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Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis

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Title: Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis
Language: English
Authors: Art Dowdy (ORCID 0000-0001-6466-6774), Saehee An, Fernando Roldan
Source: Exceptional Children. 2026 92(4):463-482.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 20
Publication Date: 2026
Document Type: Journal Articles
Information Analyses
Reports - Research
Descriptors: Autism Spectrum Disorders, Literature Reviews, Exercise, Intervention, Behavior, Behavior Modification, Self Control, Exceptional Child Research, Response to Intervention, Meta Analysis, Physical Activity Level
DOI: 10.1177/00144029251386292
ISSN: 0014-4029
2163-5560
Abstract: Physical activity is a promising strategy for strengthening behavior and social engagement through its physiological and psychological benefits. Antecedent Exercise (AE) is a structured behavioral intervention aimed at mitigating meltdowns and promoting adaptive behaviors in Autistic individuals. This synthesis and multilevel meta-analysis of 34 studies, including diverse settings and exercise types, provides a nuanced examination of AE's effectiveness. AE demonstrated moderate efficacy with effect sizes of -0.342 (SE = 0.089, p < 0.005, 95% CI [-0.517, -0.168]) for reducing meltdowns, and a substantial improvement of 0.806 (SE = 0.166, p < 0.005, 95% CI [0.481, 1.13]) for increasing adaptive behaviors. Special education settings such as day centers and schools yielded robust outcomes, thus highlighting AE's effectiveness in an educational context. Interventions involving accessible activities like aerobic exercise routines and jogging also showed to be effective. Despite variability in study rigor and some indications of publication bias, AE appears to be a scalable intervention for educators and clinicians. Future research should address the long-term maintenance effects and optimal implementation strategies for maximizing AE's benefits in educational and clinical settings. This evidence supports the integration of AE into practices for improving the quality of life and educational outcomes for Autistic individuals.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1508137
Database: ERIC
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  Value: &lt;anid&gt;AN0194392924;exc01jul.26;2026Jun10.02:32;v2.2.500&lt;/anid&gt; &lt;title id=&quot;AN0194392924-1&quot;&gt;Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis&#160;&lt;/title&gt; &lt;p&gt;Physical activity is a promising strategy for strengthening behavior and social engagement through its physiological and psychological benefits. Antecedent Exercise (AE) is a structured behavioral intervention aimed at mitigating meltdowns and promoting adaptive behaviors in Autistic individuals. This synthesis and multilevel meta-analysis of 34 studies, including diverse settings and exercise types, provides a nuanced examination of AE&#39;s effectiveness. AE demonstrated moderate efficacy with effect sizes of −0.342 (SE = 0.089, p &amp;lt;.005, 95% CI [−0.517, −0.168]) for reducing meltdowns, and a substantial improvement of 0.806 (SE = 0.166, p &amp;lt;.005, 95% CI [0.481, 1.13]) for increasing adaptive behaviors. Special education settings such as day centers and schools yielded robust outcomes, thus highlighting AE&#39;s effectiveness in an educational context. Interventions involving accessible activities like aerobic exercise routines and jogging also showed to be effective. Despite variability in study rigor and some indications of publication bias, AE appears to be a scalable intervention for educators and clinicians. Future research should address the long-term maintenance effects and optimal implementation strategies for maximizing AE&#39;s benefits in educational and clinical settings. This evidence supports the integration of AE into practices for improving the quality of life and educational outcomes for Autistic individuals.&lt;/p&gt; &lt;p&gt;Keywords: Autism; antecedent exercise; meltdown behaviors; adaptive skills; behavioral intervention; SCARF&lt;/p&gt; &lt;p&gt;Autism is a neurodevelopmental difference characterized by distinct patterns in social communication and sensory processing, along with focused interests and preferences for routine. Current estimates suggest that autism occurs in approximately one in 44 births ([&lt;reflink idref=&quot;bib13&quot; id=&quot;ref1&quot;&gt;13&lt;/reflink&gt;]). While experiences vary widely, some autistic individuals may engage in behaviors that others term &quot;challenging&quot; (a term often used in the existing literature) in certain environments or situations. In this study, we examine behaviors that may interfere with learning, safety, or social participation, recognizing that these behaviors often serve important regulatory or communicative functions. We acknowledge ongoing discussions about terminology in this field, including alternative framings such as &quot;meltdown&quot; ([&lt;reflink idref=&quot;bib9&quot; id=&quot;ref2&quot;&gt;9&lt;/reflink&gt;]), while maintaining consistency with existing research literature.&lt;/p&gt; &lt;p&gt;Although challenging behavior or meltdowns are not a defining feature of Autism, they are significantly more common among Autistic individuals than their nonautistic peers ([&lt;reflink idref=&quot;bib22&quot; id=&quot;ref3&quot;&gt;22&lt;/reflink&gt;]). In this study we use &quot;meltdown&quot; instead of &quot;challenging behavior&quot; based on [&lt;reflink idref=&quot;bib9&quot; id=&quot;ref4&quot;&gt;9&lt;/reflink&gt;], to align with their recommendations to avoid ableist language. Specifically, they suggest using terms that describe behaviors in a value-neutral way, rather than terms such as challenging behavior, which could be overly general and carry implicit negative judgments. By adopting meltdown in this study, we hope to provide an accurate and empathetic description that reflects the experiences of Autistic individuals without framing the behavior as inherently problematic. Studies have shown that meltdowns are more prevalent among Autistic children compared to other neurodevelopmental disorders, with over 50% of Autistic individuals displaying such behaviors at some point ([&lt;reflink idref=&quot;bib34&quot; id=&quot;ref5&quot;&gt;34&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib44&quot; id=&quot;ref6&quot;&gt;44&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib53&quot; id=&quot;ref7&quot;&gt;53&lt;/reflink&gt;]). These behaviors can vary widely in severity and form, encompassing disruptive actions such as continuous screaming, self-injury, aggression, and meltdowns, as well as more severe manifestations like suicidal tendencies ([&lt;reflink idref=&quot;bib67&quot; id=&quot;ref8&quot;&gt;67&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;Meltdowns can pose significant safety risks not only to the individual but also to those around them ([&lt;reflink idref=&quot;bib2&quot; id=&quot;ref9&quot;&gt;2&lt;/reflink&gt;]). Additionally, these behaviors can severely impact an individual&#39;s ability to function independently ([&lt;reflink idref=&quot;bib71&quot; id=&quot;ref10&quot;&gt;71&lt;/reflink&gt;]), adversely affect family dynamics and welfare ([&lt;reflink idref=&quot;bib75&quot; id=&quot;ref11&quot;&gt;75&lt;/reflink&gt;]), and contribute to poor mental health outcomes ([&lt;reflink idref=&quot;bib58&quot; id=&quot;ref12&quot;&gt;58&lt;/reflink&gt;]). Given these serious consequences, effective interventions to mitigate meltdowns and increase adaptive behaviors of Autistic individuals are critically needed. Adaptive behaviors refer to the skills and actions that enable individuals to effectively navigate their environment, meet personal and social demands, and achieve independence. For Autistic individuals, these behaviors may include communication skills, self-care abilities, social interactions, and on-task behaviors that support daily functioning and integration into various settings.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-2&quot;&gt;Antecedent Exercise as an Intervention&lt;/hd&gt; &lt;p&gt;Antecedent exercise (AE) is one such intervention that has shown promise in reducing meltdowns of Autistic individuals. AE leverages the positive effects of physical activity to reduce the frequency and severity of meltdowns. Research has demonstrated the potential benefits of AE in various areas, including enhanced social engagement ([&lt;reflink idref=&quot;bib17&quot; id=&quot;ref13&quot;&gt;17&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib54&quot; id=&quot;ref14&quot;&gt;54&lt;/reflink&gt;]), reduced stereotypy ([&lt;reflink idref=&quot;bib17&quot; id=&quot;ref15&quot;&gt;17&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib42&quot; id=&quot;ref16&quot;&gt;42&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib52&quot; id=&quot;ref17&quot;&gt;52&lt;/reflink&gt;]), and increased on-task behaviors ([&lt;reflink idref=&quot;bib68&quot; id=&quot;ref18&quot;&gt;68&lt;/reflink&gt;]). From a motivational standpoint, there are plausible mechanisms by which AE might influence meltdowns. One hypothesis is that AE acts as an abolishing operation for engaging in stereotypy by reducing the motivation to engage in such behaviors. Fatigue, resulting from exercise may decrease overall behavior, including meltdowns, or AE may produce a reinforcer similar to that of a meltdown, leading to satiation. For example, [&lt;reflink idref=&quot;bib41&quot; id=&quot;ref19&quot;&gt;41&lt;/reflink&gt;] found that stereotypy may serve to reduce stress, a function that physical activity has also been shown to fulfill ([&lt;reflink idref=&quot;bib18&quot; id=&quot;ref20&quot;&gt;18&lt;/reflink&gt;]). This supports the possibility of a matched-stimulation hypothesis, where AE produces sensory or emotional effects that decrease the reinforcing value of engaging in the meltdown behavior. Alternatively, AE may serve as an establishing operation for alternative behaviors, particularly if these behaviors are explicitly targeted ([&lt;reflink idref=&quot;bib35&quot; id=&quot;ref21&quot;&gt;35&lt;/reflink&gt;]). For instance, physical activity could increase thirst, making drinking water a more likely alternative behavior that is incompatible with meltdowns. Related, physical activity can lead to physiological and psychological changes that promote adaptive behavior. These changes may include increased endorphin levels, improved mood, and enhanced cognitive functioning, all of which can contribute to a reduced meltdowns ([&lt;reflink idref=&quot;bib26&quot; id=&quot;ref22&quot;&gt;26&lt;/reflink&gt;]). That is, AE provides a proactive approach to behavior management, focusing on preventing meltdowns before they occur rather than reacting to them after they have manifested.&lt;/p&gt; &lt;p&gt;One of the notable advantages of AE is its flexibility, as it can often be integrated into the daily routines of Autistic individuals, thereby enhancing its social validity and sustainability as an intervention ([&lt;reflink idref=&quot;bib14&quot; id=&quot;ref23&quot;&gt;14&lt;/reflink&gt;]). For example, aerobic exercises such as running or cycling can be incorporated into physical education classes or recreational activities, while walking or jogging may be integrated into daily routines, such as commuting to school or participating in community events. Nevertheless, it is important to recognize that the physical education programming typically provided to neurotypical children in primary school settings may not be feasible for many Autistic individuals, particularly those with comorbid intellectual disabilities or those who experience difficulty remaining in classroom environments due to meltdowns.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-3&quot;&gt;Knowledge About Effectiveness of AE and Next Steps&lt;/hd&gt; &lt;p&gt;Despite the promising evidence, there remains a need for additional research to fully understand the scope and limitations of AE. Recent reviews have highlighted the importance of examining moderating variables that may influence the effectiveness of AE. For instance, [&lt;reflink idref=&quot;bib77&quot; id=&quot;ref24&quot;&gt;77&lt;/reflink&gt;] emphasized the role of exercise intensity and duration, suggesting that more rigorous and prolonged exercise sessions may yield better outcomes. [&lt;reflink idref=&quot;bib81&quot; id=&quot;ref25&quot;&gt;81&lt;/reflink&gt;] called for more research into the long-term effects of AE on stereotypic behaviors and other adaptive behaviors, such as academic engagement and on-task behavior, emphasizing the need to better understand its impact across various behavioral domains and contexts. Previous reviews, such as those by [&lt;reflink idref=&quot;bib81&quot; id=&quot;ref26&quot;&gt;81&lt;/reflink&gt;], [&lt;reflink idref=&quot;bib77&quot; id=&quot;ref27&quot;&gt;77&lt;/reflink&gt;], and others, have primarily focused on the effects of AE on behavioral outcomes, such as reductions in stereotypy and improvements in adaptive behaviors. However, these reviews did not comprehensively analyze the characteristics of studies implementing AE. Understanding these characteristics is crucial for identifying patterns in the research, informing best practices, and improving generalizability. By addressing this gap, the current study seeks to provide a more detailed exploration of study characteristics (setting, exercise type, and dosage) offering insights that can inform the design and implementation of future AE interventions. These insights point to the need for a more comprehensive analysis of the existing literature to inform best practices and optimize the implementation of AE interventions.&lt;/p&gt; &lt;p&gt;Previous reviews, such as those by [&lt;reflink idref=&quot;bib81&quot; id=&quot;ref28&quot;&gt;81&lt;/reflink&gt;] and [&lt;reflink idref=&quot;bib77&quot; id=&quot;ref29&quot;&gt;77&lt;/reflink&gt;], have noted variability in methodological rigor across AE studies. For example, discrepancies in intervention fidelity and inconsistencies in outcome measurement methods, such as direct observations versus caregiver reports, challenge the comparability of findings. Additionally, Teh et al. highlighted the limited use of advanced analytic methods to account for within-study dependencies, which could reduce the reliability of effect size estimates. These issues illustrate the importance of systematically evaluating the quality of AE studies to strengthen the evidence base. While prior reviews, such as [&lt;reflink idref=&quot;bib77&quot; id=&quot;ref30&quot;&gt;77&lt;/reflink&gt;] and [&lt;reflink idref=&quot;bib81&quot; id=&quot;ref31&quot;&gt;81&lt;/reflink&gt;], have identified exercise intensity as a significant moderator in reducing stereotyped motor behaviors, the relationship between exercise duration and behavioral outcomes requires further exploration to fully understand its impact. Teh et al. emphasized that higher intensity exercise may yield greater reductions in meltdowns but did not suggest that longer exercise sessions necessarily produce similar benefits. Empirical studies, including those by [&lt;reflink idref=&quot;bib28&quot; id=&quot;ref32&quot;&gt;28&lt;/reflink&gt;] and [&lt;reflink idref=&quot;bib72&quot; id=&quot;ref33&quot;&gt;72&lt;/reflink&gt;], highlight the complexity of these relationships. Goldman et al. demonstrated that the effects of exercise duration vary depending on participant characteristics and environmental contexts, while Schmitz et al. found that high-intensity, longer-duration exercise could exacerbate stereotyped behaviors, with shorter, low-intensity sessions being more effective.&lt;/p&gt; &lt;p&gt;Furthermore, much of the research on AE as an intervention for mitigating meltdowns of Autistic individuals rely on single-case experimental designs (SCED). While past research syntheses have estimated the effectiveness of AE, they have not systematically evaluated the presence of a functional relation. One obstacle to the successful interpretation of SCED research is that visual analysis, a common method used to assess SCED, is not easily synthesized across multiple studies. This challenge arises because visual analysis serves both as an internal validity assessment and an outcomes assessment ([&lt;reflink idref=&quot;bib73&quot; id=&quot;ref34&quot;&gt;73&lt;/reflink&gt;]). If a functional relation is not identified, it could be due to internal validity concerns such as therapeutic or countertherapeutic baseline trends, covariation among tiers in a multiple baseline design, or failure to revert to baseline levels in a withdrawal design ([&lt;reflink idref=&quot;bib38&quot; id=&quot;ref35&quot;&gt;38&lt;/reflink&gt;]). Alternatively, inconsistent changes observed between conditions may also explain the absence of an observed functional relation ([&lt;reflink idref=&quot;bib38&quot; id=&quot;ref36&quot;&gt;38&lt;/reflink&gt;]).&lt;/p&gt; &lt;hd id=&quot;AN0194392924-4&quot;&gt;Synthesis of SCED Research&lt;/hd&gt; &lt;p&gt;The synthesis of SCED research outcomes via meta-analysis has emerged as a promising approach ([&lt;reflink idref=&quot;bib50&quot; id=&quot;ref37&quot;&gt;50&lt;/reflink&gt;]), especially with the introduction of effect size metrics appropriate to SCED and meta-analytic procedures that are robust to common violations of assumptions in SCED outcome data. Effect sizes provide an estimate of the magnitude of behavior change and generally reflect changes in level across phases, such as from baseline to intervention ([&lt;reflink idref=&quot;bib74&quot; id=&quot;ref38&quot;&gt;74&lt;/reflink&gt;], 2015). However, while effect sizes help establish the relative effectiveness of an intervention, they do not provide critical information about the presence of a functional relation. This limitation is problematic because effect sizes may indicate large effects even when visual analysis suggests that changes cannot be confidently attributed to the intervention, highlighting potential threats to internal validity ([&lt;reflink idref=&quot;bib38&quot; id=&quot;ref39&quot;&gt;38&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib74&quot; id=&quot;ref40&quot;&gt;74&lt;/reflink&gt;]). Consequently, while meta-analysis is essential for synthesizing intervention research, it may be limited in isolation for evaluating research outcomes due to varying degrees of study rigor and threats to internal validity. Taken together, to best understand what works for whom an under what conditions with respect to AE, it is critical that results from published and grey literature, which refers to unpublished research not subjected to the publication review process ([&lt;reflink idref=&quot;bib78&quot; id=&quot;ref41&quot;&gt;78&lt;/reflink&gt;]), are meta-analyzed and assessed for quality and rigor.&lt;/p&gt; &lt;p&gt;Two primary approaches are commonly employed for synthesizing evidence across multiple SCEDs in meta-analytic studies. The first approach involves fitting a multilevel model (MLM) directly to raw participant-level data, which allows for the simultaneous modeling of within-participant and between-study variability. This approach can capture fine-grained data patterns but may be limited by the heterogeneity of outcome measures and the availability of raw data. The second approach, which we adopted in this study, involves the calculation of case-specific effect sizes for individual participants, followed by the application of a MLM meta-analytic model to synthesize these effect sizes across participants and studies. This method leverages the strengths of MLM to account for hierarchical data structures while accommodating diverse outcome measures and reporting practices across studies.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-5&quot;&gt;Purpose of the Current Study&lt;/hd&gt; &lt;p&gt;The current study aims to expand the knowledge base on AE by conducting a research synthesis of the available research. This study analyzes the effects of AE on a broad range of meltdowns, evaluates the quality and rigor of the literature base, and detects the presence or absence of publication bias in the AE literature. By doing so, our aim to provide more comprehensive understanding on the effectiveness of AE and identify key factors that may enhance its impact. Previous reviews have often focused on stereotypic behaviors as a primary outcome, whereas this study aims to include a wider range of meltdowns, including those that pose physical or emotional harm to the individual or others nearby. These behaviors can hinder educational success and disrupt the learning environments for both the individual exhibiting the behaviors and their peers or classmates ([&lt;reflink idref=&quot;bib31&quot; id=&quot;ref42&quot;&gt;31&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib45&quot; id=&quot;ref43&quot;&gt;45&lt;/reflink&gt;]). For the purposes of this study, we define &quot;meltdowns&quot; as those that pose physical or emotional harm to the individual or others nearby, as well as behaviors that significantly hinder educational or social engagement.&lt;/p&gt; &lt;p&gt;While stereotypy (i.e., stimming; see Table 1 in [&lt;reflink idref=&quot;bib9&quot; id=&quot;ref44&quot;&gt;9&lt;/reflink&gt;]) has been included in some prior reviews as a primary outcome, we acknowledge that non-harmful stereotypy behaviors are often not considered problematic by many Autistic individuals and their advocates. Accordingly, we distinguish between stereotypy that impedes learning or functioning and other forms of stereotypy, focusing our analysis on the former category. In addition to analyzing the effects of AE on meltdowns, this study also examines the presence of publication bias in AE research. Publication bias occurs when studies with null or negative results are less likely to be published, potentially skewing the overall understanding of an intervention&#39;s effectiveness ([&lt;reflink idref=&quot;bib19&quot; id=&quot;ref45&quot;&gt;19&lt;/reflink&gt;]).&lt;/p&gt; &lt;hd id=&quot;AN0194392924-6&quot;&gt;Research Questions&lt;/hd&gt; &lt;p&gt;To achieve these research aims, this study employs a MLM meta-analytic approach and the Single Case Analysis and Review Framework (SCARF). MLM offers several advantages, including the ability to provide comprehensive information about services effects, model potential moderators, address issues of autocorrelation and over-dependence, and ensure accurate calculations ([&lt;reflink idref=&quot;bib5&quot; id=&quot;ref46&quot;&gt;5&lt;/reflink&gt;]). Additionally, MLM allows for the inclusion of hierarchical data structures, which is particularly beneficial in single-case research designs where data points are nested within individuals and studies. This approach enables the analysis to account for variability at different levels (e.g., within-individual and between-study), providing more precise estimates of intervention effects. It also enhances the capacity to explore the impact of study-specific characteristics and participant demographics as potential moderators, thereby offering a more detailed understanding of the conditions under which AE is most effective.&lt;/p&gt; &lt;p&gt;The SCARF provides a tool for researchers to evaluate studies along dimensions critical to SCED, such as internal validity, generality, outcomes, and overall reporting ([&lt;reflink idref=&quot;bib39&quot; id=&quot;ref47&quot;&gt;39&lt;/reflink&gt;]). It facilitates the visual analysis of multiple SCED studies simultaneously, offering a means to visually appraise the strength and rigor of SCED research evidence. By representing the presence or absence of various internal validity indicators and observed changes in behavior, the SCARF supports a high-level appraisal of the available evidence that enhance the robustness of the analysis. These approaches to synthesize the literature base allow for a more nuanced understanding of AE and its impact on meltdowns.&lt;/p&gt; &lt;p&gt;The specific research questions guiding this meta-analysis are:&lt;/p&gt; &lt;p&gt;&lt;/p&gt; &lt;ulist&gt; &lt;item&gt; What are the characteristics of studies that evaluated AE?&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; What is the quality and rigor of AE research?&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; Is AE efficacious in reducing meltdowns of Autistic individuals?&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; Are there notable moderating variables that impact the efficacy of AE?&lt;/item&gt; &lt;p&gt;&lt;/p&gt; &lt;item&gt; To what extent is publication bias, if at all, prevalent in the AE research base?&lt;/item&gt; &lt;/ulist&gt; &lt;hd id=&quot;AN0194392924-7&quot;&gt;Method&lt;/hd&gt; &lt;p&gt;&lt;/p&gt; &lt;hd id=&quot;AN0194392924-8&quot;&gt;Search Procedure&lt;/hd&gt; &lt;p&gt;Published and unpublished studies were searched across multiple databases to ensure a rigorous synthesis of relevant literature. We searched abstracts, titles, and keywords in PsycINFO (APA) to capture psychological studies; abstracts and keywords in ERIC (EBSCO) to identify education-focused research; abstracts, titles, and subject terms in Academic Search Premier (EBSCO) to capture multidisciplinary scholarly content; and abstracts and keywords in Web of Science to identify high-impact journal articles spanning various disciplines. To capture grey literature, we searched the full text of the Networked Digital Library of Theses and Dissertations (NDLTD) and Open Access Theses and Dissertations (OATD). In ProQuest One Academic, we searched dissertations, theses, and other scholarly works that explicitly addressed the research topics. Searches were conducted in January 2024 of studies published in English through the end of 2023.&lt;/p&gt; &lt;p&gt;A systematic search strategy using Boolean operators was developed to identify studies addressing the intersection of exercise/antecedent exercise interventions, Autistic populations or related developmental disabilities, and single-case research methodologies. The search terms were (&quot;exercise&quot; OR &quot;antecedent exercise&quot;) AND (&quot;aut*&quot; OR &quot;pervasive developmental disability&quot; OR &quot;Asperger&#39;s&quot;) AND (&quot;single-case research design&quot; OR &quot;single-subject research design&quot; OR &quot;single-case experimental design&quot;). Digital copies were identified using this search process, and when unavailable, research team members contacted authors to retrieve copies.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-9&quot;&gt;Inclusion and Exclusion Criteria&lt;/hd&gt; &lt;p&gt;The inclusion criteria specified that: (a) the study must include an AE intervention, defined as structured physical activity implemented prior to the occurrence of a meltdown, a behavior that impedes learning or functioning, (b) the study must utilize an SCED, and (c) participants were Autistic (Levels 1–3; [&lt;reflink idref=&quot;bib2&quot; id=&quot;ref48&quot;&gt;2&lt;/reflink&gt;]), had a related condition (e.g., pervasive developmental delay), or had a co-occurring (comorbidity) diagnosis (e.g., Intellectual Developmental Disability, Attention-Deficit/Hyperactivity Disorder, Specific Learning Disorder, etc.), or the study included a description of participant specifiers that aligned with the DSM-IV TR definition of autism spectrum disorder ([&lt;reflink idref=&quot;bib2&quot; id=&quot;ref49&quot;&gt;2&lt;/reflink&gt;]), but the diagnosis was not explicitly stated. Terms such as &quot;pervasive developmental delay&quot; and &quot;Asperger&#39;s&quot; were included in our search strategy due to shifting diagnostic boundaries over time.&lt;/p&gt; &lt;p&gt;[&lt;reflink idref=&quot;bib30&quot; id=&quot;ref50&quot;&gt;30&lt;/reflink&gt;] emphasize that Autism identification is often complicated by heterogeneous symptoms and frequent comorbid conditions, which can mask core symptoms and lead to delays in identification. Furthermore, cultural and socioeconomic influences significantly impact the timing and accuracy of Autism identification, necessitating a nuanced approach to study inclusion to capture diverse populations effectively. Additionally, iterative changes in diagnostic definitions and tools over time, such as the transitions from DSM-IV to DSM-5 and adjustments in assessment methodologies, have contributed to variability in descriptions of Autism across studies, complicating the synthesis of evidence ([&lt;reflink idref=&quot;bib30&quot; id=&quot;ref51&quot;&gt;30&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib82&quot; id=&quot;ref52&quot;&gt;82&lt;/reflink&gt;]).&lt;/p&gt; &lt;hd id=&quot;AN0194392924-10&quot;&gt;Inter-Rater Reliability&lt;/hd&gt; &lt;p&gt;For each step of the review process, the first author trained the second and third authors on the operational definitions and procedures for coding the abstracts and full-texts. Each coder independently reviewed the assigned documents, applying the inclusion criteria as outlined in the study. The first author computed inter-rater reliability (IRR) using the formula: (exact agreement/total opportunities to agree) &#215; 100. To ensure consistency, IRR was conducted on 30% of the title/abstract screening and 100% of the full-text screening. Any disagreements identified during the process were resolved through consultation with the primary document and inclusion criteria. The coders discussed their rationale for their decisions, and consensus was reached for the final code. IRR results were 94.3% for title/abstract, and 96.9% for full-text screening.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-11&quot;&gt;Data Extraction and Coding&lt;/hd&gt; &lt;p&gt;Qualifying participants&#39; data were extracted that resulted in 111 participants across 34 studies. The extracted data included (a) participant characteristics such as age, gender, race/ethnicity, diagnosis, setting, and interventionist; (b) dependent measures such as target behaviors; (c) the type of exercise; and (d) the duration of the exercise. When coding, a 1 was marked in the data frame if the participant characteristic was attributable, a 0 was marked if it was not attributable, and n/a was marked if the information was not reported.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-12&quot;&gt;Dependent measures&lt;/hd&gt; &lt;p&gt;Target behaviors were coded into two distinct categories to capture the outcomes targeted by AE interventions. These categories included meltdowns, which were defined as actions posing physical or emotional harm to the individual or others that impacted learning or functioning. This could include stereotypy or stimming if the authors of the study shared that the behavior explicitly impacted learning or functioning, referring to repetitive or restrictive movements or vocalizations that explicitly adversely impacted learning or functioning. The second category was adaptive behavior that included pro-social engagement and involved behaviors that facilitated positive social interactions; on-task behaviors, defined as active engagement with a given task or activity; and other adaptive behaviors, which included any positive behavioral outcomes not captured by the other categories. The aim of the AE intervention in each included study was further categorized into one of three descriptors: increase (adaptive behavior), or decrease (meltdown behaviors) reflecting the intended direction of change in the targeted behaviors.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-13&quot;&gt;Quality and rigor&lt;/hd&gt; &lt;p&gt;We applied the SCARF (Version 3.2; [&lt;reflink idref=&quot;bib36&quot; id=&quot;ref53&quot;&gt;36&lt;/reflink&gt;]) to assess the quality, rigor, and outcomes for each included study. SCARF has been used as an assessment in past SCED studies and research syntheses ([&lt;reflink idref=&quot;bib15&quot; id=&quot;ref54&quot;&gt;15&lt;/reflink&gt;]) and used to evaluate study rigor, quality of measurement, and primary outcomes. SCARF is designed to evaluate SCED studies that include both a single participant and multiple participants and has been used in various SCED studies that assess diverse behaviors ([&lt;reflink idref=&quot;bib39&quot; id=&quot;ref55&quot;&gt;39&lt;/reflink&gt;]). However, in studies that had multiple participants, each participant was evaluated separately.&lt;/p&gt; &lt;p&gt;Internal validity, external validity, and other relevant information were assessed using the SCARF tool, which includes three distinct scales to evaluate study quality and rigor. The first scale assesses internal validity based on 13 items, with scores ranging from 0 (lowest internal validity) to 13 (highest internal validity). A higher score indicates greater confidence in the study&#39;s conclusions, although the relative importance of individual items may vary. The second scale evaluates external validity, focusing on the extent to which study outcomes may be generalized beyond the immediate study context. This includes factors such as the presence of generalization and maintenance data, social validity evidence, the use of endogenous implementers, and typical implementation contexts. The third scale assesses the extent to which study authors provide sufficient information for replication. Additionally, primary outcomes were scored based on the consistency of observed effects. A score of 4 indicates consistent positive effects, whereas a score of 0 reflects counter-therapeutic effects. Intermediate scores (&lt;reflink idref=&quot;bib1&quot; id=&quot;ref56&quot;&gt;1&lt;/reflink&gt;, 2, or 3) represent null, inconsistent, or weak positive effects. Scores of 3 and 4 are consistent with the identification of a functional relation, as noted in SCARF (Version 3.2; [&lt;reflink idref=&quot;bib38&quot; id=&quot;ref57&quot;&gt;38&lt;/reflink&gt;]). All included studies were independently coded by multiple reviewers who are authors on this paper to ensure accuracy and consistency, with disagreements resolved through discussion and consensus.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-14&quot;&gt;Data Extraction and Publication Bias&lt;/hd&gt; &lt;p&gt;&lt;/p&gt; &lt;hd id=&quot;AN0194392924-15&quot;&gt;Data extraction&lt;/hd&gt; &lt;p&gt;Webplotdigitizer ([&lt;reflink idref=&quot;bib70&quot; id=&quot;ref58&quot;&gt;70&lt;/reflink&gt;]) was used to extract raw data from SCED studies. Webplotdigitizer is a free-to-use data extraction tool shown to be reliable with SCED ([&lt;reflink idref=&quot;bib21&quot; id=&quot;ref59&quot;&gt;21&lt;/reflink&gt;]). Baseline and intervention (AB) phase contrasts were extracted from the AE study graphs for each of the included studies. In addition to AB phase contrasts data, maintenance and generalization data were also extracted. All graphs and data paths in the included studies that did not include the AE intervention were not extracted. All data extraction was completed by either university faculty or doctoral-level students who had previous experience using Webplotdigitizer.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-16&quot;&gt;Effect size&lt;/hd&gt; &lt;p&gt;The log response ratio effect size (LRR; [&lt;reflink idref=&quot;bib65&quot; id=&quot;ref60&quot;&gt;65&lt;/reflink&gt;]) was estimated to detect the effect of AE on the dependent variable. Advantages of LRR are that it can be transformed to percent change between the baseline and intervention, and its minimal susceptibility to procedural variation in the studies ([&lt;reflink idref=&quot;bib65&quot; id=&quot;ref61&quot;&gt;65&lt;/reflink&gt;]). The LRR effect size is the natural log of proportionate change in the mean level between conditions and has been estimated in several recent meta-analyses that included SCED data (e.g., [&lt;reflink idref=&quot;bib10&quot; id=&quot;ref62&quot;&gt;10&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib20&quot; id=&quot;ref63&quot;&gt;20&lt;/reflink&gt;]). The LRR effect size has been shown to be appropriate for outcomes measured on a ratio scale such as rate, duration, and frequency measurement, and not appropriate for outcomes measured on a rating scale ([&lt;reflink idref=&quot;bib65&quot; id=&quot;ref64&quot;&gt;65&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;Autocorrelation is the degree of correlation between data points that are serially dependent on each other due the repeated nature of single-case research design and has been a challenge when synthesizing single-case research ([&lt;reflink idref=&quot;bib38&quot; id=&quot;ref65&quot;&gt;38&lt;/reflink&gt;]). The decision to use the LRR as the primary effect size metric was informed by the specific characteristics of the data and the theoretical and methodological alignment of LRR with the assumptions inherent in SCED studies. LRR is particularly advantageous for synthesizing data measured on a ratio scale, as it captures proportional change and facilitates comparability across diverse behavioral outcomes, offering a robust solution to procedural variations frequently encountered in SCED research. While [&lt;reflink idref=&quot;bib6&quot; id=&quot;ref66&quot;&gt;6&lt;/reflink&gt;] observed moderate autocorrelation in SCED data (mean autocorrelation = 0.46, &lt;emph&gt;SD&lt;/emph&gt; = 0.33) and reported no significant differences among effect size metrics such as SMD, LRR, and Tau-U when autocorrelation was controlled, the selection of LRR was predicated on its superior ability to address the heterogeneity of outcome measures and maintain analytical rigor under varying study conditions. Recognizing the evolving discourse on effect size estimation, we emphasize the value of continued future work that examines the comparative utility of multiple effect size metrics. In alignment with open science principles, all data, analysis scripts, and materials have been made publicly accessible via the OSF, fostering transparency and enabling further validation and methodological advancements in this domain.&lt;/p&gt; &lt;p&gt;Depending on the aim of the intervention effects either the log response ratio increasing (LRRi) or log response ratio decreasing (LRRd) was selected. That is, if AE was aimed to mitigate meltdowns LRRd was selected and if AE was aimed to increase adaptive behavior, then LRRi was selected. In its basic parametric form, the formula of LRR can be defined as:&lt;/p&gt; &lt;p&gt;Graph&lt;/p&gt; &lt;p&gt; &lt;ephtml&gt; &amp;lt;math display=&quot;block&quot; xmlns=&quot;http://www.w3.org/1998/Math/MathML&quot;&amp;gt;&amp;lt;mrow&amp;gt;&amp;lt;mi mathvariant=&quot;normal&quot;&amp;gt;&amp;amp;#936;&amp;lt;/mi&amp;gt;&amp;lt;/mrow&amp;gt;&amp;lt;mo&amp;gt;=&amp;lt;/mo&amp;gt;&amp;lt;mrow&amp;gt;&amp;lt;mspace width=&quot;0.25em&quot; /&amp;gt;&amp;lt;/mrow&amp;gt;&amp;lt;mi&amp;gt;ln&amp;lt;/mi&amp;gt;&amp;lt;mspace width=&quot;0.2em&quot; /&amp;gt;&amp;lt;mo stretchy=&quot;false&quot;&amp;gt;(&amp;lt;/mo&amp;gt;&amp;lt;msub&amp;gt;&amp;lt;mi&amp;gt;&amp;amp;#956;&amp;lt;/mi&amp;gt;&amp;lt;mi&amp;gt;&amp;amp;#946;&amp;lt;/mi&amp;gt;&amp;lt;/msub&amp;gt;&amp;lt;mo stretchy=&quot;false&quot;&amp;gt;)&amp;lt;/mo&amp;gt;&amp;lt;mo&amp;gt;&amp;amp;#8722;&amp;lt;/mo&amp;gt;&amp;lt;mi&amp;gt;ln&amp;lt;/mi&amp;gt;&amp;lt;mspace width=&quot;0.2em&quot; /&amp;gt;&amp;lt;mo stretchy=&quot;false&quot;&amp;gt;(&amp;lt;/mo&amp;gt;&amp;lt;msub&amp;gt;&amp;lt;mi&amp;gt;&amp;amp;#956;&amp;lt;/mi&amp;gt;&amp;lt;mrow&amp;gt;&amp;lt;mi&amp;gt;&amp;amp;#945;&amp;lt;/mi&amp;gt;&amp;lt;mrow&amp;gt;&amp;lt;mspace width=&quot;0.25em&quot; /&amp;gt;&amp;lt;/mrow&amp;gt;&amp;lt;/mrow&amp;gt;&amp;lt;/msub&amp;gt;&amp;lt;mo stretchy=&quot;false&quot;&amp;gt;)&amp;lt;/mo&amp;gt;&amp;lt;/math&amp;gt; &lt;/ephtml&gt; &lt;/p&gt; &lt;p&gt;If Ψ is greater than zero that means, there was a positive effect on the meltdowns, and if Ψ is less than zero, then there was a negative effect on the meltdowns ([&lt;reflink idref=&quot;bib65&quot; id=&quot;ref67&quot;&gt;65&lt;/reflink&gt;]). Additionally, if Ψ is zero, there was no change ([&lt;reflink idref=&quot;bib65&quot; id=&quot;ref68&quot;&gt;65&lt;/reflink&gt;]). All estimates were calculated in the R Core Team (2025) environment using the SingleCaseES package ([&lt;reflink idref=&quot;bib76&quot; id=&quot;ref69&quot;&gt;76&lt;/reflink&gt;]).&lt;/p&gt; &lt;hd id=&quot;AN0194392924-17&quot;&gt;Meta-analysis&lt;/hd&gt; &lt;p&gt;All data were wrangled and tidied using the tidyverse package in R ([&lt;reflink idref=&quot;bib80&quot; id=&quot;ref70&quot;&gt;80&lt;/reflink&gt;]). For this meta-analysis, the study-level effect sizes were analyzed using a MLM random-effects model and estimated using the metafor package in R ([&lt;reflink idref=&quot;bib79&quot; id=&quot;ref71&quot;&gt;79&lt;/reflink&gt;]). To address bias within the synthesized standard deviations and detail the overall effects of the studies and participants, Cluster-Robust Variance Estimation (CRVE; [&lt;reflink idref=&quot;bib66&quot; id=&quot;ref72&quot;&gt;66&lt;/reflink&gt;]) was applied to effect sizes and confidence intervals using the ClubSandwich package ([&lt;reflink idref=&quot;bib64&quot; id=&quot;ref73&quot;&gt;64&lt;/reflink&gt;]). CRVE was used to mitigate potential biases arising from the hierarchical structure of the data, where multiple measurements were nested within individual participants and studies. For studies reporting multiple dependent measures, only the measures aligned with the primary focus of the study (e.g., meltdowns) were included in the main models. Secondary outcomes, such as on-task behavior or social engagement, were analyzed in separate exploratory models to maintain the specificity and interpretability of the results. Random effects were specified for participants nested within studies to address the hierarchical structure of the data, and CRVE was employed to ensure robust standard errors and confidence intervals. This approach ensured that standard errors and confidence intervals were robust to the dependencies characteristic of SCED data, addressing the risk of overestimated standard errors and inflated precision ([&lt;reflink idref=&quot;bib16&quot; id=&quot;ref74&quot;&gt;16&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;Unpublished studies were included in this meta-analysis to account for publication bias. Grey literature ([&lt;reflink idref=&quot;bib78&quot; id=&quot;ref75&quot;&gt;78&lt;/reflink&gt;]) was included to help mitigate the risk of inflated meta-analysis effect size outcomes ([&lt;reflink idref=&quot;bib19&quot; id=&quot;ref76&quot;&gt;19&lt;/reflink&gt;]). During the article selection process, each unpublished article was vetted to ensure there was not a published version. Additionally, unpublished studies were checked to ensure that a later published study was not available under a different last name such as a married name. If a published version was available, only the data, participants, settings, exercise, and type of exercise from the published version were used. To address dependencies arising from multiple dependent measures collected for individual participants within primary studies, we categorized outcome measures by theoretical relevance (e.g., meltdowns, disruptive behaviors, adaptive behaviors) and analyzed them independently. Separate MLM meta-analytic models were constructed for each outcome type, ensuring that each participant contributed only one effect size per model. This approach allowed for robust analysis while reducing within-study dependencies. This review was not pre-registered. All data, code, protocols, raw SCARF outcomes, supplemental Figures, and materials are posted on the corresponding open science framework (OSF; [&lt;reflink idref=&quot;bib57&quot; id=&quot;ref77&quot;&gt;57&lt;/reflink&gt;]) project page that can be accessed here (Peer Review Link).&lt;/p&gt; &lt;hd id=&quot;AN0194392924-18&quot;&gt;Results&lt;/hd&gt; &lt;p&gt;&lt;/p&gt; &lt;hd id=&quot;AN0194392924-19&quot;&gt;Search and Screening&lt;/hd&gt; &lt;p&gt;The initial search yielded 432 articles and 287 duplicates of articles were removed. The initial screening included 145 studies that yielded 43 studies that were then assessed for eligibility (34 published articles and nine dissertations or theses). Following this assessment for eligibility 25 published and nine unpublished studies met criteria for the synthesis. Supplemental Figure 1 shows the PRISMA flowchart ([&lt;reflink idref=&quot;bib59&quot; id=&quot;ref78&quot;&gt;59&lt;/reflink&gt;]) that displays the results of the screening and selection process. Each included article was analyzed using the SCARF (Version 3.2) tool to determine the quality and rigor.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-20&quot;&gt;Study Characteristics and Context&lt;/hd&gt; &lt;p&gt;Supplemental Table 1 (published studies) and Supplemental Table 2 (unpublished studies) summarize the study characteristics coded in the research synthesis, addressing Research Question 1 by providing a detailed overview of the contexts, participants, and methodologies of the included studies. We found that most AE studies were conducted in the United States (&lt;emph&gt;N&lt;/emph&gt; = 26), with others in Canada (&lt;emph&gt;N&lt;/emph&gt; = 3), the United Kingdom (&lt;emph&gt;N&lt;/emph&gt; = 2), and Australia (&lt;emph&gt;N&lt;/emph&gt; = 1). Participant ages ranged from 3 to 53 years. AE was conducted in various settings, including schools (classrooms, school gyms, [e.g., [&lt;reflink idref=&quot;bib3&quot; id=&quot;ref79&quot;&gt;3&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib56&quot; id=&quot;ref80&quot;&gt;56&lt;/reflink&gt;]], residential facilities [care centers, residential programs, e.g., [&lt;reflink idref=&quot;bib8&quot; id=&quot;ref81&quot;&gt;8&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib47&quot; id=&quot;ref82&quot;&gt;47&lt;/reflink&gt;]]), and other environments such as gyms, playgrounds, and therapy rooms (e.g., [&lt;reflink idref=&quot;bib23&quot; id=&quot;ref83&quot;&gt;23&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib32&quot; id=&quot;ref84&quot;&gt;32&lt;/reflink&gt;]). The search yielded a range of physical activity types that included jogging (e.g., [&lt;reflink idref=&quot;bib1&quot; id=&quot;ref85&quot;&gt;1&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib12&quot; id=&quot;ref86&quot;&gt;12&lt;/reflink&gt;]), aerobic exercise (e.g., [&lt;reflink idref=&quot;bib4&quot; id=&quot;ref87&quot;&gt;4&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib25&quot; id=&quot;ref88&quot;&gt;25&lt;/reflink&gt;]), and multiple exercises (e.g., [&lt;reflink idref=&quot;bib11&quot; id=&quot;ref89&quot;&gt;11&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib43&quot; id=&quot;ref90&quot;&gt;43&lt;/reflink&gt;]). The duration of physical activity ranged from brief sessions that were under 5 min (e.g., [&lt;reflink idref=&quot;bib48&quot; id=&quot;ref91&quot;&gt;48&lt;/reflink&gt;]; [&lt;reflink idref=&quot;bib55&quot; id=&quot;ref92&quot;&gt;55&lt;/reflink&gt;]; Goldman et al., 2021), to moderate sessions around 10–20 min (e.g., Ellis, 1989; Luke et al., 2014), to longer sessions that were 45 min or more (e.g., Baumeister &amp;amp; Maclean, 1984; McGimsey &amp;amp; Favell, 1988).&lt;/p&gt; &lt;hd id=&quot;AN0194392924-21&quot;&gt;SCARF Quality and Rigor Findings&lt;/hd&gt; &lt;p&gt;All published and unpublished studies included in the review were analyzed to evaluate their quality and rigor, addressing Research Question 2. That is, the quality and rigor of 118 designs across 25 articles and unpublished studies of 105 designs across nine articles were analyzed using the SCARF (Version 3.2). Raw outcomes for published and unpublished SCARF findings can be viewed on the OSF project page.&lt;/p&gt; &lt;p&gt;Figure 1 (top panel) displays a scatter plot of the published studies, with data points sized relative to the number of SCEDs with the given score, meaning larger data points represent multiple studies with the same score. The &quot;Internal Validity Indicator&quot; reflects the extent to which studies demonstrated strong, consistent, and replicable functional relations within their designs, as assessed by SCARF criteria. Specifically, this includes considerations of data sufficiency and design quality, and safeguards against bias. While published studies demonstrated moderate internal validity on average (&lt;emph&gt;M&lt;/emph&gt; = 79.37%, range = 27.96%–96.6%) across dependent variables, and high scores in data sufficiency and design categories (&lt;emph&gt;M&lt;/emph&gt; = 89.1%, range = 56.7%–100%), they exhibited weaknesses in safeguards against bias (&lt;emph&gt;M&lt;/emph&gt; = 32%) and sufficient demonstrations of functional relations (&lt;emph&gt;M&lt;/emph&gt; = 50%). Additionally, less than 40% of the AE designs included fidelity components (&lt;emph&gt;M&lt;/emph&gt; = 20.14%, range = 8.4%−26.6%), indicating limited adherence to implementation rigor. Figure 1 (bottom panel) shows a scatter plot for unpublished studies. Based on visual analysis of the plot, the functional relation determination indicated more weak evidence across designs when compared to strong evidence. Unpublished studies included in the review demonstrated considerable internal validity within the dependent variables (&lt;emph&gt;M&lt;/emph&gt; = 77.54%, range = 14.71%–100%) and data sufficiency and design categories (&lt;emph&gt;M&lt;/emph&gt; = 92.93%, range = 75.49%–100%). However, within both categories, unpublished AE research lacked safeguards for bias (&lt;emph&gt;M&lt;/emph&gt; = 14.7%) and sufficient demonstrations (75.49%). Additionally, under 40% of the unpublished AE designs lacked the SCARF components that were included within the fidelity cluster (&lt;emph&gt;M&lt;/emph&gt; = 74.1%, range = 66%–85.9%).&lt;/p&gt; &lt;p&gt;Graph: Figure 1 Single-Case Analysis and Review Framework (SCARF; [&lt;reflink idref=&quot;bib36&quot; id=&quot;ref93&quot;&gt;36&lt;/reflink&gt;]) for Published (top) and Unpublished (bottom) Articles&lt;/p&gt; &lt;hd id=&quot;AN0194392924-22&quot;&gt;MLM Meta-Analysis Findings&lt;/hd&gt; &lt;p&gt;For Research Question 3, we synthesized findings from the included studies to evaluate the efficacy of AE in treating meltdowns of Autistic individuals. The first model built to evaluate the effectiveness of AE was used to detect its impact on mitigating meltdowns. Outcomes of the meta-analysis that included CRVE yielded an overall effect size of −0.342 (&lt;emph&gt;SE&lt;/emph&gt; = 0.089, &lt;emph&gt;p&lt;/emph&gt; &amp;gt;.005, 95% CI [−0.517, −0.168]). Benchmarks for LRR effect sizes of challenging behavior or meltdowns suggest that therapeutic change is typically reflected in values less than −1.04 ([&lt;reflink idref=&quot;bib37&quot; id=&quot;ref94&quot;&gt;37&lt;/reflink&gt;]). Thus, the observed effect size indicates a moderate impact of AE in reducing meltdowns compared to the distribution of effects. Next, a model was built to detect the magnitude of AE&#39;s effect on increasing alternative adaptive behaviors. The outcome, which also included CRVE, yielded an overall effect size of 0.806 (&lt;emph&gt;SE&lt;/emph&gt; = 0.166, &lt;emph&gt;p&lt;/emph&gt; &amp;gt;.005, 95% CI [0.481, 1.13]). Relative to benchmarks for engagement behaviors, which typically cluster around 0.42 for LRR values, this effect size reflects a substantial improvement in adaptive behavior.​&lt;/p&gt; &lt;p&gt;Supplemental Figure 2 shows study-level effect sizes presented in a forest plot, ranging from least effective (top; [&lt;reflink idref=&quot;bib3&quot; id=&quot;ref95&quot;&gt;3&lt;/reflink&gt;]) to most effective (bottom; Cannella-Malone et al., 2011). Published studies are indicated in black, while unpublished studies are shown in red. A notable feature of the forest plot is that unpublished studies are generally clustered within the top half of the forest plot and published studies are clustered towards the bottom half of the forest plot. This clustering pattern reflects a potential publication bias, where studies with larger, more favorable effect sizes are more likely to be published, while smaller or nonsignificant results remain in the grey literature. This bias can overestimate the true effectiveness of AE interventions when relying solely on published studies, as the suppression of less effective outcomes in the literature may skew the evidence base. Thus, it is essential to consider the contributions of unpublished studies as shown in Supplemental Figure 2 to provide a balanced and accurate assessment of AE effectiveness.&lt;/p&gt; &lt;p&gt;To address Research Question 4, we examined whether the setting, exercise type, and dosage of AE interventions had any effect on reducing meltdowns. Supplemental Figure 3 displays forest plots associated with these moderators. Across different settings (top plot), the implementation of AE in day centers demonstrated the largest reductions in meltdowns, followed by residential settings, and schools. For exercise type (middle plot), roller skating, biking, and structured exercise routines (e.g., combining aerobic and anaerobic movements) yielded the greatest reductions in meltdowns, while fitness games showed the smallest, but still favorable, effect. Last, dosage of AE (bottom plot) showed that interventions lasting under 31–60 min had the most robust effect, followed by those lasting 0–10 min. Interventions lasting 21–30 min and 11–20 min showed smaller effects. These findings highlight the importance of tailoring AE interventions to specific settings, with day centers and structured, diverse exercise routines being particularly effective, and suggest that shorter or longer AE sessions may be more impactful in reducing meltdowns.&lt;/p&gt; &lt;p&gt;In educational contexts, incorporating shorter, high-impact AE interventions during transitions or breaks may help reduce meltdowns and enhance students&#39; readiness to learn. Additionally, structured exercise routines, which can be embedded into physical education or classroom activities, provide a practical and evidence-based strategy to support emotional and behavioral regulation in students. To address Research Question 5, we examined the extent to which publication bias is present in the AE research base. An important observation from the analysis is that while the average internal validity scores were similar between published and unpublished studies, unpublished studies demonstrated fewer identified functional relations and smaller effect sizes compared to their published counterparts. This discrepancy may indicate the presence of publication bias, as studies with stronger evidence of functional relations and larger effect sizes are more likely to be published.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-23&quot;&gt;Discussion&lt;/hd&gt; &lt;p&gt;The purpose of this synthesis and MLM meta-analysis was to evaluate the characteristics, quality, and outcomes of AE interventions for Autistic individuals, including their efficacy in reducing meltdowns, the influence of moderating variables, and the presence of publication bias. These aims were guided by five research questions that asked about characteristics of studies, the quality and rigor of studies, the effectiveness of AE on mitigating meltdowns, potential moderating variables that resulted in differentiated effectiveness of outcomes, and if there were traces of publication bias within the AE literature base. These findings, along with their implications, future directions, and limitations, are explored in the following sections.&lt;/p&gt; &lt;p&gt;The first research question aimed to characterize studies implementing AE for Autistic individuals. When answering this question, we found that AE had been implemented across a variety of settings from schools (e.g., [&lt;reflink idref=&quot;bib40&quot; id=&quot;ref96&quot;&gt;40&lt;/reflink&gt;] &amp;amp; [&lt;reflink idref=&quot;bib51&quot; id=&quot;ref97&quot;&gt;51&lt;/reflink&gt;]) to day centers (Baumeister &amp;amp; Maclean, 1984). There were also a range of different activities that were labeled as exercise from jogging (Nakutin, 2019) to basketball ([&lt;reflink idref=&quot;bib69&quot; id=&quot;ref98&quot;&gt;69&lt;/reflink&gt;]). Notably, [&lt;reflink idref=&quot;bib49&quot; id=&quot;ref99&quot;&gt;49&lt;/reflink&gt;] included three young children between the ages of 5–6 years old and in an educational center, where AE activities included aerobic games like Simon says, mail run, frog jump, and stream jumper. Within the study, emphasis was placed on the variety of AE activities incorporated to support participants&#39; cooperation. For some studies, including Neely et al. (2015), AE sessions lasted less than 5 minutes, demonstrating that even brief exercise sessions can be implemented as part of an intervention. These findings illustrate the benefits of variety of exercises to ensure that cooperation occurs coupled with the importance of efficiency (&amp;gt; 5 min sessions). Efficiency and cooperation are particularly important in a classroom setting where teachers may be likely less motivated to implement interventions that may impede instruction time ([&lt;reflink idref=&quot;bib61&quot; id=&quot;ref100&quot;&gt;61&lt;/reflink&gt;]).&lt;/p&gt; &lt;p&gt;[&lt;reflink idref=&quot;bib24&quot; id=&quot;ref101&quot;&gt;24&lt;/reflink&gt;] developed and validated an activity preference assessment to systematically identify high and low preferred physical activities. The aim of the assessment was to identify preferred physical activities to increase health outcomes of children between ages 8–17 years old. These activities were then compared to sedentary activities. Overall, Fearnbach et al. found that 67% of participants preferred sedentary activities over physical activities. Based on the findings, it is likely that when given a choice, Autistic individuals may be less likely to choose a physical activity over a sedentary activity, especially if the physical activity is not preferred ([&lt;reflink idref=&quot;bib46&quot; id=&quot;ref102&quot;&gt;46&lt;/reflink&gt;]). This highlights the importance of conducting a priori preference assessments of AE activities to ensure sustained cooperation and maximize engagement. [&lt;reflink idref=&quot;bib27&quot; id=&quot;ref103&quot;&gt;27&lt;/reflink&gt;] demonstrated that even when interventions are designed to favor physical activities, additional manipulations are often necessary to increase exercise selection. That is, their findings indicated that interventions can be structured to promote physical activity without reducing time allocated to educational tasks. Future research should explore the sustained effects of highly preferred activities over extended periods. Identifying high-preference physical activities a priori could potentially reduce the dosage or duration of AE required to achieve meaningful outcomes, aligning with findings by McLaughlin (2017) that suggest brief interventions (e.g., 5 min) may allow for more instructional time within educational settings. Additionally, the role of context and setting is critical, as [&lt;reflink idref=&quot;bib60&quot; id=&quot;ref104&quot;&gt;60&lt;/reflink&gt;] demonstrated that engagement in physical activity varies significantly based on environmental factors, further emphasizing the need to consider setting when designing AE interventions.&lt;/p&gt; &lt;p&gt;The SCARF tool was used to assess the quality and rigor of AE interventions. Several notable features emerged after applying the SCARF tool (Version 3.2) to the AE research base that were primarily related to the external validity and reporting of results. First, little was known about the interventionist who was implementing the intervention beyond their role (teacher, parent, etc.). This was a consistent finding across both published and unpublished research. While it is important to have details on interventionists in any study, it is particularly important for the AE intervention. Strenuous exercise could result in injury of the participant or over-exhaustion if not properly monitored. Therefore, it is essential for authors of AE empirical studies to provide information on the implementers&#39; demographics and qualifications, specifically training received for implementing AE along with their ability to detect if a session should be terminated due to injury or exhaustion. Although no studies in this review and meta-analysis reported that participants were injured during exhaustion, it is critical to include demographics and qualifications, particularly if the intent is to incorporate AE into an individual&#39;s daily routine to evaluate maintenance effects.&lt;/p&gt; &lt;p&gt;Additionally, based on findings from this synthesis a methodological consideration for future AE research is the use of blinded observers to enhance study rigor. Since AE interventions typically include measurement sessions occurring after the exercise, it is feasible to employ observers who are na&#239;ve to the intervention condition. This practice can reduce observer bias and improve the internal validity of findings. Despite its potential, the use of blinded observers is underreported in the existing AE literature. Future research should prioritize incorporating na&#239;ve observers during data collection and clearly describe these procedures to increase the credibility and reliability of study results.&lt;/p&gt; &lt;p&gt;Future research should include systematic training for interventionists to ensure that they can safely and effectively implement AE with fidelity while detecting instances for when to terminate or pause intervention due to injury or over-exhaustion. One method that could be used with AE for interventionists is Behavior Skills Training (BST). BST generally includes task instructions, modeling, rehearsal, feedback, and then post-training. Evidence highlighting the effectiveness of BST has been found with a range of individuals targeting many different skills. For example, [&lt;reflink idref=&quot;bib29&quot; id=&quot;ref105&quot;&gt;29&lt;/reflink&gt;] used BST to train school staff to implement a student&#39;s behavior intervention plans. [&lt;reflink idref=&quot;bib33&quot; id=&quot;ref106&quot;&gt;33&lt;/reflink&gt;] conducted a systematic review of Behavioral Skills Training used with teachers. The majority of the 13 studies included in the Kirkpatrick et al. review were designed to teach special education teachers behavioral interventions such as discrete trial teaching and how to conduct a preference assessment, rather than how to implement AE. However, given that many studies included in this review were conducted in an educational context, and that BST has been shown to be an effective method to train educators, future research should consider incorporating this approach to train educational personnel on the AE intervention.&lt;/p&gt; &lt;p&gt;Another interesting finding when implementing the SCARF tool to assess the quality and rigor of the AE literature base was the lack of reporting on the maintenance effects of AE across the published and unpublished literature. This is concerning because it remains unclear which specific study characteristics yield the most effective outcomes for Autistic individuals. That is, questions such as &quot;Does activity variety over extended time result in greater maintained effectiveness than a single a-priori activity?&quot; or &quot;Are effects of AE more likely to maintain in a designated activity space such as a gym (e.g., [&lt;reflink idref=&quot;bib7&quot; id=&quot;ref107&quot;&gt;7&lt;/reflink&gt;]) or an educational setting such as an elementary school (e.g., Richards, 2019)?&quot; have yet to be answered. Additionally, it is unclear if the dosage of intervention is always necessary during maintenance to capture a similar intervention effect compared to the primary intervention phase. For example, participants in Richards (2019) played basketball for 45 min during AE and it is unclear if this same dosage of intervention is necessary during maintenance, or if it could be reduced to 20 or 10 min without compromising intervention effects. Additional research is needed to answer questions about the maintenance effects of AE and whether the same dosage used during initial intervention is necessary.&lt;/p&gt; &lt;p&gt;The meta-analysis was conducted to answer the third research question related to the magnitude of the effect for AE. Although more published and unpublished studies resulted in &quot;weak&quot; reporting according to the SCARF plots (see Figure 1), the overall effects of the MLM meta-analysis supported the use of AE as an intervention for mitigating meltdowns and increasing adaptive skills. Additional empirical research that is of the highest quality and rigor when measured by SCARF is necessary to further solidify the supporting evidence. Furthermore, significant gaps that include the lack of knowledge on maintenance effects of AE, and reporting of interventionist demographics and training, are important next steps in this literature base.&lt;/p&gt; &lt;p&gt;In addition to estimating overall effects, Research Question 4 asked if there were notable moderators that might result in differentiated estimates of effect sizes. Moderators were selected to better understand in what settings AE appears to be most effective and what specific types of exercise within an AE intervention are most effective. Interestingly, the AE intervention showed to be most effective in educational and residential contexts. Given the effect sizes when studies were stratified by setting, special education teachers should consider how to incorporate AE efficiently and effectively into classroom routines for Autistic learners if meltdowns are common. Special education teachers could dedicate time at the start of class (antecedent) for students to participate in AE, which, in turn, could help to mitigate meltdowns during instruction time. Several studies included in this review found that AE interventions that lasted 5 min (McLauglin, 2017) to 10 min (Currier, 2012; [&lt;reflink idref=&quot;bib63&quot; id=&quot;ref108&quot;&gt;63&lt;/reflink&gt;]) yielded therapeutic effects, which seems promising to ensure that instruction time is not compromised.&lt;/p&gt; &lt;p&gt;A promising finding when stratifying by exercise type was that two out of the four types did not require equipment, making them easier to implement; however, it is important to note that [&lt;reflink idref=&quot;bib60&quot; id=&quot;ref109&quot;&gt;60&lt;/reflink&gt;] found fixed equipment can engender greater physical activity, suggesting that equipment-based exercises may also hold unique advantages in certain contexts. Supplemental Figure 3 (bottom) showed that roller skating, biking, exercise routines, and jogging and dancing appeared to yield the greatest effect sizes. This is promising because if a special education teacher were to incorporate AE with a student or class, additional time spent setting up equipment is not necessary, therefore allowing for maximum instruction time following the AE intervention. Additionally, these findings suggest that two of the four exercise types that yielded the greatest effect in mitigating meltdowns (exercise routine, dancing) could potentially be implemented in a classroom or any other immediate setting, thus reducing the need for the student to transition to another location to engage in AE (i.e., playground, tennis court, etc.).&lt;/p&gt; &lt;p&gt;The variability observed in functional relations and effect sizes across studies may be attributable to individual-level differences among participants, as well as contextual factors influencing the implementation and outcomes of antecedent exercise interventions. It is reasonable to hypothesize that AE may not consistently result in decreased meltdowns across all individuals or situations. Individual characteristics such as sensory preferences, baseline activity levels, and responsiveness to physical activity could play critical roles in determining the effectiveness of the intervention. Similarly, contextual factors like the type of activity, duration, implementation fidelity, and environmental conditions may influence outcomes. For instance, AE might be more effective in structured settings with predictable routines or with activities tailored to individual preferences and needs. The observation that even at the highest levels of internal validity, the intervention was as likely to &quot;not work&quot; as to &quot;work&quot; highlights the importance of identifying the specific conditions under which AE is most effective. Future research should focus on exploring these moderating variables to refine the implementation of antecedent exercise and optimize its impact on meltdowns.&lt;/p&gt; &lt;p&gt;A critical consideration that warrants attention is the broader issue of physical activity levels among young children, particularly Autistic youth. Findings consistently show that most young children do not receive adequate physical activity, which has implications for long-term behavior patterns and health outcomes. This is especially relevant for Autistic children, who may develop a preference for sedentary activities due to their early exposure and the comfort of routine and familiar activities often associated with an autism diagnosis ([&lt;reflink idref=&quot;bib46&quot; id=&quot;ref110&quot;&gt;46&lt;/reflink&gt;]). These early experiences can shape lifelong preferences, potentially reducing responsiveness to interventions like antecedent exercise later in life. This illustrates the importance of policy initiatives aimed at promoting physical activity from an early age. Increasing opportunities for engaging in diverse and enjoyable physical activities during early childhood may both improve immediate health and developmental outcomes, and foster preferences that make interventions like AE more effective in the future.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-24&quot;&gt;Limitations&lt;/hd&gt; &lt;p&gt;Although systematic steps were taken to ensure that both published and unpublished research that met the inclusion criteria were included in this review and meta-analysis, this research synthesis is not without limitations. Studies that could have impacted overall results were either not identified or excluded because they did not meet our inclusion criteria. For example, [&lt;reflink idref=&quot;bib62&quot; id=&quot;ref111&quot;&gt;62&lt;/reflink&gt;] did meet inclusion criteria for including Autistic participants who emitted meltdowns, and the AE intervention was implemented; however, the study was not included in the review because there was no baseline phase that could be compared to the AE intervention when estimating LRR. In turn, the exclusion of this study hinders the comprehensiveness of the review. Another limitation of our screening process is that, while we identified overlap between some studies in this review and those included in other recent reviews, we did not systematically incorporate studies from prior reviews into our initial search. Although our search strategy encompassed multiple databases and sources, this omission may have resulted in the exclusion of eligible studies that were identified in earlier syntheses. Future research syntheses should consider cross-referencing studies from relevant reviews to ensure a more comprehensive capture of the available literature.&lt;/p&gt; &lt;p&gt;This study examined the quality and rigor of AE on Autistic participants and estimated the magnitude of the effect. However, this study is limited in that AE studies were not stratified by strong and weak evidence according to the SCARF outcomes, and separate effect sizes were not estimated for studies with strong versus weak quality and rigor. An effect size based solely on studies with strong evidence, as defined by SCARF, could provide additional insight into the effectiveness of AE when the study is of the highest quality. This limitation could be partially addressed by analyzing SCARF outcomes in combination with the data presented in Supplemental Figure 2, which could visually denote the strength of evidence for each study. Given that we share all data and materials on our OSF page, we encourage researchers to add to our data frame, engage with this scientific research process, and consider this model in future research syntheses. Related, future SCED empirical AE studies should take steps to ensure that the study is of high quality and rigor by completing the SCARF tool, and adding to this publicly available data base. Using a robust AE research corpus of high-quality studies, future meta-analyses could begin to differentiate effects between high and low quality and rigor of AE interventions.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-25&quot;&gt;Conclusion&lt;/hd&gt; &lt;p&gt;AE interventions offer an effective evidence-based option to mitigate meltdowns and support adaptive behavior of Autistic individuals. Although published studies generally yielded more robust effects compared to unpublished studies in the literature base, Autistic individuals, teachers, interventionists, and parents should consider AE to support with mitigating meltdowns. Notably, most exercise types that yielded the greatest effects were those that did not require set up, additional equipment, or a specific context (i.e., basketball or tennis court) contributing to the ease of implementation. Special education teachers should specifically consider incorporating AE during the school day since the most robust outcomes were detected when AE was implemented within a school setting. Although additional research is needed to better understand the maintenance effects and optimal dosage of AE, this intervention shows to be dynamic and effective, based upon these findings.&lt;/p&gt; &lt;hd id=&quot;AN0194392924-26&quot;&gt;Supplemental Material&lt;/hd&gt; &lt;p&gt;Graph: Supplemental material, sj-docx-1-ecx-10.1177_00144029251386292 for Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis by Art Dowdy, Saehee An and Fernando Roldan in Exceptional Children&lt;/p&gt; &lt;hd id=&quot;AN0194392924-27&quot;&gt;Supplemental Material&lt;/hd&gt; &lt;p&gt;Graph: Supplemental material, sj-docx-2-ecx-10.1177_00144029251386292 for Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis by Art Dowdy, Saehee An and Fernando Roldan in Exceptional Children&lt;/p&gt; &lt;hd id=&quot;AN0194392924-28&quot;&gt;Supplemental Material&lt;/hd&gt; &lt;p&gt;Graph: Supplemental material, sj-docx-3-ecx-10.1177_00144029251386292 for Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis by Art Dowdy, Saehee An and Fernando Roldan in Exceptional Children&lt;/p&gt; &lt;hd id=&quot;AN0194392924-29&quot;&gt;Supplemental Material&lt;/hd&gt; &lt;p&gt;Graph: Supplemental material, sj-docx-4-ecx-10.1177_00144029251386292 for Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis by Art Dowdy, Saehee An and Fernando Roldan in Exceptional Children&lt;/p&gt; &lt;hd id=&quot;AN0194392924-30&quot;&gt;Supplemental Material&lt;/hd&gt; &lt;p&gt;Graph: Supplemental material, sj-docx-5-ecx-10.1177_00144029251386292 for Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis by Art Dowdy, Saehee An and Fernando Roldan in Exceptional Children&lt;/p&gt; &lt;ref id=&quot;AN0194392924-31&quot;&gt; &lt;title&gt; References &lt;/title&gt; &lt;blist&gt; &lt;bibl id=&quot;bib1&quot; idref=&quot;ref56&quot; type=&quot;bt&quot;&gt;1&lt;/bibl&gt; &lt;bibtext&gt; Allison D. 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Header DbId: eric
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An: EJ1508137
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PubType: Academic Journal
PubTypeId: academicJournal
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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: &lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Art+Dowdy%22&quot;&gt;Art Dowdy&lt;/searchLink&gt; (ORCID &lt;externalLink term=&quot;https://orcid.org/0000-0001-6466-6774&quot;&gt;0000-0001-6466-6774&lt;/externalLink&gt;)&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Saehee+An%22&quot;&gt;Saehee An&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;AR&quot; term=&quot;%22Fernando+Roldan%22&quot;&gt;Fernando Roldan&lt;/searchLink&gt;
– Name: TitleSource
  Label: Source
  Group: Src
  Data: &lt;searchLink fieldCode=&quot;SO&quot; term=&quot;%22Exceptional+Children%22&quot;&gt;&lt;i&gt;Exceptional Children&lt;/i&gt;&lt;/searchLink&gt;. 2026 92(4):463-482.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 20
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2026
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles&lt;br /&gt;Information Analyses&lt;br /&gt;Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: &lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Autism+Spectrum+Disorders%22&quot;&gt;Autism Spectrum Disorders&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Literature+Reviews%22&quot;&gt;Literature Reviews&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Exercise%22&quot;&gt;Exercise&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Intervention%22&quot;&gt;Intervention&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Behavior%22&quot;&gt;Behavior&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Behavior+Modification%22&quot;&gt;Behavior Modification&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Self+Control%22&quot;&gt;Self Control&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Exceptional+Child+Research%22&quot;&gt;Exceptional Child Research&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Response+to+Intervention%22&quot;&gt;Response to Intervention&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Meta+Analysis%22&quot;&gt;Meta Analysis&lt;/searchLink&gt;&lt;br /&gt;&lt;searchLink fieldCode=&quot;DE&quot; term=&quot;%22Physical+Activity+Level%22&quot;&gt;Physical Activity Level&lt;/searchLink&gt;
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/00144029251386292
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0014-4029&lt;br /&gt;2163-5560
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Physical activity is a promising strategy for strengthening behavior and social engagement through its physiological and psychological benefits. Antecedent Exercise (AE) is a structured behavioral intervention aimed at mitigating meltdowns and promoting adaptive behaviors in Autistic individuals. This synthesis and multilevel meta-analysis of 34 studies, including diverse settings and exercise types, provides a nuanced examination of AE&#39;s effectiveness. AE demonstrated moderate efficacy with effect sizes of -0.342 (SE = 0.089, p &lt; 0.005, 95% CI [-0.517, -0.168]) for reducing meltdowns, and a substantial improvement of 0.806 (SE = 0.166, p &lt; 0.005, 95% CI [0.481, 1.13]) for increasing adaptive behaviors. Special education settings such as day centers and schools yielded robust outcomes, thus highlighting AE&#39;s effectiveness in an educational context. Interventions involving accessible activities like aerobic exercise routines and jogging also showed to be effective. Despite variability in study rigor and some indications of publication bias, AE appears to be a scalable intervention for educators and clinicians. Future research should address the long-term maintenance effects and optimal implementation strategies for maximizing AE&#39;s benefits in educational and clinical settings. This evidence supports the integration of AE into practices for improving the quality of life and educational outcomes for Autistic individuals.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2026
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1508137
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1508137
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/00144029251386292
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 20
        StartPage: 463
    Subjects:
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Literature Reviews
        Type: general
      – SubjectFull: Exercise
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Behavior
        Type: general
      – SubjectFull: Behavior Modification
        Type: general
      – SubjectFull: Self Control
        Type: general
      – SubjectFull: Exceptional Child Research
        Type: general
      – SubjectFull: Response to Intervention
        Type: general
      – SubjectFull: Meta Analysis
        Type: general
      – SubjectFull: Physical Activity Level
        Type: general
    Titles:
      – TitleFull: Quality, Rigor, and Outcomes of Antecedent Exercise Strategies for Supporting Autistic Individuals: A Synthesis and Multilevel Meta-Analysis
        Type: main
  BibRelationships:
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      – PersonEntity:
          Name:
            NameFull: Art Dowdy
      – PersonEntity:
          Name:
            NameFull: Saehee An
      – PersonEntity:
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            NameFull: Fernando Roldan
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          Dates:
            – D: 01
              M: 07
              Type: published
              Y: 2026
          Identifiers:
            – Type: issn-print
              Value: 0014-4029
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              Value: 2163-5560
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              Value: 92
            – Type: issue
              Value: 4
          Titles:
            – TitleFull: Exceptional Children
              Type: main
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