Journal presentation

By,
R.Angelin Thangam
Bot final year
  Title:Effectiveness of Interventions to Improve Social
Participation, Play, Leisure, and Restricted and Repetitive
Title of the Behaviors in People With Autism Spectrum Disorder: A Systematic
review
study  Year of publication:2015
 Journal site: American journal of occupational therapy
  Kelly Tanner, PhD, OTR/L, is Occupational TherapyResearch
Coordinator, Nationwide Children’s Hospital Columbus, OH, and
Lecturer, Occupational Therapy Division, School of Health and
Rehabilitation Sciences, The Ohio State University,
Columbus;Kelly.Tanner@nationwidechildrens.org
 Brittany N. Hand, MOT, OTR/L, is PhD Student,Occupational
Authors Therapy Division, School of Health and Rehabilitation Sciences,
The Ohio State University,Columbus.
 Gjyn O’Toole, MEdStud, GradDip TEFL, BA, Dip Occ Therapy, is
Senior Lecturer, School of Health Sciences, University of
Newcastle, Callaghan, New South Wales, Australia.
 Alison E. Lane, PhD, OTR/L, is Associate Professor,University of
Newcastle, Callaghan, New South Wales,Australia.
  People with autism spectrum disorder (ASD) experience lifelong
barriers to full participation in social, play, and leisure activities and
contexts.
 Many of these barriers can be attributed to core difficulties in social
communication and restricted and repetitive behaviors, including
sensory features (American Psychiatric Association, 2013).
 The costs of nonparticipation in these areas of occupation are
immense. The World Health Organization (2001) considers full
Introduction participation in daily activities and routines as the ultimate indicator
of health and functioning.
 Moreover, the achievement of intellectual, physical, social, emotional
functioning communicative potential in childhood is dependent on
full occupational engagement (King et al., 2003; Law, 2002).
 Recent estimates of the prevalence of childhood ASD in the United
States stand at 1 in 68, a 30% increase since 2008 (Autism and
Developmental Disabilities Monitoring Network, 2012).
  Thus, occupational therapists are increasingly required to provide
comprehensive evaluation and treatment of occupational
performance issues associated with ASD.
 Participation in social, play, and leisure pursuits is clearly within
the domain of occupational therapy (American Occupational
Therapy Association [AOTA], 2014) and is a particular issue for
people with ASD.
 In a large study of the social participation patterns of adolescents
Contd.. inspecial education, Shattuck, Orsmond, Wagner, and Cooper
(2011) reported that adolescents with ASD were significantly more
likely to never see friends outside of school, be called by friends, or
be invited to social activities than adolescents with other
disabilities, including adolescents with intellectual disability,
learningdisability, and speech–language impairment. Level of
social participation was mediated in this study by social
communication and functional cognitive skills (Shattuck et
al.,2011).
  Family and caregiver stress associated with ASD is higher than that
experienced by families of children with other disabilities
(Kuhaneck & Briner, 2010).
 Many studies have documented the additional risks for financial
stress, poorer mental health, and social isolation for families of
people with ASD (Kuhaneck & Briner, 2010).
 Care recipients’ challenging behavior, often in the form of
restricted and repetitive behaviors, has been identified as a primary
Contd.. stressor for caregivers (Bishop, Richler, Cain, & Lord, 2007).
 Khanna et al. (2011) reported that the extent of behavioral
problems in the child with ASD has a direct impact on family
functioning, caregiver physical wellbeing, and level of social
support available to families.
 This finding underscores the importance of addressing challenging
behaviors in people with ASD to promote caregiver coping and,
subsequently, opportunities for full participation in occupation.
  Interventions addressing social participation, restricted and
repetitive behaviors, play, and leisure are likely to enhance the
quality of occupational engagement for people with ASD,improve
health and well-being, and reduce caregiver burden.
Objectives The findings will guide occupational therapists working in school,
community, and clinic settings in selecting evidence based
approaches to treat the social, behavioral, play, and leisure
limitations of people with ASD across the lifespan.
Purpose of the The purpose of this study was to review interventions within the
scope of occupational therapy to improve social participation,
study restricted and repetitive behaviors, play, and leisure.
  The focused question for this review was
“What is the evidence for the effectiveness of interventions within
the scope of occupational therapy practice to improve social
interaction, restricted and repetitive behaviors, play performance,
and leisure participation for people with autism spectrum
Research disorders?” .
 The question was developed by the authors, an advisory group of
question experts in the field, AOTA staff, and the consultant to the AOTA
Evidence-Based Practice (EBP) Project.
 The question is one of four developed by the AOTA EBP Project to
update knowledge in the area of occupational therapy practice
and ASD.
  This systematic review was supported by AOTA as part of the EBP
Project.
 In 1998, AOTA instituted a series of EBP projects to assist
members with meeting the challenge of finding and reviewing the
literature to identify evidence and, in turn, use this evidence to
inform practice (Lieberman & Scheer, 2002).
Methods  Following the evidence-based philosophy of Sackett, Rosenberg,
Muir Gray, Haynes, and Richardson (1996), AOTA’s projects are
based on the principle that the EBP of occupational therapy relies
on the integration of information from three sources:
 (1) clinical experience and reasoning,
 (2) preferences of clients and their families, and
 (3) findings from the best available research.
 A major focus of AOTA’s EBP Project is an ongoing program of
systematic reviews of the multidisciplinary scientific literature,
using focused questions and standardized procedures to identify
practice-relevant evidence and discuss its implications for
practice, education, and research.
 An evidence-based perspective is founded on the assumption that
scientific evidence of the effectiveness of occupational therapy
interventions can be judged to be more or less strong and valid
according to a hierarchy of research designs, an assessment of the
quality of the research, or both.
 AOTA uses standards of evidence modeled on those developed in
evidence-based medicine. This model standardizes and ranks the
value of scientific evidence for biomedical practice using a grading
system
In this system, the highest level of evidence,
 Level I, includes systematic reviews of the literature, meta-analyses,
and randomized controlled trials (RCTs). In RCTs, participants are
randomly allocated to either an intervention or a control group, and
the outcomes of both groups are compared.
 Other levels of evidence include Level II studies, in which assignment
to a treatment or a control group is not randomized (cohort study);
 Level III studies, which do not have a control group;
 Level IV studies, which use a single-case experimental design,
sometimes reported over several participants; and
 Level V studies, which are case reports and expert opinion that
include narrative literature reviews and consensus statements.
  The review was limited to peer-reviewed scientific literature
published in English.
 The studies included were judged by the authors to be within the
scope of practice of occupational therapy.
 Studies that examined interventions that were occupation based or
focused on occupational outcomes were included.
Study includes  The intervention described in the study had to be deliverable by an
occupational therapist alone and not reliant on a multidisciplinary
team or classroom milieu approach. The literature included in the
review was published between 2006 and 2013 and included study
participants with ASD.
 Studies included in the review provide Level I, II, and III evidence,
but systematic reviews of lower level studies were also included.
Exclusion  The review excluded data from presentations, conference
proceedings, non–peer-reviewed research literature, dissertations,
criteria and theses.
  Search terms for the reviews were developed by the methodology
consultant to the AOTA EBP Project and AOTA staff, in consultation with
the authors, and by the advisory group.
 The search terms were developed not only to capture pertinent articles
but also to make sure that the terms relevant to the specific thesaurus of
each database were included.
 A medical research librarian with experience in completing systematic
Search review searches conducted all searches and confirmed and improved the
strategy search strategies.Databases and sites searched included
MEDLINE,PsycINFO, CINAHL, ERIC, and OTseeker.
 In addition,consolidated information sources, such as the Cochrane
Database of Systematic Reviews, were included in the search.
 Moreover, reference lists from articles included in the systematic reviews
were examined for potential articles, and selected journals were hand
searched to ensure that all appropriate articles were included. A total of
10,129 citations and abstracts were included in this review.
  The consultant to the EBP Project completed the first step of
determining which articles were relevant to the review question.
The titles and abstracts of these articles were then reviewed by
the first and last authors to determine their suitability for full
review.
 An article was included in the final review when both of these
authors agreed on its suitability.Final articles were divided among
the authorship team on the basis of a broad category.
Analysis  A single author reviewed each article, and the findings were
abstracted to an evidence table.
 AOTA staff and the EBP Project consultant reviewed the evidence
tables to ensure quality control. The authors discussed the
findings of articles when clarification was required.
 The risk-of-bias framework recommended by Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) was
used to rate study quality (Liberati et al., 2009).
  After the review process outlined, 66 articles were included in the
final review (48 Level I, 6 Level II, and 12 Level III).
 The final set of articles was grouped into four broad categories:
studies examining the effectiveness of interventions addressing
 (1) social skills,
Results  (2) social communication,
 (3) play and leisure, and
 (4) restricted and repetitive behaviors.
 A summary of the findings in each of these categories follows, and
effect sizes are reported when possible.
  Overall, few studies included in this review used a randomized
design. Although 48 Level I articles were included,most of these
articles were either systematic reviews or meta-analyses of lower
level evidence such as single-subject-design studies.
 In cases in which random assignment to groups occurred,
participants (and their families) were rarely blinded to their group
allocation.
 Moreover, there was a strong reliance on parent-report measures
Risk of bias to assess the outcomes of the intervention. There was minimal
reporting of the use of fidelity measures in the implementation of
interventions, which decreases the internal validity of the studies.
 Small sample sizes prevented meaningful subgroup analyses,
which limits the conclusions that can be drawn about the benefit
of the interventions for specific subsets of people with ASD.
 Most studies, however, reported high participant retention rates.
For a risk-of-bias analysis for each article included in this review.
  Twenty-four Level I articles, 4 Level II articles, and 7 Level III articles
examined interventions to improve social skills.
 Themes included group-based social skills trainingprograms, peer-mediated
interventions, activity-based interventions, computer-based interventions,
and Social Stories.
 Group-based social skills training programs are those in which a therapist
leads a group of people with ASD through a curriculum or training program
Effectiveness to improve social skills.

of intervention  Because of the importance of context for generalization of these skills, we

further categorized these interventions according to whether they took place

for social skills in a clinic or in the child’s natural context (e.g., school or camp).
 Six Level I (DeRosier, Swick, Davis, McMillen, & Matthews, 2011; Flynn &
Healy, 2012; Gantman, Kapp, Orenski, & Laugeson, 2012; Koenig et al., 2010;
Lopata et al., 2010; Reichow, Steiner, & Volkmar, 2013), 1 Level II (Castorina
& Negri, 2011), and 5 Level III (de Bruin & Verheij, 2012; Herbrecht et al.,
2009; Hillier, Fish, Siegel, & Beversdorf, 2011; Stichter, O’Connor, Herzog,
Lierheimer, & McGhee, 2012; White, Koenig, & Scahill, 2010) studies on
group-based social skills training programs that were administered in a
clinical setting were reviewed.
  Overall, increased social skills,increased social communication,
decreased autistic mannerisms, increased positive interactions,
and decreased negative interactions were reported as outcomes
of these interventions.
 Three Level I (Bellini, Peters, Benner, & Hopf,2007; Kasari,
Rotheram-Fuller, Locke, & Gulsrud, 2012;Lerner & Mikami, 2012),
1 Level II (Cotugno, 2009), and 1 Level III (Walker, Barry, & Bader,
2010) studies on group-based social skills training programs
Contd… administered in a school or summer camp context were included
in the review.
 Increased social skills, less solitary play, and more joint
engagement on the playground were reported as outcomes of
these interventions.
 When reported, effect sizes were medium to large; Kasari et al.
(2012) reported Cohen’s d values ranging from 0.44 to 0.97, and
Lerner and Mikami (2012) reported d values ranging from 21.8 to
20.98.
  Three systematic reviews (Level I) reported on the findings of
studies of both clinic-based and contextual group-based social
skills training programs (Rao, Beidel,& Murray, 2008; Schreiber,
2011; White, Koenig, &Scahill, 2007).
Contd…  These reviews noted improved socialcompetency and friendships
as well as increased selfesteem and social participation.
 Strong evidence supported the use of group-based social skills
training programs in both clinic-based and contextual settings to
improve social skills in people with ASD.
  Peer-mediated interventions were defined as those that included
a peer as the therapeutic agent for either all or part of the
intervention.
 Six Level I studies of interventions that used peers for all or part of
the program indicated gains in social skills (Chan et al., 2009;
Flynn & Healy,2012; Schreiber, 2011; Wang & Spillane, 2009;
Contd… Wang, Cui, & Parrila, 2011; Zhang & Wheeler, 2011). Although
most studies did not report effect sizes, Wang and Spillane (2009)
did report medium to large effect sizes for studies on peer-
mediated interventions included in their review (ds 5 0.71–1.64).
 However, other articles reported that gains achieved in the studies
were not generalized to other contexts. The overall strength of
evidence for peer-mediated interventions was mixed
  Activity-based interventions included those in which the therapeutic
modality was engagement in group tasks (either collaborative tasks or
exercise) with the goal of increasing social skills.
 One Level I systematic review and 1 Level II study were conducted on
interventions that used collaborative tasks to improve social skills. The
systematic review (Schreiber, 2011) noted gains (specific effect sizes not
provided) in social interaction and social competency with a LEGO
intervention and an increase in appropriate social interactions with
collaborative computer work.

Contd..  A Level II study of Topobo, a construction activity, observed increased parallel

play and decreased solitary play as compared with participants in a LEGO
intervention (Farr, Yuill, & Raffle,2010).
 One Level I study, a review of the effectiveness of exercise programs for
people with ASD, found an improvement in social skills (Sowa &
Meulenbroek,2012). Across all studies, people who participated in group
programs showed more improvement than people who participated in
individual programs.
 The overall strength of evidence for activity-based interventions was
moderate.
  Computer-based interventions were defined as programs in which
participants learn social skills via computer based social skills training
programs, virtual reality training programs, or video modeling. Two Level I
(Hopkins et al.,2011; Ramdoss et al., 2012) and 1 Level II (Turner-
Brown,Perry, Dichter, Bodfish, & Penn, 2008) studies noted increased social
skills and increased social cognition for those who participated in a
computer-based social skills training program.
 Results were mixed, however, for improvements in emotion recognition
(Hopkins et al., 2011; Ramdoss et al., 2012).
Contd…  One Level III study indicated increased social perception skills and increased
performance on a theory of-mind task after virtual reality training.
 Participants’conversation skills also increased from pretest to posttest,
although the difference was not statistically significant (Kandalaft,
Didehbani, Krawczyk, Allen, & Chapman, 2013).
 Four Level I studies of video modeling reported increased social skills and
decreased challenging behaviors (Flynn & Healy, 2012; Shukla-Mehta, Miller,
& Callahan, 2010; Wang & Spillane, 2009; Wang et al., 2011). The overall
strength of evidence for computer-based interventions was moderate.
 Social Stories (Gray, 2000) are an intervention in which short
narratives of a social situation are written and read to or by a child
to increase positive social behaviors or decrease challenging
behaviors.
 Six Level I studies on Social Stories were included in the review.
Half of the studies noted increased positive social behaviors and
decreased challenging behaviors (Karkhaneh et al., 2010;
Schreiber, 2011; Test, Richter, Knight, & Spooner, 2011).
 However, the remaining studies found low or highly variable levels
of effectiveness that call into question the effectiveness of this
intervention (Kokina & Kern, 2010; Reynhout & Carter, 2011; Wang
& Spillane, 2009).
 The overall strength of evidence for Social Stories was mixed.
  Seventeen Level I, 1 Level II, and 1 Level III articles that examined interventions to
improve social communication were included in this review .
 Interventions studied included the Picture Exchange Communication System (PECS) and
naturalistic behavioral,developmental, classroom-based, parent-mediated, sensory–
motor, imitation, and joint attention interventions.
 PECS (Bondy & Frost, 1998) allows for functionalcommunication through the exchange of
Effectiveness pictures or icons.Two Level I systematic reviews of single-participant studies(Flippin,
Reszka, & Watson, 2010; Ganz, Davis, Lund,Goodwyn, & Simpson, 2012) showed
of intervention improvements insocial communication and socialization, with the best effects in younger
children and children with comorbid intellectualdisability.

for social  Three Level I studies noted improvements in rate of initiation of communication and use
of PECS (d 5 0.81;Gordon et al., 2011; Howlin, Gordon, Pasco, Wade, & Charman, 2007;

communicatio Yoder & Lieberman, 2010).

 However, 1 Level I study reported that effects were not maintained at 10 mo (Howlin et

n al., 2007). One Level II study indicated that PECS was more effective than conventional
language therapy in improving social behaviors, cooperative play, joint attention,
requests, and initiations (Lerna, Esposito, Conson,Russo, & Massagli, 2012).
 The overall strength of evidence for PECS was strong, although it is important to note
that the 2 Level I systematic reviews (Flippin et al., 2010; Ganz et al.,2012) included
studies with low-level designs.
  Naturalistic behavioral interventions include those that are
behavioral in nature but take place in the person’s natural setting
(e.g., milieu therapy, functional communication training, and
pivotal response training; Brunner &Seung, 2009).
 Three Level I studies (all of which were systematic reviews)
Contd…. supported improvements in joint attention,communication
initiations, requesting, and spontaneous verb use (Brunner &
Seung, 2009; Ospina et al., 2008;Seida et al., 2009).
 The overall strength of evidence for naturalistic behavioral
interventions was moderate.
  Developmental interventions are based on child development
theory (e.g., Developmental, Individual differences, Relationship-
based [DIR] or floor time;Brunner & Seung, 2009).
 Two Level I systematic reviews reported small, positive gains in
spontaneous communication and parent–child interactions.
Contd….  Results were, however, mixed, with some studies showing no
effect (Brunner & Seung, 2009; Ospina et al., 2008).
 One Level III study resulted in increased spontaneous
verbalizations and imitation (Vismara, Colombi, & Rogers, 2009).
 The overall strength of evidence for developmental interventions
was moderate
  Classroom-based interventions are developed for use in the
classroom setting and may be used by many professionals including
occupational therapy practitioners (e.g.,Treatment and Education of
Autistic and related Communication Handicapped Children
[TEACCH]; Brunner& Seung, 2009).
Contd…  One Level I systematic review indicated that most studies were of
low quality and findings were mixed (Brunner & Seung, 2009).
 The strength of evidence for classroom-based interventions was
insufficient.
  Parent-mediated interventions engage the client’s parent or parents as
the primary therapeutic agent (e.g.,parent-mediated communication-
focused treatment [PACT], Autism 1-2-3).
 Two Level I RCTs noted improvements in initiation, joint attention,
reciprocal social interaction, vocalizations, and pointing (ds 5 0.33–1.22;
Green et al.,2010; Wong & Kwan, 2010).
Contd…  One Level I RCT did not observe any significant effects of a parent-
focused training program but noted a trend for improvements in
compliance and a decrease in avoidance in children with developmental
quotients ³ 50 (Oosterling et al., 2010).
 One Level I systematic review indicated improvements in parent–child
interactions and communication behavior (Seida et al.,2009). The overall
strength of evidence for parent-mediated interventions was moderate.
  Sensory–motor interventions use movement and sensory input
to improve social communication skills.
 Two Level I studies, both of which were systematic reviews, noted
that a variety of interventions have had mixed results on social
Contd…. outcomes (Ospina et al., 2008; Seida et al., 2009).
 In general, studies included in these reviews were of low quality.
The strength of evidence for sensory–motor interventions to
improve social communication was insufficient.
 Imitation training includes interventions that are focused on
improving imitation skills for social communication.
 Two Level I RCTs showed moderate to large improvements in
elicited and spontaneous imitation, joint attention, and social–
emotional skills, particularly for participants with higher
pretreatment play skills (hp 2s 5 .13–.38; Ingersoll,2010, 2012).
 Both studies involved small sample sizes. The strength of evidence
for imitation training was moderate
 Joint attention training interventions aim to improve the client’s
ability to engage in joint attention, which is an important early
form of social communication.
 Three Level IRCTs noted improvements in joint attention,
initiation, and responding in intervention groups after
interventions for joint attention (Kaale, Smith, & Sponheim, 2012;
Kasari,Gulsrud, Wong, Kwon, & Locke, 2010; Kasari,
Paparella,Freeman, & Jahromi, 2008).
 Effect sizes for these studies were moderate to large (ds 5 0.44–
1.35).
 One Level I RCT of a social curriculum focused on joint attention
showed improvements in socially engaged imitation (d 5 0.86),
but not in joint attention or shared positive affect (Landa, Holman,
O’Neill, & Stuart, 2011).
 Gains were maintained at 6 mo. The strength of evidence for joint
attention interventions was strong.
  Three Level I, 1 Level II, and 4 Level III articles examining play
performance or leisure participation were included in this review.
 Interventions to improve play skills included an adult modeling
and prompting intervention, an intervention for social–pragmatic
Effectiveness skills, DIR–floortime, and a pretend play intervention.
 A Level I systematic review on interventions incorporating adult
of intervention modeling and prompting found that these interventions resulted
for play and in improved pretend play behaviors (Barton & Wolery, 2008). A
one-group pre–post study (Level III) found limited support for a
leisure social–pragmatic intervention significantly affecting
communication and symbolic behaviors in children with ASD
(Keen, Rodger,Doussin, & Braithwaite, 2007).
 However, parent-reported improvements were seen in children
with lower levels of adaptive functioning before intervention.
 A Level III (one-group pre–post) study using a parent-delivered
DIR–floortime intervention showed improvements in children’s
functional developmental levels (Solomon,Necheles, Ferch, &
Bruckman, 2007).
 Moreover, evidence from a Level III (one-group pre–post) study
using a child-led play-based intervention supported improvement
in social interaction and language skills and decreased social
disconnection in children with developmental disabilities,
including ASD (Stagnitti, O’Connor, &Sheppard, 2012).
 The evidence to support interventions to improve play
performance in children with ASD was limited.
 Interventions to improve pretend play may be beneficial, but
available programs require further research to determine their
efficacy.
 Interventions to improve leisure participation included recess
interventions, a leisure group, water exercise,and Social Stories.
 A Level I systematic review of recess interventions (Lang et al.,
2011) found evidence to support strategies involving
environmental and social supports to improve social initiation,
turn taking, and group play in children with ASD on the
playground.
 Evidence from a two-group nonrandomized pre–post design study
(Level II; Palmen, Didden, & Korzilius, 2011) supported the
effectiveness of an outpatient leisure group in decreasing the need
for leisure support and increasing leisure engagement and
satisfaction in high-functioning young adults with ASD, with
medium to large effect sizes reported (ds 5 0.64–0.83).
 A single-group crossover study (Level III) demonstrated that a
water exercise intervention improved social skills in children with
ASD(Pan, 2010).
 Results from an RCT (Level I; Quirmbach,Lincoln, Feinberg-Gizzo,
Ingersoll, & Andrews, 2009) of a Social Story intervention showed
improved game play skills in children with ASD, with h2s ranging
from .18 to .669.
 The evidence for improving leisure participation in people with
ASD was moderate, with the strongest evidence for the use of
recess interventions and Social Stories.
  Four Level I articles on restricted and repetitive behaviors were
included in this review .
 Interventions within the scope of occupational therapy practice
included kata training, school interventions, exercise, and self-
management.
Effectiveness  Evidence from an RCT supported the use of kata training to
of intervention decrease the mean stereotypy severity in children with ASD
(Bahrami, Movahedi, Marandi, & Abedi, 2012).
for restricted  A systematic review of school interventions found positive effects
and repetitive for strategies such as antecedent manipulations, change in
context, differential reinforcement, and self-management
behavior interventions to decrease challenging behaviors in children with
ASD(Machalicek, O’Reilly, Beretvas, Sigafoos, & Lancioni,2007).
 Evidence from a systematic review supported exercise as a
method of decreasing self-stimulatory behaviors(Petrus et al.,
2008)
 The results of a systematic review of self-management strategies
suggested that these strategies can increase target behaviors of
students with ASD (Southall & Gast, 2011).
 Moderate evidence supported the use of behavioral techniques,
such as antecedent manipulation and self-management, to
improve restricted and repetitive behaviors in people with ASD.
 Evidence also indicates that interventions involving physical
activity (kata training and exercise) may be beneficial for
decreasing restricted and repetitive behaviors in people with ASD.
  The purpose of this systematic review was to establish the evidence for the
effectiveness of interventions within the scope of occupational therapy
practice to improve social interaction, restricted and repetitive behaviors, and
play and leisure participation for people with ASD.
 It is evident that,since the initial AOTA review in this area (Case-Smith
&Arbesman, 2008), occupational therapists now have a broader base of
literature from which to draw to inform their practice.
 The increase in research activity on this topic now allows us to make
recommendations for therapy on the basis of specific desired outcomes.
Discussion  High-quality, rigorous study designs, however, are still lacking in some areas.
The conclusions of this review are constrained by the variance in outcome
measures used among studies, a strong reliance on parent-report measures, a
strong risk for bias secondary to nonblinding of participants and
assessors,variability in the age of the participants, limited use of randomized
study designs, limited use of fidelity measures for interventions used, and a
wide variety of intervention contexts and intervention delivery modes.
 Within the limits of these constraints, we propose the following guidelines for
clinical practice for occupational therapy practitioners working with people
with ASD
  Strong evidence supported the use of group-based social skills
training programs in both clinic-based and contextual settings to
improve social skills in people with ASD.
 Occupational therapy practitioners are well placed to implement such
programs. Although time and frequency varied significantly among
studies, the most effective groups appeared to meet regularly for ³60
min at a time for a total of ³8 hr.
 Less evidence was found to support the use of computer based
Social skills interventions such as virtual reality, video modeling,and collaborative
computer work as well as activity-based interventions.
 Initial studies, however, showed promising results. Further research is
required before these techniques can be used extensively in practice.
 Studies relating to peermediated interventions and Social Stories
reported mixed results.
 Occupational therapy practitioners should proceed with caution when
implementing these interventions.
  Strong evidence supported the use of PECS and joint attention strategies to
improve social communication in young children with ASD.
 Occupational therapy practitioners should consider using these strategies
as part of a comprehensive early intervention program to support positive
social communication.
 The use of these techniques in combination may also be indicated. For
Social example, joint attention behavior has been observed to increase after
parent- or caregivermediated interventions.
communicatio  Other techniques, including parent-mediated, naturalistic behavioral,
developmental, and imitation training, also appear to be effective but
n require further investigation.
 These techniques may be indicated in specific, individual circumstances, but
more study is required before they are implemented across practice areas.
 We found insufficient evidence at this time to support the use of classroom-
based and sensory–motor strategies to improve social communication. We
would not recommend use of these strategies until further research is
conducted.
  Evidence to support interventions to improve play performance in
children with ASD is emerging, but the efficacy of the available
programs has not been established.
 Given the importance of play to children’s occupational engagement,
this area requires urgent attention in the occupational therapy
literature.
 Occupational therapy practitioners should proceed with caution
Play and when implementing these interventions because of the current lack
of evidence and should keep systematic data on their effectiveness
leisure with clients.
 The evidence for interventions aimed at improving leisure
participation in people with ASD was moderate.
 The strongest support was found for strategies implemented in the
context of recess time at the child’s school and for Social Stories.
 More studies are needed before the available leisure interventions
should be extensively implemented in practice.
  The evidence to support behavioral techniques within the scope of
occupational therapy, such as antecedent manipulation and self-
management, to improve restricted and repetitive behaviors in
people with ASD was moderate.
Restricted and  Occupational therapists should consider implementing these
strategies as part of a comprehensive, interdisciplinary
repetitive intervention to decrease restricted and repetitive behaviors that
behavior interfere with a client’s ability to participate in meaningful
occupations.
 Other strategies such as kata training and exercise may also be
beneficial, but replication of the initial promising results is needed
before broad-based use in practice.
  This review was strengthened by the extensive range of literature
considered for inclusion and its examination of a range of social
Strength and participation factors (e.g., social skills,social communication,
imitation, gestures, joint attention).
limitations  It reached across disciplinary boundaries to ensure that all
relevant literature was included to inform occupational therapy
practice.
  The review was limited by its inclusion of studies judged to be within the
scope of occupational therapy practice.
 In particular, the review did not include interventions using a
multidisciplinary or milieu approach. Interventions of this type are
obviously an essential component of a comprehensive service delivery
strategy for people with ASD.
 The purpose of this review, however, was to focus more narrowly on those
strategies that can readily be implemented by occupational therapists
Contd…. working independently.
 Similarly, this review did not include interventions based purely in
behavioral theory or medication management.
 Although occupational therapists in specialist practices may be involved in
intensive behavioral therapies, this type of practice was not considered
representative of the majority of occupational therapy practice in the field
of ASD.
 When using the results of this review to inform practice, therefore, we
encourage occupational therapists to consider the role of multidisciplinary,
milieu, and intensive behavioral therapies in their specific practice context.
  Further research is indicated to replicate promising results in
newer interventions; refine and manualize intervention protocols
Future for greater adoption in practice; increase the number of true
directions experimental, randomized study designs;and examine which
interventions are most beneficial for subgroups of people with
ASD
 The results of this study have the following implications for occupational
therapy practice:

 Occupational therapy practitioners should consider using group-based

social skills training programs to address limitations in social skills in
Implementatio children with ASD. Other interventions may also be effective, but additional
research is needed.
n of  Occupational therapy practitioners should consider using PECS, joint
occupational attention, and parent-mediated strategies to improve social
communication in individuals with ASD. Other interventions may also be
therapy effective,but additional research is needed.
 Although limitations in play and leisure should be addressed in individuals
practice with ASD, limited evidence currently exists for specific interventions to
improve these areas of occupation.
 Occupational therapy practitioners should consider the use of behavioral
techniques such as antecedent manipulation and self-management to
manage restricted and repetitive behaviors that interfere with occupational
performance in individuals with ASD
  Occupational therapists working with people with ASD to improve
social participation, play, leisure, and restricted and repetitive
behaviors now have a broad base of research to inform their practice.
 The findings of this review of the literature suggest that several well-
supported intervention techniques to improve social communication
and social skills are within the scope of occupational therapy.
 The evidence supporting interventions for play, leisure, and restricted
Conclusion and repetitive behaviors is mixed, although several interventions
show promise.
 Further research is required in this area to increase the rigor of study
designs, manualize intervention protocols, and determine which
interventions should be applied to which subgroups of people with
ASD.
 Occupational therapists should carefully consider the current
research evidence supporting treatment techniques before
determining individual plans of care.
Thank you