Jane Case-Smith, EdD, OTR, FAOTA
Scott Tomchek, PhD, OTR/L
Marian Arbesman, PhD, OTR/L
Ask the question
Review findings
Discuss how ASD research has
Identify implications for
occupational therapy
OT Practitioner Decision Making
Clinical Expertise
Research is
one piece
Practitioners make clinical decisions (shown here as the area in which the three circles
intersect) using research evidence, client preferences, and their own clinical experience
(Haynes & Haines, 2000).
What is the effect of interventions used in
occupational therapy for children with autism
spectrum disorder (ASD)?
Levels define the rigor and validity of studies
based on the type of research design (Centre for
Evidence-Based Medicine, 2008):
 Level I—Systematic reviews/meta analyses
and randomized clinical trials
 Level II—Non-randomized clinical trials
 Level III—Cohort studies and pre/post
single-group designs
 Level IV—Single-subject designs
 Level V—Case studies.
Identified search terms (all terms related to
OT) to answer the research question
Used terms to find research articles in library
databases (related to health, education, and
Evaluated individual abstracts: Eliminated
Evaluated individual articles: Eliminated more
Analyzed the studies that met all of the
17,440 citations were reviewed.
217 articles were reviewed.
After this initial review, 50 were included, the
updated review has 62:
◦ 24 Level I studies
◦ 19 Level II studies
◦ 19 Level III studies
Studies fell into 5 topics that organized the
results. I have since updated the review
using these categories.
Sensory Integration/Sensory Based
Relationship-Based Interactive
Social Skills Interventions
Comprehensive Behavioral Interventions
Interventions that Combine Behavioral and
Developmental Approaches
Types of Sensory integration studies:
◦ Sensory integration (SI; 1 systematic review)
 Three single subject studies have been completed, 2
with low positive effects, 1 study did not show effects.
 One single group study has been published
◦ Touch based, massage (2 clinical trials)
 A Level I study (small n) analyzed effect of the Hug
 A single subject study of Sensory Stories showed
positive effects (Marr et al., 2007).
One systematic review of the research
literature for SI (Baranek, 2002).
Included 3 studies that examined the effect of
traditional SI with children with autism:
◦ 2 single-subject designs (Level IV) with 2–5
preschool-age children (Case-Smith & Bryan, 1999;
Linderman & Stewart, 1999)
◦ 1 pre/post test single-group study (Level III) (Ayres
& Tickle, 1980).
◦ 1 additional single subject study was completed by
Watling & Deitz (2007)
The 3 studies found the
following effects:
◦ Increased social engagement
◦ Increased purposeful play
◦ Lower levels of hypersensitivity.
Watling & Deitz did not find changes
in engagement in play or reduction of undesired
behavior after SI intervention;
Parents reported some improvements in behavioral
regulation, compliance, and socialization.
Bottom Line
SI intervention can improve social
interaction and purposeful play
It can decrease hypersensitivity
However, the effects are small, and the
findings are inconclusive.
SI intervention may enhance the child’s
ability to modulate behaviors and
participate in social interaction
Includes massage
2 Level I randomized clinical trials (Escalona et al.,
2001; Field et al., 1997).
Hug machine study
(Edelson et al., 1999)
Both trials used massage once a day.
Children with ASD who were massaged
exhibited decreased
Aversion to touch
Off-task behavior
Stereotypic behavior
Sleep and on-task behavior increased.
Bottom Line
Touch-based interventions have moderate,
positive short-term effects on behavior and
These interventions can decrease maladaptive
behaviors, reduce hyperactivity, inhibit selfstimulation and stereotypic movements, and
improve attention and focus.
OT often uses play and interactive
activities to improve the child’s social
These studies focused on improving social
engagement and social–emotional growth.
In these studies, parents were coached
Emphasized is joint attention,
engagement, responsiveness, positive
affect, and playfulness.
The goal is not to build skills, although
skills are an indirect goal.
The goal is to improve “pivotal behaviors.”
• DIR (Floortime play) (Greenspan & Wieder, 1997)
• These interventions
Promote parents’ responsiveness and child’s social–
emotional growth
Incorporate play activities that emphasize social
interaction (e.g., reciprocal communication, eye
contact, shared attention, turn taking)
Involve child-centered activity (e.g., child leads
activity, parents imitate child’s actions).
Underlying abilities that enable children to
learn and socially interact (Mahoney & Perales,
Positive affect
Joint attention
These interventions emphasized responsive,
supportive relationships and social–emotional
development promote the child’s social
emotional growth.
Studies (level III) that examined this type of
Greenspan & Wieder, 1997
Mahoney & Perales, 2005
Gutstein, Burgess,& Monfort, 2007
Wieder & Greenspan, 2005.
◦ Children became socially competent, responsive,
and interactive.
◦ Children showed gains in developmental
performance across domains (particularly
The children with the best outcomes for DIR (16 of
200), 7 years after intervention, were within normal
range and did not appear autistic but had some
anxiety and depression (Wieder & Greenspan, 2005).
Relationship Development Intervention (RDI) is a
parent-based, cognitive-developmental approach,
that focuses on the parent-child relationship
(Gutstein et al., 2007).
◦ Hwang and Hughes (2000) analyzed 16 studies in
a systematic review. They identified the following
strategies as effective across studies:
◦ Select toys/activities that appear to be of interest
to the child.
◦ Prompt a response then wait for the child to
respond - Pause before cueing again.
◦ Arrange the environment to challenge the childengage the child in problem solving.
◦ Imitate the child’s actions.
◦ Encourage the child to stay engaged one more
Set up a challenge in the environment to
elicit communication and interaction.
Examples of challenges to elicit
◦ Initiate an activity (e.g., bring out a tricycle) and
wait for the child to ask for assistance to mount
◦ Put favorite toy on high shelf.
◦ Hide favorite toy under heavy object that needs to
be moved by an adult.
◦ Present a drink and/or treat just out of his reach
so that he must gesture or request one.
These studies provide positive evidence for
interventions that use play and focus on
interaction with the child using methods that
1. Capture the child’s attention
2. Respond to any/all communication attempts.
3. Help him or her feel safe
4. Keep the child’s attention
5. Engage him or her in problem solving
6. Help him or her learn essential elements of
social interaction.
Bottom Line
Interventions that use interactive play activity as a
context for interaction can promote social–
emotional growth, social competence, and
foundational skills for learning.
These interventions emphasize
responsiveness, positive affect,
and imitation of child.
Lack of social skills is a key feature in ASD.
Social skills training
Is often implemented in groups
Children typically high functioning
Is often used with older children/adolescents.
Most of the social interventions have been
implemented with preschool children (52%) or
school-age children (36%) (Reichow & Volkmar, 2010).
Many social skills interventions have been
developed and researched.
Often these intervention combine behavioral
techniques and use peer supports.
Two recently published meta-analyses
provide good summaries of what works.
◦ Social skills training (teaching models)
◦ Social stories
Social skills are explained, modeled, and
practiced using simple, discrete steps and
White, Keonig, & Scahill (2007) summarized
the findings of 14 studies on social kills
groups to indentify “promising teaching
Increase social
Improve appropriate
social responding
Promote skills
Make social rules clear and
Model age appropriate
initiation strategies
Use natural reinforcers for
social initiations.
Teach simple social “scripts”
for common situations.
Teach social response scripts
Reinforce response attempts
Use modeling and role play to
teach skills.
Provide opportunities to
practice skills in safe, natural
• Often implemented by OTs to teach children
appropriate behaviors and demonstrate small
positive effects
• Present descriptive, directive, perspective, and
affirmative statements
• Teach children positive and appropriate
1) Descriptive-factual statements used to describe the
2) Perspective-description of reactions, feelings, and
responses of others
3) Directive -
statements that identify an appropriate
4) Cooperative -sentences that identify what others will do
to assist
5) Affirmative - statements that enhance the meaning
6) Control - sentences written by the child
 Grapy (2004)
In a Level I study (Reynhout & Carter, 2006), 16 studies
of Social Stories were identified (12 single
◦ 9 reported reduction of problem behaviors.
◦ 8 reported increase in appropriate behaviors.
◦ Many paired Social Stories with positive
reinforcement of appropriate behavior.
Meta analysis on Social Story Interventions
(Kokina & Kern, 2010)
Reviewed 41 studies, included 18, all of which were
single subject designs.
Overall effectiveness: 60% (after the social story,
the 60% of the child’s behaviors were better than
the highest baseline behavior).
This is low or questionable effect.
Although nearly all studies had positive effects,
they were small.
Long-term effects have
not been studied.
In the photograph, a Social
Story is used to define the
steps in a cooking task with
a child with ASD.
Work best in reducing inappropriate behaviors.
Work best to change simple, singular behaviors
Are a brief intervention that is implemented
immediately before the targeted situation.
Are most effective when illustrated.
Work best with participants who have higher levels
of communication and social skills.
IBI refers to 32–40 hours/week of discrete
trial training using the ABA (applied
behavioral analysis) theory.
10 studies were identified: 4 Level I, 5 Level
II, 1 Level III.
All studies were similar in using discrete trial training.
The original study was done by Lovaas (1987), and a
follow-up was done by McEachie et al. (1993).
1 used parents to implement (Sallows & Grauper,
1 included a period when discrete trial training was
faded, and the children were integrated into
preschool (Cohen et al., 2006).
1 used a lower intensity treatment. (Eledevik et al.,
Rogers & Vismara (2008) completed a systematic
review of RTC of behavioral interventions
IBI using one-on-one discrete trial training is
widely applied to children with ASD and has
evidence of moderate to strong effects.
Lovaas (1987) compared 19 children with ASD who
had intensive behavioral treatment vs. 19 children
who received standard care.
After 2 years of IBI, 9 children had normal IQs
and were in regular education.
In the control group, 1 child had a normal IQ.
In a follow up 5 years later, these findings
were confirmed, and 9 of 19 children
continued to be in the normal range.
In 2 Level I studies and 2 Level II studies since
the original Lovaas studies, moderate effects
have been achieved with IBI:
◦ IQ increased with IBI, adaptive behaviors did not
(Smith et al., 2000).
◦ Parents did discrete trial training for one group,
clinicians did it for the other; there was no difference
between groups (Sallows & Graupner, 2005).
◦ In Norway, less-intensive treatment was used (12
hours/wk). Children improved in IQ but not in
adaptive behavior (Eldevik et al., 2006).
◦ 1 study used discrete trial training, then an
integrated model in preschool to help children
generalize their learning (Cohen et al., 2006).
◦ Positive effects resulted in both studies, but not
as dramatic as the original study.
Bottom Line
Positive effects are achieved with IBI, primarily in IQ
and language, with limited evidence of
improvement in adaptive behaviors.
Social–emotional function has not yet been
Recent models of IBI have changed and have
become more interdisciplinary
A systematic approach to prevent problem
behaviors in children with ASD:
1 Level I study was a systematic review of 9
other studies and 5 reviews (Horner, Carr,
Strain, Todd, & Reed, 2002)
Elements of PBS:
1. Establish consistent environments that prevent a
behavior’s occurrence.
2. Eliminate or modify the antecedents.
3. Eliminate the consequences that reinforce the
problem behaviors.
4. Develop appropriate behaviors through modeling,
guidance, cueing, instruction, and reinforcement.
In the 37 comparisons of PBS vs. a control
group or another intervention, 85% of the
studies found a reduction in disruptive
In most of the comparisons, the reduction of
disruptive behavior was highly significant
(90% or greater reduction).
Bottom Line
PBS has moderate-to-strong positive effects in
reducing problem behaviors in children with ASD.
Important elements include modifying the
environment to prevent behaviors, applying
consistent consequences, and modeling/
prompting appropriate behavior.
Use development and behavioral approaches
Address all developmental areas
Are play based and individualized
Include typically functioning peers
Involve professionals from multiple disciplines.
Are implemented in preschools/schools.
◦ TEACCH (Treatment and Education of Autistic and
Communication Handicapped Children) (Ozonoff &
Cathcart, 1998; Panerai et al., 2002)
◦ Rogers’ Denver Model (Rogers et al., 1986; Rogers
& DiLalla, 1991) and Early Denver Model (Dawson et
al., 2010)
14 studies: 2 Level I, 4 Level II, 8 Level III.
Programs emphasize positive affect, non-verbal
communication, play, social relationships, high
Effects are positive but small.
Recent studies have found stronger effects.
◦ TEACCH programs are highly structured and
emphasize visual learning.
◦ TEACCH structures the environment to organize a
child’s activities and transitions between activities.
2 non-randomized trials of TEACCH found
moderate positive effects.
Ozonoff and Cathcart (1998) evaluated the
effectiveness of a TEACCH-based home
program for young children.
Panerai et al. (2002) compared TEACCH to
an education program.
Moderate improvements were made across
performance areas.
Rogers established and studied a developmental
based preschool program.
She is highly influenced by OT
Her program emphasized positive affect,
communication pragmatics, structure, and routine.
This developmental
model was examined
in pre/post one-group
designs of preschool
Modest improvements
were made cognition,
communication, and
Use play (and a developmental curriculum) for
developing skills
The sensory system is viewed as a crucial regulator
of attention, arousal, and affect.
Sensory based activities are included in sensorysocial dyadic routines and through planned group
sensory activities
Skill development is carried out in routines of daily
living and play.
Social skills are taught in the context of natural
social exchanges, sensory social activities.
Most of the innovative approaches for
children with ASD combine developmental
and behavioral approaches while recognizing
the child’s sensory problems.
Current investigators use sensory strategies
and define them as efficacious strategies.
Effective interventions are individualized, data
driven, intensive, and comprehensive.
Throughout the 62 studies, developmental,
relationship-based, and behavioral models
demonstrated effectiveness.
The following reoccurring themes were
consistent across the studies.
Analysis of performance includes
Developmental level
Physiological factors (e.g., arousal, regulation)
Sensory processing
Maladaptive behaviors
Pivotal behaviors (e.g., attention, initiation,
◦ External variables related to performance.
Relationship-based interactive interventions
are good examples of family centered
Families need:
◦ A deep understanding of the child and of autism.
◦ Resources to provide an optimal learning
environment, to promote the child’s independence,
social participation, ability to cope with life.
◦ Support and a parent network.
◦ Strategies that work!
Almost all successful interventions were
data-driven, intensive, often provided for
4-8 hours/day
Comprehensive Interventions
◦ Consider all domains and all aspects of
performance; including atypical behaviors, assess
how behaviors are influenced by context.
◦ Are interdisciplinary
◦ Involve multiple adults in intensive teaching across
◦ Often combine (thoughtfully) theoretic approaches.
Active engagement is a component of most
interventions, including discrete trial training,
incidental teaching, DIR and RDI.
Includes the ability to sustain attention to an
activity or person.
Includes the child’s motivation for mastery,
his/her interests and goal-directed behaviors.
Interdisciplinary comprehensive
interventions have positive effects on
children with autism.
Recent studies have shown positive effects
when systematically combining theoretic
Additional research of sensory interventions
is needed.
Research of interventions that help children
transition into adult roles is needed.
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