Sports Games and Motor Skills in Children, Adolescents and Youth with Intellectual Disabilities

(1) Background: Sports games are one of the best ways of engaging in physical activity for individuals with intellectual disabilities (ID) and Down syndrome (DS). This systematic review of the current literature aims to identify and sum relevant data on motor skills and clarify whether there are positive effects of sports programs in motor skills games in children, adolescents, and youth with ID and DS. (2) Methods: The systematic review of the papers was carried out following the methodological guidelines and by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) consensus. The following electronic databases were researched: PubMed, MEDLINE, Google Scholar, ScienceDirect, and ERIC from 2001 to 2023. (3) Results: The basketball test battery can be used to improve and monitor basketball training. Basketball players with lower levels of ID achieved better results, especially those with disabilities of the II and III degrees. Futsal has a positive impact on the coordination, and the differences between the test results of the vertical jump with and without an arm swing, that can be seen indirectly as a coordination factor, were statistically significant. (4) Conclusions: Basketball is recommended as an effective and practical rehabilitation program for children, adolescents, and youth with ID and DS. Futsal is an interesting and helpful activity for individuals with ID as well.


Introduction
An intellectual disability (ID) is defined as a condition where the individual is physically impaired or physiologically underdeveloped, which is especially characterized by the disruption of those abilities during the developmental period and contributes to a general level of intelligence and speech and cognitive, motor, and social abilities [1]. ID is generally defined as having an IQ score below 70, along with limitations in adaptive functioning (i.e., the ability to learn and apply skills, solve problems, and adapt to new situations), which can significantly impact an individual's daily living skills, communication abilities, and social interactions. There are different levels of intellectual disability, ranging from mild, moderate, severe to profound, depending on the degree of impairment in cognitive

Materials and Methods
The systematic review of the papers was carried out following the methodological guidelines and by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) consensus [46].

Search Strategy
The following electronic databases were searched: PubMed, MEDLINE, Google Scholar, ScienceDirect, and ERIC from 2001 to 2023. The search was carried out based on a combination of keywords: intellectual disabilities, intellectual disability, Down syndrome, sports games, effect, basketball, football, soccer, futsal, and handball.
All headlines and abstracts were reviewed for the potential papers, which were included in the systematic review. The lists of previous and original research were also reviewed. The relevant studies were obtained when the studies completed the criteria for inclusion after detailed research. Wherever it was possible, the research strategy was modified and adapted to each database research to increase the sensitivity of this review paper.

Criteria for Inclusion
Type of study: • Randomized controlled and non-randomized studies were examined and included in further analysis, while uncontrolled studies were excluded. This review included studies written in Serbian and English.
The sample of participants: • Study participants included athletes (amateurs/professionals), children, adolescents, and youth, with and without ID, of both genders and any age (no restriction), regardless of the degree of disability.

Type of intervention:
• Studies that determine the effects of sports game programs on individuals with ID were examined regardless of the length and type of study.
The type of obtained results: • The preliminary results obtained for our systematic review were motor skills after the training program. Studies were included if the impact of sports game programs on the physical fitness abilities of athletes was demonstrated. Secondary results, which are primarily related to the systematic review of papers, consisted of the following variables: psychosocial characteristics, anthropometric characteristics, heart rate, blood pressure, obesity, and cholesterol.

Criteria for Exclusion
Type of study: • Studies written in a language which was not Serbian or English; • Duplicates; • Conference abstracts.

Data Extraction
The collected research projects used for this review are shown in Table. For each study, the following parameters were shown: (1) study characteristics including author (s) and year of publication; (2) information about participants such as sample size, gender, age, and groups; (3) aim of the study; (4) duration of the training program; (5) key findings of the studies obtained by the authors.

Results
One hundred and two articles were identified from the database search, with an additional six articles identified through reference lists. After removing duplicates and eliminating articles based on title and abstract screening, forty-six studies remained. An evaluation of the remaining forty-six studies was conducted independently by two researchers. Following the final screening process, seventeen studies were included in the systematic review (Table 1). Details of the study selection process are presented in Figure 1.
x FOR PEER REVIEW 4 of 17

Results
One hundred and two articles were identified from the database search, with an additional six articles identified through reference lists. After removing duplicates and eliminating articles based on title and abstract screening, forty-six studies remained. An evaluation of the remaining forty-six studies was conducted independently by two researchers. Following the final screening process, seventeen studies were included in the systematic review ( Table 1). Details of the study selection process are presented in Figure 1.

Characteristics of the Studies
The duration of the training program ranged from four weeks to four years. The most common duration of the training program was eight weeks (seven studies) [
The duration or length of the experimental program and training sessions were not stated in one study [61].
Regarding sports game programs, basketball was the most commonly represented program [32,47,[49][50][51]53,57,59,61]. Some studies had basketball players with ID as their sample [47,59]. Studies Özer and associates [63] and Baran and associates [60] identified the effects of Special Olympics (SO) Unified Sports Soccer (UNS) programs on physical fitness, football skills, and psychosocial characteristics of anthropometry in children athletes with and without ID, while the study of Niemeier and associates [48] evaluated the effectiveness of SO Fit 5 health program in improving health measures for individuals with ID. Maano and associates [57] aimed to analyze the effects of alternative sports competitions. Ilkim and Akyol [55] assessed the effects of a table tennis exercise program on reaction times in children with DS. Naczk and associates [56] estimated the influence of a thirty-three-week swimming program on aerobic capacity, physical fitness, level of adjustment and function in water, and body composition of adolescents with DS. Further details of the included studies are shown in Table 1. To determine whether a basketball battery of tests can assess basketball skills before and after eight months of training in persons with ID, in relation to competitive and pro-categories, and to analyze variations in specific abilities of basketball players with ID.

Modified basketball tests for players with ID
Competitive basketball players (ID III) ↑ BH, PS, R, SS. Pro-categories basketball (ID II) ↑ BH, R, PS. Level ID (I, II, III) have a statistically significant negative correlation with ID diagnosis, indicating that basketball players with a lower ID level achieve better results.
To determine the effects of the training program on basketball skills and psychological status in basketball players with ID during two sports seasons.

months
Modified basketball tests for players with ID. Two psychological questionnaires: (a) the perceived physical ability scale; and (b) the task and ego orientation in sport questionnaire.
Basketball training produced a general improvement after 6 months in both sport seasons. Athletes with lower ID obtained higher ability scores. NC difference PQ. This result could be justified by the positive influence of physical activity in persons with ID, who could know better their physical ability through sport experience. To examine the effects of easy goals versus difficult goals on acquisition and retention of basketball free throws in children with ID.

weeks
Sport skill learning assessment for individuals with ID. EXP1 ↑↑ performance, EXP2 failed to improve their performance. Results indicate that EXP1 children with easy goals facilitate the process of sport skill learning. To examine the effects of a competitive alternated sport program and type of sport (basketball versus running) on the domains of perceived competence and general self-worth.

months
Harter's self-perception profile NC difference between groups in AC and time, and interaction, SA, PA after seven months of training (2 h per week). NC differences in time behavior and interaction between groups. Differences (p < 0.005) in GSW time. Differences (p < 0.005) between EXP1 having basketball SO training and school competitions, and EXP2 having SO running training and school competitions.

Discussion
The primary purpose of this review was to determine the effects of sports game programs on motor skills in children, adolescents, and youth with intellectual disabilities and DS. A review of research to date has found that sports game programs, particularly basketball, represent a safe and reliable way to exercise, and an effective and practical rehabilitation program for individuals with ID. Additionally, the college football program has a positive impact on the speed of concentric contraction of the leg-extensor muscles, and therefore, on the reflective impulse.
Studies consisting of basketball players clearly show the positive effects of basketball programs on the motor skills of children, adolescents, and youth with ID. The basketball test battery can be used to improve and monitor basketball training [32,47,59,64]. Basketball training has contributed to positive changes in the final measurement regarding improved ball handling (BH), reception (R), as well as passing scores (PS) and shooting scores (SS). Mohammadi and associates [32] clearly showed that the study participants who were given easy goals improved their free-throw shooting performance in basketball, compared to a group who were given difficult goals and did not improve their performance.
The results indicate that basketball players with lower levels of ID achieve better results, as the best results were obtained in basketball players with level II and III of ID [29,47], and significant differences were obtained between level categories (I, II, III) of ID in all fields [59]. Additionally, the explosive power of the legs contributes the most to the increase in ID levels II and III [63].
Studies consisting of students, adolescents, and adults also show the benefit of basketball programs on motor abilities [49,51] and muscular strength of the upper and lower extremities in people with ID [64]. However, Stanišić and associates [49] indicate that an eight-week specially designed basketball program contributes to an increase in specifically motor skills of adolescents but not physical fitness, and the key reason is probably the short time spent in training.
The study of Tsimaras and associates [64], whose training program lasted four years, indicated differences in all tests between males with and without ID. The experimental group that participated in the four-year basketball training had higher absolute and relative values of the extensors and flexors of both knees, while the experimental group that exercised recreationally had greater antagonistic activity of the extensors and flexors of both knees. It should be emphasized that both experimental groups have higher antagonistic activity of the extensors and flexors of both knees than the control group. Hemayattalab and Movahedi [65] examined the effect of five different variations of physical exercise on learning in adolescents with ID regarding throwing free throws. They indicated that it is cognitively related to physical exercise and significantly contributes to the success of free throws in people with ID. A specially adapted basketball training program also has a positive effect on the physical fitness of basketball players, especially in the term of heart rate (HR) and a six-minute walking test (6MWT), but without changes in anthropometric dimensions, thus providing limited information on the effects; these results support the design of a full-scale experiment on this topic [50]. Therefore, basketball is a safe and reliable way to exercise for people with ID because it implies sustained and continuous physical activity and is therefore recommended as an effective and practical rehabilitation program for individuals with ID. In addition, the futsal program implemented with individuals with ID contributed to improving the results of the vertical jump test, which is an indicator of the explosive power of the legs, but without statistically significant differences. However, that experimental program had an even more significant impact on the coordination, and the differences between the test results-a vertical jump with and without an arm swing, which can be seen indirectly as a coordination factor-were statistically significant. The results of this research recommended futsal as a very interesting and helpful activity for individuals with ID [62].
Studies conducted by the SO UNS program are helpful for young people with and without ID, as it reduces behavior problems, social competence (SC), and the Friendship Activity Scale (FAS) in conjunction with physical education classes; in addition, it improves the relationship of youth without ID to participants with ID [63]. Baran and associates [60] point to the importance of the UNS program eight weeks after full-time physical education, which shows significantly higher physical fitness and soccer skills in males with and without ID compared to a control group that did not participate in any sport after regular physical education classes. It should be emphasized that there were no differences in behavior and interaction between groups and that the experimental group that had basketball SO training and school competitions performed better than the experimental group that had SO running training and school competitions [57]. Thus, SO training and the UNS program successfully increase the fitness abilities and performing abilities of football skills and reduce behavioral problems, SC, and FAS. The positive effect of SO Fit 5 training on resting heart rate (RHR), blood pressure, and BMI in adolescents and adults with ID was confirmed in the study [48].
In addition to those with ID, those included were also individuals with DS, which will be explained in more detail in the following section. Cai and Baek [54] obtained results that clearly show the positive effects of a 24-week basketball program on improving body composition, flexibility, balance, aerobic capacity, and basketball functional abilities in individuals with DS. The positive effects of the basketball program were confirmed by Aydogan and Demirok [61], who investigated the effects of basic basketball movements on the effectiveness and persistence of video modeling lessons. The results of the study showed that teaching by video models is an effective method in providing basic basketball skills to adolescents with DS.
It should be emphasized that no additional studies have been found that examine the effects of (collective) sports games programs on motor skills in children, adolescents, and youth with DS. On the other hand, there are studies that confirm the positive effects of swimming and table tennis programs in children and adolescents with DS. Ilkim and Akyol [55] showed that the reaction times of children with DS who participated in table tennis activities were better in comparison to the control group. Naczk and associates [56] indicated that a thirty-three-week swimming program has positive effects on muscle strength, aquatic skills, and health status in adolescents with DS.
Ince [52] emphasized that an eight-week BH program contributed to a statistically significant increase in upper and lower extremity muscle strength in adolescents and adults with DS as well as an increased leg strength test (LST), wall squat test (WST), and dominant handgrip strength (DHGS); however, there were no changes in the vertical jump (VJ), standing broad jump (SBJ) and non-dominant handgrip strength tests (NDHGS). It is interesting to note that there were no differences between groups, although the control group did not participate in any of the activities. In addition to the positive effect on motor skills or muscle strength, the positive effect of twelve-week training on anthropometric characteristics, body composition, blood fat, and blood pressure in individuals with and without DS did not contribute to the reduction in low-density lipoproteincholesterol [66]. Other studies confirm the positive effects of exercise programs on muscle strength in children with DS [67,68]. Therefore, muscle strength is a significant fitness parameter that needs to be developed, which means that further studies are needed to find possible factors that would contribute to the increase in muscle strength in children, adolescents, and youth with DS.

Conclusions
This is the first review study to investigate whether there are positive effects of sports game programs on motor skills in individuals with ID and DS. Basketball is recommended as an effective and practical rehabilitation program for people with ID and DS, including fitness parameters, motor skills, and interaction aspects. Basketball players with lower levels of ID achieve better results, especially those with ID II and III degrees, especially regarding better fitness abilities. However, some disagreements can certainly be attributed to the individual characteristics of the sample of participants. SO training and the UNS program successfully increase the fitness abilities and performance of soccer skills, reduce behavioral problems, SC, and FAS, which once again, confirmed the importance of basket-ball and futsal sports games, either in young people with or without ID. In individuals with DS, training programs contribute to a statistically significant increase in upper and lower extremity muscle strength; additionally, positive effects on anthropometric characteristics, body composition, blood fat, and blood pressure should be emphasized. Further studies are needed to investigate the possible factors that would contribute to the increase in muscle strength in those people.