Promoting Health-Related Fitness for ElementaryStudents With Intellectual Disabilities Through aSpecifically Designed Activity Programjppi_293 77..84

Kathryn Davis, Guili Zhang, and Patricia HodsonEast Carolina University, Greenville, NC, USA

Abstract The Motivate, Adapt, and Play Program was specifically designed as an adapted physical activity (PA) program for studentswith intellectual disabilities (ID) to meet required school PA policies to combat childhood obesity. The policies commonly require aminimum of 30 min of PA per school day. A study was undertaken to test the efficacy of the program. Twenty-five students with ID(9 girls, 16 boys; ages 9.7 � 1.2) from four elementary schools in the southeastern United States participated in the study. Thehealth-related fitness measures of the 16-m shuttle run test, the modified curl-up test, and the back-saver sit-and-reach test werecompleted at the beginning and at the end of an 8-week period. Body mass index (BMI) measurements were also obtained. Duringthe interval, participants completed a 30 min/day, 5 days/week activity program, focusing on cardiovascular endurance, flexibility, andmuscular strength and endurance activities, utilizing specialized equipment. Over the 8 weeks, there was a significant increase in thehealth-related fitness scores obtained. As expected, there was a slight decrease in BMI over 8 weeks, although it was a nonsignificantfinding. The findings suggest that the health-related fitness of students with ID can be improved through engaging in a school-baseddaily adapted PA program.

Keywords: adapted exercise program, fitness, intellectual disabilities, physical activity, physical education

INTRODUCTION

Children with intellectual disabilities (ID) have been identi-fied as having lower health-related fitness levels than their peerswithout ID (Chow, Frey, Cheung, & Louie, 2005; Fragala-Pinkham, Haley, Rabin, & Kharasch, 2005; Frey & Chow, 2006;Gillespie, 2003; Halle, Gabler-Halle, & Chung, 1999; Khalili &Elkins, 2009; Ozmen, Un Yildrim, Yuktasir, & Beets 2007; Pitetti,Yarmer, & Fernhall, 2001; Winnick & Short, 2005; Wu et al.,2010). Students with ID have also been found to be more over-weight and less motor proficient than their peers without ID(Frey & Chow, 2006). There is serious concern that students withID may not be receiving adequate levels of physical education,recess time, or the types of physical activity (PA) that will meetthe health-related fitness needs of this population.

The effectiveness of a daily exercise period on a variety ofhealth-related physical fitness measures for individuals with ID isnot well documented (Wu et al., 2010). Furthermore, simplefield-based methods which can be performed easily in classroomsand gymnasiums are sorely needed for use by adapted physical

education (APE) professionals, as well as associated professionalsand paraprofessionals (Pitetti et al., 2001). The exportability ofsuch programs to increase health-related fitness is particularlyuseful for students with ID, particularly those in self-containedclasses who may, or may not, receive regular physical education.In order to promote health-related fitness for children withdisabilities, their fitness levels must first be measured. Becausehaving higher levels of physical fitness is important to the func-tional health needed for everyday living and for the prevention ofdisease and obesity, attempts should be made to evaluate thephysical fitness of children with ID.

Most fitness studies including youth with ID have focusedon cardiovascular endurance, body composition, and/or assess-ment methodology, and there have been few efforts to utilizelarge-scale fitness test batteries (including all five components ofphysical fitness: cardiovascular endurance, muscular strength,muscular endurance, flexibility, and body composition) to assessthe fitness levels of children with ID (Chow et al., 2005). Inaddition, there have been few attempts to use exercise programinterventions to improve the health-related fitness levels inthis population for all components of fitness. There is a needto critically examine exercise programs for children with IDbecause disparities in fitness levels between children withand without ID evidenced 50 years ago still exist (Gillespie,2003). As Pitetti et al. (2001, p. 138) stated, “It is now time forthose of us concerned about the health profiles of children and

Received July 28, 2010; accepted January 12, 2011Correspondence: Kathryn Davis, East Carolina University, Exercise andSport Science, 154 Minges Coliseum, Mailstop 559, Greenville, NC27858-4353, USA. Tel: +1 252 328 5266; Fax: +1 252 328 4654; E-mail:daviska@ecu.edu

Journal of Policy and Practice in Intellectual DisabilitiesVolume 8 Number 2 pp 77–84 June 2011

© 2011 International Association for the Scientific Study of Intellectual Disabilities and Wiley Periodicals, Inc.

adolescents with (intellectual disabilities) to begin to identifypractical interventions to either improve or prevent the declineof their physical fitness portfolios.”

There is an abundance of prior research on assessing thehealth-related physical fitness of children with ID. However,classroom-based exercise programs for students with disabilitieshave not been widely developed and implemented (Sit, McKen-zie, Lian, & McManus, 2008). Khalili and Elkins (2009) admin-istered an 8-week aerobic exercise program of walking, running,and cycling for 30 min, 5 days per week, with a target of moder-ate intensity. Results showed significantly improved lung func-tion in all 44 Iranian 12-year-old children with ID as a resultof the 8-week intensive exercise program. Wu et al. (2010)conducted a 6-month physical fitness program with childrenand adults with ID (N = 146) in Taiwan. They found positiveimprovements in flexibility and abdominal strength, but noimprovements on the shuttle run or in decreasing body massindex (BMI). Halle et al. (1999) used a 10-week peer-mediatedaerobic conditioning program to significantly increase theaerobic fitness levels of 17 children with ID. Ozmen, et al. (2007)conducted a school-based 10-week cardiovascular trainingprogram for 30 boys (15 were randomly placed in a controlgroup) in Turkey. Significant increases in cardiovascular fitnesswere observed for the experimental group, but no improvementswere made in percent body fat. Yilmaz, Ergun, Heper, Knouk-man, and Zorba (2003) reported that a 10-week water exerciseand swimming program for 16 children can have viable effects oncardiovascular endurance but little impact on body composition.Fragala-Pinkham et al. (2005) studied nine children with ID whoparticipated in a 14-week exercise program (two sessions perweek, 60–70 min) designed by a physical therapist, and observedmixed improvements in all components of fitness. Pitetti and Tan(1991) administered a minimally supervised 16-week exerciseprogram to 12 adults with ID, and 11 of the 12 participantsexhibited increases in cardiovascular fitness. Finally, Bundschuhand Cureton (1982) showed increases in cardiovascular fitness ofboth their control and experimental groups of adolescents withID after just 7 weeks of training. There was agreement with theneed for additional studies focusing on the investigation of pro-grams designed to improve the health-related fitness of childrenwith ID (Fragala-Pinkham et al., 2005; Gillespie, 2003; Halleet al., 1999; Pitetti et al., 2001).

SPECIFIC AIMS

Perhaps, the most poignant rationale for the present investi-gation is the notion presented by Pitetti, Beets, and Combs (2009)that this population is at risk for a significantly substandardquality of life resulting from a lack of physical fitness. To this end,the purpose of this study was to assess the effectiveness of theMotivate, Adapt, and Play (MAP) adapted exercise program byassessing the health-related fitness of children with mild-to-moderate ID before and after a specifically designed 8-week exer-cise program. This study addresses one specific research question:Does the implementation of the 30-min/day MAP adaptedexercise program have an effect on the health-related fitnessof students with mild-to-moderate ID? A self-contained classsetting was chosen because the majority of children with mild-

to-moderate ID are in self-contained classes in school systems,and the school is the primary institution for promoting exercisebehavior (Pitetti et al., 2009).

METHOD

Participants and Research Settings

Twenty-five elementary school youths (9 girls, 16 boys; ages9.7 � 1.2 years; BMI 19.9 � 5.9 kg/m2) with mild-to-moderateID participated in this study (see Table 1 for descriptive charac-teristics). Eleven of the 25 participants were African-American, 11were Caucasian, and three were Hispanic. The 25 participantsin this study were representative of what one would find in anyself-contained placement class. All the participants had been clas-sified as having mild-to-moderate ID by the school district per-sonnel. The students were not classified in their self-containedclasses by levels of mental ability (i.e., intelligence quotients orIQs), so as not to perpetuate the stigma of being classified witha cognitive disability. Verification that the sample representedyouths with mild-to-moderate ID was based on strong adherenceto school placement and teacher confirmation.

Of the youths, 15 students with ID (60%) were classified inthe “healthy” weight zone, and 10 (40%) were in the “unhealthy”weight zone, as determined by Fitnessgram criterion-referencedBMI standards. Of the 10 students in the “unhealthy” weightzone, five (20%) were overweight and five (20%) were under-weight. In regard to the classification of the “healthy” and“unhealthy” weight, the authors chose to use the Fitnessgramstandards in order to show underweight status as well as over-weight status. The commonly used international definitions ofchildhood obesity (Cole, Bellizi, Flegal, & Dietz, 2000) have threeclassifications (non-overweight, overweight, and obese), whichdid not fit the purposes (or the sample) of this study. A recentstudy (Wu et al., 2010) also used the underweight category tomake BMI classifications.

There were 38 original participants, but 11 were below the ageof 8, and two were unable to participate or complete all measure-ments due to extended absence or co-concurring disabilities.These co-concurring disabilities impacted their ability to partici-pate in the fitness testing (e.g., sensory sensitivity associated withautism, etc.) as their data could lead to unreliable results (Frey &Chow, 2006). As a result, data from the remaining 25 participantsare reported.

TABLE 1Participant demographics by sex

Variable

Girls (n = 9) Boys (n = 16)

M SD M SD

Age (y) 9.3 1.4 9.9 1.0Height (m) 1.2 0.1 1.3 0.1Weight (kg) 81.1 34.3 73.7 18.7Body mass index (kg/m2) 21.6 7.3 19.0 4.9

Journal of Policy and Practice in Intellectual Disabilities Volume 8 Number 2 June 2011

K. Davis et al. • Fitness of Students With ID

78

The research settings were four elementary schools in oneschool district in the southeastern United States. The fourelementary schools were purposively selected from the sevenschools in the district that included K-5 self-contained specialeducation classes of students with mild-to-moderate ID (Turn-bull, Turnbull, Warren, Eidelman, & Marchand, 2002). Theseelementary schools contained approximately 600 students each.The four special-needs classes contained 5–14 students and alicensed special education teacher who was assisted by two para-educators. The amount of support (i.e., paraeducators) for eachchild depended on the needs of the child as outlined by theirindividualized educational plan.

This study was approved by the researchers’ university reviewboard, and the study was fully scrutinized because of the vulner-ability of the population. The county board of education super-intendent, the school building principals, the self-containedclassroom special education teachers, and the school physicaleducators agreed to allow the research to be conducted. Allparents received a letter explaining the research study. Signedparental consent was obtained for all children who participated inthe study.

Procedures

Before implementing the MAP program, we assessed the par-ticipants’ baseline scores on the BMI, 16-meter modified Progres-sive Aerobic Cardiovascular Endurance Run (PACER), modifiedcurl-up, medicine ball throw, and the Back-Saver Sit-and-Reach(BSSR) test. Participants were familiarized with the testing pro-cedures and allowed practice trials (except for the BMI measures);demonstrations were provided before the assessments wereadministered; and verbal cues were used to reinforce correct tech-nique and to help motivate the children during trials. The assess-ment of health-related fitness took place during a 2-week periodin the first month of a fall semester (pre-assessment), and thenagain at the end of the same fall semester (post-assessment). Allmeasures were administered during the same scheduled classtime each day. The MAP program was implemented for 8 weeks,twice per week for 30 min each time. Two trained Doctor ofPhysical Therapy graduate students and two trained APE gradu-ate students conducted the MAP program activities. In addition,the special education classroom teachers were trained to conductthe MAP program on the remaining 3 days of the week, for30 min each day. Therefore, the students with ID in this studyparticipated in the MAP program 5 days/week for 8 weeks (totalsessions = 40). Ninety-eight percent of the sessions were attendedby the sample group. The administration protocol was viewed assuccessful because all the children were able to complete theentire test battery.

The interdisciplinary research team collaborated to developthe MAP Program, an adapted PA program conceptualized anddesigned as a potentially sustainable in-school program forimproving health-related fitness for students with mild-to-moderate ID. The MAP program was also designed to meet thestate’s 30-min/day PA policy for children (both without and withID) in the state’s K-8 schools (e.g., structured classroom or activerecess exercise programs). The MAP program activities were self-designed by the study’s research experts in APE and physical

therapy. Each activity was presented in a game-like format toemphasize the element of play. There were a total of 7–8 activitiesdeveloped within each of the three health-related fitness catego-ries; these were rotated from day-to-day to add variety to theworkouts. At a workshop, graduate students and special educa-tion teachers were trained to lead these activities, and were givena MAP Activities Manual and a DVD of how to lead and adapt theactivities.

All MAP components were physically active in nature, andfocused on at least one of three health-related fitness areas:strength, flexibility, and cardiovascular endurance (Schultheis,Boswell, & Decker, 2000). The sequence of the cardiovascular andstrength activities was alternated between each day of the MAPprogram (e.g., cardiovascular endurance activities after warm-upon one day, strength activities after warm-up the next day, etc.) toincrease variety for the students with ID, but the flexibility activi-ties were maintained as the last section of the lesson on every dayof the MAP program. This format was also easily adapted to theself-contained class schedules by dividing activity sessions intoseparate parts performed at different times of the day, or byproviding a water break in between separate activities. Duringeach MAP session, short breaks of 1–2 min were providedbetween activities (which included such diversions as bubbleblowing, hand clapping, or deep breathing exercises) because theyhelped to promote consistent participation. Table 2 outlines anexample of an exercise session.

Instrumentation

The researchers for this study carefully selected the mostappropriate measures currently used with students with ID todocument health-related fitness. Three of the health-relatedfitness measures for this study were selected from the BrockportPhysical Fitness Test (BPFT), which was specifically developed forstudents with various disabilities and has been reported to bevalid and reliable with students with ID (Winnick & Short, 1999).The BPFT provides selection guides to help with the selection oftest items, and recommends that 4–6 test items are an appropriatenumber of items to use. Five testing items were selected andadministered with the careful use of verbal prompting and appro-priate motivation techniques and practice trials for students withID. These measures include: (1) BMI; (2) the BPFT 16-metermodified PACER test to measure cardiovascular endurance; (3)the BPFT modified curl-up test of abdominal strength thatmeasures muscular endurance; (4) the medicine ball throw tomeasure arm strength; and (5) the BPFT BSSR test to measureflexibility. The students were assessed using the medicine ballthrow because pilot testing showed several difficulties in using theBPFT modified pull-up test with this population (including dif-ficulty with understanding the directions for the test, difficulty inobtaining one pull-up, etc.). These measures were chosen becauseof their roles as important indicators of health-related fitness.

The BPFT is a criterion-referenced test of health-relatedfitness, that is, test scores are compared to standards that areassociated with some index of positive health (Winnick & Short,2005). Three different types of validity are claimed for the varioustest items in BPFT: concurrent, construct, and logical (Winnick& Short, 1999). For example, regarding concurrent validity,

Journal of Policy and Practice in Intellectual Disabilities Volume 8 Number 2 June 2011

K. Davis et al. • Fitness of Students With ID

79

reported correlations between the test item and the criterionmeasures are at least moderate, with most estimates between 0.70and 0.89. According to Winnick and Short (1999), the test–retestreliability coefficients associated with BPFT test items are at leastminimal levels of acceptability. The reliability estimates of themedicine ball throw for children without ID were 0.93 and 0.94for day 1 and day 2, respectively, and the test–retest reliability was0.88 (Davis et al., 2008). Validity of the medicine ball test wasshown through the known differences and the correlationalforms of validity evidence.

BMI BMI provides an indication of the appropriateness of achild’s weight relative to height, and it is considered a good indexof obesity during childhood and adolescence (Pitetti et al., 2001).BMI was determined using the formula: weight [kg]/height [m2].The BMI Calculator for Child and Teen English Version on theWeb site of the Centers for Disease Control and Prevention(CDC) (2009) was used to calculate the BMI value for each par-ticipant. Standing height (cm) was measured without shoes to thenearest 0.1 cm using a portable stadiometer (Model 214, range:20–200 cm; Seca, Hamburg, Germany). Body weight (kg) wasmeasured to the nearest 0.1 kg using a digital weight scale (ModelDG-66, maximum: 150 kg; Seca). Participants’ ages were calcu-lated by subtracting their date of birth from the date of assessment,using the Weill Medical College of Cornell University age calcula-tor for pediatric medicine (Pon, 2010). Winnick and Short (1999;p. 368) reported sufficient concurrent and predictive validity forBMI tests in the BPFT; they also reported that there is sufficientreliability, due to the “objective nature of the measurements thatcomprise BMI.” Lohman (1994, p. 59) noted that “the reliability ofBMI is very high because the measurement of height and weight isvery precise when following a standardized protocol.”

Modified 16-meter PACER The modified PACER test was per-formed on a flat nonslip surface in the school gymnasiums.Marking cones were set 16 m apart, the usual distance used forchildren with disabilities. A compact disc (CD) with audiblebeeps for keeping lap times was played in a CD player. Investiga-tors provided verbal and visual demonstrations of the task.During the two practice trials, an adult ran alongside each par-ticipant to orient the children with ID to the procedures of the

test and to give verbal motivation cues. Participants then rancontinuously from the starting point marked by the cones withrecorded beeps signaling start and stop. Participants continueduntil they were unable to keep pace with beeps for two consecu-tive ends. Credit for a lap was given only if the entire 16-mdistance was completed. The number of laps was recorded by oneof the investigators.

Modified curl-up Participants started in the supine position on afloor mat with feet flat on the floor and legs slightly apart withtheir hands placed on the thighs. Their shoulders rose off the floor,and they slid their hands along their thighs until their fingertipscontacted their patellae. Investigators placed their hands on theparticipants’ patellae to provide a tangible target. Participantsreceived two practice trials, and then the number of modifiedcurl-ups performed correctly was recorded. One modified curl-upwas counted for every return to the supine position on the floormat. Curl-ups were not counted if the participant’s feet com-pletely left the floor during the movement and if the participantdid not reach the required distance, did not return to the startposition, or performed the curl-up in any other incorrect manner.

Medicine ball throw Participants started in a seated position onthe gym floor, with their shoulders squarely touching the wall andtheir legs extended in front of them. The participants were thenasked to lift a 2-lb medicine ball from their lap to chest level, thenpush the ball (like a basketball chest pass) forward as far as theycould within a measured 36 inch-wide alley. Each participantwas given two practice throws, and the data from the next threemedicine ball throws were taken and averaged for a score.

BSSR The objective of this test is to reach across a sit-and-reachbox, keeping one leg straight. This test measures flexibility ofthe hamstring muscles (Winnick & Short, 1999). Participantsremoved their shoes and sat in front of the apparatus. One leg wasfully extended with the foot flat against the end of the testinginstrument. The other knee was flexed with the sole of the foot flaton the floor, 2–3 inches to the side of the straight knee. Arms wereextended forward over the measuring scale with the palms down,one hand on top of the other. Participants reached directlyforward with both hands and pushed a sliding scale for four trials

TABLE 2Example of MAP exercise session

Phase Purpose Activity

Warm-up (3 min) Prepare joints, muscles, bonesfor exercise

Slow walk; instant activity of low-level movement; deep breathing; liftarms high; exercises for balance, agility; clapping hands on floor whilesitting; locomotor movements

Aerobic enduranceactivities (10 min)

Improve cardiovascularendurance

Walk fast/jog; tag games; scooter boards; jumping, dribbling, skipping,hopping; animal walks; station work; movements with beanbags/hulahoops; dancing to music/instruments; partner relays

Muscular strength/endurance (10 min)

Improve upper and lowerstrength

Slow bending; light hand weights; medicine ball activities; isometricexercises; yoga; sit-ups; pull-ups; push-ups; stretch band exercises

Flexibility stretches/closure (7–10 min)

Allow body to recover/increaseflexibility of joints

Slow dances; slow, static stretches of arms, legs, trunk; parachute activities

Journal of Policy and Practice in Intellectual Disabilities Volume 8 Number 2 June 2011

K. Davis et al. • Fitness of Students With ID

80

(two were practice trials). After measuring one side, the partici-pant switched the position of the legs and reached again. Each trialwas recorded and the longest reach was the participant’s score.

RESULTS

Analysis Procedures

Students’ performances before and after the MAP program onthe fitness measures were compared to the Fitnessgram standards(Meredith & Welk, 2007) and to the BPFT standards (Winnick &Short, 1999), according to the age level standards available. Acorrelated t-test was used to investigate whether there was a sta-tistically significant difference between the before and after scoresfor each of the six measures. It is noted that this is a one-grouppretest–posttest design, which is considered weaker than thestatic-group pretest–posttest design. The concern associated withthe one-group pretest–posttest design is that natural growth(rather than the intervention) might explain the observed change.However, given the number of students with ID in self-containedclasses in the county, it was virtually impossible for us to use thestatic-group pretest–posttest design. Additionally, in this particu-lar study, due to the short time between the pretest and posttests,the amount of changes that can be attributed to natural growthshould not be of serious concern. Nonetheless, we advise readersto be cautious when interpreting the findings.

In considering the choice between the parametric t-test and itsnonparametric analogue, we decided that the parametric t-testwould be more appropriate. First, based on the distribution of thesample, it is reasonable to assume that the data come from apopulation that approximately follows a normal distribution.Second, there is a further safeguard when you choose a paramet-ric t-test even if there is a chance that the population distributionis not normal because the central limit theorem ensures thatparametric tests work well with large samples even if the popu-lation is non-normal. Unless the population distribution is reallypeculiar, it is safe to choose a parametric test when there are atleast 24 data points in a group (and we have 25).

When deciding whether a Bonferroni correction is needed tocontrol for familywise error rate, it is important to decide, prior toseeing the statistical results, whether the comparisons should beconsidered a “family” of statistical tests. While the Bonferronicorrection does a good job of controlling the familywise error ratefor multiple, independent comparisons, it may lead to a very highrate of false negatives. In this study, we were more interested inlooking at whether these fitness measures change as individualmeasures rather than collectively as a family of measures. Wedecided that our conclusions would be regarding individual mea-sures rather than an overarching conclusion about all of thesemeasures, and we would not try to capitalize the ones that werefound to be significantly different and make a general statementabout all of these measures. Because we treated each measure asan individual comparison of interest, we did not try to control thefamilywise error rate using the Bonferroni or the Bonferroni–Holme procedure.

An effect size using Cohen’s d was calculated for each measureto facilitate better interpretation because effect sizes are able to

provide vital information not available from the t-test, such asmagnitude of effect (Zhang, 2009; Zhang & Algina, 2008). Cohen(1969) suggested 0.20, 0.50, and 0.80 as small, medium, and largeeffect sizes.

BMI Measures

The average BMI of the 25 students was 19.96 before the MAPprogram and it was slightly lower (19.94) after the MAP program.Both preprogram and post-program BMI values are close to theheavier end of the “healthy fitness zone” based on the Fitnessgramstandard (Meredith & Welk, 2007). The BMIs of 15 students outof the 25 (or 60%) met the Fitnessgram standard for healthyweight before the MAP program, and the same students still metthe standard after the MAP program. Before the MAP program,eight (or 73%) of the 11 students aged 10 years and older (there-fore, they were assessed using the BPFT standard, in addition tothe Fitnessgram standard) met the BPFT standard. After the MAPprogram, nine (or 69%) of the 13 students aged 10 years andolder met the BPFT standard (Winnick & Short, 1999). The cor-related t-test results reported in Table 3 show no statisticalsignificance between the before and after BMIs (t = 0.056,p = 0.956). The effect size was d = 0.01, indicating a very trivialeffect in favor of the MAP program.

Health-Related Fitness Measures

The mean PACER laps completed by the 25 participantsincreased from 10.28 laps before the MAP program to 13.24 inthe post-MAP assessment. Perhaps, more notably, during the pre-MAP assessment, two of the students were not able to make anynumber of laps; while in the post-MAP assessment, both of themwere able to complete one or more laps. The research team com-pared students’ performance on the PACER test to the availableBPFT age- and gender-specific standards (because the Fitness-gram does not offer standards for the 16-meter PACER test).Based on the BPFT standards, six out of 11 students (54.5%) metthe standard before the MAP program, and nine out of 13students (69.2%) met the BPFT standards after the MAP pro-gram. The correlated t-test results show a significant statisticaldifference between the before and after PACER laps (t = 2.69,p = 0.013). The effect size of d = 0.55 indicates a medium-sizedpositive effect of the MAP program on students’ performance onthe PACER test (see Table 3).

On the modified curl-up, a total number of five out of 25(20%) students met the Fitnessgram standard before the MAPprogram, and 11 out of 25 (44%) met the standards after theprogram. By the BPFT standards, five out of 11 (45.4%) met thestandards before the MAP program, while eight out of 13 (61.5%)met the standards after the program. The mean number of curl-ups completed by the 25 participants increased from 7.12 curl-ups before the MAP program to 12.64 curl-ups in the post-MAPassessment. Correlated t-test results showed a significant increasebetween the before and after number of modified curl-ups com-pleted (t = 2.089, p = 0.048). The effect size of d = 0.42 suggests amedium-sized positive effect of the MAP program on students’performance on the modified curl-up (see Table 3).

Journal of Policy and Practice in Intellectual Disabilities Volume 8 Number 2 June 2011

K. Davis et al. • Fitness of Students With ID

81

The Fitnessgram and BPFT standards do not offer criteria forthe Medicine Ball Throw test; therefore, students’ performance onthe Medicine Ball Throw was not compared to the standards.Before the MAP program, students threw the medicine ball anaverage of 101.52 in. in distance; after the program, the averageincreased to 129.08 inches. A statistical comparison using thecorrelated t-test shows a significant increase between the before-MAP and after-MAP distance on the Medicine Ball Throw com-pleted by the students with ID (t = 2.081, p = 0.048). The effectsize of d = 0.42 suggests a medium-sized positive effect of theMAP program on students’ performance on Medicine Ball Throw(see Table 3).

The procedures for the BSSR in the Fitnessgram state that astudent is considered as having met the standard if he or shereached the standard on either the left side or right side, or onboth sides. Before the MAP program, 16 out of the 25 students, or64%, met the Fitnessgram standards. The number of studentswho met the BSSR standards increased to 18 (or 72%) during thepostassessment. Among the 12 students who were compared tothe BPFT standards for the BSSR, seven (58.3%) met the stan-dards before the MAP program and 10 (83.3%) met the standardsafter the MAP program. The results show a general tendency forstudents to improve on the BSSR test of flexibility from partici-pating in the MAP program. The t-test results confirms thisobserved trend; that is, a significant difference is detected betweenthe before and after distance of the BSSR completed by the stu-dents with ID both for the right side (t = 4.278, p = 0.000) and forthe left side (t = 5.329, p = 0.000). The effect sizes are d = 0.882and d = 1.07 for the right side and the left side, respectively. Thissuggests a very large effect of the MAP program on students’performance on the BSSR (see Table 3).

DISCUSSION

The purpose of this study was to investigate whether an8-week school-based exercise program can improve the health-

related fitness levels of children with ID. The results of the presentstudy suggest that children with ID do increase their health-related fitness levels and PA levels if they participate in an effectiveschool-based adapted exercise program for an 8-week length, atleast 30 min per day. Equally important is the finding that dailylow-cost, adapted classroom activities can be an effective meansof improving the health-related physical fitness of children withID. It is notable that not only were statistically significantimprovements observed in cardiovascular endurance, muscularstrength and endurance, and flexibility, but also, the exerciseprogram elicited a moderate improvement of BMI. The moderatedecrease in BMI can be attributed to the short length of theprogram intervention (8 weeks). Findings support the notionthat appropriate engagement in structured exercise programsduring physical education or recess periods can make a significantcontribution to recommended daily PA for children with ID,and it has the potential to impact future practice in the schools(Pan, 2008).

Our findings are similar to those reported from previousstudies on children with ID (Fragala-Pinkham et al., 2005; Khalili& Elkins, 2009; Ozmen et al., 2007; Wu et al., 2010). In otherfitness intervention studies of individuals with ID, the length ofthe exercise program (intervention) was between 7 and 24 weeks,with the most common duration of 10 weeks. Most of theseintervention programs only measured cardiovascular fitnesslevels before and after the intervention (Bundschuh & Cureton,1982; Halle et al., 1999; Pitetti & Tan, 1991; Yilmaz et al., 2003).The present study is unique in offering a specifically designedexercise program for children with ID that has proven effective-ness in enhancing the health-related fitness of this population.

Apart from the beneficial results gleaned from previousstudies, a noteworthy implication is that several of them usedexercise protocols that are unlikely to be accessible to many prac-titioners (e.g., adapted physical educators). When trying to dis-seminate a program for widespread implementation, programsthat use available resources might be more appealing and easier toadapt by reducing the barrier of limited facility access (Ozmen

TABLE 3Student performance before and after the MAP program (n = 25)

Measures Assessment Mean SD t df p-value ES (d)

BMI Before 19.96 5.92 0.056 24 0.956 0.01After 19.94 5.71

PACER Before 10.28 11.72 2.69 24 0.013* 0.55After 13.24 10.89

Modified curl-up Before 7.12 11.80 2.089 24 0.048* 0.42After 12.64 10.55

Medicine ball throw Before 101.52 73.92 2.081 24 0.048* 0.42After 129.08 80.02

Sit-and-reach right Before 23.08 7.49 4.278 24 0.000* 0.882After 27.10 8.67

Sit-and-reach left Before 21.86 7.84 5.329 24 0.000* 1.07After 26.68 8.07

Asterisk indicates statistical significance.ES = effect size, d = Cohen’s d.

Journal of Policy and Practice in Intellectual Disabilities Volume 8 Number 2 June 2011

K. Davis et al. • Fitness of Students With ID

82

et al., 2007). The activities incorporated in the present study wereof low-intensity and designed to be led by non-PA professionalsor paraprofessionals. Equally important is the finding that spe-cifically designed programs and simple outcome measures aremanageable in true field settings (i.e., real classrooms in typicalpublic schools), not just in laboratories or in specially focusedclinics. Our study supports the safety and feasibility of a struc-tured, 30-min/day adapted exercise program for young childrenwith ID. It is speculated that the participants in this study expe-rienced high levels of moderate-to-vigorous physical activity(MVPA) during the MAP activities.

In addition, our study found limited success in reducing BMImeasures, an indicator of obesity. The results of several otherstudies support our findings (Fragala-Pinkham et al., 2005;Ozmen et al., 2007; Wu et al., 2010). It is possible that our trainingprogram (8 weeks) and others (7–24 weeks) were not of sufficientduration or intensity to produce a reduction in body weight orbody fat. Therefore, we recommend that if a reduction in bodyfatness or obesity is desired, a longer program or one elicitinghigher levels of MVPA would be needed. In addition, as isrecommended in Healthy People 2010 (Department of Health andHuman Services (DHHS), 2000), this finding strengthens thecall for more physical education time in schools and suggeststhat unstructured time during the school day be redesigned toprovide structured exercise programs that encourage higher levelsof MVPA (Pan, 2008).

In light of the current findings, several limitations need to benoted. A limitation of this study was the lack of criterion-referenced standards available at certain age levels for studentswith disabilities. This forced comparisons of data with criterion-referenced standards for children without ID, although it washelpful for us to see that unhealthy weight in this population wasboth overweight as well as underweight. Second, one fitness mea-surement (medicine ball throw) lacked reliability and validitydata for children with ID. Because most of the validity and reli-ability estimates of the BPFT are based on those from the Fitness-gram test (for children without disabilities), it seems reasonableto assume that the medicine ball throw is reliable and valid forchildren with and without ID. One other possible limitation tothis study was the lack of a control group. A control group canhelp determine that the fitness improvements were due to theexercise program, by ruling out other possible factors such asmaturation. The sample size (n = 25) represented approximately90% of the total population of children with ID (aged 8–12) inthe school system. Because of this, it would have been difficult torandomly assign this small sample into control and experimentalgroups. Although because of the short time between the pretestand posttest, natural maturation is unlikely to be a significantcontributor to the observed changes in fitness measures, readersare cautioned when interpreting the findings. The possible differ-ences in the cultural and educational settings may have also elic-ited different outcomes than previous research (Pan, 2008). Usingfield tests (e.g., BMI calculation instead of more advancedtechniques such as bioimpedance) in the schools may havecompromised measurement precision. In addition, because theresearchers were limited by the consent of the school system, itwas not possible to adequately measure the nutritional consump-tion of the children in the study, which may have affected theslight decrease in BMI measures over the period of the study.

However, the obvious need for research on children with ID is touse practical measurement techniques that can be easily admin-istered in a school setting. Finally, this study was also limited tofour schools in one school district in the southeastern UnitedStates. The results of this study may not be entirely appropriateto be generalized to other locations because other schools withdifferent teacher-to-student ratios and facilities may experiencemore or fewer obstacles in providing exercise programs duringthe school day.

While the data collected provide insight into the health-related fitness of students with ID, other important consider-ations were not addressed. For instance, the relationship betweenhealth-related fitness and on-task behavior during exercise pro-grams is a particularly pertinent area for future study. In addition,the motivation of children with ID as they participate in exerciseprograms should be examined. Research is also needed to deter-mine if remediation of motor deficits leads to improvements inphysical fitness and reduced obesity in this population (Frey &Chow, 2006). Considering the unique needs of students with ID,it is suggested that many schools in different school districts bestudied in order to document fitness levels of a larger sampleusing the MAP activity program. Future studies should considerincluding more schools, using more field-based assessments,extending the exercise programs for students with ID to the entireschool year, examining different populations of students withdisabilities, controlling for caloric intake, and conducting longi-tudinal follow-up studies from the elementary through the highschool levels.

A major implication resulting from this study is that school-based exercise programs not only promote health, but they mayalso provide a strategy for obtaining valued social outcomes(Halle et al., 1999). In addition to studying the health benefits ofexercise in this population, research on the correlated outcomesof stress reduction, improved self-concept, improved sleep pat-terns, reduced absenteeism and behavior problems, as well asincreased cognitive functioning could be monitored. Their poten-tial deserves examination in future studies.

This study is unique because it is the first study to examineall five components of physical fitness in children with ID,after engaging in an exercise program specifically designed andadapted for children with ID. The MAP exercise program had asmall but statistically significant effect on the health-relatedfitness components in children with ID. We recommend thatchildren with ID be exposed to similar exercise programs toimprove their involvement in PAs and their quality of life whilereducing their risk for chronic diseases later in life.

REFERENCES

Bundschuh, E. L., & Cureton, K. J. (1982). Effect of bicycle ergometerconditioning on the physical work capacity of mentally retardedadolescents. American Corrective Therapy Journal, 36, 159–163.

Centers for Disease Control and Prevention (CDC). (2009). BMI percen-tile calculator for child and teen: English version. Retrieved July 20,2010, from http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx

Chow, B., Frey, G. C., Cheung, S.-Y., & Louie, L. (2005). An examinationof health-related physical fitness levels in Hong Kong youth withintellectual disability. Journal of Exercise Science and Fitness, 3, 9–16.

Journal of Policy and Practice in Intellectual Disabilities Volume 8 Number 2 June 2011

K. Davis et al. • Fitness of Students With ID

83

Cohen, J. (1969). Statistical power analyses for the behavioral sciences.New York: Academic Press, Inc.

Cole, T. J., Bellizi, M. C., Flegal, K. M., & Dietz, W. H. (2000). Estab-lishing a standard definition for child overweight and obesityworldwide: International survey. British Medical Journal, 320, 1240–1243.

Davis, K. L., Kang, M., Boswell, B. B., DuBose, K. D., Altman, S. R., &Binkley, H. M. (2008). Validity and reliability of the medicine ballthrow for kindergarten children. Journal of Strength and ConditioningResearch, 22, 1958–1963.

Department of Health and Human Services (DHHS). (2000). HealthyPeople 2010: Physical activity and fitness objectives for children andadolescents (Appendix 3). Retrieved April 24, 2011, from http://www.fitness.gov/betterhealth/ppar_a30.pdf

Fragala-Pinkham, M. A., Haley, S. M., Rabin, J., & Kharasch, V. S. (2005).A fitness program for children with disabilities. Physical Therapy, 85,1182–1200.

Frey, G. C., & Chow, B. (2006). Relationship between BMI, physicalfitness, and motor skills in youth with mild intellectual disabilities.International Journal of Obesity, 30, 861–867.

Gillespie, M. (2003). Cardiovascular fitness of young Canadian childrenwith and without mental retardation. Education and Training inDevelopmental Disabilities, 38, 296–301.

Halle, J. W., Gabler-Halle, D., & Chung, Y. B. (1999). Effects of a peer-mediated aerobic conditioning program on fitness levels of youthwith mental retardation: Two systematic replications. Mental Retar-dation, 37, 435–448.

Khalili, M. A., & Elkins, M. R. (2009). Aerobic exercise improves lungfunction in children with intellectual disability: A randomised trial.Australian Journal of Physiotherapy, 55, 171–175.

Lohman, T. G. (1994). Body composition. In J. R. Morrow, H. B. Falls &H. W. Kohl (Eds.), The Prudential FITNESSGRAM technical referencemanual (pp. 57–72). Dallas, TX: The Cooper Institute for AerobicsResearch.

Meredith, M. D., & Welk, G. J. (2007). Fitnessgram/activitygram testadministration manual. New York: Cooper Institute.

Ozmen, T., Un Yildrim, N., Yuktasir, B., & Beets, M. (2007). Effects ofschool-based cardiovascular-fitness training in children with mentalretardation. Pediatric Exercise Science, 19, 171–178.

Pan, C.-Y. (2008). Objectively measured physical activity between chil-dren with autism spectrum disorders and children without disabili-ties during inclusive recess settings in Taiwan. Journal of Autism andDevelopmental Disorders, 38, 1292–1301.

Pitetti, K. H., & Tan, D. M. (1991). Effects of a minimally supervisedexercise program for mentally retarded adults. Medicine and Sciencein Sports and Exercise, 23, 594–601.

Pitetti, K. H., Yarmer, D. A., & Fernhall, B. (2001). Cardiovascular fitnessand body composition of youth with and without mental retarda-tion. Adapted Physical Activity Quarterly, 18, 127–141.

Pitetti, K. H., Beets, M. W., & Combs, C. (2009). Physical activity levels ofchildren with intellectual disabilities during school. Medicine andScience in Sports and Exercise, 41, 1580–1586.

Pon, S. (2010). Medical calculators: Age calculator. Pediatric Critical CareMedicine, Cornell University. Retrieved July 28, 2010, from http://www-users.med.cornell.edu/~spon/picu/calc/agecalc.htm

Schultheis, S. F., Boswell, B., & Decker, J. (2000). Successful physicalactivity programming for students with autism. Focus on Autism andOther Developmental Disabilities, 15, 159–162.

Sit, C. H. P., McKenzie, T. L., Lian, J. M. G., & McManus, A. (2008).Activity levels during physical education and recess in two specialschools for children with mild intellectual disabilities. AdaptedPhysical Activity Quarterly, 25, 247–259.

Turnbull, R., Turnbull, A., Warren, S., Eidelman, S., & Marchand, P.(2002). Shakespeare redux, or Romeo and Juliet revisited: Embeddinga terminology and name change in a new agenda for the field ofmental retardation. Mental Retardation, 40, 65–70.

Winnick, J. P., & Short, F. X. (1999). The Brockport physical fitness testmanual. Champaign, IL: Human Kinetics.

Winnick, J. P., & Short, F. X. (2005). Conceptual framework for thebrockport physical fitness test. Adapted Physical Activity Quarterly,22, 323–332.

Wu, C.-L., Lin, J.-D., Hu, J., Yen, C.-F., Yen, C.-T., Chou, Y.-L., et al.(2010). The effectiveness of healthy physical fitness programs onpeople with intellectual disabilities living in a disability institution:Six-month short-term effect. Research in Developmental Disabilities,31, 713–717.

Yilmaz, I., Ergun, N., Heper, F., Knoukman, F., & Zorba, E. (2003). Effectsof an aquatic exercise and swimming program on the body compo-sition and under working capacity of mentally retarded children.Research Quarterly for Exercise and Sport, 74 (Suppl), 82–83.

Zhang, G. (2009). t Test: The good, the bad, the ugly, & the remedy.Middle Grades Research Journal, 4, 25–34.

Zhang, G., & Algina, J. (2008). Coverage performance of the non-centralF-based and percentile bootstrap confidence intervals for root meansquare standardized effect size in one-way fixed-effects ANOVA.Journal of Modern Applied Statistical Methods, 7, 56–76.

Journal of Policy and Practice in Intellectual Disabilities Volume 8 Number 2 June 2011

K. Davis et al. • Fitness of Students With ID

84