Abstract
Autism spectrum disorder (ASD) is characterized by a variance in social communication and social interaction across multiple contexts; the presence of restricted, repetitive patterns of behavior, interests, or activities; and distinct sensory processing (American Psychiatric Association, 2013). The symptoms of ASD, which occur mainly in the early years of a child’s life, may impede activity participation. Participation can be used as an indicator of health and wellness because involvement in meaningful occupations is important for all children (World Health Organization, 2007). Through participation, children develop skills, establish interpersonal relationships, achieve self-satisfaction, and gain a sense of self-worth (Lim et al., 2016). For children with ASD, activity participation may be related to their distinct modes of sensory processing, which may be associated with their health and wellness.
Sensory processing refers to the way in which the sensory information received from one’s surroundings and from the body itself is modulated (Dunn, 2014). Individual responses to sensory inputs present as a bell-shaped distribution, with most people exhibiting moderate responses to sensory stimuli and a few people responding more or less intensely. Dunn (2014) described four sensory processing patterns (i.e., Seeker, Avoider, Sensor, and Bystander) that are based on the concept of the interaction between the neurological threshold continuum (from low to high) and the behavior response continuum (from passive to active).
Past research has indicated that levels of activity participation for children and adolescents with ASD are relatively low compared with those of typically developing (TD) children and adolescents (Hilton et al., 2008; LaVesser & Berg, 2011; Solish et al., 2010; Taheri et al., 2016). However, much of the existing literature is based on studies conducted in Western countries and that involved participants of a wide range of ages. Four studies included preschool-age children with ASD; however, the samples in these studies were mainly composed of older children and adolescents between ages 3 and 19 yr (Must et al., 2014; Simpson et al., 2018; Solish et al., 2010; Taheri et al., 2016). The choice of activity type may also be affected by age factors and preference. For example, children ages 3 to 5 yr need to be accompanied or coached by adults to improve their chances of participating in parent–child activities; however, no such activities were investigated in the aforementioned four studies. Regarding preference, Simpson et al. (2018) showed that children age 5 yr most frequently participated in indoor play and games and in watching TV, videos, and DVDs at home. Must et al. (2014) also reported that children with ASD between ages 3 and 11 yr spent more time engaging in sedentary behaviors, especially screen-based activities, than did TD children.
Only one study (LaVesser & Berg, 2011) included comparison groups and focused primarily on preschool-age children; the authors reported that preschool-age children with ASD participated in significantly fewer activities in home, school, and community than did TD children. They also speculated that factors related to participation by preschool-age children with ASD may include distinct sensory processing patterns.
Most of the existing studies investigated the types and frequencies of participation by children with ASD. Only a few studies have explored the personal or environmental factors associated with participation (Little et al., 2015; Piller & Pfeiffer, 2016). One of the personal factors associated with participation is sensory processing patterns. Distinct sensory processing patterns are highly prevalent among people with ASD (Lane et al., 2010). Previous studies have indicated that distinct sensory processing patterns are strongly related to types of activity participation and may contribute to decreased participation diversity (Little et al., 2015; Reynolds et al., 2011); however, these studies focused primarily on school-age children with ASD. There is a lack of direct evidence correlating activity participation with sensory processing patterns among preschool-age children with ASD. Therefore, the two objectives of this study were as follows: (1) to compare differences in activity participation and sensory processing patterns between preschool-age children with ASD and same-age TD children and (2) to examine the relationships between activity participation and sensory processing patterns among preschool-age children with ASD.
Method
Research Design
A cross-sectional study was conducted to collect data in Tainan City, Taiwan.
Participants
Children With Autism Spectrum Disorder
Forty preschool-age children with ASD (M age = 51.5 ± 12.1 mo, 37 [92.5%] boys) were recruited from clinics, hospitals, and early intervention centers. The inclusion criteria were as follows: age 36 to 71 mo, a diagnosis of ASD made by a registered pediatric psychiatrist, mild to severe symptoms of ASD according to the Childhood Autism Rating Scale (2nd ed., Standard Version [CARS2–ST]; Schopler et al., 2010), and no visual or hearing impairment or physical disabilities.
Typically Developing Children
Forty children (M age = 55.1 ± 8.5 mo, 20 [50.0%] boys) from six preschools were recruited. The inclusion criteria were as follows: TD and age 36 to 71 mo; no visual or hearing impairments; and no diagnosis of a developmental delay, physical disability, or developmental disability. There were no significant differences between the groups on any demographic characteristic, with the exception of sex ratio (Table 1).
Participants’ Demographic Data
Note. Dashes indicate data that are missing or not applicable. In 2018, the average annual family income in Tainan City, Taiwan, was NT$1,086,077 (US$36,857; Ministry of Labor, 2018). ASD = autism spectrum disorder; CARS2–ST = Childhood Autism Rating Scale (2nd Ed.–Standard Version); TD = typically developing.
p < .006.
Procedure
The study protocol was approved by the institutional review board of National Cheng Kung University Hospital. Convenience sampling was used to recruit children for both groups. Recruitment procedures included the use of flyers in preschools and personal visits to clinics, hospitals, and early intervention centers for children with ASD. When parents communicated interest in the study, I explained the complete procedures to them. Written informed consent was obtained before children were enrolled in the study. I arranged a time to meet with the child and parents and collect the data in the laboratory. The Assessment of Preschool Children’s Participation (APCP; King et al., 2006) and Short Sensory Profile 2 (SSP–2; Dunn, 2014) were completed by the children’s mothers.
Measures
Childhood Autism Rating Scale (2nd ed.–Standard Version)
The CARS2–ST is considered a well-established measure for assessing the symptom severity of ASD in children younger than 6 yr. It consists of 15 items, and each item can be assigned a score between 1 and 4 points at 0.5-point intervals. On the basis of their cutoff scores, children are categorized into one of three groups: not autistic (<30), mild to moderate autism (30–36.5), and severe autism (≥37). The CARS2–ST has good internal consistency, interrater reliability, concurrent validity, and discriminant validity (Schopler et al., 2010). This measure was administered by a registered pediatric occupational therapist who had at least 5 yr of early intervention experience.
Assessment of Preschool Children’s Participation
The APCP is a caregiver-report measure of activity participation in preschool children age 2 yr to 5 yr, 11 mo. It includes 45 pictures that portray a child’s participation across areas of play, skill development, physical recreation, and social activities (King et al., 2006). Caregivers are asked to report the activities in which the child has participated during the past 4 mo and rate the frequency of participation on a 7‐point scale ranging from 1 (once over the past 4 mo) to 7 (once daily or more). Participation diversity and intensity scores can be generated across the four activity areas. A diversity score is calculated by dividing the sum of the number of reported activities by the number of total items in each activity area, and an intensity score is the sum of the frequencies for all activities participated in divided by the number of possible items in each activity area. A higher score indicates more diverse and intense participation. The APCP has good internal consistency and concurrent validity (Chen et al., 2013).
Short Sensory Profile 2
The SSP–2 contains 34 items selected from the Child Sensory Profile 2 for children ages 3 to 14 yr. These items are scored using the same method as the Child Sensory Profile 2 and are highly discriminating in determining whether children display definite sensory patterns. The test results provide information about the child’s level of responsivity to sensory events (e.g., overresponsiveness or underresponsiveness). Caregivers are asked to rate, on a scale ranging from 1 (almost never) to 5 (almost always), the frequency with which the child demonstrates these behaviors. The four quadrant scores of the SSP–2 (Seeker, Avoider, Sensor, and Bystander) can be calculated and interpreted according to norms. The typical performance range for the four quadrant scores is 6 to 17 (Seeker), 9 to 22 (Avoider), 10 to 24 (Sensor), and 6 to 16 (Bystander). The SSP–2 has good internal consistency and concurrent validity (Dunn, 2014).
Demographic Information
Mothers of children with ASD provided demographic information, including age, gender, comorbid conditions, early intervention services, and preschool attendance. Family characteristics included number of family members and siblings, maternal education level, and economic status.
Data Analysis
A comparison of children to ASD to TD children on APCP total score revealed an effect size of 0.95. I calculated that, with an effect size of 0.95 and α set at .05, a sample size of 40 participants in each group yielded an estimated power of .98 for a two-tailed study. Chi-square tests and t tests were conducted to compare the demographic characteristics of the two groups (ASD and TD). Multivariate analysis of variance was used to examine the four areas of participation and four sensory quadrants. In addition, the Shapiro–Wilk test was used to test for normality. The data came from a nonnormal distribution. Mann–Whitney U tests were used to examine group differences across the dependent variables of the APCP and SSP–2, with group membership as the independent variable. Spearman’s rank correlation coefficients were calculated to check for associations between the APCP scale scores and scores for the four quadrants. The level of significance was set at p < .006 after Bonferroni correction for multiple comparisons and correlations.
Results
The 40 children with ASD participated in an average of 27.1 (SD = 9.9) of the 45 activities (60.2%) depicted in the APCP, with individual children performing between 9 (20.0%) and 37 (82.2%) activities. On average, children participated in these activities 2–3×/mo. The children had an average participation diversity of 60.1 (SD = 15.3), with the highest score for play activities and the lowest score for social activities. Children with ASD had significantly lower scores on participation diversity than TD children, F(4, 75) = 6.37, p < .001. Significant differences between the two groups were found for three APCP areas (Table 2). Children in the ASD group demonstrated less diversity than those in the TD group, with the exception of the skill development activities; however, the participation intensity of children with ASD did not significantly differ from that of TD children.
Comparison of APCP and SSP–2 Measures Between the Groups
Note. APCP = Assessment of Preschool Children’s Participation; ASD = autism spectrum disorder; SSP–2 = Short Sensory Profile–2; TD = typically developing.
p < .006.
A significant difference in all scores between the ASD and TD groups was observed, F(4, 75) = 19.30, p < .001. The results demonstrated significant group differences in all four sensory quadrants (see Table 2). The ASD group displayed higher scores on the four sensory quadrants than the TD group. All children with ASD displayed unique performance in at least one of the sensory processing quadrants. The percentage of children with ASD who scored higher than most people in the four quadrants was Avoider, 75.0% (n = 30); Sensor, 75.0% (n = 30); Bystander, 62.5% (n = 25); and Seeker, 40.0% (n = 16).
The Sensor quadrant was negatively correlated with play (ρ = –.305, p = .005) and social activities (ρ = –.330, p = .003). More participation in play and social activities was associated with less sensitivity to sensory input. The Bystander quadrant was negatively correlated with social activities (ρ = –.338, p = .002), indicating that children with ASD who had fewer bystander behaviors participated more frequently in social activities.
Discussion
This is the first study to investigate participation diversity among preschool-age children with ASD in Taiwan. The results provide a valuable contribution to our understanding of participation and sensory processing patterns for children with ASD ages 3 to 5 yr in comparison with TD children. Significant group differences were found for three participation diversity scores, indicating that preschool-age children with ASD participated in less diverse activities than TD children. These findings are consistent with other studies of preschool-age children with developmental disabilities (LaVesser & Berg, 2011; Lim et al., 2016). The lowest score on the APCP was for social activities, which reflects the core symptoms of ASD. In this study, children with ASD most frequently participated in play activities (e.g., playing with toys; watching TV, videos, and DVDs). This finding is in line with previous research by Simpson et al. (2018) and Must et al. (2014). Previous research has also indicated that many children with ASD have strengths in visual–spatial skills (O’Riordan et al., 2001; Pellicano et al., 2006) and show a preference for visually based information (Shane & Albert, 2008); therefore, the highest score on the APCP was for play activities. In particular, children who spent more hours per day participating in screen-based activities did so to the exclusion of other recreational pursuits, such as physical activities or exercise.
It is interesting that no significant difference between the two groups was found for skill development activities. Activities related to skill development include drawing, painting, scrapbooking, playing with construction toys, using puzzles, playing a musical instrument, swimming, and dancing (King et al., 2006). A plausible explanation is that many children begin to develop their play occupations and refine their cognitive and motor performance skills during the preschool years (Case-Smith, 2015). The aforementioned skill development activities are commonly done with young children.
Of note is that participation intensity did not significantly differ between the two groups. These results are in line with those of previous studies showing that preschoolers with developmental disabilities can have an intensity similar to that of TD children with respect to how often they participate in activities (LaVesser & Berg, 2011; Lim et al., 2016). From the caregiver’s perspective, children with ASD are more stubborn and less flexible because of their behavior patterns, which may lead to a narrowing of the type of activities they can do with peers (Germani et al., 2016). However, when children engage in activities that they are interested in, especially if they are good at a single, repetitive activity, they have the ability to teach or lead their peers (Germani et al., 2016). In this case, their strengths can contribute to participation; therefore, parents can use the strengths of children with ASD to help them participate in more activities with their peers to promote peer interaction between children.
Participation diversity may be associated with a child’s behavioral and social characteristics. LaVesser and Berg (2011) reported that preschool-age children with ASD participated in significantly fewer activities than TD children. They also indicated that sensory processing differences may contribute to a child’s behaviors, which in turn lead to participation in a narrow range of activities. These findings support those of previous work indicating that children with ASD are considerably more likely to have scores in the “more than others” range for all four sensory quadrants (Nieto et al., 2017). In the present study, a higher reactivity in response to sensory stimuli among children with ASD was observed, a result that is consistent with other studies (Lane et al., 2010; Nieto et al., 2017). This is in line with research by Nieto et al. (2017) and Reynolds et al. (2011) showing that the most frequent SSP–2 patterns were Sensor and Avoider. Both Sensor and Avoider are reflective of low neurological thresholds, which are grouped as sensory overresponsiveness (Miller et al., 2007). Reynolds et al. reported that children with ASD who show sensory overresponsiveness may be less likely to participate in activities. In the present study, children who were categorized in the Sensor quadrant demonstrated significant negative associations on play and social activity participation. Children with less sensitivity to sensory input may have no trouble maintaining their focus on activities and tasks during daily life (Dunn, 2014).
The results of this study support previous findings that children with ASD have distinct patterns of sensory performance that shape their participation in activities (Piller & Pfeiffer, 2016; Roley et al., 2015). It is interesting that in this study a link was found between activity participation and sensory underresponsiveness (Bystander quadrant). Children with ASD in the current study participated in more social activities if they had lower scores in the Bystander quadrant. They may less passively take in sufficient sensory input to gather the information necessary for participation (Dunn, 2014). Moreover, these findings extend the results of an earlier study that showed an association between activity participation and sensory responsiveness in children with ASD ranging in age from preschool age to school age (Reynolds et al., 2011). Preschool-age children with ASD have certain sensory processing patterns and developed preferences in participation. These sensory processing strengths may contribute to participation. Thus, the use of strategies to help preschool-age children with ASD optimize sensory experience may be beneficial for increasing their participation in activities. Creating structured and organizational activities and a similar environment may also be useful (Dunn, 2014).
This study has certain limitations. First, the sample was small, and there was a disproportionately small number of female children in the ASD group; thus, these findings might not be generalizable to a larger population. Future research should recruit young children from a larger community sample. Second, I did not consider the effects of cognitive ability and other aspects of development on the quality or type of activities in which children engaged. Third, parental preference, family routines, and social context should be considered in future research. Finally, the SSP–2 addresses only sensory modulation patterns. Future research should address the full scope of sensory processing related to motor and discrimination performance.
Implications for Occupational Therapy Practice
The findings of this study have two implications for occupational therapy practice:
Children with ASD had significantly lower scores on participation diversity than TD children. Occupational therapy can facilitate the activity participation of preschool children with ASD through their strengths and extending activities that they are interested in.
The most frequent sensory processing patterns were Sensor and Avoider, and associations between activity participation and sensory processing patterns were observed. Occupational therapy practitioners should consider the role of sensory systems in promoting activity participation in natural settings.
Conclusion
There is consensus that patterns of sensory performance and participation are linked. Preschool-age children with ASD participated in more diverse social activities when they had less sensitivity to sensory input and fewer bystander-type behaviors. The present findings have implications for how preschool-age children with ASD typically engage in daily activities and suggest that some sensory processing patterns may be associated with participation in social activities. Occupational therapy practitioners can facilitate activity participation for preschool-age children with ASD by using the children’s strengths and the activities that they find interesting, and practitioners should consider the role of sensory systems to promote activity participation in natural settings. Future research is needed to explain whether sensory processing patterns are a strength or a protective factor for children with ASD.