Interventions to Support Participation in Play for Autistic Children and Youth (Dates of Review: 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 themes presented in this systematic review brief include interventions to support play across clinic and school settings as well as delivered via telehealth.

Clinical Scenario

Autistic children experience difficulties with play, which is associated with social interaction and communication differences (González-Sala et al., 2021; Lin et al., 2017; Thiemann-Bourque et al., 2019). 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) to reduce symptom severity and skill deficits. However, it is necessary for occupational therapy practitioners to consider if study outcomes are performance based or align with the aims of the investigation (e.g., if adaptive behavior interventions influence adaptive behavior in authentic contexts; 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 [AOTA], 2020). This systematic review brief presents evidence on the efficacy of interventions to support play participation for autistic children.

Summary of Key Findings

Eight articles were included in the review related to interventions that support participation in play. These eight articles were divided into three categories based on context (school, clinic, telehealth) and targeted a variety of play skills (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

Participation in play is a vital occupation for all young children (e.g., Moore & Lynch, 2018), and autistic children show limitations in play (e.g., Lee et al., 2016). Interventions often focus on increasing discrete skills; however, occupational therapy practitioners support autistic children in play occupations to engage and participate in leisure as well as increase social engagement with peers and caregivers. The research showed that participation-focused interventions delivered in school, clinic, or via telehealth enhanced play occupations. School-based interventions across studies resulted in significantly increased play engagement, specifically imagination scores (Doernberg et al., 2021), spontaneous play (Goods et al., 2013), and a variety of play types (Goods et al., 2013; Strauss et al., 2014; Wolfberg et al., 2015). Additionally, caregiver coaching led to significantly increased play frequency and diversity (Little et al., 2018). Individual and group delivery were used in these studies, and there was wide variability in intervention dosage (20–450 min/wk), frequency (3 times daily to once a week), and length (5 wk to full school year). Together, these studies guide practitioners to facilitate play occupations using guided participation and structured teaching methods while following a child’s lead in play.

The classroom-based intervention models guide practitioners to use manualized interventions (e.g., Joint Attention Symbolic Play Engagement and Regulation; see Kasari et al., 2006; Advancing social-communication and play; see Watson et al., 2011) delivered in both individual and group-based settings over the course of at least 12 wk to significantly expand children’s play repertoire and increase engagement in the classroom. Additionally, flexible strategies versus structured applied behavioral analysis approaches may more effectively improve play among autistic children (Strauss et al., 2014). The two clinic-based studies guide practitioners to use 60-min, manualized interventions, for at least 10 weeks. Autistic children were more playful during free play with a peer following structured peer, video, and therapist modeling outlined in the Ultimate Guide to Play, Language and Friendship (Kent et al., 2021). Significantly increased participation in specific play goals followed three-time weekly individual sessions of occupational therapy/sensory integration (OT/SI; Schaaf et al., 2014). The high intensity, manualized intervention with fidelity checklist and individualized measurement of play outcomes using goal attainment scaling provide guidance for practitioners when using OT/SI. Lastly, coaching delivered to caregivers of autistic children via telehealth may significantly increase children’s diversity of play over the course of 12 wk (Little et al., 2018).