Interventions for Developing Positive Mental Health in Autistic Individuals (2013–2021)

Full Systematic Review Question

This systematic review addressed the question “What are the interventions in the scope of occupational therapy to support (or improve) improved self-determination and positive mental health for persons on the autism spectrum?”

Current Theme Reported

The main theme of the studies included in this systematic review brief is interventions to support positive mental health for autistic individuals.

Clinical Scenario

Research has increasingly highlighted the need for mental health services to address co-occurring mental health concerns such as anxiety and depression in autistic individuals. According to recent participatory research, queries to the autistic community suggest that access to appropriate mental health resources is a top priority for autistic individuals (Benevides, Shore, Palmer, et al., 2020; Benevides, Shore, Anderson, et al., 2020). This is especially important because suicide is a leading cause of death for autistic individuals (Hand et al., 2020; South et al., 2021). In a rapid review of the literature, Skaletski et al. (2021) found that quality of life (QoL) was significantly lower for autistic adolescents and adults and that occupational therapy interventions, including mentoring, leisure programming, cognitive behavior therapy, and cognitive strategies, have the potential to improve QoL.

Given that QoL is a significant predictor of current and future health (Centers for Disease Control and Prevention, 2018), interventions that improve QoL and mental health functioning are critical to consider in occupational therapy service delivery. Occupational therapy practitioners have extensive training in mental health practice, often underutilized in interventions for the autistic population. This systematic review theme presents the strength of evidence of interventions that focus on improving mental health outcomes with subthemes on cognitive behavioral therapy and functional and interest-based activities.

Summary of Key Findings

Out of 24 studies included in the larger review, 19 (80%) studies targeted mental health outcomes and met the inclusion criteria. These included six Level 1B, four Level 2B, and one Level 3B studies. Subthemes are synthesized and reported in Table 1. The strength-of-evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018). We used the Oxford Centre for Evidence-Based Medicine (2009) levels of evidence for this review.

Bottom Line for Occupational Therapy Practice

When working with autistic individuals, occupational therapy practitioners should consider the importance of providing occupational therapy interventions with a mental health focus beyond interventions that are typically used (i.e., self-regulation, sensory-based practices, etc.). The autistic community has identified mental health services as a high priority (Benevides et al., 2020). This review found a combination of cognitive behavioral therapy (CBT) approaches like anxiety management, in vivo exposure, breathing exercises, role-playing, behavioral training, systematic desensitization, and functional activities effectively alleviated anxiety and stress in autistic individuals (Frank et al., 2022; Hesselmark et al., 2014; Langdon et al., 2016; White et al., 2013). Furthermore, studies that incorporated mindfulness-based stress reduction activities like mindful eating, body scans, mindful breathing, mindful walking exercises, yoga, and meditation, along with CBT and functional activities, improved positive mental health (Pagni et al., 2020; Spek et al., 2013). Most mental health programs emphasize the need for home-based activities or homework assignments and increased awareness and education about negative situations to facilitate participants’ capacity to cope with challenging or triggering situations (Frank et al., 2022; Pagni et al., 2020; Schohl et al., 2014; Spek et al., 2013). However, more studies are now incorporating functional activities like journaling, social skill training, and interest-driven tasks to develop positive mental health practices. Several programs also employed participants’ interests to reduce the impact of mental health challenges (Hesselmark et al., 2014; Kaboski et al., 2015). Hesselmark et al. (2014) also underscored that there were no significant differences between their groups where one received CBT and the other engaged in interest-based activities like visiting museums, cooking, boating, and cinema, which is evidence for utilizing these interest-based activities for an occupation-centered practice. The reason we included one study at Level 3B (Kaboski et al., 2015) was because of their adoption of a strength-based robotics intervention program to reduce social anxiety among autistic participants. This approach integrated these participants’ interests in robotics to alleviate social anxiety. Approaches that integrate the use of autistic strengths and interests in practice through personally valued goals of clients can augment their occupational performance and QoL (Patten-Koenig, 2020).

There is a need and a demand for occupational therapy practitioners to incorporate mental health practice into their work with autistic individuals. Proximal stressors such as anxiety and depression, along with distal impacts of bullying, ableism and stigmatization, have brought the mental health challenges that the autistic population experiences to the forefront, which is a call for occupational therapy to use their training and meet this societal need.