Interventions to Support Social Participation for Autistic Children and Adolescents in Schools (2013

Abstract

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 to support social participation in school contexts for autistic 1 children and adolescents (birth to 18 yr).

Full Systematic Review Question

This systematic review addressed the question “What is the evidence related to interventions within the scope of occupational therapy practice for supporting participation in basic and instrumental activities of daily living among autistic children and adolescents (birth to 18 yr)?”

Current Theme Reported

The main themes of the studies presented in this systematic review brief include interventions to support social participation in models that use peer modeling and paraprofessional training.

Clinical Scenario

Autistic children and adolescents experience difficulties with social participation (Tobin et al., 2014), which includes friendships, participation in recess, and other social opportunities in homes, communities, and schools. Previous systematic reviews related to social interaction interventions have focused on interventions to increase autistic children and adolescents’ discrete communication and/or social interaction skills (e.g., joint attention, number of utterances). As occupational therapy practitioners, however, we must consider ways to support autistic children and adolescents’ social participation. Therefore, this systematic review brief presents evidence on the efficacy of interventions to support social participation for autistic children and adolescents within school contexts.

Summary of Key Findings

Eight articles were included in the review related to intervention that support autistic children in social participation. These articles were divided into two themes: (1) paraprofessional training interventions and (2) peer-mediated interventions, which includes two subthemes (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).

Table 1.

Evidence Table for Interventions to Promote Social Participation Among Autistic Children and Adolescents

Author, YearLevel of EvidenceRisk of Bias (RoB) CountrySetting	Intervention	Statistically Significant Improvement Resulting From Interventions
Theme 1: Social Participation Interventions That Involve Paraprofessional Training
Two Level 2b waitlist control RCTs with low risk of bias showed a moderate strength of evidence that occupational therapy practitioners can use the Remaking Recess intervention to educate paraprofessionals to support the social participation among autistic children during recess.
Kretzmann et al. (2015) Level 2b RoB Low Country United States Setting School	Population N = 24, mean age 8.3, range 6–11 yr, 25% female Intervention As compared with a waitlist control group, Remaking Recess intervention aimed to support school paraprofessionals to support children with ASD on the playground and consisted of information sharing, active coaching on the playground, and systematic support fading. Children who were unengaged on the playground were provided support to socialize, and school paraprofessionals were coached on prompts and when to fade prompts. Delivery Method Group-based intervention delivered on playground during school recess Dose Targeted total of 16 sessions overall that varied between 10 and 60 min; daily active coaching for 2 wk (8–10 sessions), followed by consultation over next 6 wk (6–8 sessions).	Intervention group showed a statistically significant increase in engagement on the playground as compared with the waitlist controls. Paraprofessionals who received coaching showed significantly higher rates of responsive behaviors to autistic children on the playground as compared with controls.
Shih et al. (2019) Level 2b RoB Low Country United States Setting School	Population N = 80, mean age 8 yr, range K-fifth grade, 8.75% female Intervention As compared with a waitlist control group, the Remaking Recess intervention aimed to support school paraprofessionals to support children with ASD on the playground and consisted of information sharing, active coaching on the playground, and systematic support fading. Children who were unengaged on the playground were provided support to socialize, and school paraprofessionals were coached on prompts and when to fade prompts. Delivery Method Group-based intervention delivered on playground during school recess Dose Sixteen 20- to 30-min sessions over 12 wk	Intervention group showed a statistically significant decrease in time spent in solitary play versus children in the waitlist control group. No changes in engagement in games with rules on the playground. At follow-up, intervention group showed significant gains in social network salience and increased friend identifications.
Theme 2: Peer-Mediated Interventions
Subtheme 1: Interventions That Use Autistic Peers to Support Social Participation Two Level 3b RCTs with moderate level of evidence showed a low strength of evidence supporting occupational therapy practitioners’ use of group-based interventions that involve only autistic children to support children’s social participation.
Bauminger-Zviely et al. (2020) Level 2b RoB Moderate Country Israel Setting School	Population N = 54, autistic children who were minimally verbal (i.e., fewer than 30 spontaneous spoken words); mean age 10.93 yr; range 8–16 yr, 18.5% female Intervention Two curriculum protocols (a social conversation group and a social collaboration group), both based in the principles of the school-based peer social intervention (Bauminger-Zviely et al., 2015), and a waitlist control group. The social conversation group focused on conversational rules, while the social collaboration group focused on shared experiences and activities. Delivery Method One teacher delivered intervention to dyads matched by communication channel (e.g., sign language, writing) within each intervention group in classrooms Dose The social conversation and social collaboration groups received 60, 1-hr sessions, 4×/week for 15 wk.	Social Collaboration Intervention Significantly greater increase in active socialization as compared with the conversation group. Social Conversation Intervention While all groups showed increased socialization activity, those in the social conversation group showed significantly less gains in active socialization as compared with the social collaboration and waitlist control groups. However, they showed significantly higher gains in teacher-reported socialization domain scores versus the other two groups.
Ratcliffe et al. (2014) Level 2b RoB Moderate Country Australia Setting School	Population N = 217, mean age 9.40, range 7–13 yr, 10.14% female Intervention EBSST (Wong et al., 2010), a manualized social–emotional intervention designed to improve emotional competence specifically focused on understanding one’s own and others’ emotions, emotional problem-solving, and emotion regulation skills as compared with a waitlist control group. Delivery Method Small groups of three to eight participants with therapist; parents and teachers are also provided educational sessions. Dose Children received 16 sessions (90-min sessions over 15 wk and a booster session at the 6-mo follow-up). Parents and teachers each received six 90-min sessions over 15 wk, with one 90-min booster session at the 6-mo follow-up.	There was no significant improvement because of the intervention.
Zhao & Chen (2018) Level 2b RoB Moderate Country China Setting School	Population N = 41, mean age 6.14/6.1 yr, range 5–8 yr, 29.3% female Intervention A structured physical activity program, with specific social interaction components, including (a) get-ready and warm-up activities; (b) one to five small group instruction; (c) whole-group exercise; and (d) cooldown and reward activities as compared with a control group, who did not receive the intervention. Delivery Method Group Dose Two 60-min sessions/week for 12 wk	Postintervention, teachers reported a significant increase in the social skills and social interaction skills of children in the intervention group as compared with controls.
Subtheme 2: Interventions That Use Neurotypical Peers to Support Social Participation One Level 1b and two Level 2b RCTs with low to moderate risk of bias provided moderate strength of evidence supporting the involvement of typically developing peers in intervention approaches to increase social participation among autistic children.
Dean et al. (2020) Level 2b RoB Low Country United States Setting School	Population N = 62, autistic children who were educated in the general education setting for a minimum of 80% of the school day, mean age 14.72 yr, 12.9% female Intervention The two intervention conditions (Skills, Engage) followed the same format: (a) welcome, (b) snacks, (c) mindfulness exercise, (d) homework check-in, (e) lesson/focus skill of the week, (f) activity with group, and (g) conclusion. The Engage condition was peer mediated, and group sessions included adolescents with ASD and peer mentors who had been selected and trained to deliver a portion of the intervention. The Skills condition included only students with ASD and those with social challenges, and clinicians facilitated the group sessions using lesson plans provided in the manual (Oti et al., 2009a, 2009b). Delivery Method Group Dose Each intervention occurred 40–60 min 1×/week for 8 wk in a classroom during lunch or after school.	Postintervention, both groups showed a significant increase in joint engagement during unstructured free time (e.g., recess, lunch). Skills Group self-reported significantly more problem behaviors from baseline to follow-up compared with the Engage group, and teacher-reported social skills showed significantly greater gains in the Skills group compared with the Engage group at follow-up compared with baseline.
Kasari et al. (2016) Level 1b RoB Low Country United States Setting School	Population N = 137, autistic children, N mean age 8.18 yr, range 6–11 yr, 19.77% female Intervention The two intervention conditions (Engage and Skills) followed the same format: (a) welcome, (b) snacks, (c) mindfulness exercise, (d) homework check-in, (e) lesson/focus skill of the week, (f) activity with group, and (g) conclusion. The Engage condition was peer mediated, and group sessions included autistic children and typically developing peer mentors who had been selected and trained to deliver a portion of the intervention. The Skills condition included only students with ASD and clinicians facilitated the group sessions using manualized lesson plans. Delivery Method Group format, and two to three typically developing peers for each child with ASD included in the Engage group Dose 16 sessions (2×/week for 8 wk), and each session was 30–45 min	Children in the Skills group showed significantly increased playground socialization and decreased playground isolation as compared with the Engage group. Both groups showed moderate increases in social network salience (i.e., a child’s social prominence in their classroom).
Szumski et al. (2019) Level 2b RoB Moderate Country Poland Setting School	Population N = 52, mean age 5.10 yr, range 3.6–7.6 yr, 30.8% female Intervention The study compared three groups: PT/ST (Odom et al., 1997), ICPS (Shure, 2000), and a control group. The PT/ST: structured play-based tasks in which children are taught social skills (e.g., sharing toys, persistence in initiating social interactions, requesting to share objects); and ICPS: groups of children engaged in play to teach children to solve problems and resolve social conflicts using dialogue. Delivery Method PT/ST is delivered in dyads, matching a child with ASD to one with typical development and a therapist or teacher facilitator. ICPS occurred with groups of 6–8 children with and without ASD. Dose PT/ST lasts 100 sessions, for 15–20 min per day 5×/week; ICPS lasts 59 sessions, 10–20 min per day 5×/week	PT/ST intervention showed a significant increase in teacher-reported social interaction child abilities. ICPS intervention showed a similar significant effect on teacher-reported problematic social interaction as compared with the control group.

Note. ASD = autism spectrum disorder; EBSST = Emotion-Based Social Skills Training; ICPS = I Can Problem Solve; PT/ST = Play Time/Social Time; RCT = randomized controlled trial; RoB = risk of bias.

Bottom Line for Occupational Therapy Practice

Given that social interaction difficulties accompany the diagnostic criteria of autism spectrum disorder (APA, 2013), and social isolation in school contexts is highly reported among autistic youth (Deckers et al., 2017), occupational therapy practitioners must be armed with evidence to support intervention approaches that target social participation. Research in this systematic review brief showed that practitioners can support social participation among autistic children in school contexts. Specifically, occupational therapy practitioners can use peer-mediated intervention approaches—that is, having the autistic child matched with a neurotypical peer during unstructured time (i.e., recess, lunch, play) to increase social participation (Dean et al., 2020; Kasari et al., 2016; Szumski et al., 2019). In addition, a group physical activity intervention with neurotypical peers increased social interaction skills among autistic elementary-aged school children (Zhao & Chen, 2018). Similarly, engaging autistic peers who are also nonverbal during shared experiences/activities is more effective to increase social participation than targeting conversational skills (Bauminger-Zviely et al., 2020) or emotional regulation (Ratcliffe et al., 2014). The variability in dosage for intervention length (range 8–20 wk), time (400–3,600 min), and sessions (8–100 sessions) limits more specific guidance for practitioners.

Footnotes

1

This paper will use the identity-first language, “autistic individuals.” 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).

*

Indicates articles included in the brief systematic review.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.), https://doi.org/10.1176/appi.books.9780890425596.

Bauminger-Zviely

Estrugo

Samuel-Magal

, & Friedlin

(2015). The school-based peer social intervention (S-PSI). Unpublished protocol. Ramat-Gan, Israel: School of Education, BarIlan University.

*Bauminger-Zviely

Estrugo

Samuel-Magal

Friedlin

Heishrik

Koren

, & Bar-Yehuda

(2020). Communicating without words: School-based RCT social intervention in minimally verbal peer dyads with ASD. Journal of Clinical Child and Adolescent Psychology , 49 , 837–853. https://doi.org/10.1080/15374416.2019.1660985

Bottema-Beutel

Kapp

S. K.

Lester

J. N.

Sasson

N. J.

, & Hand

B. N.

(2021). Avoiding ableist language: Suggestions for autism researchers. Autism in Adulthood , 3 , 18–29. https://doi.org/10.1089/aut.2020.0014

*Dean

Williams

Orlich

, & Kasari

(2020). Adolescents with autism spectrum disorder and social skills groups at school: A randomized trial comparing intervention environment and peer composition. School Psychology Review , 49 , 60–73. https://doi.org/10.1080/2372966X.2020.1716636

Deckers

Muris

, & Roelofs

(2017). Being on your own or feeling lonely? Loneliness and other social variables in youths with autism spectrum disorders. Child Psychiatry and Human Development , 48 , 828–839. https://doi.org/10.1007/s10578-016-0707-7

*Kasari

Dean

Kretzmann

Shih

Orlich

Whitney

, ..., King

(2016). Children with autism spectrum disorder and social skills groups at school: A randomized trial comparing intervention approach and peer composition. Journal of Child Psychology and Psychiatry, and Allied Disciplines , 57 , 171–179. https://doi.org/10.1111/jcpp.12460

Kenny

Hattersley

Molins

Buckley

Povey

, & Pellicano

(2016). Which terms should be used to describe autism? Perspectives from the UK autism community. Autism , 20 , 442–462. https://doi.org/10.1177/1362361315588200

*Kretzmann

Shih

, & Kasari

(2015). Improving peer engagement of children with autism on the school playground: A randomized controlled trial. Behavior Therapy , 46 , 20–28. https://doi.org/10.1016/j.beth.2014.03.006

10.

Odom

McConnell

S. R.

Ostrovsky

Peterson

Skellenger

Spicuzza

, & Favazza

P. C.

(1997). Play time/social time: Organizing your classroom to build interaction skills. Minneapolis, MN: Minnesota University.

11.

Oti

Gerdts

Orlich

, & Faia

(2009a). School-Based Social Skills Curriculum for Adolescents ENGAGE Manual.

12.

Oti

Gerdts

Orlich

, & Faia

(2009b). School-Based Social Skills Curriculum for Adolescents SKILLS Manual.

13.

Oxford Centre for Evidence-Based Medicine. (2009). Levels of evidence (March 2009). https://www.cebm.ox.ac.uk/resources/levels-ofevidence/oxford-centre-for-evidence-based-medicine-levels-ofevidence-march-2009

14.

*Ratcliffe

Wong

Dossetor

, & Hayes

(2014). Teaching social–emotional skills to school-aged children with autism spectrum disorder: A treatment versus control trial in 41 mainstream schools. Research in Autism Spectrum Disorders , 8 , 1722–1733. https://doi.org/10.1016/j.rasd.2014.09.010

15.

*Shih

Dean

Kretzmann

Locke

Senturk

Mandell

D. S.

, ..., Kasari

(2019). Remaking recess intervention for improving peer interactions at school for children with autism spectrum disorder: Multisite randomized trial. School Psychology Review , 48 , 133–144. https://doi.org/10.17105/SPR-2017-0113.V48-2

16.

Shure

M. B.

(2000). I Can Problem Solve. An interpersonal cognitive problem-solving program (ICPS) preschool. Champaign, IL: Research Press Publishing.

17.

*Szumski

Smogorzewska

Grygiel

, & Orlando

A. M.

(2019). Examining the effectiveness of naturalistic social skills training in developing social skills and theory of mind in preschoolers with ASD. Journal of Autism and Developmental Disorders , 49 , 2822–2837. https://doi.org/10.1007/s10803-017-3377-9

18.

Tobin

M. C.

Drager

K. D.

, & Richardson

L. F.

(2014). A systematic review of social participation for adults with autism spectrum disorders: Support, social functioning, and quality of life. Research in Autism Spectrum Disorders , 8 , 214–229. https://doi.org/10.1016/j.rasd.2013.12.002

19.

U.S. Preventive Services Task Force. (2018). Grade definitions. https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions

20.

Wong

Lopes

, & Heriot

(2010). Emotion-based social skills training (EBSST) for children with high functioning autism and Asperger’s disorder. Sydney, Australia: The Children’s Hospital at Westmead.

21.

*Zhao

, & Chen

(2018). The effects of structured physical activity program on social interaction and communication for children with autism. BioMed Research International , 2018 , 1825046. https://doi.org/10.1155/2018/1825046

Interventions to Support Social Participation for Autistic Children and Adolescents in Schools (2013–2021)

Abstract

Full Systematic Review Question

Current Theme Reported

Clinical Scenario

Summary of Key Findings

Bottom Line for Occupational Therapy Practice

Footnotes

1

*

References