Interventions to Support Participation in Basic and Instrumental Activities of Daily Living for Autistic Children and Adolescents (2013–2021)

Full Systematic Review Question

This systematic review addressed the question “What are the interventions within the scope of occupational therapy to address participation in activities of daily living, instrumental activities of daily living, rest and sleep, work, education, play, leisure, social participation, and health management among autistic people under the age of 18?”

Current Theme Reported

The main themes of the studies included in this systematic review brief are interventions to support participation in feeding, toileting, and self-care activities of daily living (ADL) and grocery shopping instrumental activity of daily living (IADL).

Clinical Scenario

Autistic children and adolescents frequently experience a disruption in their participation in meaningful occupations such as mealtimes (Baraskewich et al., 2021; Page et al., 2022), self-care (Duncan & Bishop, 2015; Jasmin et al., 2009), toileting (Spencer & Ello, 2021), and IADLs (Matson et al., 2009). These participation limitations are often attributed to differences in social communication, social interaction, behavior regulation and sensory processing patterns (American Psychiatric Association, 2013; Askari et al., 2015; Tomchek et al., 2015). Accordingly, previous systematic reviews have often focused on the efficacy of specific intervention approaches and contexts (e.g., peer-mediated interventions, parent training, early intervention, physical activity, sensory integration, etc.) to reduce symptom severity and skill deficits at the cost of considering if the outcome measures are performance-based or align with the aims of the study (Lami et al., 2018; McConachie et al., 2015; Schaaf et al., 2021). Occupational therapy practitioners are well equipped to work collaboratively with autistic children and their families using multidimensional interventions; however, they need more information on the efficacy of interventions to promote participation in meaningful activities of daily life (American Occupational Therapy Association, 2020). This systematic review brief presents evidence on the efficacy of interventions to support participation in feeding, toileting, self-care, and grocery shopping for autistic children and adolescents.

Summary of Key Findings

Six articles were included in the review related to interventions that support participation in ADLs and IADLs. These six articles were further divided into four categories (feeding, toileting, self-care, and grocery shopping) depending on the specific occupation or outcome target of the intervention (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). The strength-of-evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018).

Bottom Line for Occupational Therapy Practice

The intentional focus on participation in occupations often differentiates occupational therapy from other providers on a care team with persons on the autism spectrum. Although many service providers focus services on skill building with the intent to generalize, occupational therapy services start by considering function and participation in authentic contexts. Participation-focused interventions led to enhanced participation in ADLs and IADLs in children and adolescents. Specific occupations included feeding, self-care, toileting, and grocery shopping.

Coaching/parent training interventions were effective in enhanced participation in feeding/mealtime routines. Improved participation in mealtime routines on the Brief Autism Mealtime Behaviors Inventory was reported in two of the studies (Johnson et al., 2019; Sharp et al., 2019). These studies used a similar number, 11 and 10, respectively, and length (up to 90 min) of sessions. Both individual and group formats were used. Notably, both studies increased between-session intervals to monitor intervention progress. One of these studies (Johnson et al., 2019) also reported improvements in caregiver/child relationship during mealtimes. The other included study (Sharp et al., 2014) used fewer (8) and shorter (60 min) group sessions, which did not reveal improvements in mealtime participation. Together, the findings provide some dosage guidance (i.e., at least 10 parent coaching/training sessions of up to 90 min) for occupational therapy practitioners when using parent training.

The remaining three individual studies measured self-care (Schaaf et al., 2014) and toileting (Mruzek et al., 2019) ADL outcomes or grocery shopping (Lamash & Josman, 2021). These studies begin to contribute to occupational therapy evidence for specific segments of the autistic population as each limited recruitment by one measure of functioning (i.e., intelligence quotient). Increased participation in specific self-care skills with reduced caregiver assistance followed 10 wk of three-time weekly individual 60-min sessions of OT/sensory integration (SI) (Schaaf et al., 2014). The high-intensity, manualized intervention with fidelity checklist and individualized measurement of self-care outcomes using goal attainment scaling provides guidance for practitioners when using OT/SI. Parent training on behavior strategies and individualized toileting planning (five sessions) in one study (Mruzek et al., 2019) yielded nonsignificant findings on toileting participation using a disposable sensor placed in child’s underwear. The only included IADL study investigated participation in grocery shopping using the contextually based Test of Grocery Shopping Skills (Lamash & Josman, 2021). Metacognitive training (explicit teaching of executive function skills, group discussion, implementation strategies) over eight, 45-min sessions in this study resulted in accuracy and use of strategies improvements when grocery shopping. The moderate risk of bias in this study limits the implications to some degree.

Available evidence supports practitioner use of parent-coaching interventions that highlight structuring mealtime routines and behavior responding to promote participation in feeding. The limited number of studies clearly focused on participation in ADLs or IADL included in this review highlights the need for additional evidence, highlighting the distinct value of OT using occupations in context as the intervention to enhance participation in self-determined occupations.