Efficacy Study of a Social Communication and Self-Regulation Intervention for School-Age Children With Autism Spectrum Disorder: A Randomized Controlled Trial

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.

The relationships among executive functions, self-regulation, and physical exercise in children with autism spectrum disorder

LAY ABSTRACT

This study examined the impacts of two types of physical exercises (two-wheel cycling vs stationary cycling) on cognition and self-regulation among 64 children with autism spectrum disorder. It also explored the role of social, emotional, and physical needs of an individual in the relationship between exercise, cognition, and self-regulation. Results showed that participants in the two-wheel cycling group showed significant improvements in their cognition and that the two exercise groups also enhanced their self-regulation. Moreover, this study also revealed that the social need is crucial in mediating the relationship between exercise and self-regulation. This study strengthens the notion that cognitively engaging exercise is more beneficial than the non-cognitively engaging exercise in enhancing cognition in children with autism spectrum disorder.

Is There a Bias Towards Males in the Diagnosis of Autism? A Systematic Review and Meta-Analysis

Autism is more frequently diagnosed in males, with evidence suggesting that females are more likely to be misdiagnosed or underdiagnosed. Possibly, the male/female ratio imbalance relates to phenotypic and camouflaging differences between genders. Here, we performed a comprehensive approach to phenotypic and camouflaging research in autism addressed in two studies. First (Study 1 - Phenotypic Differences in Autism), we conducted a systematic review and meta-analysis of gender differences in autism phenotype. The electronic datasets Pubmed, Scopus, Web of Science, and PsychInfo were searched. We included 67 articles that compared females and males in autism core symptoms, and in cognitive, socioemotional, and behavioural phenotypes. Autistic males exhibited more severe symptoms and social interaction difficulties on standard clinical measures than females, who, in turn, exhibited more cognitive and behavioural difficulties. Considering the hypothesis of camouflaging possibly underlying these differences, we then conducted a meta-analysis of gender differences in camouflaging (Study 2 - Camouflaging Differences in Autism). The same datasets as the first study were searched. Ten studies were included. Females used more compensation and masking camouflage strategies than males. The results support the argument of a bias in clinical procedures towards males and the importance of considering a 'female autism phenotype'-potentially involving camouflaging-in the diagnostic process.

The suitability and acceptability of a co-designed prototype psychoeducational activity book for autistic children aged five-eleven years

Background and aims

Evidence suggests that autistic children and young people (CAYP) can benefit from age-appropriate psychoeducation. Co-design is a methodology that iteratively involves end users and stakeholders in producing an intervention which may increase engagement and impact. Few age-appropriate co-designed psychoeducation resources for autistic CAYP exist. Therefore, a paper-based resource was co-designed for autistic CAYP who attend mainstream primary education. The resource aims to educate CAYP about their autism and provide strategies to support them to live well with their autism.

Methods

This paper describes the evaluation of the prototype resource through online workshops with 12 families and input from four specialist clinicians. The suitability and acceptability of the resource was explored, and sketch notes were taken for respondent validity and engagement purposes.

Results

A reflexive thematic analysis identified six themes and two subthemes: (1) content appropriateness (subtheme: strategies and unpredictability); (2) relating to content, (3) feelings and emotions, (4) terminology (subtheme: literal thinking); (5) positivity, and (6) communication aid. Suggested improvements were also identified. Results suggest the resource is suitable and acceptable.

Conclusions

Future intervention development research may consider individual differences of autistic CAYP and the co-design of resources for other age groups of neurodiverse populations.

Evaluation of the effectiveness of behavioral interventions for autism spectrum disorders: A systematic review of randomized controlled trials and quasi-experimental studies

The objective of this research was to assess the efficacy of behavioral therapy interventions in the treatment of autism spectrum disorders (ASD). The study utilized the PubMed and Embase databases to locate randomized controlled trials, quasi-experimental treatment studies, and randomized clinical trial comparisons. The experimental group received treatment based on an applied behavioral approach, such as PECS, DTT, PRT, TEACCH, ESDM, and EIBI. After examining seventeen studies, the researchers found that each type of behavioral intervention had a positive impact. Naturalistic protocols that employed PRT and PECS improved ASD symptoms in general, despite their targeting of particular cognitive domains such as language. ESDM enhanced receptive language, particularly in preschool-aged children. Structured and integrated interventions, like EIBI and TEACCH, improved overall adaptive functioning. Combining DTT with a TEACCH program produced greater benefits in linguistic, affective-social, and personal autonomy domains. However, there is a scarcity of high-quality research available on behavioral interventions for ASD. Further comparative studies are necessary to identify cost-efficient interventions. For example, PRT and PECS significantly improved social communication skills in only 15-40 hours over six months. The authors emphasized the need for continued research and the application of evidence-based interventions in specialized settings.

Effects of Parent-Implemented Interventions on Outcomes of Children with Autism: A Meta-Analysis

Children with autism spectrum disorder (ASD) have been shown to benefit from parent-implemented interventions (PIIs). This meta-analysis improved on prior reviews of PIIs by evaluating RCTs and multiple potential moderators, including indicators of research quality. Fifty-one effect sizes averaged moderately strong overall benefits of PIIs (g = 0.553), with studies having lower risk of research bias yielding lower estimates (g = 0.47). Parent and observer ratings yielded similar averaged estimates for positive behavior/social skills (g = 0.603), language/communication (g = 0.545), maladaptive behavior (g = 0.519), and to a lesser extent, adaptive behavior/life skills (g = 0.239). No other study, intervention, or participant characteristic moderated outcomes. PIIs with children with ASD tend to be effective across a variety of circumstances.

Association of Parental Support with Reduced Stereotypy in Children with Autism Spectrum Disorder: A Cross-Sectional Study

Background and Objectives: To analyze the influence of parental presence and use of risperidone on social interaction and apathy among patients with Autism Spectrum Disorder (ASD). Materials and Methods: Cross-sectional study in a reference center for patients with ASD in a city in northeastern Brazil. The research was carried out using a sociodemographic questionnaire, the Dimensional Apathy Scale, and the Social Communication Questionnaire (SCQ) with the domains of social interaction, language, stereotypy, and communication. The referred questionnaire was answered by the parents or guardians of the children with ASD according to the DSM V criteria. Data were analyzed via independent t-test using the SPSS software version 20. Results: Interviews were conducted with 51 parents/guardians of autistic children with a mean age of 8.8 years (±2.95) and a predominance of males, 34 (66.7%). Of this total, 49 (96.1%) of the children attended school; 40 (78.4%) children were on medication, of which 38 (74.5%) were on risperidone. Those children on risperidone had a higher score on the SCQ scale (p = 0.049) and on the domain of stereotyped behaviors (p = 0.033), which indicated greater impairment. Another statistically relevant variable was the presence of married parents, whereby children who did not have the presence of married parents had a higher average of stereotyped behaviors compared to those who had married parents. Conclusions: The results showed differences in the means of social interactions for children on risperidone, especially regarding stereotyped behaviors. However, it is not possible to state whether this difference was due to the use of risperidone or whether they used risperidone precisely because of these behaviors. Also important was that children who had the presence of married parents showed fewer stereotyped behaviors. There was no difference in apathetic behavior between children.

Comprehensive Assessments of Theory of Mind Abilities for School-Age Children: A Systematic Review

PURPOSE

Theory of mind involves perceiving both the thoughts and emotions of others. Theory of mind skills continue to develop in school-age individuals. For children at risk for social communication difficulties, evaluating theory of mind is warranted to determine whether theory of mind should be a target of intervention. There are hundreds of tasks designed to evaluate theory of mind, but many evaluate a single facet of the construct and have uneven psychometric properties. Comprehensive assessments evaluate both cognitive and affective aspects of theory of mind. The purpose of this systematic review was to identify comprehensive theory of mind assessments for school-age individuals and to critically appraise their measurement properties.

METHOD

Four databases were searched to identify 27 included records describing the measurement properties of comprehensive theory of mind assessments for 5- to 21-year-olds. Assessments appearing in at least three records were included. The methodological quality of the studies and the sufficiency of assessments' measurement properties were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN).

RESULTS

Nine assessments were evaluated, and four met COSMIN standards for sufficient content validity and internal consistency to be recommended for clinical use.

CONCLUSIONS

Comprehensive assessments enable examiners to develop a profile of children's theory of mind strengths and needs. Strengths of the identified assessments include sufficient convergent validity and internal consistency. Further research is required to develop higher quality evidence for the content validity, structural validity, and reliability of the included assessments.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23817495.

Clinic-Based Interventions to Support Social Participation for Autistic Children and Adolescents (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 clinic-based studies to support social participation for autistic1 children and adolescents (birth to 18 yr).

Autism Spectrum Disorder in the Dominican Republic: A Mini Review of the Current Situation

As the recognition of autism spectrum disorder (ASD) increases, and the prevalence estimates of ASD continue to rise throughout the world, it has become apparent that access to diagnostic and treatment services is highly dependent on geography. Even within countries such as the United States, which has received significant interest and investment in understanding, diagnosing, treating, and providing programs for those with ASD over the last 20+ years, access to information and services is uneven. In poorer countries such as the Dominican Republic (DR), where >40% of citizens live below the poverty level and access to quality healthcare overall continues to be a challenge, issues associated with ASD are not yet being adequately addressed. The objective of this review is to provide a realistic synopsis of the resources currently available to Dominicans who have a family member or loved one with ASD. We examine the challenges these families face in finding care, the stigma associated with ASD, and programs available for people with ASD. We conclude that while the DR is making progress in its efforts to address ASD, there is still much work to be done.

Australian School Staff and Allied Health Professional Perspectives of Mental Health Literacy in Schools: a Mixed Methods Study

Schools are an ideal setting to base mental health literacy programs as the learning environment is already established. Mental health literacy represents how to obtain and maintain good mental health and should be incorporated into the school curriculum. Collaboration with key stakeholders in youth mental health, such as school staff and allied health professionals, is critical in ensuring needs are addressed, and programs are sustainable. This study aimed to understand the perspectives of school staff and allied health professionals towards mental health literacy within Australian schools. An exploratory qualitative and quantitative survey was completed by 88 participants across Australia. Results indicated that school staff feel less competent to deliver mental health literacy content and perceive their training did not address mental health education compared to allied health professionals. Most mental health programs reported to be implemented within schools were social and emotional learning programs. School staff viewed mental health programs to strengthen academic performance less than allied health professionals. Thematic analysis of qualitative data identified that participants viewed mental health knowledge, where and how to seek help, and coping skills as vital content to cover in a school-based mental health literacy program. This study reveals that school staff need sufficient training and resources to address youth mental health literacy. Though mental health literacy is lacking in the Australian school system, the perspectives of school staff and allied health professionals in this study provide key ideas and considerations for the future development of school-based mental health literacy programs for youth.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10648-023-09725-5.

Social Thinking Metacognitive Strategies to Support Self-Determined Social Goals in Autistic Youth

On any given day, the social mind is taxed with attending to and making sense of a myriad of social events. The social mind is at work when trying to imagine the experiences of others and their inner mental worlds, and is equally active when people seek to approach, connect with, and sometimes avoid one another. Ultimately, the social mind is responsible for thinking about (social) thinking, or social metacognition. Social metacognitive teaching strategies can be helpful for supporting social learners as they observe social landscapes, interpret what is observed to problem solve, or decide whether and how to produce social responses. This article describes how social metacognitive strategies from the Social Thinking Methodology have been used to support the self-determined social goals of two autistic students. Visual frameworks and their underlying theories are provided as evidence-aligned tools for supporting clinical journeys.