difference between exercise and subsequent cool-down phase increased, thereby suggesting a faster recovery from exercise and an improved cardiovascular fitness. The data also showed a clear decline in the subject’s level of body rocking measured a few hours after the exercise sessions. The decline in body rocking was apparently maintained after the exercise program was terminated. Croce (1990) investigated the effects of exercise and diet on body composition and physical fitness in three moderately obese adults with severe developmental disabilities. Exercise was performed 1 hr per day for 20, 17, and 14 weeks for the three subjects, respectively. The hour was divided into warm-up (15 min), vigorous aerobic (30 min), and cool-down (15 min) periods. Instructions/prompts, positive and negative comments, as well as a token system were used to promote the subjects’ performance. Exercise produced clear improvements. The subjects’ body weight decreased, the percent of body fat was reduced, and the subjects’ physical fitness was enhanced. All three improved

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their capacity to perform continuous work and increased the intensity at which the work was performed.

III. Studies Aimed at Reducing Deviant Behavior (and Improving Constructive Responding) The 18 studies of this group, concerned with the reduction of deviant behavior, could be further divided into four subgroups based on whether they used: a) brief periods of vigorous exercise; b) extended periods of vigorous exercise; c) comparisons of vigorous with mild exercise; and d) forms of daily activity or walking as exercise. IIIa. Studies using brief (5–20 min) periods of vigorous exercise. Five studies can be listed within this subgroup concerning the use of brief periods of vigorous exercise (Allison, Basile, & MacDonald, 1991; Kern, Koegel, Dyer, Blew, & Fenton, 1982; Powers, Thibadeau, & Rose, 1992; Rosenthal-Malek & Mitchell, 1997; Watters & Watters, 1980). For example, Watters and Watters (1980) investigated the effects of 8 –10 min of jogging on the self-stimulatory behavior and on the academic responses of two children with severe developmental disabilities and autism. The observation of the children’s performance was conducted immediately after the jogging for periods of about 10 min. The academic responses consisted of auditory-visual matching-to-sample. The results indicated that one child had a decrease in the level of self-stimulatory behavior after the jogging precondition as opposed to an academic precondition. The other child did not show any significant change. With regard to the academic responses, both children tended to have somewhat lower percentages of correct responses after the jogging precondition. Powers et al. (1992) used roller skating as exercise for a 8-year-old child with mental retardation and autism (presumably functioning at the severe level of developmental disability). The exercise was provided for 10 min. Observation of the subject’s on-task behavior took place during the 15 min following the exercise; observation of the subject’s self-stimulation (i.e., nonfunctional object manipulation) took place during the 30 min after the exercise. The data showed that the exercise had positive effects on both measures recorded. The percentages of on-task behavior increased, whereas the percentages of self-stimulation declined. IIIb. Studies using extended periods (45– 60 min) of vigorous exercise. Four studies have used extended periods of vigorous exercise for reducing deviant behavior (Bachman & Sluyter, 1988; Baumeister & MacLean, 1984; Jansma & Combs, 1987; McGimsey & Favell, 1988). For example, Baumeister and MacLean (1984) performed their study with two adults with severe developmental disabilities. The program required that the subjects jog every afternoon for 1 hr (i.e., from 1 to 2 p.m.). The distance covered was to increase from 1 mile

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to 3 miles. Two observations were done daily, one from 9 to 10 a.m. and another from 3 to 4 p.m. The self-injurious behavior (face and head hitting) of the two subjects decreased during the program period. The decrease was more marked during the observations that followed the jogging sessions than during the morning observations. Also, a reduction of other problem behaviors such as body rocking and pacing was noted. Jansma and Combs (1987) worked with five adults whose levels of developmental disability ranged from mild to profound. First, they determined the time of the day in which maladaptive behaviors occurred with greater frequency. Then, they scheduled a 1-hr fitness program before that time. The program, during which systematic reinforcement was used, included warm-up activities, muscular endurance and cardiovascular fitness activities, and a cool-down phase. The program was followed by an observation period of 1 hr for recording the level of the subjects’ maladaptive behaviors. The data indicated a reduction in such behaviors during the program. A follow-up, 2 weeks after the end of the program, showed that the behaviors had returned to pre-program levels. Although the program was effective, there were variations across subjects. Because no information was given about the functioning levels of the subjects, it cannot be determined whether there was any correlation between those functioning levels and the beneficial effects of the program. IIIc. Studies comparing vigorous exercise with mild exercise. Six studies have compared the effects of vigorous (or fairly vigorous) versus mild forms of exercise for reducing deviant behavior (Bachman & Fuqua, 1983; Celiberti, Bobo, Kelly, Harris, & Handleman, 1997; Elliot, Dobbin, Rose, & Soper, 1994; Kern, Koegel, & Dunlap, 1984; Larson & Miltenberger, 1992; Morrissey, Franzini, & Karen, 1992). For example, Kern et al. (1984) compared the effects of jogging versus ball playing (catching and returning a ball to an adult) on the self-stimulatory behaviors of an autistic child with severe developmental delay. The child was exposed to each condition daily. Each condition lasted 15 min and was followed by 90 min of observation and data collection. The periods after the jogging sessions had lower levels of self-stimulatory behaviors than the periods following the ball-playing sessions. Larson and Miltenberger (1992) compared the effects of baseline sessions (regular physical education activities) with those of leisure games that involved minimal physical activity and those of jogging sessions. The duration of jogging was increased from about 5 min at the start of the program to 15 min after 2 weeks. Six adults with severe developmental disabilities participated in the study. The subjects were observed for two periods of 15 min, about 1 hr and 3.5 hr after the sessions. These observations were to determine whether jogging and the other conditions had any differential effects on the subjects’ problem (e.g., self-stimulatory and aggressive) behaviors. There were no consistent changes in problem behaviors for the six subjects after jogging or any of the other conditions.

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Celiberti et al. (1997) compared the effects of jogging with those of walking on various stereotypic behaviors of a nearly 6-year-old child with autism and presumably serious developmental disabilities. Jogging and walking sessions lasted 6 min. A session was followed by a 3-min cool-down period, which led to a 40-min observation. Jogging was more effective than walking in reducing hand and arm stereotypies and out-of-seat behavior. Yet, jogging was as ineffective as walking in reducing visual forms of self-stimulation. With regard to the effects observed on the first measures, the greatest degree of suppression occurred during the first 10 min after a jogging session with a gradual increase in the measures’ levels thereafter. IIId. Studies using forms of daily activity or walking as exercise. Three studies can be listed in this context (Lancioni, Smeets, Ceccarani, Capodaglio, & Campanari, 1984; Tarnowski & Drabman, 1985; Whitaker & Saleem, 1994). Lancioni et al. (1984) introduced a variety of gross motor activities in substitution of conventional daily tasks for three adolescents with profound multiple disabilities and self-injurious tantrums. The activities, which required considerable physical effort, were generally aimed at a specific goal (e.g., loading objects onto a wagon and transporting them to prefixed places, transporting containers with food or other material to different classrooms). For two subjects, the program started with 2 hr of gross motor activities per day and then changed to 3 hr or 2.5 hr. The third subject started with 1 hr and progressed to 2 hr. The activities were spread throughout the day and done in sessions of 15–20 min. The data were collected for about 10 hr a day. A decrease in the frequency of self-injurious tantrums for all three subjects was noted. Duration of tantrums decreased for two subjects. Tarnowski and Drabman (1985) worked with a 5-year-old child with cerebral palsy and profound developmental disabilities. The physical exercise consisted of ambulation with the help of a walker to reach interesting toys with which the child could briefly play. The duration of walking within each physical exercise period was approximately 15 min. After the completion of a physical exercise period or of a baseline session (in which the child had free access to toys), there was a 15-min observation. During this observation, nine types of stereotyped behaviors were recorded. Some of these behaviors (e.g., head weaving, body rocking, and hand weaving) were affected by the physical exercise and their level was reduced after the exercise periods. Other behaviors, however, did not show changes.

COMMENTS Findings Reported by the Studies With regard to the findings reported by the studies of the first group (those aimed at increasing independent physical exercise), one can underline three

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points. First, the use of special technology, that provides a high degree of assistance and is combined with contingencies of reinforcement, can be very effective for promoting high levels of independent, gentle exercise for persons with profound multiple disabilities (Lancioni et al., 1994, 1997). Second, the use of commonly available exercise instruments such as a bicycle ergometer can be adequately adapted for use with persons with severe developmental disabilities (Bennett et al., 1989; Caouette & Reid, 1985, 1991). The latter authors, for example, were successful with 14 of 19 subjects participating in their two studies. Their adaptation included the use of synchronous stimulation (i.e., stimulation that accompanied pedaling when this matched a preset exercise criterion). To be effective, such an adaptation requires that: a) the stimulation has reinforcing power; and b) the subjects are comfortable with the exercise so that the stimulation can compete favorably with the exercise demands (Marcus & Vollmer, 1996; Sulzer-Azaroff & Mayer, 1991). Third, the use of selfmanagement strategies for organizing one’s own exercise might not necessarily be very effective in ensuring consistency of performance with low-functioning persons (Allen & Iwata, 1980; Coleman & Whitman, 1984; Ellis et al., 1992). With regard to the second group of studies, the findings seem to suggest that it is possible to determine an improvement in the subjects’ physical fitness condition. For example, Croce (1990) in summarizing the results of his study stated that adults with severe mental retardation reacted to a program of progressive aerobic exercise and caloric restriction pretty much in the same way as persons without developmental disabilities. The main difference was represented by the need of some external control components such as prompts, verbal approval or disapproval, and tokens. The influence of improved physical fitness on psychological functioning (general intelligence scores) seems negligible (Tomporowski & Ellis, 1984, 1985). Yet, the implementation of physical fitness activities can have positive effects on deviant behavior as shown by Ellis et al. (1989) and by the third group of studies (e.g., Bachman & Sluyter, 1983; Jansma & Combs, 1987). With regard to the findings of the third group of studies, several comments can be made. First, the notion that vigorous exercise is effective in reducing deviant behavior seems generally tenable although some exceptions have been reported by Watters and Watters (1980), Bachman and Fuqua (1983), McGimsey and Favell (1988), and Elliott et al. (1994). The failures reported by Larson and Miltenberger (1992) could be largely attributable to the fact that their observations, in contrast to those of nearly all other studies, occurred 1 hr or more after the jogging sessions (see also below). Second, the effectiveness of exercise in reducing the level of deviant behavior has varied from quite large (e.g., Baumeister & MacLean, 1984; Powers et al., 1992) to relatively modest and/or limited to some of the deviant behaviors recorded (Celiberti et al., 1997; Tarnowski & Drabman, 1985). The latter findings also have been labeled as “positive” in Table 1, although the clinical value of the behavioral reduction could be questioned. Third, the reduction of deviant behavior was mostly

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restricted to a specific period of time, usually a short period after the exercise. The practical consequences of this situation are that one needs to do several exercise sessions a day (Lancioni et al., 1984; Levinson & Reid, 1993) or has to accept the restricted advantage of exercise (Larson & Miltenberger, 1992; Levinson & Reid, 1993). Fourth, any effects of exercise on constructive behavior may be relatively limited and not necessarily unequivocal. For example, Powers et al. (1992) found an increase in the child’s level of on-task behavior after the exercise sessions. Yet, Watters and Watters (1980) reported a somewhat lower level of correct academic responses after the exercise precondition.

Practicality of the Arrangements Used for Exercise The arrangements used for exercise have varied quite substantially across studies. For example, the studies of the first group have used instruments and strategies aimed at ensuring that the subjects would be fairly independent in their exercise performance. Many studies of the second and third group have resorted to combinations of demonstrations, prompts and reinforcement (supplemented with disapproval and corrections) that were provided by staff personnel individually or on a group basis (e.g., Bachman & Sluyter, 1988; Croce, 1990; Jansma & Combs, 1987; Morrissey et al., 1992; Tomporowski & Ellis, 1984, 1985). A last set of studies have resorted to direct guidance or co-active exercise with a staff person leading the subject physically (e.g., Celiberti et al., 1997; Kern et al., 1982, 1984). This more demanding form of supervision was normally applied during jogging. The amount of staff time required by the different exercise arrangements cannot be discounted as unimportant, particularly in activity and care centers for people with severe and profound developmental disabilities where staff resources are rather limited. In these centers, the possibility of implementing physical exercise may be much higher when the exercise can be peformed with only little staff involvement (Gabler-Halle et al., 1993; Halle, Silverman, & Regan, 1983; Lancioni, 1994; Lowe, Beyer, Kilsby, & Felce, 1992). Practical concerns about exercise arrangements involving direct and prolonged staff participation could encourage the development/use of strategies and technical instruments for helping subjects work independently. Such strategies and technical instruments, which would rely on forms of reinforcement tailored to the subjects’ performance (e.g., Caouette & Reid, 1991), would usually be expected to be much more suitable for ensuring exercise of relatively moderate intensity. The reason for this is that exercise requiring high/protracted physical effort (a) might be perceived as difficult and relatively unpleasant by lowfunctioning persons who cannot relate the immediate demand to subsequent benefits, and thus (b) might not be easily promoted through reinforcement, without the supplementary use of prompts or other external control variables (cf. Lavay, Giese, Bussen, & Dart, 1987; Luce, Delquadri, & Hall, 1980; Silverthorn

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& Hornak, 1993). This issue is examined in the next section of the paper, in connection with the notion of acceptability of different exercise conditions. Acceptability of Different Exercise Conditions With regard to the exercise conditions (i.e., intensity and duration) and their acceptability, several points could be considered. For example, the exercise conditions reported by the studies aimed at promoting independent performance were generally fairly mild and, allegedly, accessible/acceptable to the subjects. Perhaps it could not have been otherwise (see above). In fact, the studies pursuing subjects’ independence have to ensure that the reinforcing events contingent on or parallel to the exercise will compete favorably with the efforts required by the exercise (cf. Katz & Singh, 1986; Ringdahl, Vollmer, Marcus, & Roane, 1997; Shore, Iwata, DeLeon, Kahng, & Smith, 1997). To achieve this favorable outcome, the efforts required by the exercise cannot be too taxing or aversive for the subjects. The exercise conditions implemented by the studies aimed at improving physical fitness were usually quite demanding and required a high level of exertion on the part of the subjects. From a general standpoint, one can argue that these conditions match those available for normal people and are aimed at obtaining the same physical fitness benefits. The fact that normal people find those exercise conditions acceptable could be taken as a criterion for considering the same conditions acceptable also for persons with developmental disabilities (Combs & Jansma, 1990; King & Mace, 1990; Yell, 1988). On the other hand, one should not discount a difference in awareness between the two groups of people. Normal persons who choose to engage in a particular exercise are largely aware of the cost of such exercise as well as of the benefits that will derive from it. Their motivation could be largely maintained by the knowledge of the benefits and the importance that they attribute to those benefits. The same reasoning could hardly be implied in the case of persons with severe and profound developmental disabilities (Lavay et al., 1987). They do not choose the exercise and generally are not aware of the exercise demands. Moreover, they do not have any real appreciation of the benefits that the exercise is likely to produce. Thus, they cannot justify the high exertion based on the benefits. The availability of reinforcement events (e.g., praise, token, or other small social and tangible privileges) may generally be insufficient to lead them to the required effort. The presence of a gap between what the persons seem willing to do and what they are required to do and the employment of various forms of prompting to close that gap raise professional and ethical questions. The basic dilemma is whether certain requirements should be stressed in view of the benefits they produce or rather a more conciliatory approach should be considered (cf. Bannerman, Sheldon, Sherman, & Harchik, 1990; Bell & Bhate, 1992; Gordon, Handleman, & Harris, 1987; Guess, Benson, & SiegelCausey, 1985; Spangler, Gilman, & La Borde, 1990).

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The exercise conditions implemented for reducing deviant behavior tended to be rather demanding, with studies relying on vigorous or vigorous and prolonged exercise (e.g., Baumeister & MacLean, 1984; Jansma & Combs, 1987). An educational therapist can use two important reasons (i.e., the physical and the educational damages that can be produced by the deviant behavior) for justifying demanding exercise conditions. The justification may be tenable if the exercise program is effective in reducing the physical risks and improving the educational opportunities. However, if the results of the program show only marginal changes, the therapist would seem to have no substantive ground for continuing the use of demanding exercise (cf. Bannerman et al., 1990; Gordon et al., 1987; Levinson & Reid, 1993; Luce et al., 1980).

CONCLUSIONS The extensive sedentariness of persons with severe and profound developmental disabilities is a known problem that requires satisfactory solutions. One type of solution may consist of technical instruments combined with reinforcing events. The use of these instruments could ensure fairly mild physical exercise with relatively little direct staff supervision. This kind of exercise, which may be considered friendly and easily acceptable for the persons, could also produce beneficial effects on their general physical condition (Lalli, Mauk, Goh, & Merlino, 1994; Krebs, Eickelberg, Krobath, & Baruch, 1989; Moon & Renzaglia, 1982; Nishiyama, Kuwahara, & Matsuda, 1986; Roberts, 1990). Some technical instruments could allow the combination of forms of exercise such as walking with task performance, and thus make the walking exercise a meaningful engagement. For example, one could use visual or auditory cueing systems for helping the persons move to various task destinations and let them perform familiar occupational/vocational tasks at each destination (cf. Lancioni, Boelens, Oliva, & Bracalente, 1996; Uslan et al., 1988). The evidence available to date could not exclude that repeated periods of mild exercise combined with positive reinforcement and task engagement may also be effective for reducing deviant behavior (Lancioni, Oliva, Coppa, & Boelens, 1991; Whitaker & Saleem, 1994). Yet, if deviant behavior is really severe and dangerous to the person, physical exercise (regardless of whether mild or vigorous) would not be the treatment of choice. A procedure that can eliminate the behavior would be required. The use of vigorous physical exercise to improve fitness and behavior would not need to be rejected. However, attention should be paid to a number of points, for example: 1) the intensity of the exercise should be built gradually; 2) various reinforcing events should be employed to increase the persons’ motivation to exercise; and 3) the persons’ opinion about the exercise should eventually be assessed by allowing them to choose between various exercise options (cf. Lancioni, O’Reilly, & Emerson, 1996).

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