A Pilot Randomised Control Trial of Digitally-Mediated Social Stories for Children on the Autism Spectrum

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.

Effective digital support for autism: digital social stories

Social Stories™ is one of the most popular interventions for autistic children and has been researched extensively. However, effectiveness data has been gathered mainly through single-participant designs which generate outcomes which can lack generalizability and social validity. Stories Online For Autism (SOFA) is a digital application which supports the development and delivery of Social Stories in a real-world setting and has the potential to contribute toward furthering (1) Social Stories research and (2) research on digital applications for autism by gathering large data sets from multiple participants. Three data sets (N = 856) were gathered through the SOFA app and were analyzed to investigate three key variables: What predicted closeness-to-goal of the Social Stories (as rated by an adult/parent/guardian, n = 568); the child's comprehension of the Social Stories (assessed by story comprehension questions, n = 127); and the child's rating of the enjoyability of the Social Stories (n = 161). A merged data set then investigated correlations between these three key variables. Age range (≤15), gender, autism diagnosis, and the child's level of language understanding were the potential predictors for these three key variables. Regression analysis indicated that parental closeness-to-goal ratings for their children were highest for children who were younger and more verbal. Regression analysis also indicated that older children scored higher in comprehension assessment, and autistic children rated the Social Stories as more enjoyable. Closeness-to-goal, comprehension scores and enjoyment ratings did not significantly correlate with each other. This is the largest study of Social Stories effectiveness, which was enabled through the collection of data through a digital app from multiple participants. The results indicate that digital social stories are particularly effective for younger verbal children. While this was the case for all children, it was particularly true for autistic children and female (and gender-diverse) children. For the first time, the gathering of large digital data sets has highlighted that while digital Social Stories can be effective for autistic males, they can be more effective for autistic females and gender-diverse autistic individuals. Thus, the SOFA app can support the investigation of the factors which influence Social Stories outcomes that are generalizable and with high social validity.

A rule-based theoretical account of social stories to address the double empathy problem

Social Stories™ (SS) is one of the most popular and researched interventions for autistic children. To date, research that focuses on outcomes has been prioritized over the investigation of the psychological mechanisms that inform the intervention. In this article we consider theoretical accounts proposed thus far which could underpin SS. We argue that mechanisms that are based on social deficit theories lack validity, and propose a rule-based theoretical account to inform a strengths-based approach toward conceptualizing the mechanisms that underpin SS. We apply this account to the 'double-empathy problem' to propose that SS can be adapted to involve all parties in the development and delivery of SS support by adopting a rule-based perspective. We use the example of systemizing (the drive to analyze and explore systems in terms of 'if-and-then' rules), which is proposed to be a relative autistic strength, as a form of rule-based thinking that can provide a theoretical account of SS and a framework to address the double-empathy problem.

Maternal Variability of Amplitudes of Frequency Fluctuations Is Related to the Progressive Self-Other Transposition Group Intervention in Autistic Children

The self-to-other model of empathy (SOME) states that a key reason for the empathic deficiency in autistic individuals is the imbalance of the self-other switch. The existing interventions of theory of mind contain training of self-other transposition ability but combined with other cognitive trainings. The self-other distinction brain areas of autistic individuals have been revealed, but the brain areas of the self-other transposition ability and its intervention have not been investigated. There are normalized amplitudes of low-frequency fluctuations (mALFFs) within 0.01-0.1 Hz and many normalized amplitudes of frequency fluctuations (mAFFs) within 0-0.01, 0.01-0.05, 0.05-0.1, 0.1-0.15, 0.15-0.2, and 0.2-0.25 Hz. Therefore, the current study established a progressive self-other transposition group intervention to specifically and systematically improve autistic children's self-other transposition abilities. The transposition test with a three mountains test, an unexpected location test, and a deception test was used to directly measure autistic children's transposition abilities. The Interpersonal Responsiveness Index Empathy Questionnaire with perspective-taking and fantasy subscales (IRI-T) was used to indirectly measure autistic children's transposition abilities. The Autism Treatment Evaluation Checklist (ATEC) was used to measure autistic children's autism symptoms. The experiment was designed with two (intervention: experimental group vs. control group) independent variables and two (test time: pretest vs. posttest or tracking test) × three (test: transposition test vs. IRI-T test vs. ATEC test) dependent variables. Furthermore, it used eyes-closed resting-state functional magnetic resonance imaging to investigate and compare the relevant maternal mALFFs and average energy rank and energy rank variability of mAFFs of autistic children's transposition abilities, autism symptoms, and intervention effects. The results showed the following: (1) There were many improvements (pretest vs. posttest or tracking test) greater than chance 0 in the experimental group, such as the three mountains, lie, transposition, PT, IRI-T, PT tracking, cognition, behavior, ATEC, language tracking, cognition tracking, behavior tracking, and ATEC tracking improvements. However, there was no improvement greater than chance 0 in the control group. (2) The maternal mALFFs and maternal average energy rank and energy rank variability of mAFFs could predict the autistic children's transposition abilities, autism symptoms, and intervention effects with some overlap and some difference in maternal self-other distinction, sensorimotor, visual, facial expression recognition, language, memory and emotion, and self-consciousness networks. These results indicated that the progressive self-other transposition group intervention successfully improved autistic children's transposition abilities and reduced their autism symptoms; the intervention effects could be applied to daily life and last up to a month. The maternal mALFFs, average energy rank, and energy rank variability of mAFFs were three effective neural indictors of autistic children's transposition abilities, autism symptoms, and intervention effects, and the average energy rank and energy rank variability of mAFFs were two new neural indictors established in the current study. The maternal neural markers of the progressive self-other transposition group intervention effects for autistic children were found in part.

Interventions to Support Participation in Education for Autistic Students (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 from the systematic review on interventions to support autistic1 children and youth (up to 18 yr old) and focuses on participation in education settings.

Characteristics and Potential Challenges of Digital-Based Interventions for Children and Young People: Scoping Review (Preprint)

BACKGROUND

Digital health technologies are becoming increasingly available to children and young people and their families. However, there are no scoping reviews that provide both an overview of the characteristics of digital interventions for children and young people and potential challenges to be considered when developing and implementing them.

OBJECTIVE

This study aimed to systematically review scientific publications to identify the current characteristics and potential complications of digital interventions for children and young people.

METHODS

This scoping review was conducted using the framework of Arksey and O'Malley and adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews. A search of 5 databases (PubMed, Scopus, Embase, MEDLINE, and CINAHL) and Google Scholar was performed for eligible clinical trials published between January 1, 2018, and August 19, 2022.

RESULTS

The initial search of the 5 databases yielded 3775 citations; duplicates and those not meeting the inclusion criteria were eliminated. In total, 34 articles were included in the final review and relevant information, such as the descriptive characteristics and potential challenges, were classified. Mental health (26/34, 76%) was the most common target for the digital intervention for children and young people, exceeding physical health (8/34, 24%) by more than 3 times. In addition, a substantial number of digital interventions were dedicated solely to children and young people. Digital interventions for children and young people were more likely to be delivered via computers (17/34, 50%) rather than smartphones (13/34, 38%). More than one-third of the studies (13/34, 38%) applied cognitive behavioral theory as the theory of digital interventions. The duration of the digital intervention for children and young people was more likely to vary depending on the target user rather than the target disease. Intervention components were classified into 5 categories: guidance, task and activity, reminder and monitoring, supportive feedback, and reward system. Potential challenges were subcategorized into ethical, interpersonal, and societal challenges. For ethical challenges, the consent of children and young people or caregivers, potential risk of adverse events, and data privacy issues were considered. For interpersonal challenges, the engagement of children and young people was affected by the preference or barrier of caregivers to participate in studies. For societal challenges, restricted ethnicity in recruitment, limited availability of digital technology, differences in internet use patterns between girls and boys, unified clinical settings, and language barriers were described.

CONCLUSIONS

We identified potential challenges and provided suggestions about ethical, interpersonal, and societal aspects to consider when developing and deploying digital-based interventions for children and young people. Our findings provide a thorough overview of the published literature and may serve as a comprehensive, informative foundation for the development and implementation of digital-based interventions for children and young people.

The impact of using digitally-mediated social stories on the perceived competence and attitudes of parents and practitioners supporting children with autism

A Social Story (SS) is a highly acceptable and widely used intervention by the autism community. Yet, inconsistent implementation of the intervention is reported to be one of the causes of variability in terms of outcome research, particularly in a naturalistic context. This study aimed to (1) investigate whether digitally-mediated social stories (SSs) can improve competence in developing and delivering a SS and thus contribute towards improved implementation, and (2) investigate the impact of the digitally-mediated SS on attitudes towards the SS intervention. Ninety-three participants took an initial pre-engagement survey. Forty-eight of these participants also complete a post-engagement survey. A pre-post design was utilised with the participants who completed both surveys. These 48 participants were invited to develop a digitally-mediated SS with the aim of exploring how digitally-mediated SSs impacted perceived competence and attitudes. Post-engagement data was collected two weeks after the pre-engagement data. Outcomes of this study indicate that both perceived competence and attitudes improved after engaging with digitally-mediated SSs. It is concluded that digitally-mediated SS not only impacted the integrity of how the intervention was delivered but also the beliefs in the participants’ capabilities to develop and deliver a SS. Digitally-mediated SS, thus, has the potential to effectively support development and delivery whilst also addressing challenges related to intervention implementation in a naturalistic context.

Mothers' and practitioners' insights on the use of digitally-mediated social stories with children on the autism spectrum: A convergent mixed-methods study

BACKGROUND

While end-user interest in digitally-mediated Social Story (SS) intervention for children on the autism spectrum is growing, research on the use of SSs in digital form is currently lacking.

AIMS

This study aimed to investigate how digital-mediation can influence parents' and practitioners' attitudes towards the SS intervention as well as impact their perceived competence in their ability to administer the intervention.

METHODS AND PROCEDURES

This study used a convergent mixed-method design. Nineteen participants (ten practitioners and nine mothers) participated in two focus group sessions. Participants then engaged with a digitally-mediated SS and completed a pre- and post-engagement survey measuring attitude, competence and user experience with the intervention.

OUTCOMES AND RESULTS

The mothers' perceived competence ratings improved after engaging with digitally-mediated SSs. Mothers and practitioners also indicated that digitally-mediated SSs increased their perceived efficiency, while mothers felt it improved their autonomy and further empowered them as end-users.

CONCLUSION AND IMPLICATIONS

Digitally-mediated SS has the potential to effectively address challenges related to intervention implementation whilst also empowering further the end-user.

Meta-Analysis of RCTs of Technology-Assisted Parent-Mediated Interventions for Children with ASD

Technology-assisted parent-mediated interventions improve accessibility and are acceptable but not proven to be effective. We conducted a systematic search of 6 databases. We included and analysed results from studies on social and communication outcomes. Sixteen Randomised-Controlled-Trials (RCTs) with 748 participants were included. Most studies were rated as of good quality. Meta-analysis suggested that interventions were probably effective in improving emotion recognition. No significant differences were found in social communication, social functioning or language outcomes. At present, isolated tech interventions do not fulfil criteria for promising or established evidence-based interventions for ASD. Future research needs to focus on improving the effectiveness of technology-assisted parent-mediated interventions for ASD. Prospero Registration Number: CRD42020162825.

Study protocol for autism specific transition resources (T-Res Study): developing a flexible resource package for dealing with the loosening and/or lifting of COVID-19 related restrictions

Autism specific transition resources (T-Res) aims to develop a flexible resource package to support children and young people with a diagnosis of autism spectrum disorder (ASD), as well as their families and educators, during the loosening and/or lifting of coronavirus disease 2019 (COVID-19) related restrictions on movement. A secondary aim is to determine the current and long-term impacts of the COVID-19 related restrictions on the wellbeing of individuals with autism spectrum disorders and their parents/caregivers. Measuring and addressing the psychosocial impact of the COVID-19 pandemic and related restrictions in movement is of prime importance at this time.  The impacts of this crisis will be far reaching and many may not be realised for many years. The proposed research will focus on children and young people with a diagnosis of ASD, their families and educators.  The ASD population alone is sizable with 14,000 (or 1.55%) of students in schools holding a diagnosis. When parents, teachers, tutors and special needs assistants (SNAs) are also considered this is a considerable group. The proposed research has the potential to have impacts that are social, psychological, educational and economic. This will be achieved through development of an online transition package to guide parents and educators in preparing children and young people for the resumption of regular daily routines following the lifting of COVID-19 restrictions.  This resource will be developed based on the needs of families and young people, as measured through surveys, as well as expert consensus on the targets and means of intervention.  This ambitious project can be commenced quickly and is designed to produce outputs quickly, which will in turn be disseminated to key stakeholders.

Digitally-Mediated Social Stories Support Children on the Autism Spectrum Adapting to a Change in a 'Real-World' Context

Social Stories™ (SS) is a widely used intervention for children on the autism spectrum. A preliminary survey of 103 practitioners highlighted that SS are often used to support adapting to a change. This study investigated the use of digitally-mediated SS to support ten children on the autism spectrum attending a school summer camp. Teacher perceptions of anxiety, understanding and closeness to the goal of the SS were assessed before and after the intervention (prior to the event). The pre- post-intervention comparisons highlighted significant improvements in child understanding, anxiety, and closeness to goal with medium-large effect sizes. The child’s understanding and closeness to SS goal post-intervention related to their difficulties with the SS goal and their anxiety during the event.