Integrated play groups: promoting symbolic play and social engagement with typical peers in children with ASD across settings

Occupational Therapy Practice Guidelines for Autistic People Across the Lifespan

IMPORTANCE

Occupational therapy practitioners need evidence to support interventions that promote subjective well-being among autistic people and their families through optimal engagement and participation in occupations.

OBJECTIVE

These Practice Guidelines are informed by systematic reviews to expand knowledge of interventions that promote access, inclusion, engagement, and optimal participation in occupations that are meaningful to autistic people. Our intent was to foster occupational therapy practitioners' clinical decision-making and reasoning when working with autistic people and their care partners.

METHOD

These Practice Guidelines were developed on the basis of four systematic reviews, supporting evidence and literature, along with continued revisions and integration through an iterative and collaborative process.

RESULTS

A total of 98 articles were included in the systematic reviews, which are the foundation for practice recommendations in these guidelines. Forty-eight of the systematic review articles were used to inform the clinical recommendations included in these Practice Guidelines.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence indicates the need for multidisciplinary, goal-oriented interventions to support autistic people in different contexts. Although there is only emerging evidence in the inclusion of autistic people's strengths, interests, and perspectives to guide occupational therapy interventions, such practices can enhance the delivery of neurodiversity-affirming and trauma-informed practices. In addition, evidence is needed to support participation in activities of daily living (ADLs) for autistic youths. We recommend the use of strengths-based language to describe autistic people and the use of environmental adaptations, care partner education, and coaching to enhance occupational therapy service delivery. Plain-Language Summary: The literature is sparse regarding neurodiversity-affirming and trauma-informed practices for autistic youths, as well as for participation in activities of daily living (ADLs). These Practice Guidelines provide new information on positive mental health development; self-determination; ADLs, instrumental ADLs, play, and leisure occupations for children, adolescents, and adults; person-centered planning for adolescents and adults; and rest and sleep. Information on health management is also provided. Positionality Statement: This article uses the identity-first language autistic people. This nonableist language describes their strengths and abilities and is a conscious decision. This language is favored by autistic communities and self-advocates and has been adopted by health care professionals and researchers (Bottema-Beutel et al., 2021; Kenny et al., 2016). However, we respect the use of person-first language and have made a conscious decision to include research articles that have used this language.

Interventions to Support Participation in Play for Autistic Children and Youth (Dates of Review: 2013-2021)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings to support participation in play for autistic1 children and adolescents (birth to 18 yr).

Play therapy in children with autism: Its role, implications, and limitations

Play is a pleasurable physical or mental activity that enhances the child’s skills involving negotiation abilities, problem-solving, manual dexterity, sharing, decision-making, and working in a group. Play affects all the brain's areas, structures, and functions. Children with autism have adaptive behavior, adaptive response, and social interaction limitations. This review explores the different applications of play therapy in helping children with autism disorder. Play is usually significantly impaired in children with autism. Play therapy is mainly intended to help children to honor their unique mental abilities and developmental levels. The main aim of play therapy is to prevent or solve psychosocial difficulties and achieve optimal child-healthy growth and development. Play therapy helps children with autism to engage in play activities of their interest and choice to express themselves in the most comfortable ways. It changes their way of self-expression from unwanted behaviors to more non-injurious expressive behavior using toys or activities of their choice as their words. Play therapy also helps those children to experience feeling out various interaction styles. Every child with autism is unique and responds differently. Therefore, different types of intervention, like play therapy, could fit the differences in children with autism. Proper evaluation of the child is mandatory to evaluate which type fits the child more than the others. This narrative review revised the different types of play therapy that could fit children with autism in an evidence-based way. Despite weak evidence, play therapy still has potential benefits for patients and their families.

Peer mediation in play settings for minimally verbal students with autism Spectrum disorder

Background and aims

Peer-mediated interventions (PMIs) are effective strategies to foster socialization of children with autism spectrum disorder (ASD) in natural settings. However, research examining the efficacy of peer mediation for students with ASD who have the greatest cognitive and language impairments remains limited. Additionally, previous studies essentially targeted communicative abilities of participants. To address this gap, the present study evaluated the effects of a play-based PMI on three socio-communicative skills (play, social engagement and imitation) of minimally verbal students with ASD who also have a comorbidity of intellectual disability (ID).

Methods

Seven children with ASD attending ordinary school settings and 14 typically developing (TD) preschoolers participated. Seven single-sex groups were formed, and children played together during two 30 min weekly sessions. TD children were trained according to the principles of the integrated play group model. We used a multiple-baseline design across participants to measure the effects of the intervention on play skills, social engagement and motor imitation of students with ASD.

Results

Outcomes revealed an intervention effect for most of the participants, despite some variations across children. After the peer training, four children increased their duration of functional/symbolic play, six children improved their duration of interactive play and five children increased their rates of motor imitation. Concerning maintenance gains, inter-individual differences are also important.

Conclusions and implications

These findings suggest that a play-based PMI may be a feasible option for targeting inclusive education and improving socio-communicative skills of some minimally verbal students with ASD who also have an ID. However, variations across children invite further research to clarify how individual factors can moderate the effects of PMIs in children with ASD who are the most impaired.

Effect of Video Augmentative and Alternative Communication Technology on Communication During Play With Peers for Children With Autism Spectrum Disorder

PURPOSE

Children with autism spectrum disorder (ASD) are at risk for exclusion from play with their peers due to difficulty with communication skills. Video augmentative and alternative communication (AAC) technology has the potential to support communication within the context of play using videos with integrated visual scene displays. This study investigated the effect of a video AAC intervention on the number of turns in which children with ASD demonstrated symbolic communication during interactions with a peer without disabilities. Maintenance of skills, generalization to untrained play scenarios, and stakeholder perceptions of the video AAC technology were also investigated.

METHOD

This study used a single-case, multiple-probe design across participant dyads. It included baseline, intervention, maintenance, and generalization phases. Six children with ASD and six peers participated in the study.

RESULTS AND CONCLUSIONS

All six participants with ASD demonstrated an increase in the number of turns in which they demonstrated at least one symbolic communication act following intervention, although one participant demonstrated variability in baseline performance, making it difficult to draw conclusions. Results provide preliminary evidence that instruction with video AAC technology can support communication for children with ASD during play interactions with peers.

A Systematic Review of Play-Based Interventions Targeting the Social Communication Skills of Children with Autism Spectrum Disorder in Educational Contexts

Children with autism spectrum disorder (ASD) experience social communication difficulties which can be compounded by increased social demands and expectations of the school environment. Play offers a unique context for social communication development in educational settings. This systematic review aimed to synthesize play-based interventions for the social communication skills of children with ASD in educational contexts and identified nine studies. Overall, studies in this review provided a promising evidence base for supporting social communication skills through play in education for children with ASD. The review also highlighted gaps in research on play-based interventions for the social communication skills of children with ASD within naturalistic educational settings.

Occupational Therapy Interventions for Children and Youth Ages 5 to 21 Years

Evidence Connection articles provide a clinical application of practice guidelines developed in conjunction with the American Occupational Therapy Association’s (AOTA’s) Evidence-Based Practice Program. Each article in the series summarizes the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. The articles illustrate how the research evidence from the practice guidelines can be used to inform and guide clinical decision making. In this Evidence Connection article, we describe a case report of a child receiving occupational therapy services and summarize the evaluation and intervention processes for supporting sleep, activities of daily living, and social participation. The practice guideline on this topic was published in the July/August 2020 issue of the American Journal of Occupational Therapy (Cahill & Beisbier, 2020).

Enhancing Social Initiations Using Naturalistic Behavioral Intervention: Outcomes from a Randomized Controlled Trial for Children with Autism

Deficits in social skills are common in children with Autism Spectrum Disorder (ASD), and there is an urgent need for effective social skills interventions, especially for improving interactions with typically developing peers. This study examined the effects of a naturalistic behavioral social skills intervention in improving social initiations to peers through a randomized controlled trial. Analyses of multimethod, multi-informant measures indicated that children in the active group (SIMI) demonstrated greater improvement in the types of initiations which were systematically prompted and reinforced during treatment (i.e., behavior regulation). Generalization to joint attention and social interaction initiation types, as well as collateral gains in broader social functioning on clinician- and parent-rated standardized measures were also observed.

Challenges Surrounding the Diagnosis of Autism in Children

This comprehensive thematic review aims to highlight and familiarize readers with the challenges and pitfalls encountered in differential diagnosis of autism spectrum disorders (ASD) in children to facilitate the process of accurate identification by stakeholders. Accordingly, articles that best answer our questions and highlight our concerns were chosen from well-established publishers with prime peer reviewed journals. Included are studies showing alternate views of the issues so as to point readers to other possibilities. ASD, a complex dynamic biological-neurodevelopmental disorder, is underscored by its heterogeneous symptomology, severity, and phenotypes - all characterized by social communication deficits and presence of restricted interests and repetitive behaviours (RRBs), the core symptoms in ASD. Language and intellectual capacities do not form ASD core symptoms although vary considerably. Accurate identification is challenging as ASD is often enmeshed with other neurodevelopmental disorders, and medical comorbidities, a situation now recognized as the rule rather than the exception in child psychiatry and developmental medicine. ASD is a disorder with varying performance and severity of symptoms over time, including unexpected loss of early skills, and lost diagnosis in some children following treatment. The review reiterates the urgency in accurate diagnosis in face of the rapid rise in ASD prevalence globally, and risk-increase in delayed or denied treatment with undesirable life-long consequences for most of the affected children. In addition, a call for change is advised to circumvent the ethical dilemma posed by the present "deficit model" in ASD diagnosis. Here, ASD prevalence is presented first, followed by emphasis on importance of accurate early diagnosis, and challenges in its accomplishment due to flaws in diagnostic instruments and other contributing factors. Next follow the required criteria for accurate identification, and its difficulties attributed to comorbid conditions, gender differences, and socio-economic and cultural influences. The conclusion includes future directions and a take away message.

Occupational Therapy Practice Guidelines for Children and Youth Ages 5-21 Years

IMPORTANCE

Demand is increasing for activity- and occupation-based interventions to address occupational performance and support maximal participation of children and youth.

OBJECTIVE

This Practice Guideline was developed to guide decision making and support best practices in service delivery for children and youth ages 5-21 yr at home, at school, and in the community.

METHOD

The results from three systematic reviews (SRs) of activity- and occupation-based interventions for children and youth ages 5-21 yr were reviewed, synthesized, and translated into recommendations for education, practice, and research.

RESULTS

One hundred eighty-five articles were included in the three SRs examining the evidence for interventions to promote activities of daily living, instrumental activities of daily living, play and leisure, and rest and sleep; to improve mental health, positive behavior, and social participation; and to enhance learning, academic achievement, and successful participation in school. The reviews provide evidence for interventions associated with typical concerns addressed by occupational therapy practitioners.

CONCLUSIONS AND RECOMMENDATIONS

On the basis of the evidence, this guideline recommends that occupational therapy practitioners consistently collaborate with families and caregivers and provide services in the natural context of the desired occupation. The evidence also supports group service models and models that include peer mediation; these models can promote participation across areas of occupation. Skills-based training and therapeutic practice in the context of valued occupations are recommended over isolated sensorimotor approaches. Technology, manualized programs, and sports activities can be effective but should be evaluated and matched to age, diagnosis, and outcomes as guided by the evidence.

WHAT THIS ARTICLE ADDS

When guided by evidence, activity- and occupation-based interventions are effective in promoting participation and enhancing performance in valued occupations of children and youth ages 5-21 yr.

Activity- and Occupation-Based Interventions to Support Mental Health, Positive Behavior, and Social Participation for Children and Youth: A Systematic Review

IMPORTANCE

Children and youth are often challenged to maintain well-being, positive behavior, and social participation.

OBJECTIVE

To identify evidence for occupational therapy interventions for children and youth with and at risk for mental health concerns.

DATA SOURCES

Articles published in English-language peer-reviewed journals between January 2010 and March 2017 identified through searches of MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane databases.

Study Selection and Data Collectio

: The methodology in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to complete the review. Of 5,310 articles screened by title and abstract, 357 were retrieved for full-text review, and 62 met inclusion criteria. Articles describing interventions that were activity or occupation based were included. Conference proceedings, non-peer reviewed publications, dissertations, theses, and presentations were excluded.

FINDINGS

Of the 62 studies included in the review, 20 (32%) were Level I studies, 22 (36%) were Level II studies, and 20 (32%) were Level III studies. Articles were categorized by type: outdoor camps, video and computer games, productive occupations and life skills, meditation, animal-assisted interventions, creative arts, play, sports, and yoga. Moderate to strong evidence supports the use of yoga and sports. Moderate-strength evidence supports the use of play and creative arts. Evidence for the use of animal-assisted interventions, meditation, video and computer games, and productive occupations was of low strength.

CONCLUSION AND RELEVANCE

Substantial evidence exists to support the use of activity- and occupation-based interventions to address the mental health, behavioral, and social participation concerns of children and youth. Occupational therapy practitioners should match the desired outcome of therapy with the appropriate intervention to provide the best and most effective services to their clients.

WHAT THIS ARTICLE ADDS

This review provides additional support for the use of activity- and occupation-based interventions (i.e., those that involve active participation) to improve the behavior, social participation, and mental health of children and youth.

A Systematic Review of Interventions to Improve the Occupation of Play in Children With Autism

Play in children with autism spectrum disorder (ASD) is often atypical, yet consensus regarding effective occupational therapy strategies for improving play is not established. To examine the efficacy of strategies used in occupational therapy to improve play in ASD, authors completed a systematic review of papers from January 1980 through January 2019. Search terms included autism, Asperger's, ASD, autistic in combination with play, playfulness, pretend, imagination, praxis, creativity, and generativity. Twenty papers met inclusion criteria and were reviewed. Reviewed interventions included parent education, modified play materials or environments, imitation of the child, and modeling by an adult, a peer, or video. Moderate to strong support exists for the specific strategies of imitation of the child and modeling for the child, with lesser or mixed support for other strategies. Certain strategies commonly used in occupational therapy may be effective in improving the occupation of play in ASD.

Imaginary Companions in Children with Autism Spectrum Disorder

One of the deficits observed in autism spectrum disorder (ASD) is impaired imaginative play. One form of imaginative play common in many typically developing (TD) children is having an imaginary companion (IC). The occurrence of ICs has not been investigated extensively in children with ASD. We examined differences in parent report of IC between TD and ASD populations in 215 (111 with ASD) gender-matched children aged between 2 and 8 years. Findings indicate that significantly fewer children with ASD created ICs, although there were many between-group similarities in IC forms and functions. Results are discussed in terms of qualitative differences in play, social attributions, and how children with ASD conceptualize their ICs' minds.

Similarities in Functional Play and Differences in Symbolic Play of Children With Autism Spectrum Disorder

Contradictory reports of play strengths and weaknesses for children with autism spectrum disorders (ASD) persist in the literature. We compared the play of 19 children with ASD to 19 typically developing (TD) children matched on language and cognitive skills. All children were verbal. Results revealed no differences in indiscriminate actions, functional play, and object interest. The children with ASD showed less symbolic play and a significantly fewer number of children met criteria for emerging or mastered symbolic play. A specific deficit was observed for "doll as agent" symbolic play. Outcomes suggest that compared to children without disabilities, children with ASD may have comparable functional play skills and struggle with the transition to some, but not all types of symbolic play.

The play skills of children with high-functioning autism spectrum disorder in peer-to-peer interactions with their classmates: A multiple case study design

BACKGROUND/AIM

Children with ASD are known to have lower play skills than their typically developing peers. However, the play skills of children with ASD are rarely investigated using observational measures in the context of their everyday peer-to-peer play interactions. To explore the play skills of children with ASD and their aged matched classmates during a peer-to-peer play interaction.

METHODS

Using convenience sampling, four children with ASD (5-11 years) attending mainstream schools were recruited for this multiple case design study. Each child with ASD was paired with one of their aged matched typically developing classmates. Children's play skills were measured using the Test of Playfulness (ToP). Additional case data were collected through teacher-reported social skills and behaviours. Rasch analysis was utilised to convert raw ToP scores into an interval level overall score for each child. Children's individual ToP item scores, social skills and behaviours are presented by case.

RESULTS

The two children with ASD who had the highest ToP scores, also had the highest teacher-reported social skills. All children with ASD had greatest difficulty on ToP items reflecting suspension of reality and framing. Two children with ASD had higher ToP scores than their classmate. In these two cases, the classmates had similar play skills of children with ASD.

CONCLUSION

The play skills of children with ASD varied by case. Across the cases, teacher-reported social skills, classmate age and existence of friendship between children were all factors observed to influence play. These findings require replication and investigation in larger scale studies.

To include or not to include: Evaluations and reasoning about the failure to include peers with autism spectrum disorder in elementary students

Given the significant role that typically developing children play in the social lives of children with autism spectrum disorder, it is important to understand how they evaluate and reason about the inclusion/exclusion of children with autism spectrum disorder in social situations. The objective of this study is to determine elementary students' evaluations, reasoning patterns, and reasoning complexity regarding the failure to include children with autism spectrum disorder in social activities. Forty-four elementary-aged students participated in interviews, which included vignettes describing four contexts in which a child with autism spectrum disorder is not invited to a social event. Responses were analyzed according to social domain theory, an approach emphasizing that children identify and coordinate different domains of social knowledge, including the moral, personal, societal, and prudential. Results showed that regardless of grade and context, most children judge that failure to include on the basis of disability status is not acceptable. However, the complexity of children's reasoning (i.e. the extent to which they drew upon and coordinated multiple domains) was higher in older children. Mean complexity scores were also higher in a birthday party context as compared to a playdate context. We offer implications for future research and practice regarding the social inclusion of children with autism spectrum disorder.

Children with autism spectrum disorder and social skills groups at school: a randomized trial comparing intervention approach and peer composition

BACKGROUND

Peer relationships improve for children with autism spectrum disorder (ASD) in clinic-based social skills groups but rarely generalize to real world contexts. This study compares child outcomes of two social skills interventions conducted in schools with children in Kindergarten through fifth grade.

METHOD

Children with ASD were randomized to one of two interventions that varied on group composition (mixed typical and ASD vs. all ASD or social difficulties) and intervention approach (didactic SKILLS based vs. activity-based ENGAGE groups). Interventions were implemented at school for 8 weeks (16 sessions) with an 8-week follow-up. Innovative measures of peer nomination and playground peer engagement, as well as teacher reports of child behavior problems and teacher-child relationship were analyzed for 137 children with ASD across four sites.

RESULTS

On the primary outcome of social network connections from the peer nomination measure, there was no main effect of treatment, but there were moderator effects. Children with low teacher-child closeness or high conflict improved more in their social connections if they received the SKILLS intervention, whereas children with higher teacher-child closeness improved more if they received the ENGAGE intervention. Only two secondary outcome measures yielded significant effects of treatment. Children in the SKILLS groups increased peer engagement and decreased isolation during recess. Child behavior problems and teacher-child closeness moderated peer engagement such that children with higher behavior problems and lower closeness benefitted more from SKILLS groups.

CONCLUSIONS

These findings suggest that social skills groups conducted at school can affect both peer engagement during recess as well as peer acceptability. Child characteristics and teacher-child relationship prior to intervention yield important information on who might benefit from a specific social skills intervention.

A comprehensive peer network intervention to improve social communication of children with autism spectrum disorders: a randomized trial in kindergarten and first grade

The purpose of this randomized control group study was to examine the effects of a peer network intervention that included peer mediation and direct instruction for Kindergarten and First-grade children with autism spectrum disorders. Trained school staff members provided direct instruction for 56 children in the intervention group, and 39 children participated in a comparison group. Results showed children in the intervention group displayed significantly more initiations to peers than did the comparison group during non-treatment social probes and generalization probes. Treatment session data showed significant growth for total communications over baseline levels. Children in treatment also showed more growth in language and adaptive communication. Finally, teachers' ratings of prosocial skills revealed significantly greater improvements for the intervention group.