Exercise and Sleep in Children with Disabilities
By Megan Alder, PhD, RN
“Exercise should be regarded as a tribute to the heart.” – Gene Tunney
Physical activity and exercise are the foundation for growth and development.1 Physical activity, exercise, and physical fitness have substantial health benefits. The focus of this article will be on exercise and sleep in children with intellectual and developmental disabilities (referred to disabilities throughout the article). In this article, the terms physical activity and exercise will be used interchangeably.
Vignette 1: “Molly” is a 10-year-old girl with Down syndrome. After school, she plays video games with her siblings and doesn’t exercise. Molly is overweight. Her pediatrician has concerns about her sleep. Molly is not able to fall asleep or stay asleep. Recently at school, Molly’s teacher noticed that she is not able to regulate her mood and seems down lately.
What is physical activity? Physical activity is when the skeletal muscles produce a bodily movement that results in energy expenditure (or kilocalories burned).
What is exercise? Exercise is a “planned, structured, and repetitive” type of physical activity that improves or maintains physical fitness.
What is physical fitness? Physical fitness is a set of health-related (e.g., muscular endurance, flexibility) or skill-related (e.g., balance, speed, power) characteristics that people have or aim to achieve.2
Engaging in regular physical activity is one of the best ways to improve health. Physical activity strengthens our minds, hearts, and bodies.3 There are many benefits of physical activity, including: prevents obesity, improves sleep, strengthens the cardiovascular system, lowers stress, improves mood, improves cognitive function, and reduces the risk of developing a chronic condition (e.g., diabetes).1
How does exercise relate to sleep? Studies show a strong link between exercise and sleep.4,5 Achieving the recommended amount of exercise can improve sleep, while a healthy sleep-wake cycle improves strength and endurance the next day.6 It is also important to know that the time of day (morning vs. evening), duration (30 vs. 60 minutes), type and intensity (moderate vs. vigorous) of exercise impacts sleep differently. The optimal time of day to exercise to improve sleep is still unknown.4 A good rule of thumb is to avoid engaging in vigorous-intensity exercise at least one hour before bedtime for optimal sleep. Also, exercising outside in the natural sunlight helps regulate our sleep-wake cycle.7
In 2019, over 3 million children in the United States had a disability.8 Some of the most common developmental disabilities in children include cerebral palsy, Angelman syndrome, Down syndrome, and Prader-Willi syndrome.9 In 2018, among the common developmental disabilities, 1 in 44 children in the United States were diagnosed with autism spectrum disorder.10 With the increase in reported prevalence of disabilities in children, the importance of promoting physical activity to improve health is more critical now than ever.
Physical activity in children with disabilities is as important as it is for their peers. Children with disabilities have higher rates of physical inactivity and lower physical fitness levels compared to their peers.11 In children with autism spectrum disorder, the risk of obesity is much higher for those who do not exercise.12 In children and youth with autism spectrum disorder, > 60 minutes of moderate-to-vigorous physical activity each day improves academic performance, mood, and sleep behaviors.13,14 However, compared to 60% of their peers, only 37% of children with autism spectrum disorder achieved the recommended 60 minutes or more of moderate-to-vigorous physical activity each day.15 Given the substantial health benefits, promoting physical activity for children with disabilities is critical.
Some considerations for how to best promote physical activity in children with disabilities:
Children with disabilities can achieve the key physical activity guidelines. Each child, with or without disabilities, has a unique set of health-related fitness (e.g., flexibility, muscular strength, body composition – % of muscle, fat, and bone) and skill-related fitness (e.g., balance, coordination, speed, power, reaction time) characteristics that can be carefully considered when planning appropriate exercise activities. The benefits of exercise are greater than the risk of injury.1
A good way of doing this is to be careful and know that you do not have to do it all in one day. Spreading exercise out over several days also has substantial health benefits. The less you sit, the better.1 Getting kids off of their electronics, for example, requires some effort! Perhaps adding in a reward program with stickers and buying new equipment for exercise goals. Start incorporating exercise early to encourage an active lifestyle. The goal is to make exercise part of your child’s daily routine. Make exercise fun for your child. Ask them what they enjoy. Invite friends and family to exercise with your child. Be a positive example for your child.16
Vignette 2: Molly’s parents encouraged exercise by starting with family walks. Then Molly’s parents purchased tennis equipment and a bicycle to integrate more vigorous activity. Her family started a daily exercise calendar to encourage an active lifestyle. At the end of each month, Molly’s family let her pick a movie to watch to recognize her progress and achievements.
How do we measure physical activity and sleep?
Physical activity and sleep can be measured by a self-report diary, wearable device (e.g. actigraphy), and other methods. Due to limitations of a self-report diary (e.g., forgetting to record data), actigraphy is a promising, objective measure of physical activity and sleep. Actigraphy – similar to a wristwatch – is a non-invasive, device that is used to detect sleep (e.g., total sleep time, sleep quality or efficiency) and physical activity (e.g., moderate-to-vigorous physical activity) movement patterns over time.12,17 Actigraphy data helps us make informed decisions about ways to improve our health. For example, actigraphy can tell us the total sleep time, which can then be used to develop targeted sleep interventions. Ultimately, it is important to use a validated measure of physical activity and sleep, so that we can optimize sleep and physical activity recommendations and interventions for children.
Vignette 3: After a few months of exercise, Molly saw her pediatrician for a wellness visit. Her pediatrician noticed that Molly had lost weight and that her sleep was better. Molly’s teacher said that her mood improved and that she was more social than before. Molly’s self-esteem improved as well. Molly’s teacher said she was able to focus better, and her grades improved.
The important takeaway is that adequate exercise at any level each day can improve sleep quality. Another important takeaway is that even walking counts as exercise and can improve sleep quality.
“A balanced diet and exercise are of vital importance, yes. But we now see sleep as the preeminent force in this healthy trinity.” – Matthew Walker, PhD, author of Why We Sleep.
The Author:
Megan Alder, PhD, RN, is a Postdoctoral Research Fellow, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Marcus Autism Center.
References
1. Physical Activity Guidelines for Americans U.S. Department of Health and Human Services; 2018.
2. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985 Mar-Apr 1985;100(2):126-31.
3. Physical activity Accessed December 23, 2021. https://www.who.int/news-room/fact-sheets/detail/physical-activity
4. Kline CE, Hillman CH, Bloodgood Sheppard B, et al. Physical activity and sleep: An updated umbrella review of the 2018 Physical Activity Guidelines Advisory Committee report. Sleep Med Rev. 08 2021;58:101489. doi:10.1016/j.smrv.2021.101489
5. Wachob D, Lorenzi DG. Brief Report: Influence of Physical Activity on Sleep Quality in Children with Autism. J Autism Dev Disord. Aug 2015;45(8):2641-6. doi:10.1007/s10803-015-2424-7
6. Pacheco D. Can You Change Your Circadian Rhythm? OneCare Media, LLC. Accessed December 23, 2021. https://www.sleepfoundation.org/circadian-rhythm/can-you-change-your-circadian-rhythm
7. Stores G. A Clinical Guide to Sleep Disorders in Children and Adolescents. Assessment of Sleep Disorders. Cambridge University Press; 2001.
8. Young N, Crankshaw K. Disability Rates Highest Among American Indian and Alaska Native Children and Children Living in Poverty. Accessed December 29, 2021. https://www.census.gov/library/stories/2021/03/united-states-childhood-disability-rate-up-in-2019-from-2008.html
9. Developmental Disabilities. May Institute. Accessed December 30, 2021. https://www.mayinstitute.org/autism-aba/developmental-disabilities.html
10. Maenner MJ, Shaw KA, Bakian AV, et al. Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2018. MMWR Surveill Summ. 12 03 2021;70(11):1-16. doi:10.15585/mmwr.ss7011a1
11. Collins K, Staples K. The role of physical activity in improving physical fitness in children with intellectual and developmental disabilities. Res Dev Disabil. Oct 2017;69:49-60. doi:10.1016/j.ridd.2017.07.020
12. Memari AH, Ghaheri B, Ziaee V, Kordi R, Hafizi S, Moshayedi P. Physical activity in children and adolescents with autism assessed by triaxial accelerometry. Pediatr Obes. Apr 2013;8(2):150-8. doi:10.1111/j.2047-6310.2012.00101.x
13. Brand S, Jossen S, Holsboer-Trachsler E, Puhse U, Gerber M. Impact of aerobic exercise on sleep and motor skills in children with autism spectrum disorders - a pilot study. Neuropsychiatric Disease and Treatment. 2015;11:1911-1920. doi:10.2147/ndt.s85650
14. Oriel KN, George CL, Peckus R, Semon A. The effects of aerobic exercise on academic engagement in young children with autism spectrum disorder. Pediatr Phys Ther. 2011;23(2):187-93. doi:10.1097/PEP.0b013e318218f149
15. Pan CY. Objectively measured physical activity between children with autism spectrum disorders and children without disabilities during inclusive recess settings in Taiwan. J Autism Dev Disord. Aug 2008;38(7):1292-301. doi:10.1007/s10803-007-0518-6
16. Making Physical Activity a Part of a Child’s Life. Centers for Disease Control and Prevention (CDC) Accessed December 30, 2021. https://www.cdc.gov/physicalactivity/basics/adding-pa/activities-children.html
17. Wiggs L, Stores G. Sleep patterns and sleep disorders in children with autistic spectrum disorders: insights using parent report and actigraphy. Dev Med Child Neurol. Jun 2004;46(6):372-80. doi:10.1017/s0012162204000611