Perceptions of Physical Activity Participation Among Adolescents with Autism Spectrum Disorders: A Conceptual Model of Conditional Participation
Journal of Autism and Developmental Disorders
Perceptions of Physical Activity Participation Among Adolescents with Autism Spectrum Disorders: A Conceptual Model of Conditional Participation
Susann Arnell 0 1 2
Kajsa Jerlinder 0 1 2
Lars‑Olov Lundqvist 0 1 2
0 Faculty of Health and Occupational Studies, University of Gävle , Gävle , Sweden
1 School of Health Sciences, The Swedish Institute for Disability Research (SIDR), Örebro University , Örebro , Sweden
2 Faculty of Medicine and Health, University Health Care Research Center, Örebro University , P. O. Box 1613, 701 16 Örebro , Sweden
3 Susann Arnell
Adolescents with an autism spectrum disorder (ASD) are less physically active compared to typically developing peers. The reasons for not being physically active are complex and depend on several factors, which have not been comprehensively described from the adolescent's perspective. Therefore, the aim was to describe how adolescents with an ASD perceive, experience and reflect on their participation in physical activity. Interviews with 24 adolescents diagnosed with high-functioning ASD, aged 12-16 years, were analysed with qualitative content analysis with an inductive approach. They expressed a variety of reasons determining their willingness to participate, which were conceptualized as: Conditional participation in physical activities. The present study presents an alternative perspective on participation in physical activity, with impact on intervention design.
Autism spectrum disorder; Adolescent; Physical activity; Participation
Adolescents with an autism spectrum disorder (ASD) are
less physically fit
(Borremans et al. 2010)
, less physically
(Jones et al. 2017)
and participate in fewer physical
activities compared to typically developing peers
et al. 2016; Memari et al. 2015; Potvin et al. 2013)
. Few of
these adolescents meet the physical activity (PA) guidelines
of 60 min of moderate-to-vigorous PA each day
et al. 2013; Pan and Frey 2006)
, which leads to impaired
(Biddle and Asare 2011; Janssen and Leblanc 2010;
Strong et al. 2005)
. Reasons for adolescents with an ASD not
being physically active are complex and depend on several
(Obrusnikova and Cavalier 2011)
. The most common
reasons relate to intrinsic factors such as lack of motivation
(Obrusnikova and Miccinello 2012; Stanish et al. 2015)
interest in PA (Obrusnikova and Cavalier 2011), low
perceived motor skill competence
(Loprinzi et al. 2015)
enjoyment of PA
(Eversole et al. 2016)
. Other reasons relate
to the symptoms of ASD, such as impaired communication,
limited social interaction and motor difficulties
et al. 2015)
. In particular, their participation is hampered by
their difficulties complying with others’ requests or
adjusting to rules, regulations and social norms
et al. 2016; Ghaziuddin 2002)
. This may be most apparent
in the traditional contexts for PA such as physical education
(PE) and organized sports
(Ayvazoglu et al. 2015; Menear
and Neumeier 2015)
. In these contexts, participation often
requires both social interaction and athletic skills, which can
be problematic for adolescents with an ASD.
Research on the benefits of specific PA interventions
among adolescents with an ASD has shown improvements
in behaviour, health and motor skills
(Bremer et al. 2016;
Dillon et al. 2016; Lang et al. 2010; Sorensen and Zarrett
2014; Sowa and Meulenbroek 2012)
. The feelings of
adolescents with an ASD about PA have been investigated through
questionnaires and compared to typically developing
adolescents, revealing both similarities, for example the
enjoyment of PA and awareness of PA being “good for them”, and
differences, such as lower enjoyment of group PA among
adolescents with ASD compared to typically developing
(Stanish et al. 2015)
. Other studies have found
that these adolescents face challenges regarding perceived
physical ability, sensory issues and concerns about
negative social interaction such as bullying or being compared
to others when they participate in PE
(Healy et al. 2013)
in leisure activities
(Brewster and Coleyshaw 2011)
affects their preferences and choice of activities. Despite an
awareness among professionals of the benefits of PA and
of factors that may affect participation in specific
activities, interventions have yet not fully succeeded in
changing habits to increase PA levels among adolescents with an
(McCoy et al. 2016; Obrusnikova and Cavalier 2011;
Pan et al. 2016; Stanish et al. 2015; Tyler et al. 2014)
may therefore assume that other aspects not accounted for
in previous research are influencing participation in PA.
Thus, there is a need for research that more comprehensively
describes these adolescents’ views of participating in PA.
The aim of this study was thus to describe how
adolescents with an ASD perceive, experience and reflect on their
participation in PA.
All adolescents aged 12–16 years diagnosed with an ASD
(DSM 5 299.00) without a co-occurring intellectual
disability (N = 190), registered at the Child and Youth
Habilitation Centre in a county in the central region of Sweden,
were asked to participate in this study. A letter of invitation
with information about the study was sent to parents or legal
guardians of the adolescent during a period from March to
April 2015. An age-appropriate version of the written
information was also sent to each adolescent. A follow-up phone
call was made in order to answer any questions about the
study. The adolescent and parents (or guardian) submitted
written informed consent before participating in this study.
Participants were assured that their identities would remain
anonymous in all reporting of the study and that their
personal information would be kept confidential. The study was
approved by the Regional Ethical Review Board in Uppsala,
Sweden (Approval No.: dnr 2014/243).
Twenty-four adolescents with a formal diagnosis of ASD
agreed to participate in this study. The study included 17
boys and 7 girls, from grades 6–9 and aged 12–16 years.
All adolescents followed the national curriculum of
Swedish mainstream compulsory schooling. Thirteen adolescents
participated in mainstream classroom education and 11 had
an adapted form of schooling, including small group
education or education at home.
As shown in Table 1, the adolescents’ PA habits and
preferences varied greatly. Some were highly physically active
and interested in sports, whereas others preferred being
sedentary and lacked any interest in PA. For some,
mandatory PE was their main context for being physically active.
Among those who were physically active, the preferred PA
varied: some preferred solitary activities whereas others
enjoyed being part of a team. The choice of PA companions
also varied: parents and siblings were commonly mentioned,
but sometimes a friend was preferred. In summary, the
adolescents in the present study form a heterogeneous group
concerning their current PA habits and preferences.
The adolescents’ perceptions, experiences and reflections
concerning participation in PA were collected through
qualitative interviews. An interview guide was developed for the
study in order to cover the adolescents’ experiences in a
range of PA contexts. To enhance the construct validity of
the interview guide, four pilot interviews were performed
prior to the interviews. Based on the pilot interviews the
interview guide was revised and refined, allowing more
context-specific and directed questions, in order to better
capture the adolescents’ perspective of participation in PA
in different contexts. The pilot interviews also gave insights
into how to approach adolescents with an ASD in an
interview situation with respect to the difficulties in social
interaction and communication associated with these disorders.
The four pilot interviews were not included in the results.
The individual interviews took place according to each
adolescent’s preference: at the adolescent’s home (n = 10)
or at their local habilitation centre (n = 14). Two interviews
were conducted with a parent present in the room but not
taking any active part. The first author, an experienced
physiotherapist who had no professional connection with
the adolescents, conducted all interviews to ensure internal
consistency. Prior to the interviews, the adolescents were
assured of confidentiality and reminded that they were free
to stop their participation at any time without being obliged
to give any explanation. The interviews lasted between 30
and 80 min. They were conducted as conversations and
started with a discussion of the terminology used in PA
contexts. The adolescents were asked to narrate their perceived
experiences of PA and participating in PA in different
settings. Follow-up questions were posed in order to
encourage further and more reflective narrations or to clarify the
adolescent’s answers. All interviews were digitally recorded
with the participant’s permission and transcribed verbatim
by the first author. The quotations that are presented in the
results were professionally translated in order to capture the
adolescent’s voices; the text may thus include grammatical
Gender: B = boys, G = girls. Type of PA: team sport = football, floorball etc., individual PA= individual
exercise in the home setting, dual PA = tennis, badminton etc. Social context: T = team, F = friends, P =
parents, S = siblings, R = relatives, e/c = escort/contact person
errors found in transcribed speech, as well as jargon and
slang phrases used by this population.
An inductive qualitative latent content analysis was used
to analyse the material and to reveal the underlying
meanings of the interview texts
(Graneheim and Lundman 2004)
Since qualitative content analysis aims at describing
variations of the phenomenon under study, the focus was on
finding similarities and differences in the text, not on how many
of the adolescents expressed the same experiences. Initially,
all the transcribed interviews were read through to obtain a
sense of the overall content of the data. The authors then
conducted the analysis in two phases. First, all authors
developed a preliminary coding structure by selecting one of the
most comprehensive interview transcripts. Each author read
the transcript independently and identified any statement
pertaining to PA. The statements, also referred to as meaning
units, are constellations of words or sentences related to each
other through the content and context
. Thereafter, the meaning units were condensed
and designated as codes by each author independently. The
authors then met to compare and consolidate the codes. The
first author completed the coding process for the
remaining interview transcripts. All codes sharing a commonality
were formed into tentative categories and themes, using the
NVivo 10 software program
(QSR International 2014)
the second phase, all authors met to discuss the tentative
categories and themes. Differences of opinion were resolved
via consensus until the final subthemes were identified,
leading to one overarching theme.
The analysis resulted in a main theme with five subthemes
that encapsulated the adolescents’ experience of
participation in PA (Table 2). Statements from each adolescent are
represented in almost all subthemes. In order to reflect the
T, F, P
F, S, e/c
P, S, R
T, P, F
Competence and confidence
Conditional participation—but it depends
inductive analysis process, the subthemes that emerged are
presented first and the main theme concludes this section.
Representative quotations are used to illustrate the
adolescents’ perceptions, experiences and reflections concerning
participation in PA.
Competence and Confidence
The adolescents indicated in their narratives that they
perceived their physical ability, competencies in PA and
selfconfidence as important factors that affected their
willingness to engage in PA. Perceived low ability in PA and low
self-confidence made them feel more vulnerable during PA.
The adolescents expressed having both low and high
competencies in PA. Their narratives also highlighted that
different kinds of competencies were required for successful
participation in PA, for instance motor skills and physical
abilities combined with knowledge about the activity itself,
i.e., knowing how to perform it.
It’s a tactical game, if everyone does what he has to do
it’ll work…In fact, I have only done this for one year
but most people tell me it looks as if I’ve been playing
for three years... I have got the knack of the sport so
damn easily and I have sort of developed quite quickly
in it (boy 1).
The adolescents expressed that, in order to participate in
PA at all, they had to have a certain minimum level of
physical competence; if not, they were less likely to be willing to
I sometimes have problems with the ‘motions’…I
lack the automatic ability…to be able to improvise
what motions to use, sometimes I must think
beforehand which ones to use…it’s hard when I don’t get
the flow that’s needed and even if I plan it, it doesn’t
turn out right (boy 20).
On the other hand, adolescents also perceived
themselves as competent in some specific type of PA, especially
in activities that they considered easy and were used to.
As with competence, some adolescents felt confident
whereas others expressed a lack of confidence during PA.
Lack of confidence could be related to their performance
in PA but also to low self-esteem related to their persona,
body and appearance. This lack of confidence, particularly
when related to their persona, led to feelings of insecurity:
“I was ashamed and felt sick…I couldn’t cope…either I
didn’t understand what they meant or I didn’t have the
physical fitness required” (boy 9).
In addition, perceiving oneself as lacking in competence
and being unconfident in PA led to a perceived
vulnerability. Whereas some found that PA gave them a respite from
stress, others said they became anxious and stressed out
merely by thinking about physical activities. Particularly
in conjunction with PE, feelings of anxiety and stress were
reported, especially by the girls: “There was such a
terrible lot of anxiety involved with PE…A whole day could
be ruined just because of the PE…I almost didn’t want
to go to school if we were supposed to have PE that day”
Vulnerability that was related to their body and
appearance was particularly reflected in the changing room and in
the showers at PE. Low perceived body satisfaction, due to
physical changes associated with adolescence led to high
levels of insecurity that affected the adolescents’ actions:
“I don’t like exposing myself…I waited until everyone had
been in the shower…was the only one still showering…I
was wary of my body…it’s hardest in the changing room…
then you might get comments” (boy 1).
According to the adolescents, the enjoyment and perceived
meaningfulness of the activity were the two main aspects
that influenced their motivation to be physically active. If
PA was perceived as fun and important, and conducted with
specific persons selected by the adolescents themselves,
these were strong motivators for participation in PA. But,
even where the activity was enjoyable and meaningful, the
adolescents still reported having difficulties initiating PA
themselves, indicating low self-regulation skills.
Both enjoyment and discomfort associated with being
physically active were expressed. Enjoyment of the activity
itself was a primal motivator for attendance and engagement
in PA, and it increased their activity levels: “I don’t miss one
single practice, I like it and I’m motivated…as long as it’s
fun you want to do more and then you get more exercise”
(boy 17). Having someone to be physically active with, who
was undemanding and supportive, further increased their
enjoyment, since participation in PA with someone specific
was preferred to being completely solitary during PA.
The adolescents’ narratives further revealed that the
perceived meaningfulness of the activity was another essential
motivating factor, sometimes being crucial for involvement
and engagement in PA. Health-enhancing PA and activities
with a specific, useful purpose or goal were considered as
meaningful by the adolescents. The motivation for
participating in PA and in PE varied especially strongly according
to this purpose or goal. Some adolescents referred to PE as
unimportant, although they were aware of its purpose and
the benefits of being physically active. Others participated
in PE even though they did not find the activities meaningful
or enjoyable, but only because it was required of them, and
some attended only in order to receive a grade in PE.
I participate as much as I can [in PE]…but at the end
of the lessons…I often get understimulated…I tend
to keep away…to be more passive…don’t make an
effort…don’t take any initiatives of my own…the
activity is simply too boring…
To me personally it is not important at all [to take part
in PE]…the reason for me to take part is that I don’t
want to fail…if it wasn’t for that I wouldn’t participate
However, some of the adolescents were exempted or
excluded from PE, whereas others only participated
occasionally, depending on the type of activity during the PE
class: ‘I have no PE in school, I’ve ruled it out…I thought
it was unnecessary and it would be hell…but as long as it
is theory, I’m in’ (girl 6). Where meaning was lacking, the
physical activities were perceived as unnecessary and
pointless, leading to an unwillingness to participate: ‘Football
is useless…the only thing you learn from football is to run
chasing after a ball, like a dog’ (boy 18).
The adolescents showed an awareness of the health
benefits of regular PA. The health-promoting aspects were thus
also a strong motivator in terms of gaining better health or
a fitter body. The opposite, a fear of ill health and an
avoidance of obesity, were thus also reported motivators of PA: “I
run…want to keep fit, I don’t want to get fat…I care about
my weight” (girl 10).
Despite their awareness of the physical and mental health
benefits of PA, the adolescents described that they
struggled with their own physical inactivity and self-regulation.
Difficulties initiating and maintaining an activity were
reasons for not being physically active: “Physical activities are
important, of course, but…if I get the chance to do
something else I’ll do something else…either I don’t have time or
energy enough to fancy any activity…” (boy 9).
Their narratives also showed that PA and their physical
and mental wellbeing had a reciprocal influence on their
PA habits. Being physically active enhanced their wellbeing
and self-esteem: “When I am not active I get sulky,
irritated and insecure… I feel better from it [exercising]…it’s
made me accept that I am doing all right” (boy 1). Equally,
being aware of the positive health outcomes but not being
physically active could lead to feelings of anguish: “I should
activate myself more than I do…but lately I haven’t made it
since I haven’t been feeling so well…so I have sort of put it
aside…instead it gives me anxiety…a feeling that I am not
active enough” (girl 4).
Adjustment to External Demands
The adolescents reported that they experienced a variety
of external demands during PA, such as social demands,
demands regarding the activity itself and environmental
demands, all affecting their participation in different ways.
They perceived social demands in conjunction with social
interaction during PA. This was a reason for not
participating, especially if it was in a social context they were
uncomfortable with. More specifically, they described that they had
difficulties adjusting to others, which lead to unwillingness
to participate: “It is hard and tiring to have to adjust to what
other people say and to have activities together, then I lose
interest” (boy 20). For some adolescents, these demands led
to reduced involvement in group activities or team sports and
instead they increasingly preferred solitary PA. Social
situations also evoked fear of spoiling the fun for others, which
further contributed to unwillingness to participate in PA.
Being watched and judged by others was another challenging
aspect of PA, leading to anxiety about others’ opinions and
comments and to fear of making a fool of oneself. Especially
the adolescent girls expressed concerns regarding being
different compared to their peers: “I don’t like being watched…
it’s tough…I’m scared of being judged …I don’t want to be
like others but I want to do it my own way without being
judged” (girl 6).
But even being judged in a positive light could be
troublesome, as the adolescents were ambivalent regarding
encouragement, depending on who, where and in what situation
the encouragement was given: “I can’t take encouragement,
it disturbs me, I get unfocused and then it’s hard for me to
concentrate and it gets embarrassing” (boy 3).
Many physical activities are competitive, particularly
team sports and PE activities. For some adolescents the
competitive element in the PA was a reason for not participating;
for others it was a triggering factor that enhanced their
willingness to participate: “I work harder, have more go when
it is a competition, and the results are usually better since
it’s fun to win” (boy 21). The perceived seriousness of the
PA further affected their willingness to participate. Games
and playful team sports that included PA were preferred by
the adolescents to more serious team sports where specific
performance requirements were more common.
The adolescents also reported that certain elements in the
environment, such as insects, high temperatures and rainy
or sunny weather, affected their willingness to participate
in PA. Consequences of environmental factors perceived as
negative could be a reason for reduced participation in PA:
“I don’t like sweating,’cause then I have to take a shower…
that’s one of the things that stops me from training” (girl 6).
Other environmental factors, such as loud and noisy
situations could inhibit their willingness to participate in PA:
“Dancing is tiresome…too much noise…I can’t focus” (boy
Nevertheless, many of the adolescents reported that they
participated in PA even though it meant adjusting to different
kinds of demands, but only if the demands were perceived
to be on an acceptable level from the adolescent’s point
of view. If the demands were perceived as overwhelming,
willingness to participate subsided, whereas when adapted
physical activities were offered, willingness to participate
increased. The adolescents expressed frustration that a lack
of physical activities adapted to their needs limited their
ability to participate in PE: “The bad thing about PE is that
it has been developed for those who already are active…and
you shouldn’t be forced to worry about PE” (girl 15).
In order to feel comfortable about participation in PA the
adolescents expressed a need for predictability of the
activity itself and how they should perform it. Being familiar
with the activity (both the type of activity and the setting),
being prepared and knowing what to do increased a sense of
predictability, which played an important role for the
adolescents’ willingness to attend and engage in PA.
Performing familiar activities in a familiar setting was
connected to positive experiences, thus enhancing the
predictability of the activities, whereas unpredictability was a
cause of insecurity: “I tend to lose confidence…it sort of
depends on how many times I’ve done it and whether I had
fun…then it usually gets easier, anyway” (girl 4).
A familiar social context was likewise reported as
positive, in particular performing the activity with someone they
knew and trusted: “It might help to have a friend by your
side, someone who can motivate you…someone who knows
your ways…someone who dares to push you” (boy 3).
Similarly, they wanted to be prepared for the activity.
Knowing what to expect beforehand allowed them to plan
their own participation and engagement in the activity. The
adolescents found it important to know what to do and how
to perform during the PA, since perceptions of uncertainty
linked to the PA, such as not knowing what to do, or what
expectations to have of their own performance, led to
feelings of uncertainty. Not being prepared was perceived as
…You never knew what was happening…we were
supposed to take out things, we were supposed to do
this and that, afterwards we were told what it was [we
were going to do] I didn’t like it at all…besides, I had
difficulties with almost everything (boy 9).
Particularly the PE context and participating in PE was
considered unpleasant due to insufficient information about
the activities and insufficient instructions “…to explain in a
better way how you should do it…demonstrate it…and make
amendments for you…[since] you don’t ever want to say that
you don’t understand” (girl 6).
Freedom of Choice
The adolescents also emphasized the importance of freedom
of choice and having an opportunity to influence the PA
themselves: “you shouldn’t force anyone…you should be
free to decide for yourself…now I am training’cause I want
to [and] feel like it” (boy 17).
The adolescents wanted to make active choices regarding
the activity itself, the activity context and the social
context, which was expressed as a condition for willingness to
participate at all. Since participation in PE is mandatory, it
resulted in perceptions of reduced freedom of choice and
thus reduced willingness to participate and a negative
attitude toward PE: “[PE] limits the free choice of the
individual…it tries to make everyone do all kind of things…
which is no good” (boy 20).
The PE teacher had a cardinal role affecting the
adolescents’ participation in PE by offering them possibilities to
influence the choice of activities and PA companions during
PE. According to the adolescents, it was important that the
PE teacher was keen, responsive and clear, besides being
understanding of their abilities and needs: “I have spoken to
the PE teacher and we’ve decided that if there is something
I don’t like then I don’t have to join in…more often than not
I’m in… [refused] dancing and football” (boy 3). In order to
cope with PE, the adolescents further emphasized the need
to be allowed to select their activity partner. Not being able
to freely choose PA companions from among their peers led
to feelings of uncertainty: “I hate it when there are so many
team activities, then you can’t choose who you want to work
with and it gets scary” (girl 4). The adolescents thus clearly
expressed a wish to both select and exclude different aspects
of PE. Being offered a possibility to influence the activities
was perceived as something positive since it affected the
feeling of control.
Freedom of choice was limited by the activities that were
available and accessible. According to the adolescents,
preferred and age-appropriate activities were not always
available, and sometimes a lack of transportation to the PA
hindered them from participating: “I’d have been more
physically active if there had been a beginners’ group for people
my age…[but] there are no dancing beginners’ groups for
young people my age” (girl 15).
The Overarching Theme: Willing to Participate, but it depends …
The adolescents were a heterogeneous group in regard to
their preferences, habits and needs, but a common theme
was that some specific individual preferences had to be
fulfilled. A common statement regarding their PA
participation was, “but it depends on….”. This sentiment was found
in all subthemes and was conceptualized as Conditional
participation. Even where most conditions were met, such
as being competent and confident in an activity,
appreciating the activity itself, having had the opportunity to choose
to attend and knowing how to perform it, the adolescent
could choose to abstain simply because of a “wrong person”
appearing during the activity.
The elements of conditional participation were found
both during leisure time PA and during mandatory PE, but
the PE stood out as an especially challenging context for the
adolescents to cope with. During PE, the level of demands
was perceived as high, which affected the adolescents’
willingness to participate. PE was highly regulated, with low
responsiveness to the adolescents’ specific needs and thus
did not allow for individual solutions. Consequently, the
adolescents wished for a certain level of freedom of choice,
another consistent finding in all the subthemes, whereby the
perceived control was enhanced in an otherwise
unpredictable PA context.
The aim of this study was to develop an understanding
of the perceptions, experiences and reflections of
adolescents with ASDs about participation in PA from their own
perspective. According to the adolescents with an ASDs’
narratives, their experiences, PA habits and willingness to
participate in PA varied markedly, showing heterogeneity
within the group not fully captured in previous research.
Intrinsic factors such as confidence and competence
were evident in the adolescents’ narratives as important
for their willingness to participate in PA. This corresponds
to research showing that higher levels of competence
predict greater enjoyment and intensity of involvement in PA
among children and adolescents with and without
(King et al. 2013; Humbert et al. 2006)
. According to
the adolescents in the present study, perceived enjoyment
in its turn was crucial for motivation, especially for their
willingness to attend and to get involved in PA.
Other aspects that affected the adolescents’ willingness
to participate in PA were the different kind of external
demands that the adolescents perceived. The perceived
social demands were prominent, leading to increased
levels of anxiety and uncertainty. One reason for increased
anxiety was that social interaction during PA was
experienced as stressful, which is in line with research showing
that anxiety and fear in connection with peer relationships
are common among adolescents with an ASD
and Coleyshaw 2011; Chen et al. 2016)
. Team sports were
considered particularly challenging, since the activity
itself requires both social interaction and a certain measure
of social skills. In fact, less interaction with other
participants can make activities more predictable, tolerable and
thus even enjoyable by adolescents with an ASD
(Ayvazoglu et al. 2015; Muller et al. 2008; Potvin et al. 2013;
Stanish et al. 2015)
The adolescents also stressed that the predictability of
the activity and the freedom to choose between
activities were two crucial aspects affecting their willingness
to take part in PA. Being prepared, knowing what, where,
how and with whom to perform enhanced their
willingness to participate, especially if they were familiar with
these different aspects. This can be due to intolerance of
uncertainty, which is related to anxiety and by adolescents
with ASD reported reasons to restricted repetitive
(Joyce et al. 2017)
. The present study also found that
the desire for freedom of choice was a significant factor
affecting their participation, and the PE context stood out
as especially demanding.
PE is mandatory in schools and autonomy is reduced
compared to PA in leisure time. PE often includes
elements of evaluation of abilities and performance, which
the adolescents in the study disliked. Despite their
reluctance to participate in PE, many of the adolescents still
participated in order to receive a grade in that school
Conditional Participation in PA
During the interviews, the adolescents frequently said, “but
it depends” or equivalent expressions. This sentiment was
found in all subthemes and was conceptualized as
Conditional participation. The factors that the adolescents
expressed were organized into a model of conditional
participation, as outlined in Fig. 1. The model consists of five
interdependent aspects (i.e., the subthemes) and proposes
that, for sustainable participation in PA, individual
conditions in all five aspects have to be met. With fewer
conditions met, PA participation can still be present but will be
less likely and less sustained. The model is conceptual and
does not put any weight on the relative importance of each
condition for willingness to participate. However, conditions
regarding freedom of choice and perceptions of
meaningful activities have previously been identified as influential
for PA participation
(Haegele and Sutherland 2015)
suggests that being able to choose and influence different
aspects of participation with regard to when, where, with
whom and to what extent, may be cardinal for increased
participation in PA.
The conceptual model is based on the subthemes that
emerged inductively from the interviews with adolescents
with an ASD, yet it has similarities with models on
participation among children and adolescents in general, such
as Imms et al. (2017) “family of participation-related
constructs” (fPRC). Factors affecting participation categorized
in the fPRC framework
(Imms et al. 2017)
“personfocused processes” and “environment-focused processes”
were also found in the present study. “Person-focused
processes” were expressed in terms of competence,
confidence, motivation and being able to choose and
influence physical activities, whereas “environmental-focused
processes” included availability and accessibility of PA.
However, the adolescents in the present study highlighted
other concepts not described in the fPRC model, such as
the need for predictability, adjustment to external demands
and the demand of fulfilling specific individual conditions
for participation to occur. This demonstrates that different
processes may be salient among adolescents with an ASD
compared with typically developing youth and youth with
other disabilities. Common difficulties related to ASD,
such as impaired social interaction skills, motor difficulties
and intolerance of uncertainty, can to some extent be
controlled by clearly expressed conditions regulating the PA
While this study provides additional insight into the
experiences and perceptions of adolescents with an ASD about
participation in PA, some limitations and methodological
considerations have to be addressed. First, the result is
limited to those adolescents with high functioning autism who
felt comfortable taking part in an interview, and there is no
data from a comparative group of age- and gender-matched
adolescents without ASD. Even though the sample included
a range of adolescents with ASD, from those who were very
physically active to those who were mostly sedentary, the
descriptions of experiences of participation in PA may not
fully reflect the source population in this study. Adolescents
with more severe ASD impairments may experience other
demands and may express other conditions, leading to the
emergence of other categories and subthemes. Thus, it
cannot be excluded that some new dimensions might emerge
in the model with a more heterogeneous sample. It should
be noted that the purpose of this study was not primarily
to generate data that could be generalizable but rather to
increase our understanding of how young people with an
ASD experience and perceive participation in PA.
Second, only seven girls were interviewed compared to
17 boys. Although this corresponds to the epidemiology of
the ASD population, the results may not reflect the girls’
experiences to the same extent as the boys’. Some gender
differences were observed with regard to how challenging
they found PA situations. With more girls, the study might
have unveiled more gender differences.
Third, interviewing adolescents with an ASD can be
difficult, since there is a risk that they might respond in a way
that they think the interviewer wants rather than speaking
out their own perceptions and feelings. In order to enhance
their confidence in the interview situation the interviewer’s
bias was discussed and the adolescents were informed that
there were no right or wrong answers to the questions,
focusing instead on the adolescent’s own experiences and
perceptions of PA. The four pilot interviews that were conducted
prior to the interviews were vital to refine the interview
guide in order to better focus on the adolescents’
perspectives and narratives.
Finally, attention must be paid to the researchers’
preconceptions as a result of their professional background
and experiences that affect the research
The first author is an experienced physiotherapist in child
and adolescent habilitation with focus on adapted PA. The
co-authors had a supervisory role and both are experienced
researchers, one with deep knowledge in ASD and the other
specialized in adapted PA. Thus, the authors represent
different but complementary disciplinary perspectives, reducing
the risk of unilateral or biased interpretations of the results.
Clinical Implications and Future Research
Even though some of the attitudes expressed by the
adolescent participants in this study are similar to those of
adolescents without an ASD, their distinctive demands to
participation in PA stood out. Future research is needed to examine
whether and to what extent the adolescents’ demands
regulate their PA participation. A survey, developed from the
conditional participation model, could be used in a
comparison of conditional PA participation in adolescents with
an ASD and typically developing adolescents. The findings
in this study suggest that challenges expressed by
adolescents with an ASD can be misinterpreted as unwillingness
to participate in PA, even though they in fact are willing to
participate but refrain due to some individual condition not
being met. One solution to promote PA among adolescents
with an ASD is to teach them strategies for dealing with
some of their conditions not being met and thus to enhance
their “inner readiness” to meet perceived demands and
(Camargo et al. 2014)
Adolescents with an ASD may further lack equal
opportunities with others to participate in PA, especially in PE,
because of poor physical skills, or a perceived demand to
adjust to specific activities and comply with requests, rules
and social norms
(Ostfeld-Etzion et al. 2016; Williams
White et al. 2007)
. Failure to fully recognize the individual
needs of adolescents with disabilities constitutes a barrier to
full participation (Jerlinder et al. 2009). This may be
particularly problematic for adolescents with an ASD.
A better developed and organized interdisciplinary
collaboration between educational and health care personnel
could give a more comprehensive view of physical
inactivity problems and thereby offer solutions to increase PA.
Finally, the families of adolescents with an ASD have a vital
and proactive role, since they were often reported by the
adolescents as the preferred activity partner. This suggests
that the families ought to be included in collaboration with
stakeholders involved in PA enhancement interventions.
Adolescents with an ASD express a variety of individual
conditions for participation in PA. Different individual
conditions, if not recognized, decrease their willingness to be
physically active, which negatively affects future PA habits.
We propose that knowledge of these individual conditions
is a key factor for increasing participation in PA among
adolescents with an ASD. The in-depth interviews in this study
provide a preliminary understanding of the perspectives of
adolescents with an ASD on participation in PA, with
implications for understanding their participation in activities in
Acknowledgments This research was financially supported by
Sunnerdahls Handikappfond, Kempe-Carlgrenska fonden and Region Örebro
County, Sweden. We wish to thank all the adolescents who participated
and shared their experiences. We would also like to thank Ulla Roseen
who professionally translated the adolescents’ “voices” in all quotations
and Maria Bergman, Region Örebro County, for assistance with the
illustration of the conceptual participation model.
Author Contributions SA, LOL and KJ collectively conceived the
study, participated in its design, assisted with analysis and
interpretation of data, drafted the manuscript, and revised it for important
intellectual content. All authors read and approved the final manuscript.
Conflict of interest None of the authors reports any conflict of interest.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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