Physical activity guideline compliance among a national sample of children with various developmental disabilities

Journal Pre-proof Physical Activity Guideline Compliance among a National Sample of Children with Various Developmental Disabilities Layne Case, MS, Samantha Ross, PhD, MPH, Joonkoo Yun, PhD PII:

S1936-6574(19)30200-6

DOI:

https://doi.org/10.1016/j.dhjo.2019.100881

Reference:

DHJO 100881

To appear in:

Disability and Health Journal

Received Date: 16 July 2019 Revised Date:

18 October 2019

Accepted Date: 7 December 2019

Please cite this article as: Case L, Ross S, Yun J, Physical Activity Guideline Compliance among a National Sample of Children with Various Developmental Disabilities, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100881. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.

Manuscript Title: Physical Activity Guideline Compliance among a National Sample of Children with Various Developmental Disabilities

Author Information: Layne Case, MS (corresponding author), [email protected] a Samantha Ross, PhD, MPH, [email protected] b Joonkoo Yun, PhD, [email protected] c Oregon State University, College of Public Health and Human Sciences, 160 SW 26th St, Corvallis, OR, 97330, USAa; West Virginia University, College of Physical Activity and Sport Sciences, 375 Birch St, Morgantown, WV, 26506, USAb; College of Health and Human Performance, East Carolina University, E 5th St, Greenville, NC, 27858, USAc Corresponding author: Layne Case College of Public Health & Human Sciences 13 Women’s Building Oregon State University Corvallis, OR 97330 [email protected] Phone: (541) 737-3353

Key Words: youth, disability, function, PA, diagnosis

Funding: This manuscript was partially supported by a grant from the US Department of Education (H325D160023 [PI Yun/MacDonald]). However, the contents do not necessarily represent the policy of the US Department of Education, and you should not assume endorsement by the Federal Government. Project Office Louise Tripoli.

The authors report no conflicts of interest.

Manuscript details DHJO ID: DHJO-D-19-002549 Type of submission: Original research Abstract word count: 248 Manuscript word count: 3806 Number of references: 35 Number of tables: 2

Running head: NATIONAL PA GUIDELINES YOUTH WITH DISABILITIES Physical Activity Guideline Compliance among a National Sample of Children with Various Developmental Disabilities

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Abstract Background: Researchers have reported relatively low estimates of physical activity among children with various developmental disabilities. However, there are inconsistencies within these reports due to methodological issues. Objective: The goals of this study were to estimate the prevalence of meeting national physical activity guidelines among children with various developmental disabilities and examine the relative influence of different disability descriptors on meeting the guidelines. Methods: A sample of 3,010 U.S. children between the ages of 6 and 17 years with parent-reported diagnoses of autism spectrum disorder, cerebral palsy, Down syndrome, developmental disability, and/or intellectual disability was drawn from the combined 2016 and 2017 datasets of the National Survey of Children’s Health. Multivariate logistic regression analyses explored the unique contributions of multiple child characteristics and disability descriptors, such as diagnosis type, severity, complexity, and functionality, toward meeting physical activity guidelines and compared the likelihood of meeting guidelines between children with these diagnoses. Results: The results of this study reveal that the majority of children with developmental disabilities are not achieving adequate levels of daily physical activity, with only 19% of the study sample engaging in 60 minutes of physical activity daily. Child age and functionality were significant predictors of meeting physical activity guidelines among children within the sample. Conclusions: The findings of this study highlight the potentially limiting view of physical activity participation when diagnosis type is considered alone and demonstrate the importance of considering function and other individual factors as significant predictors of physical activity among children with disabilities.

Key Words: youth, disability, function, PA, diagnosis

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Physical activity (PA) has been widely recognized as an important contributor to positive health outcomes among children. Benefits of regular PA for children include improved cardiorespiratory and muscular fitness, improved weight status, and reduced risk of depression,1 as well as small effects on academic achievement and cognitive functions.2 To enhance potential health benefits, the newly released 2018 Physical Activity Guidelines for Americans, 2nd edition recommends that school-aged children 6-17 years of age, with and without disabilities, engage in at least 60 minutes of moderate-to-vigorous physical activity (MVPA) daily.3 Despite evidence that children with disabilities experience comparable health benefits, researchers have reported relatively low levels of PA participation among this population.4,5 For example, a systematic review by Carlon and colleagues4 indicated that youth with cerebral palsy engage in lower levels of PA compared with their typically-developing peers. Whitt-Glover, O’Neill, and Stettler6 similarly suggested that children with Down syndrome spend significantly less time in vigorous intensity PA than their siblings without Down syndrome. Low PA rates have been attributed to unique barriers associated with disability, such as physical limitations, negative societal attitudes and lack of professional training within PA settings.7 These barriers may translate to children with disabilities experiencing an unfair disadvantage to engage in adequate amounts of PA compared to their same-age peers without disabilities.8 In contrast, a body of evidence suggests that children with disabilities do not demonstrate PA deficits relative to their same-age peers.9,10 Ketcheson and colleagues,10 for example, found that children with autism spectrum disorder (ASD) spent significantly more time in accelerometer-measured MVPA when compared to children without ASD. Faison-Hodge and Porretta11 additionally found no significant differences in MVPA between children with and without intellectual disabilities based on direct observation within Physical Education and recess

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settings. Collectively, these studies highlight that the extent to which children with disabilities engage in sufficient amounts of PA remains unclear12 and suggest a need to investigate the potential reasons for this inconsistency. Inconsistencies in the amounts of PA among children with disabilities within the literature may be attributable to methodological issues, including sample size and variability in measures of disability. The findings noted above, for example, were drawn from convenience samples and targeted children with specific diagnosis types. These differences in methodology challenge meaningful interpretations of results across studies. Specifically, the use of disability type as an indicator of PA among children with disabilities adds a layer of complexity to understanding PA within this population. Some researchers have highlighted differences in PA levels between disability types.13,14 For example, Longmuir and Bar-Or13 found that activity levels varied by disability type, with youth with visual impairments and physical disabilities engaging in significantly lower levels of activity than children with hearing impairments or chronic medical conditions. In an examination of frequency of sport participation among Chinese children with various disabilities, Sit, Lindner, and Sherrill14 similarly suggested differences across disability type, with children with a cognitive disability, physical disability or a visual impairment reporting the lowest activity levels compared to children diagnosed with maladjustment or hearing impairments. As a whole, these findings suggest that PA may be influenced by the specific type of disability, despite common group-level interpretations of PA among children with disabilities. Other studies contradict these findings, however, with some researchers arguing against the use of disability type as the most meaningful determinant of a child’s participation in PA.15,16 A recent meta-analysis by Jung and colleagues,16 for example, suggests that children with

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disabilities, regardless of disability type, experience low levels of MVPA across studies. Researchers have instead pointed to other child characteristics or disability-related factors that may provide meaningful information beyond disability type and diagnosis regarding a child’s participation in life activities.15,17 For instance, researchers have found evidence that children with more severe disability experience greater limitations than those with lesser severities of the same diagnosis,18,19 suggesting that disability severity may lend greater insight to understanding health behaviors of children with disabilities than diagnosis. Other studies have indicated that diagnostic complexity, or having more than one diagnosis, may uniquely contribute to the PA levels and health of children with disabilities.17,20 Phillips and Holland,20 for example, found that among a sample of 152 individuals with intellectual disabilities, with and without Down syndrome, none met PA recommendations across a seven-day span. However, individuals with diagnoses of both intellectual disability and Down syndrome engaged in significantly less PA than those with a single diagnosis of intellectual disability, suggesting diagnostic complexity may be more indicative of risk for insufficient PA than the specific type. Additionally, Law and colleagues15 argued against the use of diagnosis to flag children for health risks and instead suggested that functional ability, a measure of disability severity, may better explain participation of children with disabilities. In their examination of the relationship between diagnosis, function, and participation in life situations, including physical activities, among children with physical disabilities, the results interestingly showed that diagnosis was washed out as a predictor of activity participation when age, sex and function were added to the regression model.15 Overall, these findings highlight the potential gaps in understanding determinants of PA when diagnosis is considered as the only disability descriptor, and offer the possibility that other

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or supplemental disability descriptors may better contribute to meaningful and accurate interpretations of PA participation. The contradicting results surrounding PA and disability type are problematic as programming decisions involving children with disabilities are typically made based on disability diagnosis or status. If disability type is not an important determinant of PA, there is a need to examine other disability descriptors that may better identify children at risk for low levels of PA. Moreover, the inconsistent estimates of PA among children with disabilities have been drawn from small samples of variable disability populations. Therefore, there is a need to obtain more robust, updated estimates of PA among children with various developmental disabilities and to identify disability groups with the lowest levels of PA. The purpose of this study was twofold: (1) estimate the prevalence of children with various developmental disabilities meeting the national PA guidelines, and (2) identify the extent to which disability descriptors, such as diagnosis type, complexity, severity, and function, account for differences in meeting the national PA guidelines among children with various developmental disabilities, using an existing nationally representative dataset. Methods Data Source Data for this study was drawn from the 2016 and 2017 combined National Survey of Children’s Health (NSCH) dataset. Administered annually, the NSCH monitors the health and healthcare utilization of non-institutionalized U.S. children, birth to 17 years. Mail and webbased surveys were administered to randomly selected households across the U.S. using a complex sampling design described in detail elsewhere.21

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Survey respondents initially completed a screener asking if one or more children between the ages of 0 and 17 years lived in their household. Affirmative responses were then sent an agespecific survey (a) 0-5 years, (b) 6-11 years, or (c) 12-17 years for one child randomly selected from the household. Children ages 0-5 years-old and children with special health care needs were oversampled (80% and 60%, respectively) to ensure adequate representation of these priority populations. For the 2016-2017 cycles, a total of 71,811 surveys were completed, for an overall weighted response rate of 39%. To account for complex sampling methods, child weights were produced in a two-step process and included in the public datasets. First, a base sample weight was calculated as the inverse probability of a household being selected from the Census Master Address File. Then, base weights were adjusted for non-response, within-household subsampling, and for the 2015 American Community Survey 1-year population control estimates. Weighted estimates obtained from the NSCH are representative of non-institutionalized U.S. children birth to 17 years of age. Each survey year is individually weighted. To adjust weights for combined years of data, individual survey weights were divided by two, the number of survey years combined, following recommended procedures.22 A full methodology report of the NSCH is described elsewhere.23,24 Sample The analytic sample included 3,010 U.S. school-age children 6-17 years-old who had complete data for the primary outcome and predictor variables and one or more of the following developmental disability diagnoses: autism spectrum disorder (ASD), cerebral palsy (CP), developmental disability (DD), Down syndrome (DS), and intellectual disability (ID). Collectively, there are more than 25 possible diagnoses to examine using the NSCH survey questions. To provide an initial snapshot of PA guideline compliance, and the relative

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contribution of disability descriptors in determining risk for low PA, among children with disabilities and health conditions, the sample was limited to five diagnoses that have been shown to be associated with risk for low PA levels and high-interest populations within the field of adapted physical activity.4,9,20,25 All five of these diagnoses have been recognized as developmental disabilities elsewhere26,27 and hence were operationalized as “developmental disability diagnoses” for this study to represent children with one or more of these diagnoses. The methods and results from this study may serve as a template for exploring other subgroups of children with disabilities. Children were identified as having a diagnosis based on affirmative responses to both of the following: “Has a doctor or other health care provider EVER told you that this child has [diagnosis]” and “does your child CURRENTLY have this condition?” Descriptive statistics, including age, sex, race/ethnicity, functionality, and family characteristics by disability diagnosis are reported in Table 1. Diagnosis categories were not mutually exclusive, as some children may have more than one condition. Within the sample of children, 71.02% (SE=2.01) had one diagnosis only, 23.39% (SE=1.99) had two diagnoses, and 5.60% (SE=0.72) had three or more diagnoses among the five possible diagnoses. A control group of children without disability diagnoses was not used in this study, as the specific aim of this study was to identify disability descriptors associated with engaging in sufficient PA, among a population known to be at-risk for low PA. Children without ASD, CP, DD, DS or ID, children without a disability diagnosis but with functional limitations, and children without disability diagnoses were all excluded from this study’s sample. Parsing out a meaningful control group for comparison is thus challenging and was outside the scope of the current study. To aid interpretation, findings from this study are discussed in reference to

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published estimates of PA for children without disabilities from NSCH datasets that are publicly available from www.census.gov. **Insert table 1** Measures Compliance with PA Guidelines. One survey item was used to measure children’s PA: “During the past week, on how many days did this child exercise, play a sport, or participate in physical activity for at least 60 minutes?” Response options included (1) 0 days, (2) 1-3 days, (3) 4-6 days or (4) every day. Based on the current Physical Activity Guidelines for Americans, 2nd Edition3 recommendation that children engage in at least 60 minutes of MVPA daily, responses were collapsed into a dichotomous variable indicating that guidelines were (a) met (i.e. every day) or (b) not met (i.e. 0-6 days). Disability characteristics. Two additional variables were created to characterize the complexity and severity of disability. Complexity of disability was defined by the number of diagnoses out of five that each child was reported to currently have (1, 2, or 3+ diagnoses). Severity was measured using an independent survey item for each diagnosis. Following an affirmative response to a diagnosis, respondents were prompted to indicate if the child’s condition was (1) mild, (2) moderate, or (3) severe. A single severity variable was created using the highest severity reported across the five potential diagnoses. Function. Functional limitations were defined by a single survey item: “During the past 12 months, how often have this child’s health conditions or problems affected his or her ability to do things other children his or her age do?” Responses to this survey item ranged from (1) never to (4) always. A dichotomous variable was created to indicate if the child’s condition(s) either (a) never affected or (b) sometimes, moderately, or always affected his or her activities.

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Covariates. Several child and family characteristics were selected as covariates based on current literature indicating their associations with PA among children with and without disabilities.16,28 Child characteristics included age group (6 to 11 years, 12 to 17 years), sex (male, female), and race/ethnicity (Hispanic, White non-Hispanic, Black non-Hispanic, Other), as categorized by the NSCH. Family characteristics included highest education level in the household and household income compared to the 2010 Federal Poverty Level. Missing data on education and household income was treated using multiple imputation methods prior to release of the publicly available datasets.23,24 The remaining covariates included in the present analysis had less than 5% missing data and were thus not treated. Data Analysis Prevalence estimates of meeting the national PA guidelines among children with developmental disabilities were calculated and reported alongside Roa-Scott Chi-square statistical comparison of distributions across groups. The relative contribution of disability descriptors (type, complexity, severity, and function) in accounting for variance in PA outcomes was evaluated using a multivariate logistic regression. All disability descriptors and covariates were entered into a logistic regression analysis predicting the likelihood of meeting PA guidelines. Predictor variables were evaluated against alpha <0.05 for inclusion in the final model. Crude and adjusted odds ratio estimates, and corresponding 95% confidence intervals (CI), were reported. All analyses were conducted using SAS statistical software (version 9.4., SAS Institute, Cary, NC) for complex sampling design (e.g. SURVEYFREQ and SURVEYLOGISTIC). Results Prevalence of Meeting Physical Activity Guidelines

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Table 2 provides the prevalence rates for meeting the national PA guidelines, weighted standard error (SE) estimates, and 95% CIs for children with various developmental disability diagnoses, as a group and by diagnosis type. Among children with a disability, the overall prevalence of meeting the guidelines was 19% (SE=1.47, 95% CI [16.18, 21.86]). The prevalence of meeting the guidelines by diagnosis type ranged from 14% to 20%. Children with ASD had the lowest prevalence rate (14.18%, SE=2.12, 95% CI [10.02, 18.35]), whereas children with ID had the highest prevalence rate among the sampled children (20.87%, SE=3.54, 95% CI [13.94, 27.80]. Disability Type, Complexity, Severity, and Function The crude and adjusted association between disability characteristics and meeting national PA guidelines are also reported in Table 2. The unadjusted odds of meeting guidelines did not significantly differ between those with and without a given diagnosis, with the exception of children with ASD. Among children with ASD, the unadjusted odds of meeting guidelines were 0.65 times the odds among children without an ASD diagnosis (95% CI [0.43,0.97]). The unadjusted odds of meeting the guidelines did not significantly differ among children based on disability complexity or severity. The unadjusted odds of meeting the guidelines among children with functional limitations was 0.81 times the odds among children without a functional limitation (95% CI [0.70, 0.93]). According to the adjusted association estimates from the multivariate regression model, function and age were significant predictors of meeting PA guidelines, after controlling for disability complexity, severity, type, and all other covariates (see Table 2). The adjusted odds of meeting the guidelines among children with functional impairments was 0.48 times the odds among children with no functional impairment, after adjusting for disability type and covariates

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(95% CI [0.32, 0.73], p < 0.001). After accounting for functional impairment, the odds of meeting PA guidelines among children with ASD no longer significantly differed from the odds among children without ASD, suggesting that function washed out disability type as a predictor of PA among children with ASD. The relative odds of meeting PA guidelines did not significantly differ by disability complexity or severity. **Insert Table 2** Discussion This study was a secondary analysis of the 2016 and 2017 combined NSCH datasets and examined compliance with the national PA guidelines among a nationally representative sample of children with ASD, CP, DD, DS and/or ID. As a group, approximately 1 in 5 children with one or more of these developmental disability diagnoses met the guidelines and engaged in 60 minutes of PA daily. Diagnosis type was washed out as a significant predictor of a child’s likelihood for meeting the guidelines, after accounting for age and function. The following discussion addresses how these findings align with current literature and challenge the use of diagnosis as a sole predictor of PA among children with disabilities. Our findings support a body of literature documenting insufficient levels of PA among children with disabilities.4,8 The 19% prevalence rate for meeting PA guidelines observed among the current sample of children with ASD, CP, DS, DD and ID is consistent with prior indications that the majority of children with disabilities are not achieving recommended levels of PA.5,9 In addition, this prevalence rate is similar to national PA estimates for children,29 suggesting that when sampled by diagnosis status, this population does not seem to greatly differ from children without disabilities in terms of sufficient PA levels.

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Age and function accounted for significant differences in the odds of meeting PA guidelines among children with various developmental disabilities. Children 12 to 17 years were significantly less likely to meet PA guidelines compared to children 6 to 11 years, regardless of disability type. This is consistent with literature documenting younger children with disabilities spend more time in PA than older children,30 and that PA levels decline with age.16 In addition, children with functional impairments sometimes, usually or always affecting their activities were significantly less likely to meet the guidelines compared to children without functional impairments, regardless of disability type. Our results echo Law and colleagues’15 argument that function is a more meaningful descriptor for identifying a risk of low participation than diagnosis among children. This finding also challenges traditional methods of sampling children with disabilities by diagnosis when assessing PA within this population and warrants further research that evaluates the practice of recruiting children for PA interventions based on disability type. Children’s functional limitations in this study may contribute to meeting the PA guidelines for several reasons. First, the corresponding survey item measured ‘the extent to which the child’s diagnosis affects participation in daily activities that other children his or her age do.’ Consistent with previous literature, limited physical function may impact a child’s abilities to perform physical movements7 and subsequent engagement in PA. Additional functional characteristics, however, may also affect a child’s participation in PA.31 According to the International Classification of Functioning, Disability and Health (ICF), for example, functional limitations may include restrictions at the body, activity, or participation levels.32 This indicates that, in addition to physical function, a wide variety of individual and disability characteristics, including physiological and psychological functions, difficulties in executing

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specific tasks, and contextual issues, such as the social and attitudinal environment, may affect a child’s participation in PA. A multidimensional view of functionality, therefore, not only reflects the contemporary definition of disability as the interaction between the child’s diagnosis, personal factors, and the environment,32 but may be necessary to fully capture PA participation among children with disabilities. For example, in addition to impairments in sensory and motor functioning related to the diagnosis, children with ASD may experience other functional differences, such as communication and behavior, that limit PA participation. In fact, Healy, Judge, Block, and Kwon33 suggest that a high percentage of future adapted physical educators indicated the need for increased training in behavior management and communication strategies in order to work with and enhance experiences for children with ASD. In this scenario, regardless of the influence of diagnosis-specific factors, the lack of professional training may affect a child’s ability and potential to participate in adequate PA. Moving forward, it will therefore be important for a variety of functional characteristics to be considered, as opposed to diagnostic criteria alone, when evaluating and targeting PA levels. Additionally, examining how to lessen the impacts of functional limitations and provide a variety of supports in order to improve PA opportunities for children would be valuable. This study has several implications for future research and practice. Consistent with recent literature, this study has demonstrated that disability type may have limited ability to adequately describe PA of children with various developmental disabilities. While diagnostic criteria are important for understanding the potential characteristics a child may demonstrate, the significant variation in ability and severity observed among children within each diagnosis category creates difficulty in fully understanding PA by each diagnosis type. Instead, based on

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the present study’s findings, function may allow for a more comprehensive understanding of PA levels among children with disabilities. Diagnosis should therefore be considered in conjunction with other factors, such as age and function, when aiming to enhance PA. Lastly, this study points to the influence of age on the PA behaviors of children with disabilities. PA promotion efforts should target all children, including older children with disabilities who appear to have lower odds of acquiring sufficient levels of PA. Some limitations to this research should be noted. While this study involved a national survey, smaller sample sizes were observed within specific disability subgroups that may limit generalizability. Second, the structure of the NSCH survey items may have hindered in-depth investigation of disability type and PA. Many children within our sample had more than one of the five potential diagnoses. Inconsistent patterns of diagnosis combinations, however, inhibited us from examining the unique contribution of each diagnosis. Additionally, while our research focused on children’s complete compliance with PA guidelines, the approximate 80% of children with disabilities that did not meet guidelines may have either been insufficiently active (i.e. 1-6 days of 60 minutes of PA) or inactive (i.e. 0 days). Further investigation is needed to examine how children distribute across these PA amounts. Given the strong evidence of health benefits of meeting the recommended 60 minutes of PA daily,3 however, the low percentage of children fully meeting the guidelines is concerning. Researchers should continue to investigate how to increase PA among children with disabilities, including increasing access and opportunities for PA.34 Finally, the NSCH is a parent-reported survey and, thus, child variables are subject to reporter bias. Parents, however, have been shown to reliably report on diagnosis and life complexity of their children with disabilities.35 Although parent-proxy surveys are a feasible

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approach to national surveillance, further research employing more direct measures of disability and PA are warranted. In sum, this study used a large, nationally representative sample of children with disabilities, strengthening our ability to estimate population-level patterns of PA and explore the relative contribution of disability descriptors in meeting the national PA guidelines among children. Low guideline compliance rates among children with disabilities are consistent with levels observed among children nationally. Despite traditional methods of examining health risks of children with disabilities by diagnosis type, however, child age and function washed out diagnosis as a meaningful predictor of PA among children in this sample. The results of this study contribute to our understanding of PA among children with disabilities and draw attention to the importance of considering multiple child and disability descriptors when evaluating the health and PA of children with disabilities.

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References 1.

Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020-2028. doi:10.1001/jama.2018.14854

2.

Álvarez-Bueno C, Pesce C, Cavero-Redondo I, Sánchez-López M, Martínez-Hortelano JA, Martínez-Vizcaíno V. The effect of physical activity interventions on children’s cognition and metacognition: A systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2017;56(9):729-738. doi:10.1016/j.jaac.2017.06.012

3.

U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd Edition. Washington, D.C.: U.S. Department of Health and Human Services; 2018:118.

4.

Carlon SL, Taylor NF, Dodd KJ, Shields N. Differences in habitual physical activity levels of young people with cerebral palsy and their typically developing peers: a systematic review. Disabil Rehabil. 2013;35(8):647-655. doi:10.3109/09638288.2012.715721

5.

Wouters M, Evenhuis HM, Hilgenkamp TIM. Physical activity levels of children and adolescents with moderate-to-severe intellectual disability. J Appl Res Intellect Disabil. 2019;32(1):131-142. doi:10.1111/jar.12515

6.

Whitt-Glover MC, O’Neill KL, Stettler N. Physical activity patterns in children with and without Down syndrome. Pediatr Rehabil. 2006;9(2):158-164. doi:10.1080/13638490500353202

7.

Shields N, Synnot A. Perceived barriers and facilitators to participation in physical activity for children with disability: A qualitative study. BMC Pediatr. 2016;16(1):9. doi:10.1186/s12887-016-0544-7

8.

Rimmer JH, Rowland J. Physical activity for youth with disabilities: a critical need in an underserved population. Dev Neurorehabilitation. 2008;11(2):141-148. doi:10.1080/17518420701688649

9.

Bandini LG, Gleason J, Curtin C, et al. Comparison of physical activity between children with autism spectrum disorders and typically developing children. Autism Int J Res Pract. 2013;17(1):44-54. doi:10.1177/1362361312437416

10. Ketcheson L, Hauck JL, Ulrich D. The levels of physical activity and motor skills in young children with and without autism spectrum disorder, aged 2-5 years. Autism Int J Res Pract. 2018;22(4):414-423. doi:10.1177/1362361316683889 11. Faison-Hodge J, Porretta DL. Physical activity levels of students with mental retardation and students without disabilities. Adapt Phys Act Q. 2004;21(2):139-152. doi:10.1123/apaq.21.2.139

Running head: NATIONAL PA GUIDELINES YOUTH WITH DISABILITIES

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12. Frey GC, Stanish HI, Temple VA. Physical activity of youth with intellectual disability: Review and research Agenda. Adapt Phys Act Q. 2008;25(2):95-117. doi:10.1123/apaq.25.2.95 13. Longmuir PE, Bar-Or O. Factors influencing the physical activity levels of youths with physical and sensory disabilities. Adapt Phys Act Q. 2000;17(1):40-53. 14. Sit CHP, Lindner KJ, Sherrill C. Sport participation of Hong Kong Chinese children with disabilities in special schools. Adapt Phys Act Q. 2002;19(4):453. 15. Law M, Finkelman S, Hurley P, et al. Participation of children with physical disabilities: relationships with diagnosis, physical function, and demographic variables. Scand J Occup Ther. 2004;11(4):156-162. doi:10.1080/11038120410020755 16. Jung J, Leung W, Schram BM, Yun J. Meta-analysis of physical activity levels in youth with and without disabilities. Adapt Phys Act Q. 2018;35(4):381-402. doi:10.1123/apaq.2017-0123 17. Miller AR, Masse L, Shen J, Schiariti V, Roxborough L. Diagnostic status, functional status and complexity among Canadian children with neurodevelopmental disorders and disabilities: Population-based study. Disabil Rehabil. 2012. doi:10.3109/09638288.2012.699580 18. Bramlett M, Read D, Bethell C, Blumberg S. Differentiating subgroups of children with special health care needs by health status and complexity of health care needs. Matern Child Health J. 2009;13(2):151-163. doi:10.1007/s10995-008-0339-z 19. MacDonald M, Lord C, Ulrich DA. Motor skills and calibrated autism severity in young children with autism spectrum disorder. Adapt Phys Act Q APAQ. 2014;31(2):95-105. doi:10.1123/apaq.2013-0068 20. Phillips AC, Holland AJ. Assessment of objectively measured physical activity levels in individuals with intellectual disabilities with and without Down’s syndrome. Adamovic T, ed. PLoS ONE. 2011;6(12):e28618. doi:10.1371/journal.pone.0028618 21. Ghandour RM, Jones JR, Lebrun-Harris LA, et al. The design and implementation of the 2016 national survey of children’s health. Matern Child Health J. 2018;22(8):1093-1102. doi:10.1007/s10995-018-2526-x 22. U.S. Census Bureau. 2017 National Survey of Children’s Health: Guide to Analysis of Multi-Year NSCH Data. 2018. https://www.census.gov/content/dam/Census/programssurveys/nsch/tech-documentation/Guide_to_Multi-Year_Estimates.pdf. 23. U.S. Census Bureau. 2016 National Survey of Children’s Health: Methodology report. 2018. https://www.census.gov/content/dam/Census/programs-surveys/nsch/techdocumentation/methodology/2016-NSCH-Methodology-Report.pdf. Accessed December 6, 2018.

Running head: NATIONAL PA GUIDELINES YOUTH WITH DISABILITIES

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24. U.S. Census Bureau. 2017 National Survey of Children’s Health: Methodology report. 2018. https://www.census.gov/content/dam/Census/programs-surveys/nsch/techdocumentation/methodology/2017-NSCH-Methodology-Report.pdf. Accessed December 6, 2018. 25. Shields N, Dodd KJ, Abblitt C. Do children with Down syndrome perform sufficient physical activity to maintain good health? A pilot study. Adapt Phys Act Q APAQ. 2009;26(4):307-320. 26. Zablotsky B, Black LI, Maenner MJ, et al. Prevalence and trends of developmental disabilities among children in the United States: 2009–2017. Pediatrics. 2019;144(4):e20190811. doi:10.1542/peds.2019-0811 27. National Institutes of Health. Intellectual and Developmental Disabilities. 2010. https://www.report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=100. Accessed October 9, 2019. 28. Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the built environment underlies key health disparities in physical activity and obesity. Pediatrics. 2006;117(2):417-424. doi:10.1542/peds.2005-0058 29. Child and Adolescent Health Measurement Initiative. 2016-2017 National Survey of Children’s Health data query. Data Resource Center for Child and Adolescent Health. https://www.childhealthdata.org. Published 2016. 30. Belcher BR, Berrigan D, Dodd KW, Emken BA, Chou C-P, Spruijt-Metz D. Physical activity in US youth: effect of race/ethnicity, age, gender, and weight status. Med Sci Sports Exerc. 2010;42(12):2211-2221. doi:10.1249/MSS.0b013e3181e1fba9 31. Rimmer JH. Use of the ICF in identifying factors that impact participation in physical activity/rehabilitation among people with disabilities. Disabil Rehabil. 2006;28(17):10871095. doi:10.1080/09638280500493860 32. WHO. International Classification of Functioning, Disability and Health. Geneva: World Health Organization; 2001. 33. Healy S, Judge JP, Block ME, Kwon EH. Preparing adapted physical educators to teach students with autism: Current practices and future directions. Phys Educ. 2016;73(1):97109. 34. Murphy NA, Carbone PS. Promoting the participation of children with disabilities in sports, recreation, and physical activities. Pediatrics. 2008;121(5):1057-1061. doi:10.1542/peds.2008-0566 35. Williams U, Rosenbaum P, Gorter JW, McCauley D, Gulko R. Psychometric properties and parental reported utility of the 19-item “About My Child” (AMC-19) measure. BMC Pediatr. 2018;18(1):174. doi:10.1186/s12887-018-1147-2

Running head: NATIONAL PA GUIDELINES YOUTH WITH DISABILITIES Table Captions Table 1. Descriptive statistics of sample children 6-to-17 years with a developmental disability diagnosis Table 2. Prevalence of meeting physical activity guidelines among children 6-to-17 years old with a developmental disability diagnosis, by diagnosis type

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Tables Document Table 1. Table 1. Descriptive statistics of sample children 6 to 17 years with a developmental disability diagnosis (N=3,010). Unweighted sample size (n); Weighed proportion (%) and standard error (SE); Source: 2016-2017 combined National Survey of Children’s Health Developmental Disability Diagnosis Autism Developmental Down Intellectual Spectrum Cerebral Any (1+) Delay Syndrome Disability Disorder Palsy (CP) (DD) (DS) (ID) (ASD) Sample size 3010 757 168 2496 97 626 Weighted population 2,848,473 609,120 139,892 1,376,376 71,290 646,886 estimate Child Characteristics % % % % % n n n n n n % (SE) (SE) (SE) (SE) (SE) (SE) Age 6-11 years 1318 51.42 292 42.58 59 35.15 1142 54.63 38 38.24 228 47.17 (2.13) (3.85) (6.31) (2.27) (8.09) (5.63) 12-17 years 1692 48.58 465 57.42 109 65.85 1354 45.37 59 61.76 398 52.83 (2.13) (3.85) (6.31) (2.27) (8.09) (5.63) Sex Male 2057 69.62 597 78.80 93 66.95 1674 68.46 50 57.03 399 65.63 (1.87) (2.70) (5.79) (2.07) (8.60) (4.72) Female 953 30.38 160 21.20 75 33.05 822 31.54 47 42.97 277 34.45 (1.87) (2.70) (5.79) (2.07) (8.60) (4.72) Race/ethnicity 10.86 22.70 33.88 34.35 Hispanic 23.75 20.94 15 284 16 77 338 69 (2.52) (4.94) (3.79) (2.71) (9.56) (21.42) White, 51.47 61.69 54.43 51.09 49.70 3.72 2065 566 120 1678 66 425 non-Hispanic (2.18) (4.45) (31.65) (6.85) (2.37) (8.70) Black 16.49 7.29 22.07 17.78 3.44 3.46 243 36 16 220 2 55 non-Hispanic (1.51) (1.65) (6.88) (1.72) (2.50) (12.75) Other 8.28 10.86 11.64 8.42 12.98 1.16 364 86 17 314 13 69 (0.78) (2.10) (4.39) (0.89) (4.98) (2.94)

Function* No Yes

650 2348

Highest Education Level < high school 603 > high school

2348

24.92 (1.89) 75.08 (1.89)

35.26 (2.40) 64.74 (2.40)

189 566

90 657

31.88 10.35 15 494 (4.62) (3.94) 68.12 89.65 153 1991 (4.62) (3.94) Family Characteristics

22.55 (1.87) 77.45 (1.87)

24.05 (4.82) 75.95 (4.82)

35.33 (2.61) 64.67 (2.61)

29 136

Household Income, Percent of Federal Poverty Level (FPL) <100% 67.26 62.81 73 1310 300 (1.70) (3.37) 100-199% 10.40 9.04 418 90 20 (0.95) (1.59) 200-299% 6.04 4.61 327 72 19 (0.83) (0.88) 300-399% 6.22 9.10 281 84 16 (0.72) (1.68) >400% 10.09 14.45 40 647 211 (0.79) (1.90)

35.81 (7.20) 64.19 (7.20) 63.21 (6.35) 11.38 (4.42) 4.75 (1.71) 6.87 (2.57) 13.80 (4.92)

525 1919

1106 359 279 228 524

68.07 (1.81) 10.66 (1.06) 5.67 (0.68) 5.98 (0.78) 9.62 (0.86)

11 85

22 75

42 15 9 7 24

10.32 (3.79) 89.68 (3.78)

46.39 (8.97) 53.61 (8.97) 64.13 (7.86) 13.93 (4.65) 4.68 (2.12) 3.42 (1.75) 13.83 (6.56)

36 588

137 478

290 85 72 47 132

9.05 (2.26) 90.95 (2.26)

46.03 (5.80) 53.97 (5.80) 68.95 (4.35) 10.71 (2.69) 7.17 (2.70) 3.67 (0.91) 9.51 (1.96)

*DURING THE PAST 12 MONTHS, how often have [child’s] conditions or problems affected his or her ability to do things other children his or her age do?

Table 2. Table 2. Prevalence of meeting physical activity guidelines among children 6-to-17 years old with a developmental disability diagnosis, by diagnosis type {ASD, CP, DS, DD, and ID]. Crude and adjusted odds ratios, alongside 95% confidence intervals (95% CI) for meeting PA guidelines among children with a given diagnosis compared to the odds among children one or more of the other developmental disability diagnoses. Source: National Survey of Children’s Health 2016-17 ASD1 3

Diagnosis1 No Yes Complexity2 1

OR [95% CI]

aOR [95% CI]

Reference 0.65* [0.43, 0.97]

Reference 0.68 [0.42, 1.10]

Reference 0.85 [0.42, 1.73]

Reference 1.01 [0.47, 2.17]

Reference 0.76 [0.37, 1.54]

Reference 0.84 [0.36, 1.98]

Reference 1.50 [0.84, 2.68]

----

Reference 1.26 [0.76, 2.12] 1.26 [0.55, 2.31]

----

Reference 1.14 [0.71, 1.84] 1.00 [0.51, 1.96]

----

Reference 1.15 [0.71, 1.85] 1.05 [0.48, 2.31]

----

Reference 1.39 [0.91, 2.11] 1.43 [0.79, 2.57]

----

2

----

3+

----

Severity Mild Moderate Severe Functional Limitations No Yes Age group 6 to 11

4

Meeting Physical Activity Guidelines, 60+ minutes of exercise, sport of physical activity daily in the past week CP1 DS1 DD1 3 4 3 4 3 OR aOR OR aOR OR aOR4 [95% CI] [95% CI] [95% CI] [95% CI] [95% CI] [95% CI]

----------

----------

Reference 1.22 [0.77, 1.93] 1.12 [0.63, 2.32] Reference 0.48 [0.32, 0.73]

----------------

-------

Reference 1.38 [0.91, 2.10] 1.43 [0.79. 2.59] Reference 0.48 [0.31, 0.74]

----------------

-------

Reference 0.48 [0.31, 0.74]

-------

-------

-------

ID1 OR [95% CI]

aOR4 [95% CI]

Reference 1.28 [0.63, 2.59]

Reference 1.16 [0.73, 1.85]

Reference 1.41 [0.59, 3.35]

Reference 1.12 [0.69, 1.79] 0.96 [0.48, 1.95]

----

Reference 0.94 [0.47, 1.86] 0.74 [0.25, 2.18]

Reference 1.32 [0.82, 2.13]

----

1.37 [0.74, 2.54] Reference 0.48 [0.31, 0.74]

3

-------

-------

-------

Reference 1.32 [0.88, 1.98] 1.32 [0.71,2.46] Reference 0.48 [0.31, 0.74]

Reference ---Reference ---Reference ---Reference ---Reference 0.48 0.48 0.48 0.49 0.48 12 to 17 ---------------[0.33,0.69] [0.33,0.69] [0.33,0.69] [0.34, 0.72] [0.33, 0.69] 1 Diagnoses categories, not mutually exclusive: ASD= autism spectrum disorder, CP = cerebral palsy, DS = Down syndrome, DD= developmental delay, ID = intellectual disability; 2 Complexity indexed by number of diagnoses; 3 OR = crude odds ratio, bivariate logistic regression analyses; 4 aOR = Adjusted odds ratio, adjusted for diagnosis, complexity, severity, functional limitations and age-group; Bold = p < 0.001 *Example interpretation: The odds of meeting PA guidelines among children with ASD are 0.65 times the odds among children with CP, DD, DS, and/or ID.