Adherence to 24-Hour Movement Guidelines Among Children and Adolescents with Intellectual Disabilities: A Systematic Review and Meta-Analysis

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However, no systematic review or meta-analysis have identified the prevalence of meeting the guidelines (i.e., physical activity, screen time, and sleep duration). Therefore, this study aimed to examine the pooled prevalence of adherence to each individual behavior recommendation. Methods Five electronic databases, including Web of Science, Medline, PubMed, PsycINFO, and Scopus, were searched from their inception to September 2025. Meta-analysis with random-effects model was applied to pool the prevalence of multiple studies. Results Fifteen studies comprising 3261 participants (female = 36.5%) aged 7 to 18 years from ten countries/districts were identified. The meta-analysis demonstrated that 26% of children and adolescents with intellectual disabilities achieved the recommendations of the physical activity guidelines (95% CI: 0.21–0.32, p < 0.01); 54% of the target population adhered to the screen time guidelines (95% CI: 0.32–0.75, p < 0.01); and 47% of the sample met the sleep guidelines (95% CI: 0.19–0.77, p < 0.01). Conclusions Current evidence showing that prevalence of adherence to each individual behavior recommendation in children and adolescents with intellectual disabilities is low. In addition, due to most studies did not report combined behavior data at the individual level, preventing analysis of integrated guideline adherence patterns (e.g., the prevalence of meeting overall, any two, and any one movement guidelines). Physical activity screen time sleep duration movement behavior children and adolescents intellectual disability Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 1 Introduction The integrated 24-hour movement paradigm, as encapsulated in guidelines by the World Health Organization and other major public health bodies, recognizes that physical activity (PA); sedentary behavior (SB), particularly recreational screen time (ST); and sleep duration (SD) are co-dependent behaviors that collectively influence the physical, mental, and social health of children and adolescents [ 1 ]. A growing body of evidence underscores the significant health implications of adhering to these combined recommendations. For instance, a systematic review of 39 studies found that meeting all three 24-hour movement guidelines was favorably associated with a range of health indicators, including adiposity, cardiometabolic health, and physical fitness [ 2 ]. Crucially, pooled data from international studies indicate that children who meet the integrated guidelines have substantially lower odds of obesity (OR = 0.28, 95% CI: 0.18–0.45) compared to those who meet none, highlighting the powerful synergistic effect of these behaviors on health outcomes [ 3 ]. Children and adolescents with intellectual disabilities represent a population of particular concern within this framework [ 4 ]. Intellectual disabilities, characterized by significant limitations in intellectual functioning and adaptive behavior, is associated with pronounced health disparities [ 5 ]. This group is at markedly higher risk for unhealthy movement behaviors compared to their typically developing peers, including insufficient physical activity, excessive sedentary time, and inadequate sleep [ 6 ]. These maladaptive behavioral patterns form a vicious cycle, leading to tangible and severe health harms. Critically, the high prevalence of SB and low level of PA contribute to elevated obesity rates within this population [ 5 ]. Furthermore, excessive screen time, a key component of SB, is independently linked to adverse developmental outcomes. One study found that children exposed to more than 4 hours of screen time per day at age 2 had a 14.8% prevalence of communication developmental delay, compared to 3.5% among those with less than 1 hour of daily exposure [ 7 ]. Concurrently, sleep disorders are extraordinarily common, with prevalence rates as high as 86% among individuals with intellectual disabilities, which severely impacts daytime functioning, cognitive performance, and exacerbates behavioral challenges [ 8 ]. Despite the profound and wide-ranging health consequences associated with suboptimal 24-hour movement behaviors in children and adolescents with intellectual disabilities, a critical barrier to developing effective interventions and policies remains: the lack of a synthesized, quantitative evidence base that is specific to this population. To date, no systematic review or meta-analysis has specifically quantified 24-hour movement guideline adherence exclusively among children and adolescents with intellectual disabilities. Existing syntheses are derived from broader reviews encompassing heterogeneous disability groups. For example, one meta-analysis of children and youth with various disabilities (aged 6 to 21) reported pooled adherence rates of 22% for PA, 49% for ST, and 59% for SD, with only 7% meeting all three recommendations [ 9 ]. Another review included an even wider age range (aged 6 to 65 years) across various disabilities [ 10 ]. While these studies provide valuable preliminary insights, their broad scopes inevitably obscure the unique behavioral patterns, challenges, and adherence profiles specific to the target population. Therefore, this study aims to conduct the first systematic review and meta-analysis focused specifically on 24-hour movement guideline adherence among children and adolescents with intellectual disabilities. The primary objective is to estimate the pooled prevalence of adherence to each individual behavior recommendation (i.e., PA, ST, and SD). We initially sought to also investigate the prevalence of meeting overall, any two, and any one movement guidelines. However, as the available literature provided insufficient extracted data for such information, this review will focus on synthesizing evidence for the separate behavioral components. By addressing this critical gap, this work aims to establish a foundational evidence base to guide future research, the development of tailored interventions, and the promotion of holistic health in this vulnerable population. 2 Methods This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement [ 11 ], the checklist was provided in Supplementary material S1. Additionally, the protocol for this study was registered in the International Prospective Register of Systematic Reviews (no. CRD420261294529). 2.1 Search strategy Five electronic databases, including Web of Science, Medline, PubMed, PsycINFO, and Scopus, were searched from their inception to September 2025 by two researchers. Search terms included population-related, disability-related, and behavior-related. Detailed search strategy is presented in Table 1. Table 1 Search strategy 2.2 Study selection Studies were included if they met the following criteria: (1) participants aged between 5 to 17 years, or with a mean age between 5 to 17 years; (2) participants were identified as having intellectual disabilities; (3) prevalence of meeting PA, SB, and/or sleep guidelines were reported; (4) observational studies or experimental studies as baseline date were provided; and (5) published in English peer-reviewed journals. On-going studies and review articles were excluded. Regarding process of study selection, title, abstract, and full-text screening were conducted according to the above selection criteria. In addition, relevant reviews in study area and reference lists of included studies, were checked for eligible studies. Two co-authors selected and reviewed articles in parallel, corresponding author of this study made final decisions when there were any disagreements. 2.3 Methodological quality assessment Methodological quality assessment of the included studies was conducted by using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields [ 12 ]. This tool has been applied to evaluate quality of experimental and observational studies that examine the prevalence of meeting 24-hour movement guidelines in the study area [ 9 ]. Totally 14 items were included in this tool, with each item scored as “yes” (2 points), “partial” (1 point), “no” (0 point), or “not applicable” (excluded from final score calculation). The final scores were presented as a percentage of the relevant items achieved. High quality (scores > 75%), medium quality (scores of 55–75%), and low quality (scores < 55%), were classified according to the final scores achieved by each included study [ 12 ]. Two co-authors assessed the quality independently, the corresponding author made final decisions when there were any disagreements. 2.4 Data extraction and analysis The following data were extracted for systematic review, including author information, study design, sample characteristic, measurements of movement behaviors, and compliance of meeting the movement guidelines. Meta-analysis was conducted using Stata (version 18.0). Sample size and number of participants who met the behavior guidelines in each study were extracted. Random-effects model with DerSimonian-Laird method were applied to pool the prevalence of multiple studies [ 13 ]; Clopper-Pearson method was used to estimate 95% confidence intervals (95%CI) for prevalence [ 14 ]; I 2 statistic was used to assess heterogeneity of the pooled proportions [ 15 ]; Egger’s test and Begg rank correlation test were conducted for publication bias of the included studies [ 16 ]; and finally, sensitivity analysis was conducted by changing the random-effects model to the fixed- effects model to examine the reliability of the results [ 17 ] 3 Results 3.1 Study selection Figure 1 provides a flow diagram documenting the selection process. A total of 2652 records were identified through the search. After removing the duplicates, 2577 records were screened by title and abstract. Next, full texts of 93 records were retrieved, of which 78 studies were excluded according to the inclusion and exclusion criteria. Finally, 15 studies were included. 3.2 Study characteristics The main characteristics of the 15 included studies are presented in Table 2. The publication dates ranged from 2009 to 2024. A total of 3261 participants (female = 36.5%) aged 7 to 18 years were included. Mixed levels of intellectual disabilities including mild, moderate, severe and profound were identified in the participants. In terms of geographical regions, the included studies were predominantly from China [18-23], which contributed 40% of the total publications, while the remaining studies were distributed across 9 other countries/districts spanning Spain [24], Northern Ireland [25], Bosnia and Herzegovina [26], Sweden [27], United States [28], The Netherlands [29], Poland [30], England [31], and Australia [32]. Regarding study design, two were longitudinal studies [19, 25], whilst the other thirteen were cross-sectional studies. In terms of outcomes and measurements of the 24-hour movement behaviors: (1) 14 studies evaluated PA, with eight studies using accelerometers [18, 20, 24, 25, 28, 29, 31, 32], and six using parental/caregiver proxy-reports [19, 21-23, 27, 30]; (2) six studies assessed ST, parental/caregiver proxy-reports were applied by all the six studies [18, 19, 21, 23, 24, 26]; and (3) five studies measured SD, accelerometer was applied in one study [18], whilst the remaining four used parental/caregiver proxy-reports [19, 23, 24, 26]. 3.3 Quality assessment Results of quality assessment are presented in Table 3. The quality scores ranged from 0.68 to 0.96. Specifically, 13 (86.7%) of the included studies were considered to have “high quality”, and two were considered “medium quality” [21, 26]. All the studies met the reporting criteria of the research question described (Item 1) and the conclusion identified (Item 14). Most studies met the reporting criteria regarding study design (Item 2, 93.3%), subject selection (Item 3, 93.3%), descriptions of participants’ characteristics (Item 4, 60.0%), defined outcome(s) and exposure measure(s) (Item 8, 53.3%), larger sample size (Item 9, 73.3%), analytical methods (Item 10, 86.7%), and sufficient details in results (Item 13, 86.7%). Few studies provided appropriate variance estimates (Item 11, 40.0%) and indicated information about controlled for confounding (Item 12, 46.7%). In addition, regarding items on randomization and blinding (Items 5 to 7), two longitudinal studies fully satisfied the criteria. 3.4 Prevalence of meeting physical activity, screen time, and sleep guidelines Among the 15 included studies, 14 studies reported prevalence of meeting PA guidelines [18-25, 27-32]; six studies reported prevalence of meeting ST guidelines [18, 19, 21, 23, 24, 26]; and five studies reported prevalence of meeting sleep guidelines [18, 19, 23, 24, 26]. The results of meta-analysis showed that, 26% of children and adolescents with intellectual disabilities achieved the recommendations of the PA guidelines (95% CI: 0.21-0.32, p<0.01, I 2 =89.64%); 54% of the target population adhered to the ST guidelines (95% CI: 0.32-0.75, p<0.01, I 2 =98.59%); and 47% of the sample met the sleep guidelines (95% CI: 0.19-0.77, p<0.01, I 2 =98.62%). For details, please see Figures 2 to 4. In addition, no significant publication bias was detected by both Egger’s test (PA: p=0.51; ST: p=0.86; sleep: p=0.90) and Begg rank correlation test (PA: p=0.66; ST: p=1.00; sleep: p=0.81). Regarding sensitivity analysis, the results of the three behaviors did not change significantly when we changed the random-effects model to the fixed-effects model, which increased the reliability of the findings. The detailed information about the results of sensitivity analysis is provided in Figures 5 to 7. 4 Discussion This systematic review and meta-analysis provide the first quantitative global evidence synthesis on 24-hour movement guideline adherence among children and adolescents with intellectual disabilities. The pooled analyses indicate that adherence to the PA guideline is 26% (95% CI: 0.21–0.32). Adherence to the SD guideline is 47% (95% CI: 0.19–0.77), and adherence to the ST guideline is 57% (95% CI: 0.32–0.75), with this estimate characterized by considerable heterogeneity (I² = 98.59%). These findings establish a baseline for understanding movement behaviors in this population and highlight aspects that require consideration in health promotion strategies. Regarding PA, the adherence rate of 26% identified in this review requires contextual interpretation. This rate is numerically higher than the 22% reported for a broader, mixed-disability youth population in a prior international meta-analysis [ 9 ]. This difference suggests that the overall estimate for the mixed-disability group likely reflects contributions from various subgroups with differing behavioral profiles [ 10 ]. For children and adolescents with intellectual disabilities specifically, the observed rate remains low from a public health perspective, as levels of PA are consistently reported to be significantly lower than those of their typically developing peers. This indicates that barriers to achieving sufficient PA continue to exist for this group. Documented barriers include motor skill deficits that limit participation, a lack of adapted and inclusive community programs, and social environments that may not provide adequate support [ 33 ]. Future research should move beyond monitoring prevalence to prioritize studies that identify modifiable determinants of PA for youth with intellectual disabilities, supporting the development of evidence-based promotion programs [ 34 ]. Turning to ST, this study found that the guideline adherence rate among children and adolescents with intellectual disabilities was 57% (95% CI: 0.32–0.75). This point estimate is higher than the 49% reported in a prior meta-analysis involving a broader population of children and youth with disabilities [ 9 ]. The discrepancy between these estimates may be attributed to differences in the composition of the study populations or variations in measurement methodologies across the studies [ 10 ]. For individuals with intellectual disabilities, screen use often serves multiple purposes such as entertainment, education, and behavioral management, which complicates the assessment of "healthy adherence" based solely on duration [ 35 ]. Research indicates that guided modification of ST coupled with increased social interaction is associated with improvements in certain social skills among young children [ 36 ]. Consequently, future research should look beyond mere duration to further distinguish the type, content, and context of screen activities, thereby facilitating the development of more targeted assessment and guidance [ 37 ]. Similarly, for SD, the guideline adherence rate found here is 47%, which is lower than the 59% reported for the broader disability population in an international synthesis [ 9 ]. This difference may relate to measurement methods, but also to the nature of sleep disturbances in this population, which often include problems with sleep initiation and nighttime awakenings, linked to individual mood and behavior [ 38 ]. Consequently, future sleep research would benefit from integrating multi-dimensional assessments. There is also a need for studies to clarify the associations between intellectual disability subtypes, comorbid conditions, and specific sleep problems to inform targeted guidance. A high degree of statistical heterogeneity was observed in the pooled estimates for all three outcomes. Meaningful subgroup analyses to explore specific sources of this heterogeneity were not feasible due to the limited number of available studies for each behavior (PA: n = 14; ST: n = 6; SD: n = 5). However, potential sources of variation could be inferred from the literature. These likely include the inherent heterogeneity of the population with intellectual disabilities, which encompasses a wide spectrum of functioning levels linked to different behavioral patterns. Methodological inconsistencies, such as the use of both objective and subjective measures for PA and SD, also contribute to variability, as different tools yield different adherence estimates [ 9 ]. Furthermore, the broad age range of participants across studies, from childhood to late adolescence, introduces variation due to significant developmental changes in lifestyle and autonomy [ 10 ]. Future primary studies should aim for more homogeneous samples or report key moderators systematically to enable future syntheses to quantify these sources of variance. This study has several strengths, primarily its novelty in providing the first global quantitative evidence synthesis on this topic for this specific population using systematic methodology. The review followed reporting standards and conducted bias assessments. Limitations include constraints from the primary evidence: most studies did not report combined behavior data at the individual level, preventing analysis of integrated guideline adherence patterns. The geographical distribution of studies is uneven, and the predominance of cross-sectional designs hinders causal inference. 5 Conclusion In conclusion, this systematic review and meta-analysis provides quantitative data on 24-hour movement guideline adherence among children and adolescents with intellectual disabilities. The pooled analyses indicate that adherence to the PA guideline is 26%; adherence to the SD guideline is 47%; and adherence to the ST guideline is 57%. These findings offer baseline data for public health policy. Future efforts could focus on: methodologically, using combined methods to capture integrated behavior data; in research content, investigating multi-level determinants longitudinally; and in practice, developing and evaluating personalized health behavior interventions based on evidence. Abbreviations PA: physical activity SB: sedentary behavior ST: screen time SD: sleep duration OR: Odds ratio 95%CI: 95 percent confidence interval Declarations Ethics approval and consent to participate This review used secondary data from peer-reviewed published articles and does not require ethics clearance or consent to participate. Consent for publication Not applicable. Availability of data and materials If you need any supplementary materials related to data availability for further review, please kindly contact the corresponding author of this manuscript. Competing interests The authors declare that they have no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. Funding This work was supported by “Green Yang Golden Phoenix Plan” high-level innovative and entrepreneurial talent introduction project. Authors' contributions WAW wrote the protocol; YGS developed the search strategy; LL and PYY selected articles in parallel; WT and ZZ parallelly reviewed the selected articles and retrieved the data; WAW made final decisions when there were any discrepancies in the review; WJQ and TTZ contributed to data extraction; LC and JBY were responsible for quality assessment; JZ conducted the data analysis; WAW wrote up the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British journal of sports medicine. 2020;54(24):1451-62. Ross R, Chaput JP, Giangregorio LM, Janssen I, Saunders TJ, Kho ME, et al. Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep. 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Screen time reduction and focus on social engagement in autism spectrum disorder: A pilot study. Pediatr Int. 2022;64(1):e15343. Straker L, Zabatiero J, Danby S, Thorpe K, Edwards S. Conflicting Guidelines on Young Children's Screen Time and Use of Digital Technology Create Policy and Practice Dilemmas. J Pediatr. 2018;202:300-3. Harper L, McAnelly S, Walshe I, Ooms A, Tuffrey-Wijne IM. Behavioural sleep problems in children and adults with intellectual disabilities: An integrative literature review. J Appl Res Intellect Disabil. 2023;36(5):916-28. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Qin","email":"","orcid":"","institution":"Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Weijie","middleName":"","lastName":"Qin","suffix":""},{"id":586543013,"identity":"944176f3-fdf4-4fb8-875c-168d8f4ee680","order_by":6,"name":"Tiantian Zhang","email":"","orcid":"","institution":"Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Tiantian","middleName":"","lastName":"Zhang","suffix":""},{"id":586543014,"identity":"9e5da29f-1585-4406-bea3-f96c2b6ad313","order_by":7,"name":"Lu Chen","email":"","orcid":"","institution":"Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Lu","middleName":"","lastName":"Chen","suffix":""},{"id":586543019,"identity":"2b6414b6-4f50-40e9-8ba1-ae7296c8fe94","order_by":8,"name":"Yagang Song","email":"","orcid":"","institution":"Shanghai University of Sport","correspondingAuthor":false,"prefix":"","firstName":"Yagang","middleName":"","lastName":"Song","suffix":""},{"id":586543020,"identity":"8964b7d5-1f68-4fde-a5bc-61d65646ed30","order_by":9,"name":"Junbin Yang","email":"","orcid":"","institution":"Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Junbin","middleName":"","lastName":"Yang","suffix":""},{"id":586543021,"identity":"e17077cb-4d24-4e88-b8c1-3599fa965688","order_by":10,"name":"Jun Zhang","email":"","orcid":"","institution":"Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-01-31 12:38:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8749857/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8749857/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102244850,"identity":"d5ff0d0d-4caf-49a5-93ed-9db9673a22f7","added_by":"auto","created_at":"2026-02-09 17:40:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35540,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA 2020 flow diagram\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/3e336e4f9253062e507448a1.png"},{"id":102244755,"identity":"ebb9fca4-2a87-48c5-9e96-d2373250b07a","added_by":"auto","created_at":"2026-02-09 17:40:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":125267,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of adherence to physical activity guidelines\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/902580109bf780b4ee038ab5.png"},{"id":102244849,"identity":"53943f0c-6765-4c0f-a611-0a9007cd83c7","added_by":"auto","created_at":"2026-02-09 17:40:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":137452,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of adherence to screen time guidelines\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/f27dc7af2d1eacb956c6a6c5.png"},{"id":102244854,"identity":"cec284e2-4422-4442-8fe2-d676ae29ba62","added_by":"auto","created_at":"2026-02-09 17:40:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":124503,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of adherence to sleep duration guidelines\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/40e35e7407c219f0d014ae2c.png"},{"id":102244756,"identity":"7696dbdd-2a63-4fc5-a1ca-6682901d3eee","added_by":"auto","created_at":"2026-02-09 17:40:46","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":121435,"visible":true,"origin":"","legend":"\u003cp\u003eSensitivity analysis for physical activity\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/4ea47c8e7523da8bbe4141ab.png"},{"id":102244757,"identity":"89e42fe5-a5c3-45c4-b496-ef2b0295fd95","added_by":"auto","created_at":"2026-02-09 17:40:46","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":132926,"visible":true,"origin":"","legend":"\u003cp\u003eSensitivity analysis for screen time\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/f9625ce8b580d60d17e4f64a.png"},{"id":102244846,"identity":"9a9bea1b-c19a-4514-837f-0889d28e46e8","added_by":"auto","created_at":"2026-02-09 17:40:55","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":122287,"visible":true,"origin":"","legend":"\u003cp\u003eSensitivity analysis for sleep duration\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/0e4ce08cdd4a8bde725199d0.png"},{"id":104399803,"identity":"2a1b0448-79a4-445f-991f-003764d95992","added_by":"auto","created_at":"2026-03-11 12:07:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1117712,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/dd5504b9-99be-4314-b419-542ce82f7282.pdf"},{"id":102244855,"identity":"9902580f-a695-48dc-9137-d2e440a1a8d9","added_by":"auto","created_at":"2026-02-09 17:40:59","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":67099,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarymaterialS120260131.doc","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/1bc58730cef8658c0ef18c2b.doc"},{"id":102244752,"identity":"d2ad176e-dfd9-4c40-a7be-b79ca46f28e4","added_by":"auto","created_at":"2026-02-09 17:40:45","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":33562,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8749857/v1/692c4a3e981bc66b2df70bec.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adherence to 24-Hour Movement Guidelines Among Children and Adolescents with Intellectual Disabilities: A Systematic Review and Meta-Analysis","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eThe integrated 24-hour movement paradigm, as encapsulated in guidelines by the World Health Organization and other major public health bodies, recognizes that physical activity (PA); sedentary behavior (SB), particularly recreational screen time (ST); and sleep duration (SD) are co-dependent behaviors that collectively influence the physical, mental, and social health of children and adolescents [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A growing body of evidence underscores the significant health implications of adhering to these combined recommendations. For instance, a systematic review of 39 studies found that meeting all three 24-hour movement guidelines was favorably associated with a range of health indicators, including adiposity, cardiometabolic health, and physical fitness [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Crucially, pooled data from international studies indicate that children who meet the integrated guidelines have substantially lower odds of obesity (OR\u0026thinsp;=\u0026thinsp;0.28, 95% CI: 0.18\u0026ndash;0.45) compared to those who meet none, highlighting the powerful synergistic effect of these behaviors on health outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChildren and adolescents with intellectual disabilities represent a population of particular concern within this framework [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Intellectual disabilities, characterized by significant limitations in intellectual functioning and adaptive behavior, is associated with pronounced health disparities [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This group is at markedly higher risk for unhealthy movement behaviors compared to their typically developing peers, including insufficient physical activity, excessive sedentary time, and inadequate sleep [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These maladaptive behavioral patterns form a vicious cycle, leading to tangible and severe health harms. Critically, the high prevalence of SB and low level of PA contribute to elevated obesity rates within this population [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Furthermore, excessive screen time, a key component of SB, is independently linked to adverse developmental outcomes. One study found that children exposed to more than 4 hours of screen time per day at age 2 had a 14.8% prevalence of communication developmental delay, compared to 3.5% among those with less than 1 hour of daily exposure [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Concurrently, sleep disorders are extraordinarily common, with prevalence rates as high as 86% among individuals with intellectual disabilities, which severely impacts daytime functioning, cognitive performance, and exacerbates behavioral challenges [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the profound and wide-ranging health consequences associated with suboptimal 24-hour movement behaviors in children and adolescents with intellectual disabilities, a critical barrier to developing effective interventions and policies remains: the lack of a synthesized, quantitative evidence base that is specific to this population. To date, no systematic review or meta-analysis has specifically quantified 24-hour movement guideline adherence exclusively among children and adolescents with intellectual disabilities. Existing syntheses are derived from broader reviews encompassing heterogeneous disability groups. For example, one meta-analysis of children and youth with various disabilities (aged 6 to 21) reported pooled adherence rates of 22% for PA, 49% for ST, and 59% for SD, with only 7% meeting all three recommendations [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Another review included an even wider age range (aged 6 to 65 years) across various disabilities [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While these studies provide valuable preliminary insights, their broad scopes inevitably obscure the unique behavioral patterns, challenges, and adherence profiles specific to the target population.\u003c/p\u003e \u003cp\u003e Therefore, this study aims to conduct the first systematic review and meta-analysis focused specifically on 24-hour movement guideline adherence among children and adolescents with intellectual disabilities. The primary objective is to estimate the pooled prevalence of adherence to each individual behavior recommendation (i.e., PA, ST, and SD). We initially sought to also investigate the prevalence of meeting overall, any two, and any one movement guidelines. However, as the available literature provided insufficient extracted data for such information, this review will focus on synthesizing evidence for the separate behavioral components. By addressing this critical gap, this work aims to establish a foundational evidence base to guide future research, the development of tailored interventions, and the promotion of holistic health in this vulnerable population.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003eThis systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], the checklist was provided in Supplementary material S1. Additionally, the protocol for this study was registered in the International Prospective Register of Systematic Reviews (no. CRD420261294529).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Search strategy\u003c/h2\u003e \u003cp\u003eFive electronic databases, including Web of Science, Medline, PubMed, PsycINFO, and Scopus, were searched from their inception to September 2025 by two researchers. Search terms included population-related, disability-related, and behavior-related. Detailed search strategy is presented in Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;1 Search strategy\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study selection\u003c/h2\u003e \u003cp\u003e Studies were included if they met the following criteria: (1) participants aged between 5 to 17 years, or with a mean age between 5 to 17 years; (2) participants were identified as having intellectual disabilities; (3) prevalence of meeting PA, SB, and/or sleep guidelines were reported; (4) observational studies or experimental studies as baseline date were provided; and (5) published in English peer-reviewed journals. On-going studies and review articles were excluded. Regarding process of study selection, title, abstract, and full-text screening were conducted according to the above selection criteria. In addition, relevant reviews in study area and reference lists of included studies, were checked for eligible studies. Two co-authors selected and reviewed articles in parallel, corresponding author of this study made final decisions when there were any disagreements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Methodological quality assessment\u003c/h2\u003e \u003cp\u003eMethodological quality assessment of the included studies was conducted by using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This tool has been applied to evaluate quality of experimental and observational studies that examine the prevalence of meeting 24-hour movement guidelines in the study area [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Totally 14 items were included in this tool, with each item scored as \u0026ldquo;yes\u0026rdquo; (2 points), \u0026ldquo;partial\u0026rdquo; (1 point), \u0026ldquo;no\u0026rdquo; (0 point), or \u0026ldquo;not applicable\u0026rdquo; (excluded from final score calculation). The final scores were presented as a percentage of the relevant items achieved. High quality (scores\u0026thinsp;\u0026gt;\u0026thinsp;75%), medium quality (scores of 55\u0026ndash;75%), and low quality (scores\u0026thinsp;\u0026lt;\u0026thinsp;55%), were classified according to the final scores achieved by each included study [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Two co-authors assessed the quality independently, the corresponding author made final decisions when there were any disagreements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data extraction and analysis\u003c/h2\u003e \u003cp\u003e The following data were extracted for systematic review, including author information, study design, sample characteristic, measurements of movement behaviors, and compliance of meeting the movement guidelines.\u003c/p\u003e \u003cp\u003eMeta-analysis was conducted using Stata (version 18.0). Sample size and number of participants who met the behavior guidelines in each study were extracted. Random-effects model with DerSimonian-Laird method were applied to pool the prevalence of multiple studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]; Clopper-Pearson method was used to estimate 95% confidence intervals (95%CI) for prevalence [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]; I\u003csup\u003e2\u003c/sup\u003e statistic was used to assess heterogeneity of the pooled proportions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]; Egger\u0026rsquo;s test and Begg rank correlation test were conducted for publication bias of the included studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]; and finally, sensitivity analysis was conducted by changing the random-effects model to the fixed- effects model to examine the reliability of the results [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Study selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 provides a flow diagram documenting the selection process. A total of 2652 records were identified through the search. After removing the duplicates, 2577 records were screened by title and abstract. Next, full texts of 93 records were retrieved, of which 78 studies were excluded according to the inclusion and exclusion criteria. Finally, 15 studies were included.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Study characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main characteristics of the 15 included studies are presented in Table 2. The publication dates ranged from 2009 to 2024. A total of 3261 participants (female = 36.5%) aged 7 to 18 years were included. Mixed levels of intellectual disabilities including mild, moderate, severe and profound were identified in the participants. In terms of geographical regions, the included studies were predominantly from China [18-23], which contributed 40% of the total publications, while the remaining studies were distributed across 9 other countries/districts spanning Spain [24], Northern Ireland [25], Bosnia and Herzegovina [26], Sweden [27], United States [28], The Netherlands [29], Poland [30], England [31], and Australia [32]. Regarding study design, two were longitudinal studies [19, 25], whilst the other thirteen were cross-sectional studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn terms of outcomes and measurements of the 24-hour movement behaviors: (1) 14 studies evaluated PA, with eight studies using accelerometers [18, 20, 24, 25, 28, 29, 31, 32], and six using parental/caregiver proxy-reports [19, 21-23, 27, 30]; (2) six studies assessed ST, parental/caregiver proxy-reports were applied by all the six studies [18, 19, 21, 23, 24, 26]; and (3) five studies measured SD, accelerometer was applied in one study [18], whilst the remaining four used parental/caregiver proxy-reports [19, 23, 24, 26].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Quality assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults of quality assessment are presented in Table 3. The quality scores ranged from 0.68 to 0.96. Specifically, 13 (86.7%) of the included studies were considered to have “high quality”, and two were considered “medium quality” [21, 26]. All the studies met the reporting criteria of the research question described (Item 1) and the conclusion identified (Item 14). Most studies met the reporting criteria regarding study design (Item 2, 93.3%), subject selection (Item 3, 93.3%), descriptions of participants’ characteristics (Item 4, 60.0%), defined outcome(s) and exposure measure(s) (Item 8, 53.3%), larger sample size (Item 9, 73.3%), analytical methods (Item 10, 86.7%), and sufficient details in results (Item 13, 86.7%). Few studies provided appropriate variance estimates (Item 11, 40.0%) and indicated information about controlled for confounding (Item 12, 46.7%). In addition, regarding items on randomization and blinding (Items 5 to 7), two longitudinal studies fully satisfied the criteria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Prevalence of meeting physical activity, screen time, and sleep guidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 15 included studies, 14 studies reported prevalence of meeting PA guidelines [18-25, 27-32]; six studies reported prevalence of meeting ST guidelines [18, 19, 21, 23, 24, 26]; and five studies reported prevalence of meeting sleep guidelines [18, 19, 23, 24, 26].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of meta-analysis showed that, 26% of children and adolescents with intellectual disabilities achieved the recommendations of the PA guidelines (95% CI: 0.21-0.32, p\u0026lt;0.01, I\u003csup\u003e2\u003c/sup\u003e=89.64%); 54% of the target population adhered to the ST guidelines (95% CI: 0.32-0.75, p\u0026lt;0.01, I\u003csup\u003e2\u003c/sup\u003e=98.59%); and 47% of the sample met the sleep guidelines (95% CI: 0.19-0.77, p\u0026lt;0.01, I\u003csup\u003e2\u003c/sup\u003e=98.62%). For details, please see Figures 2 to 4.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, no significant publication bias was detected by both Egger’s test (PA: p=0.51; ST: p=0.86; sleep: p=0.90) and Begg rank correlation test (PA: p=0.66; ST: p=1.00; sleep: p=0.81). Regarding sensitivity analysis, the results of the three behaviors did not change significantly when we changed the random-effects model to the fixed-effects model, which increased the reliability of the findings. The detailed information about the results of sensitivity analysis is provided in Figures 5 to 7.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003e This systematic review and meta-analysis provide the first quantitative global evidence synthesis on 24-hour movement guideline adherence among children and adolescents with intellectual disabilities. The pooled analyses indicate that adherence to the PA guideline is 26% (95% CI: 0.21\u0026ndash;0.32). Adherence to the SD guideline is 47% (95% CI: 0.19\u0026ndash;0.77), and adherence to the ST guideline is 57% (95% CI: 0.32\u0026ndash;0.75), with this estimate characterized by considerable heterogeneity (I\u0026sup2; = 98.59%). These findings establish a baseline for understanding movement behaviors in this population and highlight aspects that require consideration in health promotion strategies.\u003c/p\u003e \u003cp\u003eRegarding PA, the adherence rate of 26% identified in this review requires contextual interpretation. This rate is numerically higher than the 22% reported for a broader, mixed-disability youth population in a prior international meta-analysis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This difference suggests that the overall estimate for the mixed-disability group likely reflects contributions from various subgroups with differing behavioral profiles [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. For children and adolescents with intellectual disabilities specifically, the observed rate remains low from a public health perspective, as levels of PA are consistently reported to be significantly lower than those of their typically developing peers. This indicates that barriers to achieving sufficient PA continue to exist for this group. Documented barriers include motor skill deficits that limit participation, a lack of adapted and inclusive community programs, and social environments that may not provide adequate support [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Future research should move beyond monitoring prevalence to prioritize studies that identify modifiable determinants of PA for youth with intellectual disabilities, supporting the development of evidence-based promotion programs [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Turning to ST, this study found that the guideline adherence rate among children and adolescents with intellectual disabilities was 57% (95% CI: 0.32\u0026ndash;0.75). This point estimate is higher than the 49% reported in a prior meta-analysis involving a broader population of children and youth with disabilities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The discrepancy between these estimates may be attributed to differences in the composition of the study populations or variations in measurement methodologies across the studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. For individuals with intellectual disabilities, screen use often serves multiple purposes such as entertainment, education, and behavioral management, which complicates the assessment of \"healthy adherence\" based solely on duration [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Research indicates that guided modification of ST coupled with increased social interaction is associated with improvements in certain social skills among young children [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Consequently, future research should look beyond mere duration to further distinguish the type, content, and context of screen activities, thereby facilitating the development of more targeted assessment and guidance [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, for SD, the guideline adherence rate found here is 47%, which is lower than the 59% reported for the broader disability population in an international synthesis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This difference may relate to measurement methods, but also to the nature of sleep disturbances in this population, which often include problems with sleep initiation and nighttime awakenings, linked to individual mood and behavior [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Consequently, future sleep research would benefit from integrating multi-dimensional assessments. There is also a need for studies to clarify the associations between intellectual disability subtypes, comorbid conditions, and specific sleep problems to inform targeted guidance.\u003c/p\u003e \u003cp\u003eA high degree of statistical heterogeneity was observed in the pooled estimates for all three outcomes. Meaningful subgroup analyses to explore specific sources of this heterogeneity were not feasible due to the limited number of available studies for each behavior (PA: n\u0026thinsp;=\u0026thinsp;14; ST: n\u0026thinsp;=\u0026thinsp;6; SD: n\u0026thinsp;=\u0026thinsp;5). However, potential sources of variation could be inferred from the literature. These likely include the inherent heterogeneity of the population with intellectual disabilities, which encompasses a wide spectrum of functioning levels linked to different behavioral patterns. Methodological inconsistencies, such as the use of both objective and subjective measures for PA and SD, also contribute to variability, as different tools yield different adherence estimates [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, the broad age range of participants across studies, from childhood to late adolescence, introduces variation due to significant developmental changes in lifestyle and autonomy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Future primary studies should aim for more homogeneous samples or report key moderators systematically to enable future syntheses to quantify these sources of variance.\u003c/p\u003e \u003cp\u003eThis study has several strengths, primarily its novelty in providing the first global quantitative evidence synthesis on this topic for this specific population using systematic methodology. The review followed reporting standards and conducted bias assessments. Limitations include constraints from the primary evidence: most studies did not report combined behavior data at the individual level, preventing analysis of integrated guideline adherence patterns. The geographical distribution of studies is uneven, and the predominance of cross-sectional designs hinders causal inference.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003e In conclusion, this systematic review and meta-analysis provides quantitative data on 24-hour movement guideline adherence among children and adolescents with intellectual disabilities. The pooled analyses indicate that adherence to the PA guideline is 26%; adherence to the SD guideline is 47%; and adherence to the ST guideline is 57%. These findings offer baseline data for public health policy. Future efforts could focus on: methodologically, using combined methods to capture integrated behavior data; in research content, investigating multi-level determinants longitudinally; and in practice, developing and evaluating personalized health behavior interventions based on evidence.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePA: physical activity\u003c/p\u003e\n\u003cp\u003eSB: sedentary behavior\u003c/p\u003e\n\u003cp\u003eST: screen time\u003c/p\u003e\n\u003cp\u003eSD: sleep duration\u003c/p\u003e\n\u003cp\u003eOR: Odds ratio\u003c/p\u003e\n\u003cp\u003e95%CI: 95 percent confidence interval\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review used secondary data from peer-reviewed published articles and does not require ethics clearance or consent to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIf you need any supplementary materials related to data availability for further review, please kindly contact the corresponding author of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by \u0026ldquo;Green Yang Golden Phoenix Plan\u0026rdquo; high-level innovative and entrepreneurial talent introduction project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWAW wrote the protocol; YGS developed the search strategy; LL and PYY selected articles in parallel; WT and ZZ parallelly reviewed the selected articles and retrieved the data; WAW made final decisions when there were any discrepancies in the review; WJQ and TTZ contributed to data extraction; LC and JBY were responsible for quality assessment; JZ conducted the data analysis; WAW wrote up the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British journal of sports medicine. 2020;54(24):1451-62.\u003c/li\u003e\n\u003cli\u003eRoss R, Chaput JP, Giangregorio LM, Janssen I, Saunders TJ, Kho ME, et al. Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep. 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Effects of a School-Based Physical Activity Intervention for Obesity, Health-Related Physical Fitness, and Blood Pressure in Children with Intellectual Disability: A Randomized Controlled Trial. Int J Environ Res Public Health. 2022;19(19).\u003c/li\u003e\n\u003cli\u003eWang T, Qian Y, Zhong T, Qi J. Associations between Fundamental Movement Skills and Moderate-to-Vigorous Intensity Physical Activity among Chinese Children and Adolescents with Intellectual Disability. Int J Environ Res Public Health. 2022;19(20).\u003c/li\u003e\n\u003cli\u003eYuan YQ, Ding JN, Bi N, Wang MJ, Zhou SC, Wang XL, et al. Physical activity and sedentary behaviour among children and adolescents with intellectual disabilities during the COVID-19 lockdown in China. J Intellect Disabil Res. 2022;66(12):913-23.\u003c/li\u003e\n\u003cli\u003eYuan YQ, Wang MJ, Zhang QX, Zhang Y, Wang XL, Hou X, et al. Physical activity levels of children and adolescents with intellectual disabilities in Northern China. J Appl Res Intellect Disabil. 2022;35(3):752-60.\u003c/li\u003e\n\u003cli\u003eWang J, Gao Y, Kwok HHM, Huang WYJ, Li S, Li L. Children with Intellectual Disability Are Vulnerable to Overweight and Obesity: A Cross-Sectional Study among Chinese Children. Child Obes. 2018;14(5):316-26.\u003c/li\u003e\n\u003cli\u003eGutierrez-Hervas A, Nova E, Izquierdo-G\u0026oacute;mez R, Veiga \u0026Oacute; L, Padilla C, Castro-Pi\u0026ntilde;ero J, et al. Association Between Lifestyle Patterns and Abdominal Obesity with Biochemical and Inflammatory Biomarkers in Adolescents with Down Syndrome: The UP\u0026amp;DOWN Study. Nutrients. 2024;16(22).\u003c/li\u003e\n\u003cli\u003eMullhall P, Taggart L, McDermott G, Slater P, Fitzpatrick B, Murphy MH, et al. \u0026apos;Walk Buds\u0026apos;: A walking intervention to increase physical activity, physical fitness, and emotional wellbeing, in 9-13\u0026thinsp;year old children with intellectual disabilities. Results of a clustered randomised feasibility trial. J Appl Res Intellect Disabil. 2024;37(5):e13260.\u003c/li\u003e\n\u003cli\u003eSaletovic A, Pasalic A, Memisevic H. Sleeping patterns in children with developmental disabilities. Journal for ReAttach Therapy and Developmental Diversities. 2021;4(1):28-38.\u003c/li\u003e\n\u003cli\u003eLobenius-Palm\u0026eacute;r K, Sj\u0026ouml;qvist B, Hurtig-Wennl\u0026ouml;f A, Lundqvist LO. Accelerometer-Assessed Physical Activity and Sedentary Time in Youth With Disabilities. Adapt Phys Activ Q. 2018;35(1):1-19.\u003c/li\u003e\n\u003cli\u003ePitchford EA, Adkins C, Hasson RE, Hornyak JE, Ulrich DA. Association between Physical Activity and Adiposity in Adolescents with Down Syndrome. Med Sci Sports Exerc. 2018;50(4):667-74.\u003c/li\u003e\n\u003cli\u003eWouters M, Evenhuis HM, Hilgenkamp TIM. Physical activity levels of children and adolescents with moderate-to-severe intellectual disability. J Appl Res Intellect Disabil. 2019;32(1):131-42.\u003c/li\u003e\n\u003cli\u003eWyszyńska J, Podg\u0026oacute;rska-Bednarz J, Dereń K, Mazur A. The Relationship between Physical Activity and Screen Time with the Risk of Hypertension in Children and Adolescents with Intellectual Disability. Biomed Res Int. 2017;2017:1940602.\u003c/li\u003e\n\u003cli\u003eDowns SJ, Fairclough SJ, Knowles ZR, Boddy LM. Physical Activity Patterns in Youth With Intellectual Disabilities. Adapt Phys Activ Q. 2016;33(4):374-90.\u003c/li\u003e\n\u003cli\u003eShields N, Dodd KJ, Abblitt C. Do children with Down syndrome perform sufficient physical activity to maintain good health? A pilot study. Adapt Phys Activ Q. 2009;26(4):307-20.\u003c/li\u003e\n\u003cli\u003eShields N, Synnot AJ, Barr M. Perceived barriers and facilitators to physical activity for children with disability: a systematic review. Br J Sports Med. 2012;46(14):989-97.\u003c/li\u003e\n\u003cli\u003eMcGarty AM, Downs SJ, Melville CA, Harris L. 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Behavioural sleep problems in children and adults with intellectual disabilities: An integrative literature review. J Appl Res Intellect Disabil. 2023;36(5):916-28.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Physical activity, screen time, sleep duration, movement behavior, children and adolescents, intellectual disability","lastPublishedDoi":"10.21203/rs.3.rs-8749857/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8749857/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e Meeting the 24-hour movement guidelines has been associated with a range of physical, mental, and social health in children and adolescents with intellectual disabilities. However, no systematic review or meta-analysis have identified the prevalence of meeting the guidelines (i.e., physical activity, screen time, and sleep duration). Therefore, this study aimed to examine the pooled prevalence of adherence to each individual behavior recommendation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFive electronic databases, including Web of Science, Medline, PubMed, PsycINFO, and Scopus, were searched from their inception to September 2025. Meta-analysis with random-effects model was applied to pool the prevalence of multiple studies.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFifteen studies comprising 3261 participants (female\u0026thinsp;=\u0026thinsp;36.5%) aged 7 to 18 years from ten countries/districts were identified. The meta-analysis demonstrated that 26% of children and adolescents with intellectual disabilities achieved the recommendations of the physical activity guidelines (95% CI: 0.21\u0026ndash;0.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01); 54% of the target population adhered to the screen time guidelines (95% CI: 0.32\u0026ndash;0.75, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01); and 47% of the sample met the sleep guidelines (95% CI: 0.19\u0026ndash;0.77, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCurrent evidence showing that prevalence of adherence to each individual behavior recommendation in children and adolescents with intellectual disabilities is low. In addition, due to most studies did not report combined behavior data at the individual level, preventing analysis of integrated guideline adherence patterns (e.g., the prevalence of meeting overall, any two, and any one movement guidelines).\u003c/p\u003e","manuscriptTitle":"Adherence to 24-Hour Movement Guidelines Among Children and Adolescents with Intellectual Disabilities: A Systematic Review and Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 17:39:49","doi":"10.21203/rs.3.rs-8749857/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"554d698b-f269-48fa-ac84-b27adb64635f","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T01:39:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 17:39:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8749857","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8749857","identity":"rs-8749857","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}