Drums-Alive Intervention Effect on the Motor and Functional Skills in Youth with Intellectual Disabilities and Autism Spectrum Disorder: A Pilot Study

Intellectual disability (ID) and autism spectrum disorder (ASD) are associated with impairments in motor development, attention, and behavior. Physical activity (PA) has been demonstrated to improve these conditions. However, many individuals with ID and ASD are not motivated to persist at performing PA tasks for an extended period of time. Therefore, there is a great need to find forms of PA that could motivate individuals to stay at performing PA. One such form of PA is Drums-Alive, which involves movement, drumming, and music to increase enjoyment motivation. While it is speculated the Drums-Alive could have an effect on motor skills, attention, and behavior, this concept has not been examined in persons with ID and ASD. Therefore, this study aimed to explore the effect of Drums-Alive on motor skills, attention, and behavior for individuals with ID and ASD. Nine adolescents diagnosed with ID or ASD participated in an eight-week Drums-Alive program intervention. Motor skills, attention, and behavior were measured before and after the intervention. Paired-samples t-tests were used, and the statistical significance was established at p ≤ 0.05. The results suggested no significant differences in motor skills, attention, and behavior before and after the Drums-Alive intervention (p > 0.05). Though no statistical significance was found, improvements were observed from the pretest and posttest means, and all participants be needed in future research.


Introduction
Intellectual disability (ID) and autism spectrum disorder (ASD) are neurodevelopmental disorders characterized by impairments in motor and functional skills, which will affect daily life. Therefore, there is a great need to explore evidence-based practice to improve those skills. ID and ASD co-occur in many cases; 38% of individuals with ASD are also diagnosed with ID, which is higher than 10% of individuals with ID who are also diagnosed with ASD or as demonstrating autistic traits (Antshel et al., 2016). ID is defined by impairment of adaptive and intellectual functioning during the development period. ASD is typically characterized by developmental deficits in social skills, communication skills, and accompanying restricted, repetitive behavioral problems (America Psychiatric Association [APA], 2013). Recently, the number of people diagnosed with ID and ASD has increased dramatically. Based on the prevalence rates reported on ASD, one in 68 children were diagnosed with ASD in 2014, but the number increased to one in 54 in 2020 (Baio et al., 2018), and about one percent of the world's population has ASD (Zablotsky et al., 2015).
People with ASD and ID have established motor development delays (Lloyd et al., 2013;Staples & Reid, 2010;Vuijk et al., 2010). Motor development delay was defined as delays refer to a person who has not gained the developmental skills expected of him or her, compared to others of the same age (SSM Health). Motor skills were characterized by stiff arms and legs, inability to bear weight in legs, problems with balance, postural stability, gait, joint flexibility, and movement speed (Jansiewicz et al., 2006;Kohen-Raz et al., 1992). Staples and Reid's (2010) research indicated that for individuals with ASD, by the age of 12, their motor function is the same as six years old typically developing children.
Functional skills are essential for daily living and for establishing the quality of life (Center for Autism Research). Specific in this current study, the function skills include attention and behavior. Attention is defined as the action of dealing with or taking special care of someone or something. Behavior is defined as the way in which one acts or conducts oneself, especially toward others, or responds to a particular situation or stimulus (Dictionary.com). However, individuals with ID and ASD often occurred with an attentional disorder, often being off-task, lacking persistence, and having difficulty sustaining focus and organization (APA, 2013). Alongside this, the prevalence of psychiatric and behavior disorders among individuals with ID compared with the general population  (Bregman, 1991). The psychiatric and behavioral disorder is also a cause of the attentional orienting problem (Murphy et al., 2017).
Physical activity (PA) has shown positive effects on the motor skills development and wellbeing of people with ID and ASD (García-Villamisar et al., 2017).
PA as an intervention is beneficial for increasing on-task behavior and academic achievement and reducing maladaptive behavior and stereotypical behavior (Celiberti et al., 1997;Elliott et al., 1994;Oriel et al., 2011). In a free-play condition, spending more extended time and doing a moderate or moderate-vigorous physical activity has a significant and positive association with adolescent attention capacity test performance (Vanhelst et al., 2016). However, only about 21% of people met the 2008 Physical Activity Guidelines, and merely 30% of high school students get 60 minutes of PA per week (Piercy et al., 2018). Moreover, the number of students with disabilities participating in PA is much lower when compared with their typically developing peers (Pan et al., 2011). Although the curriculum in schools for students with mental disabilities includes walking, running, ball games, swimming, and skiing, it is often difficult to motivate children with ID and ASD to participate in PA (Bodde et al., 2012). Participation in PA is often a challenge for people with ID and ASD because of poor motor functioning and low motivation (Koegel et al., 2001;Reid et al., 2003), and short attention spans. In addition, it also produces difficulties in planning and generalization (Klinger & Renner, 2000;Ozonoff et al., 1994), and more difficulty in self-monitoring (Hughes et al., 1994). Therefore, new forms and more enjoyable PA types should be explored for students with ID and ASD with external reinforcement. The external reinforcement may motivate students to participate in an activity and may then be replaced by internal operants to promote independence (Firman et al., 2002).
Interestingly, researchers have reported that music has a positive effect on increasing on-task behavior (Dieringer et al., 2017) and decreasing off-task behavior (Titus & Porretta, 2012) for children with ASD. Further, dance and drumming's aerobic motion can increase cardiovascular activity and oxygenation of blood (Maschi & Bradley, 2010). Drumming and voice generate harmonic frequencies absorbed by organs, tissues, bones, and fluid that resonate with the source's expressed activity (Kalyani et al., 2011). Drumming also increases body temperature, stimulates sweat and triggers hormonal fluctuations, induces relaxation, and reduces stress and anxiety, depression, and socially resilient and aggressive behavior (Fancourt et al., 2016;Janse van Rensburg et al., 2016;Núñez, 2016). With knowledge of the positive effect of PA, music, and drumming, a program called Drums-Alive, which combines physical movement, music, and drumming, will be proposed as an intervention to improve motor skills, attention, and behavior of youth with ID and ASD.  (Dawson-Cook, 2010). Drums-Alive has been shown to produce strong physiological effects and positively influence the human immune system as well as helping Alzheimer's patients with their attention spans (Ekins et al., 2019). Additionally, as an intervention, it has improved motor performance in children and coordination and strength in children with ID (Ekins et al., 2019). However, Drums-Alive has not been used as an intervention for youth with ID and ASD targeting motor skills, attention, and behavior.
Therefore, the purpose of this study is to explore the effect of Drums-Alive intervention on motor skills, attention, and behavior for youth with ID or ASD.
It is hypothesized that there will be a significant improvement in motor skills, attention, and behavior after the eight-week Drums-Alive intervention. Findings from this study will provide a direction for future research on applying Drums-Alive intervention among individuals with ID and ASD.

Study Design
This study applied a quasi-experimental research design to examine the effects of an eight-week Drums-Alive intervention for youth with ID and ASD. Motor skills, attention, and behavior were the three variables measured before and after the eight-week intervention.

Participants
A convenience sampling method was used to recruit nine youth (three girls and six boys) with ID (n = 4) and ASD (n = 5), aged 17 to 20 years, for this study.
Participants with ID were in the mild level category, while all participants with ASD require level 1 supports. All participants were receiving special education services through a public-school transition program. Participants were instructed not to participate in any types of physical activities involving music and drumming. According to the participants' individualized education program (IEP) and their school record, all of them exhibited deficits in adaptive behaviors (e.g., motor, attention, behavior). However, no participants had known sensory impairments that would inhibit drumming performance or the movements involved in the current study protocol (Drums-Alive intervention). Written consent forms were sent home to the parents or guardians of the participants, and assent forms were orally delivered to each participant on the first day of assessment. An explanation of the proposed study was included in the consent form, which required a parent's or guardian's signature before the participants were able to participate. Institutional Review Board (IRB) approval was obtained from Southern Connecticut State University (SCSU).

Intervention Procedures
One week before and one week after the eight-week Drums-Alive intervention, fine and gross motor skills, attention, and behaviors were measured for all of the participants. The Drums-Alive intervention program used in this study was based on the Drums-Alive Academic-Beats program, which was specially de-

Instruments
Motor skills. The Bruininks-Oseretsky Test of Motor Proficiency (2nd ed.) (BOT-2) short form (Bruininks & Bruininks, 2005)  Attention. The Moss Attention Rating Scale (MARS) (Hart et al., 2006) was used to measure participants' attention. The MARS was originally designed as an observational rating scale to provide a reliable (r = 0.64), quantitative, and ecologically valid measurement of attention-related behavior after traumatic brain injury (TBI) (Hart et al., 2009). This rating scale was completed by the participants' special education program director, who had been working with all participants for at least two years. The MARA uses a 5-point Likert-type scale to indicate how well statements describe the participant's behavior on 22 items. The 5-point scale ranges from "1 = definitely false" to "5 = definitely true." All items in the scale were separated into three categories: restlessness, initiation, and con-  (Hart et al., 2006). The operational definitions of the restlessness category include: 1) Is restless or fidgety when unoccupied; 2) Persists with an activity or response after being told to stop; 3) Attends to nearby conversations rather than the current task or conversation; 4) Perseveres on previous topics of conversation or previous actions; and 5) Begins to touch or manipulate nearby objects not related to the task. The operational definitions of initiation category include: 1) Initiates communication with others; 2) Tends not to initiate tasks which are within his/her capabilities; and 3) Initiates activity (whether appropriate or not) without cues. The operational definition of consistent attention category include: 1) Performance is best early in the day or after a rest; 2) Speed or accuracy deteriorates over several minutes on a task but improves after a break; and 3) Performance of comparable activities is inconsistent from one day to the next (Hart et al., 2006).
Behavior. Behavior data were collected using a revised Achenbach System of Empirically Based Assessment-Children Behavior Checklist for Ages 6 -18 (CBCL) (Achenbach & Rescorla, 2013), which was completed by the parents/guardians.
The CBCL assesses competencies, adaptive functioning, and specific behavioral problems with a total of 103 items. In this current study, a revised CBCL was used with 22 items selected from the behavioral problem section addressing social, emotional, and behavioral problems. Three selected item examples: 1) suddenly change mood or feeling; 2) Temper tantrums or hot temper; 3) Underactive, slow moving, or lacks energy. The selection of items for this revised CBCL was based on the participants' attributes and content experts' opinions. The parents/guardians rated this checklist for their child with values such as 0 = not true (as far as you know), 1 = somewhat or sometimes true, and 2 = very true or often true. A total score is calculated on a scale of 0 to 44, with lower scores indicating a mild level of behavioral problems.

Statistical Analysis
A within-subject research design with paired T-tests was conducted to analyze the statistical mean difference between the pretest and posttest of motor skills, attention, and behavior. The statistical significance level was set up at p ≤ 0.05.
The mean and standard deviation data were used to describe both demographic and test variables. The Statistical Package for Social Sciences was used (version 25.0, SPSS IBM, Chicago, IL).

Participants Descriptive Characteristics
Nine youth (three girls and six boys) with ID (n = 4) and ASD (n = 5) participated in this study with a mean age of 19 years old. The mean BMI was 24 kg/m 2 , which is in the normal range for this age group of people (See Table 1).

Paired-Samples T-Test
This study aimed to explore the effect of an eight-week Drums-Alive program   Table 2).

Discussion
Based on the results of the paired-samples t-test, it appeared that the eight-week Drums-Alive program intervention did improve motor skills, attention, and behavior for the nine youth with ID or ASD, but the differences were not significant. The non-significant difference in the current pilot study could be due to the small sample size, lack of a control group, short intervention period, and the variability in the participants' motor skills and behaviors. With all of these limitations, the eight-week intervention twice a week could just be too short. motor skills and on-task behavior for individuals with ID and ASD (Miramontez et al., 2016;Neely et al., 2015;Pan et al., 2017;Oriel et al., 2011). However, Vanhelst et al. (2016) reported that more prolonged and moderate to moderate-vigorous PA are needed in order to have positive benefits on attention capacity. McCoy et al. (2019) research suggested that adolescents with ASD were found to engage in less PA and were more likely to be overweight and obese compared with their typically developing peers. Previous research suggested that music and movement therapies are powerful tools for supporting children with ASD in developing communication, expression, and motor skills (Ragone, 2020).
However, sometimes motor difficulties can limit individuals with ID and ASD to participate in PA. Sefen et al. (2020) research on the beneficial use and potential effectiveness of PA in managing ASD suggested that in terms of PA programs and behavior interventions, each person with ASD has a highly individualized set of symptoms and characteristics that require highly individualized plans.
Interestingly, though no statistical significance was seen on three variables in the current study, the Drums-Alive intervention process did bring a lot of enjoyment to the participants. All participants expressed their love for the Drums-Alive program and could stay on task for a longer duration of the Drums-Alive program and follow the instructor's director drumming with music. Feedback from the participants' director showed that all participants were motivated to do more PA after the eight-week intervention. In the field of adapted physical education, the practical significance is equally crucial as statistical significance.
Therefore, the Drums-Alive program should still be encouraged to be implemented in youth with ID and ASD to increase the motivation and enjoyment in participating in physical activity programs.

Conclusion
Based on the current pilot study results, it appears that Drums-Alive as an intervention did not significantly improve the motor skills, attention, and behavior of youth with ID or ASD, but all participants loved the Drums-Alive program when it combined movement, music, and drumming together. It is hard to improve motor skills, attention, and behavior for youth with ID and ASD. This pilot study could encourage further research in this area, emphasizing extending the intervention's duration and intensity with a larger population at a younger age. Early interventions are crucial in human motor and functional skills development. Future research can also consider examining variables, such as enjoyment, social skills, and motivation in physical activity participation, based on this pilot study.