American Journal of Occupational Therapy

Health reform promotes the delivery of patient-centered care. Occupational therapy’s rich history of client-centered theory and practice provides an opportunity for the profession to participate in the evolving discussion about how best to provide care that is truly patient centered. However, the growing emphasis on patient-centered care also poses challenges to occupational therapy’s perspectives on client-centered care. We compare the conceptualizations of client-centered and patient-centered care and describe the current state of measurement of client-centered and patient-centered care. We then discuss implications for occupational therapy’s research agenda, practice, and education within the context of patient-centered care, and propose next steps for the profession.

Occupational therapy has much to offer to families of people with autism spectrum disorder (ASD). However, people outside the profession may be unaware of occupational therapy’s breadth and scope. It is our responsibility and our duty to express the full range of occupational therapy services through research, clinical practice, advocacy, and consumer education. This special issue of the American Journal of Occupational Therapy, with its focus on autism, embarks on this endeavor by highlighting research and theoretical articles that address the various aspects of occupational therapy practice that can help to fully meet the needs of people with ASD and their families.

People with autism spectrum disorder (ASD) commonly experience difficulties with social participation, play, and leisure along with restricted and repetitive behaviors that can interfere with occupational performance. The objective of this systematic review was to evaluate current evidence for interventions within the occupational therapy scope of practice that address these difficulties. Strong evidence was found that social skills groups, the Picture Exchange Communication System, joint attention interventions, and parent-mediated strategies can improve social participation. The findings were less conclusive for interventions to improve play and leisure performance and to decrease restricted and repetitive behaviors, but several strategies showed promise with moderately strong supporting evidence. Occupational therapists should be guided by evidence when considering interventions to improve social participation, play, leisure, and restricted and repetitive behaviors in people with ASD. Additional research using more robust scientific methods is needed for many of the currently available strategies.

OBJECTIVE. To examine interventions addressing work, activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, and sleep for people with autism spectrum disorder.

METHOD. A total of 23 studies were identified, and 9 work-, 11 ADL/IADL-, and 3 education-related interventions were examined. No sleep studies were identified.

RESULTS. Use of mobile and tablet technologies for vocational skills was supported. Support for ADL/IADL intervention is variable, with indications that Cognitive Orientation to Occupational Performance, sensory integration, and contextual interventions may increase occupational performance. Preliminary evidence suggests that daily yoga and brief exercise may improve classroom performance and behavior; group physical activities may assist with school readiness variables. Evidence for using technologies for IADLs was limited, as was evidence determining effective interventions for feeding and eating issues.

CONCLUSIONS. Studies investigating interventions related to sleep are lacking. More studies are needed in all areas, presenting opportunities for the expansion of science-driven occupational therapy practice and research for people with ASD.

This systematic review examines the literature published from January 2006 through April 2013 related to the effectiveness of Ayres Sensory Integration^® (ASI) and sensory-based interventions (SBIs) within the scope of occupational therapy for people with autism spectrum disorder to improve performance in daily life activities and occupations. Of the 368 abstracts screened, 23 met the inclusion criteria and were reviewed. Moderate evidence was found to support the use of ASI. The results for sensory-based methods were mixed. Recommendations include performing higher level studies with larger samples, using the Fidelity Measure in studies of ASI, and using carefully operationalized definitions and systematic methods in examination of SBIs.

This systematic review examined the literature published from January 2006 to April 2013 related to the effectiveness of occupational therapy interventions for children with autism spectrum disorder (ASD) and their parents to improve parental stress and self-efficacy, coping, and resilience and family participation in daily life and routines. From the 4,457 abstracts, 34 articles were selected that matched the inclusion criteria. The results were mixed and somewhat inconclusive because this body of literature is in its infancy. Studies of children with ASD do not routinely measure parental and family outcomes. Recommendations include an emphasis on family measures other than parental stress and a greater focus on measures of parental and family functioning in all future studies of pediatric interventions to more fully understand the impact of interventions in a wider context.

Parents often focus on independence in activities of daily living and social participation when setting goals for their children with autism spectrum disorders. Occupational therapy practitioners use clinical reasoning to translate these goals to define occupation-based outcomes. This article describes an exploratory analysis of 160 parent-identified goals for children with autism. We identified sensory integrative factors hypothesized to influence each goal and then categorized the goals using the Occupational Therapy Practice Framework: Domain and Process and the International Classification of Functioning, Disability and Health (ICF). Most goals were at the ICF participation and activity levels. Activities of daily living were the most common area of occupation identified, followed by social participation and play. Sensory reactivity and somatopraxis were the most frequently occurring sensory integrative factors. The value of addressing parent goals using a systematic reasoning process to identify factors affecting participation and the importance of measuring participation outcomes are discussed.

OBJECTIVE. Prior research has documented caregiving difficulties in families of children with autism spectrum disorder (ASD). However, Latino families may encounter unique challenges. The purpose of this study was to understand the caregiving experiences of Latino families with children with ASD, including daily activities, coping strategies, and service utilization.

METHOD. Fifteen Latino parents of children with ASD were interviewed. The interviews were transcribed for analysis to identify themes of experiences unique to this population.

RESULTS. Latino families of children with ASD encounter many similar issues as non-Latino families but also unique issues that affect service utilization. Four themes were identified: dealing with the diagnosis, dealing with stigma and isolation from family and community, understanding the role of mothers in changing family routines, and utilizing services.

CONCLUSION. To meet the unique needs of Latino families, services need to be provided in culturally sensitive context that address children’s needs within family units.

This qualitative study investigated how resilience functions in the context of daily occupations for mothers of children with autism spectrum disorder (ASD). Fourteen mothers of children with ASD participated in two focus groups that were used to elicit stories of the mothers’ resilience in daily occupations. A constant comparative method was used for data analysis. A model of resilience in daily occupations of mothers of children with ASD was developed consisting of four categories: (1) creating and re-creating accepting conditions, (2) finding solutions, (3) striving for balance among daily occupations, and (4) thinking about the child’s future. Sources of resilience were found to reside in both the mothers themselves and their social environments. Occupational therapy practitioners can use these findings in developing supportive approaches aimed at mothers, family members, and other people in the lives of children with ASD.

OBJECTIVE. Through a content analysis of qualitative research published 1993–2011, we sought to determine how qualitative research can inform clinical reasoning among occupational therapy practitioners to support evidence-based, occupation-focused services for children and youth with autism and their families.

METHOD. A qualitative literature search of journals inside and outside occupational therapy, including international journals, yielded 125 articles. We reviewed 110 articles that met inclusion criteria, 79 of which were coded by four occupational therapists with experience working with families with a child or youth with autism.

RESULTS. Nineteen content codes were initially derived. Three themes were identified: (1) service challenges for the family, (2) day-to-day experience of autism, and (3) reframing family.

CONCLUSION. This content analysis illustrates how qualitative research may help occupational therapy practitioners make comprehensive, occupation-based intervention decisions by considering the lived experience of children and youth with autism and their families.

Sensory processing differences in preschool-age children with autism spectrum disorder (ASD) affect their engagement in everyday activities, thereby influencing opportunities to practice and develop skills such as social communication and adaptive behavior. The purpose of this study was to investigate the extent to which specific sensory processing patterns relate to aspects of development (i.e., adaptive behavior, expressive and receptive language, fine and gross motor skills, social behavior) in a sample of preschool-age children with ASD (N = 400). A retrospective chart review was used to gather clinical data. Results suggest that sensory processing patterns differentially affect children’s developmental skills and adaptive behavior. Certain sensory processing patterns predicted children’s development of language, motor, and adaptive skills. These findings have clear implications for occupational therapy practice with young children with ASD. Practitioners should consider how sensory processing in ASD both supports and limits children’s ability to engage in social communication and learning opportunities.

This study examined sensory differences and mealtime behaviors in children with autism spectrum disorder (ASD; n = 34) and compared the results with those of similarly aged peers who were typically developing (TD; n = 34). Results from parent-report and child-report questionnaires indicated that children with ASD scored significantly differently from TD peers on the measures of sensory differences and eating behaviors. Data also supported a correlation between sensory differences and eating difficulties in children with ASD. The results of this study will help caregivers and their children with ASD identify problem eating behaviors that may be associated with sensory differences. Sensory strategies and techniques offered by occupational therapy practitioners may contribute to greater success during mealtimes for children with ASD and their families, with increased comfort and less stress. The findings also support a need to further explore the influence of sensory differences on mealtime behaviors.

OBJECTIVE. This study sought to investigate the impact of developmental dyspraxia on the play skills of children with autism spectrum disorder (ASD).

METHOD. The praxis abilities of 32 children with ASD (mean age = 7.5 yr) were assessed using two subtests of the Sensory Integration and Praxis Tests and the Planning and Ideas domain of the Sensory Processing Measure Home Form. Play and leisure skills were measured with the Vineland Adaptive Behavior Scales, Second Edition. Utilizing correlation coefficients, we investigated the relationship between developmental dyspraxia and the play skills of children with ASD.

RESULTS. Children with ASD demonstrated definite dysfunction in imitative praxis abilities, the generation of ideas, and participation in age-appropriate play and leisure activities.

CONCLUSION. Praxis problems in children with ASD greatly affect their successful participation in play and leisure activities.

OBJECTIVE. To measure upper-extremity and gross motor skill development in infants with and without risk factors for autism spectrum disorder (ASD).

METHOD. Data were coded retrospectively from 39 infants who participated in longitudinal structured early developmental assessments. Twenty-five infants were at high risk for ASD, and the remaining 14 infants were classified as low risk. Upper-extremity and motor skill development were coded at ages 2, 4, and 6 mo. Five infants went on to receive an ASD diagnosis at age 2–4 yr.

RESULTS. Infants at high risk for ASD demonstrated fewer midline behaviors with the upper extremities and delayed motor skill development than the low-risk group. Differences in motor skills were most apparent at age 4 mo.

CONCLUSION. Early monitoring for motor delay in infants at high risk for ASD is warranted. Midline control and play with the upper extremities and overall motor skill development are possible assessment and therapeutic targets.

Home modification interventions have the potential to provide support to informal caregivers; however, the impact of these interventions on caregivers is understudied, and adequate assessments are lacking. This study describes the development and preliminary psychometric properties of a performance-based assessment that identifies environmental barriers to performance of daily caregiving activities. An existing assessment of person–environment fit was modified using key informant interviews and was administered to 31 informal caregivers. The In–Home Occupational Performance Evaluation for Providing Assistance demonstrated reliability across raters, good internal consistency for all subscales, and convergent validity with existing measures. This assessment has the potential to guide home modification interventions and measure the impact on informal caregiving in the home.

OBJECTIVE. The objective of this study was to evaluate the effectiveness of an activity pacing self-management (APSM) intervention in improving performance of daily life activities in women with chronic fatigue syndrome (CFS).

METHOD. A total of 33 women with CFS (age 41.1 ± 11.2 yr) were randomly allocated to APSM (experimental group; n = 16) or relaxation (control group; n = 17). Main outcome measures included the Canadian Occupational Performance Measure (COPM; primary) and Checklist Individual Strength (CIS).

RESULTS. COPM scores changed significantly over time in both groups (p = .03). The change in Satisfaction scores showed a significant difference in favor only of APSM (effect size = 0.74 [0.11, 1.4]). CIS scores decreased significantly in the experimental group only (p < .01).

CONCLUSION. APSM was found to be feasible and effective in optimizing participation in desired daily life activities in women with CFS. Replication in a larger sample with long-term follow-up is required.

OBJECTIVE. To describe environmental barriers, accessibility problems, and powered mobility device (PMD) users’ autonomy indoors and outdoors; to determine the home environmental barriers that generated the most housing accessibility problems indoors, at entrances, and in the close exterior surroundings; and to examine personal factors and environmental components and their association with indoor and outdoor autonomy.

METHOD. This cross-sectional study was based on data collected from a sample of 48 PMD users with a spinal cord injury (SCI) using the Impact of Participation and Autonomy and the Housing Enabler instruments. Descriptive statistics and logistic regression were used.

RESULTS. More years living with SCI predicted less restriction in autonomy indoors, whereas more functional limitations and accessibility problems related to entrance doors predicted more restriction in autonomy outdoors.

CONCLUSION. To enable optimized PMD use, practitioners must pay attention to the relationship between client autonomy and housing accessibility problems.

Appraising the best available evidence substantiating and informing occupational therapy practice is a commonly expressed obligation for the profession (American Occupational Therapy Association [AOTA], 2007). In this article we argue for the full inclusion of qualitative research, on parity with quantitative research, as a source for evidence of relevant and effective occupational therapy practice, review the limitations of quantitative research, and outline the distinctive contributions of qualitative studies to the practice of occupational therapy for people with autism spectrum disorder (ASD). In addition, we describe the role of qualitative studies in the fulfillment of the Centennial Vision (AOTA, 2007) and recommend three action steps for the profession.

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association's (AOTA's) Evidence-Based Practice project. The clinical condition discussed in this inaugural Evidence Connection article is adults with stroke. Findings from the systematic reviews on this topic were published in the January/February 2015 issue of the American Journal of Occupational Therapy and in AOTA’s Occupational Therapy Practice Guidelines for Adults With Stroke (Wolf & Nilsen, 2015). Each article in this series will summarize the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical decision making.