American Journal of Occupational Therapy

The coronavirus disease 2019 pandemic accelerated the impending youth mental health crisis in the United States, necessitating a comprehensive approach to providing mental health education and interventions. School-based occupational therapy practitioners’ scope of practice includes wellness promotion, early detection, and evidence-based interventions for mental health challenges. Given the rise of school-based wellness programs, the growing legislation supporting the formation of such programs, and the burgeoning burden of pediatric mental health concerns, occupational therapy practitioners are uniquely positioned to create and implement interventions to support student access to the general education curriculum and can do so by using both prepandemic funding sources and pandemic response funds. This Health Policy Perspectives column is a call to action to refocus the occupational therapy practitioner’s role in school settings to include providing high-quality, evidence-based preventive mental health education and interventions. In this column, we examine prevention-based occupational therapy services in Mason City Schools, Mason, Ohio, as a model of success in the execution of this vision for school-based practice. In addition, we outline the importance of expanding the role of occupational therapy practitioners in schools, which will in turn increase the visibility and relevancy of the profession and broaden its impact on mitigating the youth mental health crisis.

This Health Policy Perspectives column is a call to action to refocus the occupational therapy practitioner’s role in school settings to include providing high-quality, evidence-based preventive mental health education and interventions.

Research has indicated a high prevalence of mental health problems among autistic people, with elevated rates of depression, anxiety, and suicidality. The profession of occupational therapy has its roots in mental health and can offer a unique focus on occupation to support the mental health needs of autistic clients. In this Guest Editorial we introduce articles for this special issue of the American Journal of Occupational Therapy related to autism and mental health and use the Person–Environment–Occupation Model. The articles offer insights into how interactions among person, environment, and occupation factors affect the mental health of autistic populations and demonstrate ways that mental health can be supported through occupational engagement. Opportunities to support the mental health of autistic people include promoting engagement in meaningful activities, supporting individual strengths, and bolstering clients’ sense of self and identification with their autistic identity. Future research is needed to uncover and test interventions to support autistic clients and should reflect cultural humility and participatory approaches. We chose to use identity-first language (rather than person-first language) to describe the autistic community in this Guest Editorial out of respect for common community member preferences and in accordance with recommendations for anti-ableist language use (Bottema-Beutel et al., 2021). Decisions about language for each article in this special issue were made by the respective authors.

This special issue includes review articles, qualitative exploratory studies, assessment tool content validation, and novel interventions and reveals opportunities for growth in the field of occupational therapy, both for more research as well as for intervention development and clinical involvement to support clients with autism across the lifespan.

Importance: The coronavirus disease 2019 (COVID-19) pandemic highlighted unique neurodiversity-affirming practices that may support autistic people’s mental health, many of which run contrary to typical notions of autism. These insights are critical for occupational therapists working with this population.

Objective: To (1) understand the self-reported mental health experiences of autistic adults during the COVID-19 pandemic and (2) identify ways that occupational therapy practitioners and other clinicians can help autistic adults during unexpected and challenging times.

Design: This qualitative interpretative phenomenological study used surveys and interviews to collect data between August 15, 2020, and May 1, 2021. Two researchers independently coded interview transcripts. Any disagreements were resolved through consensus.

Setting: Qualtrics survey and Zoom interviews.

Participants: Participants (N = 34) met the following inclusion criteria: self-reported diagnosis of autism spectrum disorder or Asperger’s syndrome, ages 18 to 35 yr, residing in the Eastern United States, able to understand English, and able to participate in a one-on-one interview using verbal or written communication. Recruitment was conducted via snowball sampling through local agencies serving autistic people.

Results: Two themes emerged from the data: (1) autistic adults’ social experiences during the COVID-19 pandemic paradoxically supported and hindered their mental health and (2) during the COVID-19 pandemic, mental health was tied to daily activity among autistic adults.

Conclusions and Relevance: Participants reported feelings of anxiety and depression, as well as a need for social interaction on their own terms. Clinical recommendations are provided.

What This Article Adds: This article includes suggestions generated from autistic people’s input on how clinicians can support this population. The suggested supports and alteration to occupations can be both applied in the case of another unexpected event (e.g., another pandemic) and incorporated to promote the participation and well-being of autistic adults.

Positionality Statement: We use identity-first language (e.g., autistic person) throughout this article because disability advocates and scholars assert that person-first language (e.g., person with autism) contributes to disability stigma (Collier, 2012; Gernsbacher, 2017).

This article includes suggestions generated from input from people with autism spectrum disorder or Asperger’s syndrome for how to support the mental health needs and promote the participation and well-being of autistic adults in case of another pandemic or other unexpected event.

Importance: Autism spectrum disorder (ASD) is one of the most prevalent neurodevelopmental disorders and is characterized by compromised social interactions, reduced verbal communication, stereotyped repetitive behaviors, restricted interests, and sensory abnormalities. Yet absent from the knowledge base is information about sensory abnormalities related to pain experiences. Exploring the pain experiences of people with ASD may provide occupational therapy practitioners with a baseline to determine areas of need and effective interventions.

Objective: To conduct a systematic review of the literature to summarize current evidence from case–control studies comparing sensory abnormalities with regard to pain experiences of people diagnosed and not diagnosed with ASD.

Data Sources: A systematic literature search of the CINAHL, Cochrane, MEDLINE (PubMed), OTseeker, and Web of Science databases, using MeSH terms and broad keywords.

Study Selection and Data Collection: A search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Newcastle–Ottawa Scale was used to evaluate the risk of bias of the included studies.

Findings: A total of 27 case–control studies involving 865 people with ASD and 864 control participants were included. Several methods were used to explore pain experiences, such as threshold detection or pain threshold.

Conclusion and Relevance: The results indicate that people with ASD may have an abnormal sensory experience with regard to pain sensitivity. Occupational therapy practitioners should develop an intervention to focus on pain.

What This Article Adds: This study adds to the body of literature indicating that people with ASD have sensory abnormalities with regard to pain experiences. Results highlight the need for occupational therapy interventions to focus on pain experiences.

This systematic review adds to the body of literature indicating that people diagnosed with Autism spectrum disorder (ASD) have sensory abnormalities with regard to pain experiences and highlights the need for occupational therapy interventions to focus on pain experiences.

Importance: Families raising children on the autism spectrum experience a confluence of life factors that influence their adaptation to self-care. The Family Assessment of Quality in Self-Care Engagement (FAQ–Self-Care) focuses on unpacking the factors that influence such families’ self-care participation.

Objective: To contribute to the content validity of the FAQ–Self-Care, a tool that aims to measure the quality and extent to which families who are raising children on the autism spectrum are participating in self-care.

Design: Mixed-methods research design. Qualitative data were drawn from experts’ feedback, and the relevance of FAQ–Self-Care test items was quantitatively analyzed.

Participants: Ten occupational therapists with expertise in the fields of pediatrics and family practice were invited to review the FAQ–Self-Care. Six occupational therapists agreed to participate.

Outcomes and Measures: Occupational therapy experts reviewed the FAQ–Self-Care and rated how essential each test item is in measuring the construct of families’ self-care participation using a 4-point Likert scale. An item-level content validity index (I-CVI) and a scale-level content validity index (S-CVI) were then calculated.

Results: Twenty test items with an I-CVI score between 0.833 and 1.000 were accepted. Items 3 and 16 obtained an I-CVI score below the cutoff range (0.667) and, therefore, were revised. Additional amendments to test items were made according to the qualitative feedback provided by content experts.

Conclusions and Relevance: Initial content validity of the FAQ–Self-Care assessment tool was established. Further rigorous evaluation of validity and reliability of the FAQ–Self-Care is necessary.

What This Article Adds: The FAQ–Self-Care is a promising assessment tool that highlights the influential life factors that intersect with the self-care participation of families raising neurodiverse children on the autism spectrum.

The Family Assessment of Quality in Self-Care Engagement (FAQ–Self-Care) is a promising tool that highlights the influential life factors that intersect with the self-care participation of families raising neurodiverse children on the autism spectrum.

Importance: Hospitals pose a threat to autistic children’s mental health. Adapting hospitals to meet children’s needs can address this issue.

Objective: To determine the impact of an interprofessional program (Adaptive Care) to support autistic children’s mental health on nursing staff’s knowledge, efficacy, and confidence.

Design: Pretest–posttest, quasi-experimental design.

Setting: Large pediatric hospital.

Participants: Nursing staff were the first participants in the program implementation. Approximately 300 nursing staff received training through the program, and 107 completed program evaluation surveys. Of these, 18 nursing staff completed both the pretest and posttest surveys approximately 1 yr apart.

Intervention: Occupational therapy practitioners and other professionals developed and implemented the program, which consists of staff training and resources to adapt hospital physical and social environments and to ultimately improve patients’ hospital experiences.

Outcomes and Measures: Researcher-developed, pilot-tested, online survey to assess knowledge, perceived effectiveness, confidence, and strategies that staff used while caring for autistic children in the hospital.

Results: Respondents had increased effectiveness and confidence working with autistic children in the hospital after program implementation. Respondents reported significantly more strategies to care for autistic children.

Conclusions and Relevance: Interprofessional collaboration and programming can positively affect social environments in the hospital by enhancing nursing staff’s self-efficacy, confidence, and strategies to support mental health and to enhance health care for autistic children.

What This Article Adds: The Adaptive Care program is an example of occupational therapy practitioners and other interprofessional team members adapting physical and social health care environments to support autistic children’s mental health. This program was effective at increasing nursing staff’s self-efficacy, confidence, and strategies while caring for autistic children in the hospital.

Positionality Statement: This article uses the identity-first language autistic people. 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).

The Adaptive Care program is an example of occupational therapy practitioners and other interprofessional team members adapting physical and social health care environments to support the mental health needs of autistic children.

Importance: A paucity of studies have focused on pain experiences among people with autism spectrum disorder, particularly those addressing social pain in daily life contexts or learning from the perspective of autistic people.

Objective: To explore the social pain experience of autistic people.

Design: A descriptive qualitative design followed by deductive thematic analysis. Interviews were semistructured to capture the social pain experience, coping strategies, and implications for the participation of autistic people.

Setting: Online interviews using Zoom videoconferencing software.

Participants: Fifteen autistic people were recruited for the study using purposeful and criterion sampling.

Results: Four primary themes emerged from the data analysis: (1) a definition of social pain and the distinction between social pain and other types of pain; (2) the sources—internal, external, and combined—of social pain; (3) the loneliness outcome, which echoes the gap between the desire for and lack of social contacts; and (4) coping strategies pertaining to the continuum between inward and outward coping strategies to deal with social pain.

Conclusion and Relevance: The study indicates the existence of a discrepancy between autistic people’s need for social interactions and the social pain they experience. It calls for intervention programs for autistic people to improve their coping strategies and promote their self-acceptance and better inclusion in the community.

What This Article Adds: Promoting social functioning is a prime role of occupational therapists, and this article adds a novel theoretical model that contributes to that role. The model represents the social pain experiences of autistic people and their strategies to overcome this phenomenon. Firsthand accounts of autistic people regarding social pain enable a better understanding of their desire to be involved in the social context. This study suggests directions for further intervention programs to assist autistic people in fulfilling their wish for social relationships and enabling their enhanced integration into society.

Positionality Statement: We recognize that use of person-first versus identity-first language is a source of debate and controversy. We have chosen to use identity-first language for two reasons. First, studies indicate person with autism is the term least preferred by autistic people (Botha et al., 2021). Second, autistic is the term used by the majority of our participants during interviews.

This study highlights a discrepancy between autistic people’s need for social interactions and the social pain they experience, and suggests directions for intervention programs to improve their coping strategies and promote their self-acceptance and better inclusion in the community.

Importance: Existing autism assessments, interventions, and research focus primarily on deficits rather than strengths, which affects autistic people’s well-being and their physical and mental health.

Objective: To develop an operational definition for strengths-based practice, develop a taxonomy to classify studies that characterize and provide strengths-based assessments and interventions, and present the impact on the mental health and well-being of autistic people of using strengths and interests in practice.

Data Sources: Literature was searched from 2000 to 2021 in the CINAHL, PsycINFO, EBSCOhost, MEDLINE, Web of Science, JSTOR, and ERIC databases.

Study Selection and Data Collection: A five-stage scoping review framework was merged with Joanna Briggs Institute enhancements to scrutinize peer-reviewed studies written in English that characterized and provided strengths-based assessments and interventions.

Findings: We sorted the 38 studies into four categories: strengths-based interventions, descriptive studies, exploratory studies, and commentaries. We found three fundamental themes: mental health outcomes, increased knowledge in interest areas, and supportive environments. Strengths-based interventions were related to positive social engagement, learning, self-advocacy, and anxiety reduction. Descriptive studies used strength assessments and examined stakeholder perceptions of strengths. Exploratory studies explored ways to incorporate strengths in practice. Finally, commentaries discussed the need to presume autistic competence and involve autistic people in research and practice.

Conclusions and Relevance: Despite the small body of literature, these findings have implications for pushing the boundaries of support to center the needs of autistic people and form genuine client collaborations.

What This Article Adds: This article adds to the understanding of using the strengths and interests of autistic people by incorporating their voices into occupational therapy research and practice in meaningful and purposeful ways.

Positionality Statement: This article uses the identity-first language autistic people. 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).

This article adds to the understanding of using the strengths and interests of autistic people by incorporating their voices into occupational therapy research and practice in meaningful and purposeful ways.

Importance: Some autistic adults experience depression and anxiety related to their social relationships. There is a need for evidence-based occupational therapy interventions that decrease depression and anxiety and improve the health of social relationships for autistic adults.

Objective: To determine the feasibility and preliminary effectiveness of the Healthy Relationships on the Autism Spectrum (HEARTS) intervention, a six-session, group-based psychoeducational intervention for the improvement of relationship health.

Design: One-group pretest–posttest design with a 3-mo follow-up after baseline.

Setting: United States; online intervention through community organization.

Participants: Fifty-five adults, ages 20 to 43 yr, with a professional or self-diagnosis of autism and the capacity to independently participate in an online, group-based, participatory class.

Intervention: Participants received 6 90-min weekly sessions that addressed healthy relationship topics, including recognizing abuse, meeting people, maintaining relationships, setting interpersonal boundaries, neurohealth for relationships, and ending relationships. A psychoeducational approach that provided education and involved guided discovery and strategy acquisition was used.

Outcomes and Measures: All measures were self-administered through an online survey. Depression and anxiety were assessed using instruments from the Patient-Reported Outcomes Measurement Information System.

Results: Fifty-five participants completed the intervention. Postintervention scores revealed statistically significant improvements in depression and anxiety.

Conclusions and Relevance: HEARTS is a promising intervention for improving depression and anxiety among autistic adults and should be investigated further.

What This Article Adds: HEARTS offers a potentially effective, nonpharmacological, psychoeducational group-based intervention option to promote healthy relationships for autistic adults.

Positionality Statement: This article uses identity-first language (autistic person) in accordance with the preference of autistic self-advocates (Autistic Self Advocacy Network, 2020; Kenny et al., 2016; Lord et al., 2022).

Healthy Relationships on the Autism Spectrum (HEARTS) offers a potentially effective, nonpharmacological, psychoeducational group-based intervention option to promote healthy relationships for autistic adults.

Importance: Although a central tenet of occupational therapy practice, evidence-based practice is at times overrepresented by research and can overlook the contributions of clinical expertise, the lived experience, and context. This survey affords the occupational therapy practitioner the opportunity to understand sensory integration and processing (SI/P) as experienced by autistic adults.

Objective: To explore the following research question through a retrospective analysis of an internet-based survey: What is the relationship between the SI/P differences and mental health concerns reported by autistic adults?

Design: Nonexperimental; retrospective analysis of data collected from September 2018 through June 2019. The analysis team joined the project after the survey had been launched.

Setting: The Grand Sensory Survey (GSS) was available internationally through the websites and social media accounts of the Autistic Empire and STAR Institute for Sensory Processing.

Participants: The sample included 440 total responses. Excluding responses from participants ages ≤18 yr (n = 24), 416 responses were included: n = 189 identified as autistic, n = 147 identified as nonautistic, and n = 80 did not provide a response to this query.

Outcomes and Measures: The GSS included questions about demographics, mental health, and sensory experiences.

Results: Both SI/P disruptions and sensory sensitivity predicted anxiety and depression (p < .001).

Conclusions and Relevance: Differences in SI/P are significant factors in mental health for autistic adults.

What This Article Adds: We implicate multiple aspects of SI/P and their influence on mental health among autistic adults. The autistic-led design of the survey ensures representation of issues that are pivotal to the autistic community, broadening the template for aspects of SI/P that should be considered when looking at client factors in autism and influence on function and participation.

Positionality Statement: The authors deliberately use identity first language in keeping with requests from the autistic community (see https://autisticadvocacy.org/about-asan/identity-first-language/). 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). This article is written from the perspective of the social model of disability and a neurodiversity affirming frame of reference. Three of the five authors are autistic.

This autistic-led, internet-based survey broadens consideration of the dimensions and mechanisms inherent in sensory integration and processing (SI/P) and provides insight into the intersection of SI/P differences with depression and anxiety among autistic adults.

Importance: Autistic children experience reduced participation in life activities. One factor that may contribute to their reduced levels of participation is anxiety, which is identified at higher rates among young autistic children than among their neurotypical peers. Anxiety is also strongly associated with sensory overresponsivity and has a considerable impact on daily functioning.

Objective: To determine the feasibility, acceptability, and usefulness of a small-group, parent-mediated intervention to prevent and reduce anxiety.

Design: Pre–post.

Setting: University research center.

Participants: Three parents of autistic children (ages 4–7 yr).

Outcomes and Measures: Parents completed a six-session group training program. Parents completed an anxiety scale for their child before and after parent training. At the end of training, parents participated in a focus group and were interviewed 4 mo after training.

Results: Positively received aspects of the intervention were the benefits of a small group, composed of parents of autistic children, run by a facilitator with expertise in autism and anxiety. Parents gained knowledge, resulting in “taking a different approach” with their child and “seeing an interplay between anxiety and autism.” After the intervention, parents reported a reduction in children’s reported anxiety levels.

Conclusions and Relevance: Knowledge of autism and anxiety acquired during a parent-mediated group increased parents’ understanding of their child’s behaviors and assisted them in supporting their child’s participation. Further research, including larger studies, is required to determine the effectiveness of this intervention.

What This Article Adds: The findings from this research provide preliminary support for the adaptation of an existing parent intervention (Cool Little Kids) to reduce anxiety among autistic children. Parents reported an increased awareness and understanding of anxiety and of the interplay between anxiety and autistic traits.

Positionality Statement: This article uses the identity-first language autistic people. 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).

The findings from this research provide preliminary support for the adaptation of an existing small-group, parent-mediated intervention (Cool Little Kids) to prevent and reduce anxiety among autistic children.

Importance: Social participation (SP) is an important facilitator of positive mental health for children and families. Children are dependent on their families to mediate SP, yet families of children with autism spectrum disorder (C-ASD) seemingly limit SP because of behavioral and functional challenges in community environments. The resulting isolation can affect the child’s and the family’s mental health.

Objective: To distill the essence of everyday SP experiences in the community of families raising C-ASD.

Design: Data collected via in-depth, semistructured interviews with a purposive sample and analyzed in the phenomenological tradition.

Setting: Community.

Participants: We recruited seven families with English-speaking parents (ages 18–64 yr) raising one C-ASD (age 2–8 yr). Families with more than one C-ASD or those whose C-ASD was diagnosed with complex medical condition or a neurological or genetic disorder were excluded.

Results: The essence of experiences of SP emerged in the form of three themes depicting the mismatch between societal expectations for SP and families’ experience: (1) “the struggle,” (2) “it’s hard to feel like you belong,” and (3) what we “have to do.”

Conclusions and Relevance: As a collective, families expressed desire for everyday community SP and could do so only in select environments with core groups. The findings, as interpreted through the lens of mental health promotion, reveal opportunities to reduce barriers and to promote meaningful family SP so as to facilitate positive mental health and well-being through the transactional intersecting characteristics of the child with ASD, the family, and the community.

What This Article Adds: This study illuminates the experience of SP of families raising a young C-ASD, highlighting both supports and barriers. Practitioners can use this information to potentially prevent isolation and promote both child and family mental health and well-being.

This study highlights the social participation (SP) experiences of families raising children with autism spectrum disorder (C-ASD), focusing on both supports and barriers. Occupational therapy practitioners can use the findings to potentially prevent isolation and promote both child and family mental health and well-being.

Importance: Play is an area of difficulty for autistic children, and occupational therapy practitioners need evidence to guide interventions to improve play for this population. Ayres Sensory Integration^® (ASI) intervention has not yet been studied for its impact on play outcomes.

Objective: To examine the impact of ASI intervention on play types in autistic children.

Design: Nonconcurrent, multiple-baseline design across subjects.

Setting: Outpatient occupational therapy clinic in New England.

Participants: Three autistic children, ages 5, 6, and 6 yr.

Intervention: Twenty-four ASI sessions.

Outcomes and Measures: Frequency of play type was coded using partial interval coding. Progress monitoring used Goal Attainment Scaling.

Results: All three participants demonstrated changes in the frequency of specific types of play, but changes varied among them.

Conclusions and Relevance: Findings suggest that ASI intervention may alter a child’s patterns of play.

What This Article Adds: This study is the first to examine the impact of ASI on play and the third that documents the feasibility of single-subject research for studying ASI. If confirmed in future studies, ASI could become an evidence-based intervention for improving play, an important outcome for autistic children and the profession of occupational therapy.

Positionality Statement: This article uses the identity-first language autistic people. 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).

This study is the first to examine the impact of the Ayres Sensory Integration^® (ASI) intervention on play outcomes for autistic children and the third study to document the feasibility of single-subject research for studying ASI.

Importance: Participation in meaningful occupations supports quality of life and health. Because quality of life is lower in autistic children than in children without this diagnosis, it is important to consider aspects contributing to the participation difficulties this population experiences.

Objective: To identify predictors of participation difficulties in a large data set from autistic children to inform professionals about potential intervention targets.

Design: Retrospective cross-sectional design using a large data set with multivariate regression models for home life, friendships, classroom learning, and leisure activities.

Setting: 2011 Survey of Pathways to Diagnosis and Services data set.

Participants: Parents or caregivers of 834 autistic children with co-occurring intellectual disability (ID) and 227 autistic children with no ID.

Results: The strongest participation predictors within the scope of occupational therapy practice were sensory processing, emotional regulation, behavioral variables, and social variables. Our results are consistent with those of smaller previous studies and indicate the importance of addressing these areas in occupational therapy intervention in line with client priorities.

Conclusion and Relevance: Focusing interventions with autistic children on sensory processing, emotional regulation, behavioral skills, and social skills to address their underlying neurological processing can support their increased participation in home life, friendships, classroom learning, and leisure activities.

What This Article Adds: Our findings support a focus in occupational therapy interventions on sensory processing and social skills to increase activity participation in autistic children with and without ID. Emotional regulation and behavioral skills can be supported by interventions that target cognitive flexibility.

Positionality Statement: This article uses the identity-first language autistic people. 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).

This study supports a focus in occupational therapy interventions on sensory processing, emotional regulation, behavioral skills, and social skills in autistic children with and without intellectual disability (ID) to increase participation in home life, friendships, classroom learning, and leisure activities.

Importance: Ayres Sensory Integration^® (ASI) is commonly used with children on the autism spectrum to promote sensory processing and improved occupational performance, including play. To date, there has been no explicit effort to examine improvements in playfulness through ASI.

Objective: To explore whether ASI, coupled with parent training, improves child playfulness and fathers’ support of child playfulness.

Design: Single-subject A–B–BC design secondary analysis of a nonconcurrent multiple-baseline study.

Setting: Occupational therapy clinic.

Participants: Three father–child dyads; children were ages 3 to 6 yr, with autism spectrum disorder (ASD) and documented sensory processing concerns.

Intervention: After a baseline phase, each child received at least 24 sessions of ASI, and fathers received parent training focusing on sensory processing issues and play via an online presentation.

Outcomes and Measures: The Parent/Caregiver’s Support of Children’s Playfulness and the Test of Playfulness.

Results: Visual analysis of the baseline phase, ASI phase, and ASI with parent training phase shows that all 3 fathers demonstrated an increase in the way they supported their child’s playfulness; however, this change was not maintained. Children’s playfulness fluctuated, reaching a peak after fathers received training, but none of the children maintained that change.

Conclusions and Relevance: Additional support by the therapist is required for fathers to learn and use new strategies to promote consistent change in child playfulness during play. Pilot data can be used to inform future studies.

What This Article Adds: Occupation- and family-centered frameworks may be useful in guiding practice when working with families of children with ASD.

This study explores whether Ayres Sensory Integration^® (ASI), coupled with parent training, improves child playfulness and fathers’ support of child playfulness.

Importance: Understanding the roles of caregivers of autistic adults is important given the increasing number of autistic adults and their ongoing need for various supports.

Objective: To address the following question: What roles do caregivers enact to support autistic adults?

Design: This study had a descriptive qualitative design. Caregivers completed a two-part interview. Data analyses included extracting narratives and a multiple-step coding process that resulted in the identification of three main caregiving themes.

Participants: Thirty-one caregivers of autistic adults.

Findings: Three main themes that reflected caregiving roles were identified: (1) managing daily living needs, (2) obtaining services and supports, and (3) providing invisible supports. Each theme comprised three subthemes. The roles were enacted regardless of the autistic adults’ age, gender, adaptive behavior scores, employment status, or residential status.

Conclusions and Relevance: Caregivers enacted many roles to support their autistic adult to participate in meaningful occupation. Occupational therapy practitioners can support autistic people across the lifespan in areas such as daily living, leisure, and executive function strategies to decrease the need for caregiving or services. They can also support caregivers as they manage the present and plan for the future.

What This Article Adds: This study provides descriptions that illustrate the complexity of caregiving for autistic adults. With an understanding of the many roles that caregivers enact, occupational therapy practitioners can provide services that support both autistic people and their caregivers.

Positionality Statement: We recognize that use of person-first versus identity-first language is a source of debate and controversy. We have chosen to use identity-first language, for two reasons. First, studies indicate that person with autism is the term least preferred by autistic people (e.g., Botha et al., 2021). Second, autistic is the term used by the majority of our participants during interviews.

Occupational therapy practitioners can support autistic people across the lifespan in areas such as daily living, leisure, and executive function strategies, as well as support their caregivers as they manage the present and plan for the future.

Importance: Playgrounds facilitate important opportunities for growth and development during childhood. Despite accessibility regulations, these experiences are not afforded to children with disabilities as a result of environmental and societal barriers.

Objective: To identify and synthesize existing research on the relationship between key areas of development and accessible play settings for children with disabilities to inform evidence-based interventions and advocacy work.

Data Sources: The following databases were searched on January 30, 2021: Academic Search Complete/EBSCO, CINAHL/EBSCO, Education Research Complete/EBSCO, ERIC, OTseeker, and PubMed.

Study Selection and Data Collection: This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were peer-reviewed, included children with disabilities ages 3 to 12 in an accessible play setting, and had outcomes related to areas of childhood development. Validated tools were used to determine risk of bias and quality of evidence.

Findings: Nine articles met inclusion criteria: 1 Level 3b matched case–control study, 4 Level 4 cross-sectional studies, 3 Level 5 qualitative studies, and 1 mixed-methods study with Levels 4 and 5 evidence. Eight of 9 studies reported that social participation, play participation, and motor skills development were negatively affected despite playgrounds being labeled accessible.

Conclusions and Relevance: Children with disabilities have decreased engagement in activities that provide opportunities for play, social participation, and motor skills development. Practitioners should address occupational injustice in the playground setting by engaging in program development, policy, and playground design to reduce stigma and increase accessibility.

What This Article Adds: By addressing play accessibility, occupational therapy practitioners could significantly reduce instances of play inequity. Creating interdisciplinary teams to address accessible playground design locally would allow occupational therapy practitioners the opportunity to make a lasting impact for the children in their community.

This systematic review identifies and synthesizes existing research on the relationship between key areas of development and accessible play settings for children with disabilities to inform evidence-based interventions and advocacy work.

Importance: Parent–child play is a beneficial and meaningful co-occupation. Therapists who want to optimize parent–child play for Latino- and Latina-American dyads need valid, reliable measures to assess caregiver playfulness in addition to preexisting measures of child playfulness.

Objective: To evaluate data collected from Latino-American caregivers with the Scale of Parental Playfulness Attitude (PaPA), a 28-item parent self-report to determine its construct validity, internal reliability, and cross-cultural validity.

Design: Quantitative exploratory design applying a latent-trait psychometric model.

Setting: Online survey.

Participants: Convenience sample of 50 Spanish-speaking parents from the mainland United States recruited via snowballing (88% mothers, ages 24–47 yr; M = 34.8 yr; 82% first-generation Americans). The inclusion criteria were age ≥18 yr; literate in Spanish; primary caregiver to a child age 2.5–7 yr. Data from an existing sample of 50 parents dwelling in Puerto Rico were used to examine cross-cultural validity.

Outcomes and Measures: Rasch analysis demonstrated evidence for adequate construct validity: positive point-measure correlations, 93% fit of items, logical item hierarchy, and good progression of the rating scale. Range and mean for parent playfulness exceeded those of the items; principal-components analysis revealed one contrast of 4.46 eigenvalues, bringing unidimensionality into question. Evidence suggested excellent internal reliability (person-reliability index = 0.85, strata = 3.55) and good cross-cultural validity (25 of 28 items formed a similar hierarchy for parents dwelling in the mainland United States and Puerto Rico).

Conclusions and Relevance: Although the PaPA can be used to assess caregiver playfulness with culturally diverse Latino-American dyads, further research is required.

What This Article Adds: This study provides evidence for the construct validity and internal reliability of a tool that measures parent playfulness in the context of parent–child play. The PaPA is an important tool for occupational therapists working with Latino-American families.

The evidence for this study suggests excellent internal reliability and good cross-cultural validity for the Scale for Parental Playfulness Attitude (PaPA), an important tool for occupational therapists working with Latino-American families to measure parent playfulness in the context of parent–child play.

Importance: There is a paucity of research that explores the effectiveness of sensory integration interventions in the school setting.

Objective: To test the effectiveness of a sensory integration intervention paired with teacher consultation, aligned with the principles of Ayres Sensory Integration^® and the Sensory Therapies and Research Frame of Reference, to improve functional regulation and active participation in school for students with sensory integration and processing differences.

Design: Concurrent, multiple-baseline, single-subject design.

Setting: Public elementary school in the United States.

Participants: Students (N = 3; ages 5–8 yr) whose sensory integration and processing differences were affecting their school occupational performance and were not remediated by integrated support.

Intervention: For 15 wk, each student had one-to-one sensory integration intervention 2×/wk for 30 min and a consultation between the occupational therapist and teacher weekly for 10 min.

Outcomes and Measures: The dependent variables, functional regulation and active participation, were measured weekly. The Short Child Occupational Profile and Behavior Assessment System for Children, Third Edition, were given before and after intervention. Goal Attainment Scaling and semistructured interviews with the teachers and participants were completed after intervention.

Results: All 3 students showed meaningful improvement in functional regulation and active participation in the classroom during the intervention period as demonstrated by a 2-SD band method or celeration line analysis. All additional measures noted positive change.

Conclusions and Relevance: Findings suggest that sensory integration intervention with consultation in the education setting can improve school performance and participation for children with sensory integration and processing challenges.

What This Article Adds: This study offers an evidence-based model of service delivery for the school setting that is effective in improving the functional regulation and active participation of students whose sensory integration and processing challenges interfere with occupational engagement and are not mitigated by embedded supports.

This study tests the effectiveness of a sensory integration intervention paired with teacher consultation, aligned with the principles of Ayres Sensory Integration^® and the Sensory Therapies and Research Frame of Reference, to improve functional regulation and active participation in school for students with sensory integration and processing differences.

Importance: Limited research has elucidated factors predicting occupational therapy–specific service utilization by children with autism. Such research is needed to inform reasons for receipt of services.

Objective: To examine factors associated with occupational therapy service utilization by children with autism. We hypothesized that elevated sensory hyperresponsiveness; greater sensory interests, repetitions, and seeking; and lower adaptive behavior would predict more service utilization.

Design: Analysis of extant data from a prospective, longitudinal survey study about autism symptom severity, adaptive behavior, sensory features, and demographic and service utilization information of children with autism ages 3 to 13 yr.

Setting: Online parent survey regarding child behaviors during daily activities and contexts.

Participants: 892 parents of children with autism from 50 U.S. states.

Outcomes and Measures: We used scores on the Vineland Adaptive Behavior Scale–Second Edition, the Social Responsiveness Scale, and the Sensory Experiences Questionnaire Version 3.0 and responses to a demographic questionnaire. We formulated hypotheses after data collection but before analysis.

Results: Predictors of higher occupational therapy service utilization were lower enhanced perception; lower adaptive behavior; elevated sensory interests, repetitions, and seeking behaviors; younger child age; and higher household income.

Conclusion and Relevance: Results partially support our hypotheses. Sensory interests, repetitions, and seeking behavior predicted occupational therapy service utilization, whereas other sensory response patterns did not, suggesting a possible referral bias for certain sensory response patterns. Occupational therapy practitioners can educate parents and teachers about the scope of practice, which includes addressing sensory features beyond sensory interests, repetitions, and seeking behaviors.

What This Article Adds: Children with autism who have impairments in adaptive functioning and high levels of sensory interests, repetitions, and seeking behaviors receive more occupational therapy services. Occupational therapy practitioners should be well trained to address such concerns and advocate for the profession’s role in mitigating the impact of sensory features on daily life.

This study found that sensory interests, repetitions, and seeking behavior predicted occupational therapy service utilization by children with autism, whereas other sensory response patterns did not, suggesting a possible referral bias for certain sensory response patterns and the opportunity for occupational therapy practitioners to educate parents and teachers about the scope of practice.

Importance: A viable occupational therapy program based on joint attention is needed to ensure that children with autism spectrum disorder (ASD) lead lives in which they interact socially.

Objective: To explore the benefit of a joint attention–based occupational therapy program offered simultaneously with the usual special education program (USEP) compared with USEP alone.

Design: Randomized controlled study, including pre-, post-, and follow-up testing.

Setting: Special education and rehabilitation center.

Participants: Twenty children with ASD in the study group, M = 4.80 yr (SD = 0.78 yr), and the control group, M = 5.10 yr (SD = 0.73 yr), were included.

Intervention: All children received USEP (2 sessions/wk for 12 wk). Joint attention–based occupational therapy was applied to the study group in addition to USEP (3 sessions/wk for 12 wk).

Outcomes and Measures: The Social Communication Questionnaire (SCQ), Autism Behavior Checklist (ABC), and Motor-Free Visual Perception Test–4 (MVPT–4) were implemented.

Results: The study group had a statistically and clinically significant improvement in SCQ, ABC, and MVPT–4 scores after the intervention (p < .001). The control group did not show statistically significant improvement in measurements (p > .05). The mean values of SCQ–Total, ABC–Total, and MVPT–4 variables measured at 3-mo follow-up were significantly different than preintervention (p < .05).

Conclusions and Relevance: Joint attention–based intervention, including a child-centered approach, can improve social communication, reduce ASD-related behaviors, and improve visual perception.

What This Article Adds: This study emphasizes the importance of occupational therapy with a holistic perspective, based on joint attention, in terms of increasing the effectiveness of special education programs attended by children with ASD and reinforcing visual perception, communication, and positive behaviors in children with ASD.

Occupational therapy based on joint attention–based intervention can enhance the effectiveness of special education programs attended by children with autism spectrum disorder (ASD) by improving visual perception, social communication, and positive behaviors.

Executive functions—specifically, problem-solving skills—are crucial for school success. Challenges in these functions faced by autistic adolescents are often unrecognized or viewed through a behavioral lens that requires correction or normalization. A lack of development of higher order problem-solving skills leads to increased instances of secondary mental health issues, creating further behavioral and social challenges. We propose using the Engineering Design Process (EDP), a flexible, cyclical, top-down, self-sustaining approach that uses peer mediation to teach group problem-solving skills. We then position this cycle within existing occupational therapy models to demonstrate its adaptability and flexibility, describe the distinct features of this problem-solving strategy, and present a real-world case study in which the EDP is used as a problem-solving approach in an after-school program. The EDP develops crucial social and interpersonal skills using interest-driven occupations and can be organically used as a group strategy. This article uses the identity-first language autistic people. 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).

This article discusses using the Engineering Design Process (EDP) within existing occupational therapy models to demonstrate its adaptability and flexibility, describes the distinct features of this problem-solving strategy, and presents a real-world case study in which the EDP is used in an after-school program.

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Project and illustrate how the research evidence from the reviews can be used to inform and guide clinical decision making. Each article in this series summarizes the evidence from published reviews on a given topic and presents an application of the evidence to a related clinical case. This Evidence Connection article presents a case report of a college student receiving occupational therapy services after sustaining repeated sports-related concussions. The occupational therapy evaluation and intervention process is described. Systematic review briefs on interventions for people with traumatic brain injury were published in Vol. 76 (Suppl. 2) of the American Journal of Occupational Therapy.

This Evidence Connection article describes the occupational therapy evaluation and intervention a college student received after sustaining repeated sports-related concussions.