A Protocol for Basketball as Inclusive Sport to Boost Motor and Social Skills in Autistic Preschoolers

Abstract

This paper presents the Early Basketball Protocol, a sports-based intervention designed to improve motor and socio-emotional skills in autistic preschoolers. Recognizing the paucity of sports protocols for younger autistic children, we developed this protocol using basketball rules to foster an inclusive setting where autistic preschoolers (n = 4) and their typically developing peers (n = 13) could engage in activities together. The protocol aims to simultaneously develop motor and socio-emotional skills through inclusive sports activities. Due to the COVID-19 pandemic, the effectiveness of the protocol was evaluated using parent-reported measures. A narrative approach synthesized the parental answers, and a pre–post-test analysis evaluated the preliminary application of the EB protocol based on parent-reported perceptions. Encouraging longitudinal results emerged, particularly in the improvement of socio-emotional skills for all participants. However, the early disruption of activities due to the pandemic may have contributed to the lack of improvement in gross motor skills. The paper discusses the practical implications of these findings and outlines future research directions, emphasizing the critical role of social inclusion.

1. Introduction

Autistic traits have mainly been related to deficits in social communication and interaction as well as restricted/repetitive patterns of behaviors, interests, and activities (DSM-5; [1]). To be specific, autistic individuals may show poor and/or atypical eye contact [2], lack of gesture use [3,4], difficulties involving themselves in social relationships [5,6], lack of facial emotional recognition and production [7,8], impairments in socio-emotional reciprocity [9], and poor interest in peers [10]. Collectively, similarly to other atypical conditions (e.g., deafness and blindness [11,12,13]), these autistic traits are related to a deficit in their theory of mind ability [14,15,16]. Additionally, autistic people may exhibit repetitive behaviors and motor stereotypies [17], clumsiness [18], hyper- and/or hypo-reactivity, or unusual interest in environmental sensory stimuli (i.e., light, sound, materials [19]). The complexity and the pervasiveness of all these traits have a detrimental impact on their social functioning [20].

Although motor skills deficits have not been reported among the diagnostic criteria for autism, their prevalence among this population ranged from 50% to 80% [21,22]. This deficit was also reported by parents of children later diagnosed with autism [21,23,24], highlighting that motor impairments precluded the individual’s involvement in several social settings, including sports activities. For autistic people, the bidirectional relationship [25,26] between motor and social skills may take a vicious circle: the first one may lead the autistic people to not involve themselves in team sports and this under-involvement may reinforce their social withdrawal. Nevertheless, when autistic people were involved in sports activities, their resulting positive effects and benefits on the motor [27,28,29] and social skills [30,31,32] were broadly demonstrated. In this vein, a recent systematic narrative review [33] outlined that sports training programs provided positive benefits both on motor and socio-emotional skills as well as autistic traits. Furthermore, a huge body of evidence [33,34,35,36,37,38] has reported a significant enhancement in the general well-being of autistic people due to the sport.

Moreover, in the last two decades, research in the autism field has devoted attention to the pivotal role played by the early procedure of screening [39,40], diagnosis [41], and psychological intervention [41] on the individual’s prognosis. In other words, the earlier the screening, diagnosis, and intervention, the better the prognosis. In addition to attending autism-specific psychological interventions, sports activities could be pivotal for this population because they may provide the opportunity to generalize the skills learned in therapy settings.

With this rationale in mind, according to the review [33] revealing the requirement to design sports protocols for autistic (henceforth ASD) preschoolers also enrolling typically developing (henceforth TD) peers, we conceived the Early Basketball Protocol (henceforth EB protocol). Among the sports applied to autistic children [33,42,43], two main issues support basketball application. To begin with, basketball is a team sport that was previously applied successfully in a group of autistic and typically developing children [42,44] as well as with a population with other disabilities (i.e., physical and/or psychiatric disability; [45]). In addition, basketball is a sport that could be practiced in a setting that is not very large, limiting the environmental sensory stimuli disturbing autistic people.

The EB protocol consists of a set of sports activities according to basketball rules focusing on the development and promotion of motor and socio-emotional skills; the EB protocol is developed to be applied to a group of autistic preschoolers and typically developing peers aged 3–6 years in an inclusive setting.

In this paper, we summarized the main characteristics of the EB protocol and reported the encouraging results of its first application. It is worth noting that the application of the EB protocol has been disrupted because of the COVID-19 pandemic. Thus, the evaluation of the application of the EB protocol is based on parent-report measures. Following this, a narrative approach was used to synthesize parental answers to questions related to the children’s improvement in motor/social skills and social inclusion in sports activities; the pre–post-test analysis evaluating the preliminary application of the EB protocol based on parent-reported measure was computed. Nevertheless, we evaluated its initial pre–post efficacy according to the parental perception of improvement in preschoolers’ motor and socio-emotional skills. To this, three research questions were formulated:

RQ1: 

Is there a difference in motor and socio-emotional skills between the pre-and post-test of the EB-protocol application (i.e., time effect)?

RQ2: 

Is there an interaction (group*time effect) between the two groups of children (i.e., group effect) and the pre-and post-test evaluation (i.e., time effect)?

RQ3: 

Is there any difference in the two groups of children (ASD vs. TD) on motor and socio-emotional skills (i.e., group effect)?

2. Materials and Methods

2.1. EB-Protocol Design and Sample Recruitment

The EB protocol has been designed following a 2-step procedure. To begin, multi-disciplinary team training was carried out. The expert developmental psychologists (n = 2) supported by in-training psychologists (n = 3) scheduled three meetings to train the basketball coaches (n = 2) on the autistic symptoms and the main strategies to manage them. One meeting focused on autistic presentation and two discussed case reports. Afterwards, two meetings were scheduled to train experts and in-training psychologists on the main rules of the target sport (basketball). The second step consists of 5 meetings of brainstorming on what sports activities can be included in the EB protocol and how they can be adapted to the autistic population. For instance, basketball training includes tiptoe activities which have to be excluded to not promote this autistic trait. In contrast, sports activities promoting reciprocity and collaboration between children have been encouraged. Special attention was given to the choice of the setting where the sports activities have been carried out. The target setting meets several criteria for minimizing sensory stimuli: To begin, a moderately sized setting and a sound-absorbing floor reduce the echo and auditory distractions. In addition, no bleachers or other spaces for visitors are allowed in order to limit the presence of people not participating in the activities. The soft tones of the floor and wall colors avoid excessive visual stimulation. Finally, in the setting, no sports equipment can distract participants.

Following the main psychological frameworks [46], the multi-disciplinary team discussed the role of TD peers: their crucial role was outlined by the psychologists suggesting the design of specific sports activities to the basketball coaches.

The EB protocol followed a pre–post-test design. In the pre-test, all children’s motor and social skills were evaluated via standardized measures and parent-report ones. The intervention included two sessions weekly of 60 min each of sports activities in a setting limiting the hyper- and/or hypo-reactivity to sensory stimuli for autistic preschoolers. All sports activities have been supervised by two trained coaches and five developmental psychologists (henceforth operators). Both groups of preschoolers, autistic and typically developing preschoolers, practiced the same sports activities together.

Table 1. Detailed description of the sports activities carried out.

Step	Activities
(a) 10 min circle time on greetings and warm-up	During circle time, operators introduced the emotion game: they showed the children’s balls displaying the 5 basic emotions (happiness, fear, sadness, anger, and neutral) and asked them to recognize the emotion and to produce it. After this game, the coaches started the motor warm-up (e.g., walking and running).
(b) 20 min sports activity on basic basketball skills	During the sports activity, each operator supported an autistic child (dyadic relationship) in walking, running, pushing, grabbing, crawling, dribbling, ball-passing, shooting, and handling). To promote the social and inclusive setting, during the ball-passing, shooting, and handling activities, the operators supported both an autistic child and a typically developing peer (triadic relationship).
(c) 5 min time break	During the break, coaches and operators solicited and supported all children to socialize among themselves.
(d) 20 min basketball match	During the match, the coaches structured the activities to improve motor and balance control, space orientation, and visual anticipation. All activities were defined taking account of autistic symptomatology. Operators supported all children in dyadic, triadic, and small group sports activities.
(e) 5 min cool-down and circle time on good-bye	This step was similar to step (a). Specifically, to reinforce the children’s emotional competence (in terms of recognition and production), the operators again proposed the emotion game and socio-interactive activities (i.e., a song with facial expressions and gestures) centered on emotions. The socio-interactive activities led to a decrease in the children’s arousal because of the sports activity.

shows the detailed activities included in the EB protocol.

As reported in Table 1, steps (b) and (d) resulted in age-appropriate moderate-intensity physical activities performed individually, in the dyad (operator–autistic preschooler), in triadic (operator–autistic preschooler–typically developing peers), and in small group interaction.

The post-test evaluation was performed after 10 weeks of sports activities (n = 20 days of sports activities) because of the restriction measures imposed by the COVID-19 pandemic. Thus, the evaluation of the preschoolers’ motor and socio-emotional skills via standardized measures was not carried out, whereas the parental perception of the participants’ improvement in motor and socio-emotional skills was considered. A narrative approach synthesized the parental perception of children’s skills and social inclusion via sports activities.

Regarding the participants’ recruitment, the snowballing technique was used. Firstly, the application of the EB protocol was presented to the community at the University Sport Center by the multi-disciplinary team; in addition, a flyer including the main information was distributed on the main social media platforms (e.g., Facebook, WhatsApp). During the presentation of the EB protocol and on the flayer, the benefits related to the application of an inclusive sport for both autistic children and typically developing peers were highlighted. A Facebook page was created to promote the sports activities and directly interact with possible interested families. An operator of the psychologists’ team managed the public relations with families addressing any questions or concerns they might have.

Parents who agreed signed an informed consent form and received the instructions to register their child. Each enrolled child received a sports kit consisting of a backpack and t-shirt. The EB protocol was performed between November 2019 and January 2020 at a school gym in a small city in South Italy (i.e., Lecce). Because of the initial restrictions to contain the spread of the COVID-19 infection in Italy, sports activities were interrupted in the first week of February 2020. Hence, the EB protocol was partially completed.

2.2. Participants

A total of 17 preschoolers (n = 4 autistic preschoolers; n = 13 TD preschoolers) were enrolled in the EB protocol. The mean age of the autistic preschoolers (all males) was 59.2 months (SD = 4.5 months; range = 55–64 months). All autistic preschoolers received the diagnosis by the local health service according to DSM-5 criteria [1]. The scores of the diagnostic evaluation were not provided to researchers by the local health service for privacy. Three of the autistic preschoolers showed no cognitive or language impairment. All attended behavioral intervention (i.e., Applied Behavioral Analysis), psychomotor, and speech therapy. The mothers’ mean age was 37.7 years (SD = 9.7 years; age range = 24–46 years) and their educational level was high (up to 13 years of education) for 50%, and low (up to 8 years of education) for 50%; the fathers’ mean age was 46.6 years (SD = 2.52; age range = 44–49 years) and their educational level was low for 75%.

The mean age of the TD children (n = 6 males) was 50.9 months (SD = 9.7 months; months range = 38–64 months). The mothers’ mean age was 41.2 years (SD = 7.1; age range = 25–48 years) and their educational level was high for 75% and low for 25%; the fathers’ mean age was 42.9 years (SD = 9.2; age range = 27–62 years) and their educational level was high for 41.6% and low for 58.3%. All parents were married and European.

2.3. Measures

2.3.1. Preschoolers’ Motor Skills

The gross-motor subscale of the Griffiths Scale of Child Development [47] was administered. It is a standardized and structured observative procedure administered to evaluate children’s global functioning. The gross-motor scale was applied to assess the child’s postural development, his/her gross-motor abilities and balance, his/her strength, visuospatial skills, rhythm, and body coordination. A standardized score was calculated as a development quotient with a higher score indicating higher performances.

2.3.2. Preschoolers’ Socio-Emotional Skills

Two measures were applied: the Facial Emotional Recognition Task (henceforth FERT) and the Basic Emotion Production Task (henceforth BEPT). Both were technical reports successfully applied on typically and atypically developing children by two authors (A.L. and F.L.) in previous studies (e.g., [48]). To be specific, the FERT consists of 20 visual stimuli: each stimulus comprises 4 black-and-white photographs of faces producing the four basic emotions (happiness, sadness, fear, and anger) according to Ekman’s FACS system [49]. The operator asked each child “Show me the (happy—sad—fear—anger) face” following a sequential order (happiness–sadness–fear–anger). The visual stimuli are counterbalanced. Each stimulus was asked to each child five times. One point was attributed when the child indicated the correct photo and zero points when he/she indicated the incorrect photo or he/she refused to indicate. Two scores were calculated: a partial score in the range of 0–5 for each emotion and a total score as a sum of the correct answers (range 0–20). The BEPT consists of 20 requests asking the child to produce the four basic emotions (i.e., the same included in the FERT). An imitating model was not provided to the children. The operator asked each child, “Do you make me the (happy—sad—fear—anger) face?” following a sequential order (happiness–sadness–fear–anger). Each request was asked to each child five times. A video was recorded for each child and its duration varied according to the child’s degree of collaboration with the operator. Videos were scored by validated software which evaluates the child’s correct or incorrect facial expression. One point was attributed when the child expressed the emotion correctly and zero points when he/she expressed the emotion incorrectly, or he/she refused. Two scores were calculated: a partial score in the range of 0–5 for each emotion and a total score as a sum of the correct answers (range 0–20). Because of the disruption of the sports activities, both measures were administered on the pre-test step only.

2.3.3. Parent-Reported Evaluation of Preschoolers’ Skills

Five parent-reported questions, developed for the study’s purpose, were administered. They evaluated the parental perceptions regarding the impact that the sports activities could have on the preschoolers’ motor and social skills. Following the topic that the questions evaluated (i.e., parental perception), both the expert and in-training psychologists involved in the study formulated a set of potential questions. To begin with, brainstorming among psychologists determined the more readable and understandable questions using adequate educational level and topic-specific terms. Afterwards, these questions were proposed to a group of parents of children with and without autism (not involved in the study), scholars, and clinicians with expertise to determine the ultimate best comprehensible questions exploring the parents’ perceptions. Here are the questions exploring the parental perceptions on (1) the interaction between motor and social skills (“In your opinion, is there an association between motor and social skills?”) and (2) whether the EB protocol could encourage preschoolers to learn social competences (“In your opinion, how much the EB protocol sports activity could improve your child’s social skills?”); (3) their evaluation regarding the preschoolers’ competence on emotional (in terms of recognition and expression of emotions), (4) social (sharing with peers; turn taking; social overture), and (5) gross-motor (jumping, running, throwing a ball) skills. Response options ranged from 0 (“not agree”) to 4 (“very agree”). These questions were administered to parents during the pre–post-test.

2.3.4. Parent-Reported Perception of Social Inclusion via Sports Activities

Two parent-reported questions were developed for the current study. The method applied in developing these questions is similar to the ones followed for questions regarding the impact that the sports activities could have on the preschoolers’ motor and social skills. To begin with, each psychologist involved in the study formulated a set of questions. Brainstorming among them determined the more readable and understandable questions using adequate educational level and topic-specific terms. Afterwards, these questions were proposed to a group of parents of children with and without autism (not involved in the study), scholars, and clinicians with expertise to determine the ultimate best comprehensible 2 questions exploring the parents’ perceptions. The two questions explored the parental perceptions on (1) the possibility of increasing the awareness of typically developing children about disability attending sports activities in an inclusive setting (“Can a typically developing child be aware about disability attending sports activities with autistic children?”) and (2) the effectiveness of a multi-disciplinary team: i.e., whether coaches and psychologists could facilitate the social inclusion process of autistic children in the TD peer group (“Can the multi-disciplinary team (basketball coaches and psychologists) facilitate the social inclusion of autistic children in a typically developing peers group?”). Response options ranged from 0 (“not agree”) to 4 (“very agree”). These questions were administered to parents during the post-test step only. These questions were administered to parents during the post-test.

2.4. Statistical Analyses

The data were analyzed using RStudio [50] and the Statistical Package for the Social Science v.25 [51]. Nonparametric analyses for longitudinal data—specifically the F1LDF1 design for small sample size—were computed using the nparLD package [52] for RStudio. The children’s group (ASD vs. TD) was included as a group variable to estimate the group effect. The two evaluations (pre- vs. post-test) were included as a time variable to estimate the time effect. The interaction of group*time was included as well. The ANOVA-Type Statistic and the Modified ANOVA-Type Statistic with box approximation were calculated for test group effect, time effect, and their interaction. As reported by Noguchi and colleagues [52], the higher degree of freedom of each ANOVA model was equal to infinity “to improve the approximation of the distribution under the hypothesis of “no treatment effects” and “no interaction between whole-plot factors” (p. 14). The Relative Treatment Effect (RTE) was reported as a measure of the group*time interaction effect ranging from 0 to 1 [52]. When the group*time interaction was significant, the Mann–Whitney U with Bonferroni’s corrections were calculated. The Hedge’s g effects size [51] was calculated as well. A p < 0.05 was taken as statistically significant.

3. Results

3.1. Descriptive Results

Descriptive scores on each child’s motor and socio-emotional skills evaluation at the pre-test were tabulated, as shown in

Table A1. Frequencies of each child’s motor and socio-emotional skills.

	Child Age (Months)	Griffith Gross-Motor Scale	Griffith DQ 2	FERT_H	FERT_S	FERT_F	FERT_A	FERT_T	BEPT_H	BEPT_S	BEPT_F	BEPT_A	BEPT_T
ASD group
ID1	61	14	117	5	5	5	5	20	3	1	5	3	12
ID2	55.1	3	60	4	1	5	5	15	0	0	0	1	1
ID3 1	64.8	0	50	-	-	-	-	-	-	-	-	-	-
ID4	56	11	104	3	2	1	5	11	3	0	4	0	7
TD group
ID5	64.7	15	124	5	5	5	5	20	5	2	3	5	15
ID6	42.5	11	103	4	1	3	5	18	3	0	1	4	8
ID7	52.9	10	101	5	5	5	5	20	5	4	1	4	14
ID8	38.5	13	117	3	0	4	2	9	0	0	0	5	5
ID9	51.8	13	117	4	4	4	4	16	5	2	2	3	12
ID10	63.5	6	78	5	5	5	5	20	4	3	3	5	15
ID11	45.9	8	89	2	0	2	1	5	0	0	1	2	3
ID12	40.5	12	109	5	4	2	5	16	0	3	2	4	9
ID13	57.9	13	112	5	5	5	5	20	5	5	4	1	15

Note: Griffith DQ = Griffith developmental quotient; FERT_H = facial emotional recognition task—happiness; FERT_S = facial emotional recognition task—sad; FERT_F = facial emotional recognition task—fear; FERT_A = facial emotional recognition task—anger; BEPT_H = basic emotion production task—happiness; BEPT_S = basic emotion production task—Sad; BEPT_F = basic emotion production task—fear; BEPT_A = basic emotion production task—anger. ¹ Child had a low-functioning autism diagnosis; the ability to recognize and express was severely impaired. ² Range: ≤69 = extremely low; 70–79 = low; 80–89 = below average; 90–109 = average; 110–119 = above average; 120–129 high; ≥130 = extremely high.

(see Appendix A).

Regarding gross motor skills, two out of four autistic preschoolers reached an extremely low developmental quotient (≤69), whereas the other two children scored average (90–109) and above average (110–119). Among TD children, except for two children (who scored low and below average), all performances were average and above average. Regarding the socio-emotional competencies, the group of autistic preschoolers showed a fair performance on the facial emotional recognition task (FERT), whereas they reached a poor score when the ability to express basic emotions (BEPT) was evaluated. The TD children performed facial emotion recognition and expression tasks ranging between intermediate and high scores.

The results for questions on parental perception of children’s improvement in social and motor skills and social inclusion via sports activities were narratively synthesized.

3.2. Parent-Reported Evaluation of Preschoolers’ Skills

Both parent groups (those of children with an autism spectrum disorder and those with typically developing children) highlighted that their children’s social and motor skills improved because of the sports activities. Indeed, before sports activities, all parents slightly agreed on the association between social and motor skills, and they perceived their children as considered skillful according to their developmental profile. Nevertheless, all parents’ perceptions were reversed because of the sports activities. In other words, all parents (those of children with autism and those with typically developing children) were more aware that there is an association between social and motor skills; in addition, parents of typically developing children perceived their children as more competent in social and motor skills. The results showed that parents of autistic children’s perception of children’s improvement in social and motor skills were slightly improved because of the sports activities.

3.3. Parent-Reported Perception of Social Inclusion via Sports Activities

On the parental perception of the role played by sports activities in an inclusive setting to improve awareness about the disability of a typically developing child, most of them agree with this question. Regarding the second question, which evaluated whether a multi-disciplinary team could facilitate the social inclusion of autistic children in a typically developing peer group, only parents of autistic children strongly agree. Of parents of TD children, a little over half agree.

3.4. Longitudinal Data Analysis

The results of the nonparametric analyses are reported in

Table A2. Results of the longitudinal analyses for the parameter considered.

Parameter	ANOVA-Type Test Statistic			Relative Treatment Effects		Hedges’s g (LoCI, HiCI 95%)	Mann–Whitney U	Bonferroni’s Correction	Mean (SD)
		F (df)	p	TD-Group	ASD-Group
(P1) Motor and social skills	Group	0.792 (1, ∞)	0.373						TD group: 3.39 (0.70)	ASD group: 3.25 (0.46)
	Time	6.173 (1, ∞)	0.012					0.006	Pre: 3.08 (0.64)	Post: 3.61 (0.51)
	Group*Time	0.005 (1, ∞)	0.943	TD*pre = 0.42	ASD*pre = 0.33				TD group*pre: 3.11 (0.78)	ASD group*pre: 3 (0)
				TD*post = 0.63	ASD*post = 0.56				TD group*post: 3.67 (0.50)	ASD group*post: 3.5 (0.58)
Modified-ANOVA-Type Test Statistic	F(1,8) = 0.792; p = 0.397					5.39 (4.20, 6.56)
(P2) Social relation skills via EB	Group	2.223 (1, ∞)	0.135						TD group: 3.28 (0.89)	ASD group: 3.75 (0.46)
	Time	4.405 (1, ∞)	0.035					0.017	Pre: 3.15 (0.89)	Post: 3.69 (0.63)
	Group*Time	0.080 (1, ∞)	0.776	TD*pre = 0.54	ASD*pre = 0.69				TD group*pre: 3.56 (0.73)	ASD group*pre: 4 (0)
				TD*post = 0.32	ASD*post = 0.49				TD group*post: 3 (0)	ASD group*post: 3.5 (0.58)
Modified-ANOVA-Type Test Statistic	F(1,9) = 2.223; p = 0.167					4.46 (3.58, 5.68)
(P3) Child’s emotional competence	Group	6.148 (1, ∞)	0.013				U = 31.500; p = 0.013	0.006	TD group: 2.5 (0.51)	ASD group: 1.75 (0.70)
	Time	16.976 (1, ∞)	0.000				U = 61.000; p = 0.046	<0.000	Pre: 2.08 (0.76)	Post: 2.46 (0.52)
	Group*Time	9.505 (1, ∞)	0.002	TD*pre = 0.56	ASD*pre = 0.13			0.001	TD group*pre: 2.44 (0.53)	ASD group*pre: 1.25 (0.50)
				TD*post = 0.61	ASD*post = 0.47				TD group*post: 2.56 (0.53)	ASD group*post: 2.25 (0.50)
Modified-ANOVA-Type Test Statistic	F(1,6) = 6.148; p = 0.048					3.35 (2.50, 4.19)
(P4) Child’s social competence	Group	8.047 (1, ∞)	0.004				U = 39.000; p = 0.024	0.002	TD group: 2.17 (0.51)	ASD group: 1.62 (0.52)
	Time	7.225 (1, ∞)	0.007				U = 62.500; p = 0.032	0.003	Pre: 1.85 (0.69)	Post: 2.15 (0.37)
	Group*Time	3.977 (1, ∞)	0.046	TD*pre = 0.55	ASD*pre = 0.18			0.023	TD group*pre: 2.11 (0.60)	ASD group*pre: 1.25 (0.50)
				TD*post = 0.59	ASD*post = 0.50				TD group*post: 2.22 (0.44)	ASD group*post: 2 (0)
Modified-ANOVA-Type Test Statistic	F(1,9) = 8.047; p = 0.018					3.20 (2.37, 4.02)
(P5) Child’s gross-motor skills	Group	5.094 (1, ∞)	0.024				U = 40.500; p = 0.047	0.012	TD group: 2.55 (0.61)	ASD group: 2.12 (0.35)
	Time	4.684 (1, ∞)	0.030				U = 56.000; p > 0.05	0.015	Pre: 2.23 (0.60)	Post: 2.61 (0.51)
	Group*Time	0.238 (1, ∞)	0.625	TD*pre = 0.47	ASD*pre = 0.29				TD group*pre: 2.33 (0.71)	ASD group*pre: 2 (0)
				TD*post = 0.66	ASD*post = 0.41				TD group*post: 2.78 (0.44)	ASD group*post: 2.25 (0.50)
Modified-ANOVA-Type Test Statistic	F(1,10) = 5.094; p = 0.046					3.95 (3.01, 4.89)

Note: Motor and social skills = parent-reported perception of the association between motor activity and social skills improvement; social relation skills via Early Basketball = parent-reported perception of the improvement in child’s social skills via Early Basketball; child’s emotional competence = parent-reported perception on the child’s emotional competence; child’s social competence = parent-reported perception on the child’s social competence; child’s gross-motor skills = parent-reported perception on the child’s gross-motor skills. ASD group = autistic children; TD group = typically developing children, time = pre- vs. post-sports activity; group*time = interaction between the two groups of children and within the two times of parental evaluation.

(see Appendix A). Five parameters (P) were tested: P1: the association between motor and social skills; P2: the children’s social skills improvement because of EB protocol; P3: the children’s emotional competence (in terms of recognition and expression); P4: the children’s social competence (e.g., sharing; turn-taking; social overture); P5: the children’s gross-motor skills (e.g., jumping, running, throwing a ball).

The Modified-ANOVA-Type Tests Statistics were not significant for Parameters 1 and 2. Moreover, the ANOVA-Type Statistics showed that a significant time effect can be considered for them. This means that all parents—after the experience of EB protocol—perceived the association between motor and social skills (P1) as crucial, as well as they reported more social competencies acquired by their children (P2) because of the basketball activities.

The Modified-ANOVA-Type Tests Statistics were significant for Parameters 3, 4, and 5. Specifically, the results showed group*time interactions for P3 and P4. In other words, there is a significant improvement in children’s emotional (P3) and social (P4) competencies for both groups as reported by parents, with higher scores on the post-test compared to the pre-test in both groups. Between the two groups of children, the Mann–Whitney U tests found a significant difference: TD preschoolers showed more emotional and social skills than autistic preschoolers. About Parameter 5, which is the children’s gross-motor skills improvement, results showed that a significant group*time interaction can be excluded, whereas a group effect and time effect can be considered for P5. In other words, TD children reached higher scores than ASD children (group effect) in terms of gross-motor skills; there is also a time effect with a higher score on the post-test than the pre-test, albeit a significant difference between group was not found.

In sum, the results showed an improvement in all considered parameters because of the practice of basketball sports activities (RQ1—time effect). Parameter 3 and 4 findings revealed an improvement both in autistic and typically developing children after the practice of the basketball sports activities (RQ—group*time effect). Finally, a group effect (RQ3) is reached for Parameters 3, 4, and 5.

4. Discussion

The current paper aims to present the initial and promising results of the application of a sports protocol based on basketball for 3–6-year-old autistic preschoolers. The EB protocol was designed to promote motor and socio-emotional skills simultaneously within an inclusive setting. The EB protocol consists of sports activities based on basketball rules that consider autistic-related traits. To explore the applicability of the EB protocol in enhancing motor and socio-emotional skills, three research questions (RQs) have been formulated. To be accurate, the first one probed whether the sports activities planned by the EB protocol improved (or not) the children’s motor and socio-emotional skills (RQ1—time effect). Furthermore, the interaction (RQ2—group*time interaction) between the two groups of children (ASD vs. TD) and time (pre vs. post) was investigated. Finally, the group effect (RQ3), which is the differences in motor and socio-emotional skills between the two groups of children (ASD vs. TD), was explored.

Before discussing the main study outcomes, a narrative approach was used for parental perception of the importance of attending team sports in an inclusive setting. The results showed that both parents of autistic and typically developing children were aware of the association between social and motor skills. Parents of typically developing children perceived their children as more social and motor competent because of the sports activities. Although slight, parents of autistic children reported an improvement in their children’s competence.

In addition, all parents perceived the sports activities in an inclusive setting as useful to increase typically developing children’s awareness about disability, especially autism. Thus, play, enjoyment, and collaboration with autistic children can help preschooler TD children to understand early on that there are children with special needs (e.g., who hate loud noise or who need help to achieve a task). Consequently, TD children can increase their awareness of all types of disabilities and learn that there are specific communicative strategies to interact with others. This awareness of disability can positively affect their understanding of their own and others’ mental states during the early developmental stage. On the role played by a multi-disciplinary team (coaches and psychologists), parents of autistic children showed more agreement than parents of TD children. This may be related to the fact that parents of autistic children have greater familiarity with the essential role served by psychologists in developing and/or promoting social behaviors and socio-emotional skills than those of TD children. In this vein, there may be a critical change in the perception of the role of the psychologists: They are not professionals working only when disability occurs, but their scientific knowledge regarding the life cycle may also be helpful for parents of TD children. For example, psychologists may support parents in parenting and/or suggest parental strategies to promote the children’s smooth development.

The improvement in parental perceptions of children’s competence was supported by a quantitative approach used to evaluate the preliminary application of the EB protocol. Interesting findings emerge. Firstly, the sports activities boosted a wide range of children’s abilities (i.e., motor, social, emotional, gross motor) regardless of the disability condition. Indeed, both autistic and typically developing children showed progress in motor and social skills after the attendance of sports activities based on basketball. As found by others [33,53,54,55,56], our results support the pivotal role played by sports activities in the development and advancement of individual motor and socio-emotional competencies. The human interactions in sports practice, in terms of verbal and nonverbal communication, physical and eye contact, are boosters of motor and socio-emotional skills development [33,53,54]. This study supports the idea that these improvements can be reached through a team sport during the early developmental stage, i.e., early childhood (3–6 years). Indeed, during this stage, the development and/or the strengthening of motor and socio-emotional abilities are the foundation for smooth children’s development (Erikson, 1950). Motor skills such as running, jumping, and climbing play a key role in improving coordination and balance, allowing children to explore their environment more safely and independently. These motor skills not only contribute to physical development but also promote social interactions with peers. By actively engaging with their environment, children improve on a full set of skills, such as cooperation, sharing, understanding of themselves and other mental states, and respect for rules. Consequently, the general development trajectory is significantly enhanced. This improvement is evident in both the increase in self-confidence and self-esteem, which are critical to personal development, and the increase in the child’s spatial awareness (e.g., understanding of space, size, and distance).

Regarding the RQ2 on the interaction between groups (ASD vs. TD) and time (pre vs. post), the present study reported an improvement in emotional and social competence in all children (ASD and TD) after (post) the practice of sports activities. Although no evidence comparing ASD and TD on basketball exists, it is not surprising that TD children demonstrated higher emotional and social skills than their peers with ASD. However, the added value of our study is that the EB protocol we designed for this study allowed us to develop and/or improve the emotional and social skills of autistic children, which are the most impaired skills. Albeit preliminarily, this result may demonstrate that the structure of the EB protocol we designed may be promising. Knowing that this result is initial, it provides the foundation for further application of the EB protocol to the population with autism, in combination with psychological therapies, in supporting their prognosis.

A final reflection concerns the reached group effect (RQ3). Our study highlighted that TD children showed more emotional and social competence, and gross motor skills than the autistic group. This result is like others [57,58] considering the deficit and/or the delay in these areas for the autistic children group. Nevertheless, this finding may be negligible because the encouraging finding is related to the improvement shown by autistic children after the attendance of sports activities with TD peers.

In support of the current study, outcomes are also the recent systematic review with meta-analysis by Jia et al. [59]. Two main issues have been highlighted by the authors [59], i.e., the enhancement for autistic individuals linked to the kind of sport and to the age stage it is practiced. To be accurate, the authors found that individual skills improved because the team sports during the early developmental stage. In this vein, our EB protocol fits well with the meta-analysis conclusion.

To this, the key novelty of the EB protocol is the social inclusion framework in which sports activities have been designed. The cornerstones of this framework concern the role of TD peers who served as scaffolders and operators who served as social mediators in the accomplishment of the tasks. Further studies are required which may bring to light the mechanisms and strategies fostering this improvement.

With these reflections in mind, the EB protocol that is based on a team sport (i.e., basketball) and is designed for young children (i.e., preschoolers) in an inclusive setting may be full of promise, albeit merits further research.

Strengths and Limitations

Knowing that further applications of the EB protocol are mandatory, several strengths can be highlighted. First of all, (i) we recruited younger children than previous studies focusing on basketball; (ii) all sports activities were defined according to autistic traits and to limiting the exacerbation of the symptoms; (iii) the sports activities were pre-defined by the close and synergic collaboration between basketball coaches and developmental psychologists; (iv) sports activities were designed to develop and promote at the same time motor and socio-emotional skills; (v) the EB protocol aimed at emphasizing the pivotal role of social inclusion: a setting where children could practice recreational activities jointly to other peers may promote social skills as theory of mind [14,60,61] and enable the development of interpersonal trust [62,63]; to our knowledge, our protocol is the first involving a group of TD children as playmates and scaffolders [64]; finally, (vi) the EB protocol highlighted the pivotal role of the trained operator: she/he should be trained both in sport and psychological fields to serve as a mediator between autistic preschoolers and TD peers. Unfortunately, the spread of the COVID-19 pandemic disrupted the EB-protocol application after 10 weeks (n = 20 days of sports activities). Nevertheless, we evaluated the effectiveness of the protocol according to parent-reported measures. We are aware that the results must be interpreted cautiously; nevertheless, we believe they were very encouraging.

The findings should be read considering three limitations, i.e., the lack of a standardized assessment in the post-test, the small sample size, and the unbalanced gender distribution. Further investigations are required to evaluate the effectiveness across time of EB protocol considering the short- and long-term effects of the COVID-19 pandemic on motor and socio-emotional skills considering both vulnerable [65,66] and general [67,68,69] populations. Regarding the small sample size, the evaluation of the effectiveness of the EB protocol may be of benefit using a large group. Nevertheless, this limitation may be considered negligible because the evidence [35,70,71,72,73] reported the best outcomes when autistic preschoolers were included in a small group. Finally, while this study is gender unbalanced, future research should be focused only on autistic females or enroll a large size of girls.

5. Conclusions

Practical Implications and Future Directions

The findings paved the way for two main practical implications. Firstly, the results confirmed the sports setting as appropriate for learning socio-emotional skills which, in turn, can be generalized in settings (e.g., home, school). Specifically, for autistic preschoolers, involvement in an inclusive sports setting could positively impact the development and/or promotion of specific socio-emotional skills (e.g., recognizing and expressing facial expression emotions, turn-taking, sharing) as well as the reinforcement of other social skills learned in the therapy setting (e.g., eye contact, joint attention, non-verbal communication). For TD children, the inclusive sports setting applying the EB protocol could be a useful opportunity to learn patterns of socially adequate behaviors to interact with and be responsive toward autistic children and/or other disabilities.

Additionally, when preschoolers attend an inclusive setting, the parental representation of their social development may benefit. To be specific, regarding parents of autistic preschoolers, the availability of inclusive sports could decrease parental distress and the children’s social withdrawal [74,75] and support parental acceptance of the diagnosis of the disability process [76]. Parents of the TD children could perceive the inclusive sport as a potential setting to promote their children’s awareness towards the disability promoting their socio-emotional competencies and decreasing stereotypes toward mental illness.

A further pivotal issue that is useful to boost an inclusive setting is around the trained operators who serve as social mediators. These adults should be trained according to sport and psychological assumptions; in other words, they should be trained on (i) the motor prerequisites of basketball; (ii) the detection of the current developmental levels of the child to define activities according to the proximal development zone assumptions [46]; (iii) the typically developing trajectories of motor and social skills to define age-appropriate activities; (iv) the main deficits regarding the targeted disability to define activities which do not worsen and/or exacerbate symptoms. In summary, designing an effective protocol cannot rely solely on the expertise of a developmental psychologist or coach in isolation. Rather, it requires a multi-disciplinary team that integrates diverse competencies to ensure a comprehensive approach.

The novelty of the current study opens the way to further investigations maintaining and/or reinforcing its strengths and overcoming the limitations. As previously mentioned, future studies should aim to implement the EB protocol considering an extended time range. It may be useful to also include a mid-evaluation to monitor the participants’ progress. These mid-evaluations would allow for improvement in the EB protocol changing or adjusting activities accordingly. Enhancing the protocol based on these findings could refine and bolster its existing strengths.

Furthermore, considering the growing interest in female autistic traits [77], future studies should be focused on female participants. Evidence has shown that social skills in autistic females are often preserved compared to their male counterparts [78,79]. Hence, exploring whether and how these social skills are used by females in interactive contexts, such as sports activities, may expand the emerging knowledge about the female phenotype. It would be interesting to explore how the social skills of autistic females may be used to facilitate the creation and maintenance of social relationships.

Finally, future research lines could apply the EB protocol to groups of autistic children with different severity. This approach would help in defining a set of tailored strategies and sports activities specific to different levels of severity, thereby optimizing the protocol’s effectiveness for diverse needs.