Occupational Therapy Practice Guidelines for Autistic People Across the Lifespan.

IMPORTANCE: Occupational therapy practitioners need evidence to support interventions that promote subjective well-being among autistic people and their families through optimal engagement and participation in occupations. OBJECTIVE: These Practice Guidelines are informed by systematic reviews to expand knowledge of interventions that promote access, inclusion, engagement, and optimal participation in occupations that are meaningful to autistic people. Our intent was to foster occupational therapy practitioners' clinical decision-making and reasoning when working with autistic people and their care partners. METHOD: These Practice Guidelines were developed on the basis of four systematic reviews, supporting evidence and literature, along with continued revisions and integration through an iterative and collaborative process. RESULTS: A total of 98 articles were included in the systematic reviews, which are the foundation for practice recommendations in these guidelines. Forty-eight of the systematic review articles were used to inform the clinical recommendations included in these Practice Guidelines. CONCLUSIONS AND RECOMMENDATIONS: Strong to moderate evidence indicates the need for multidisciplinary, goal-oriented interventions to support autistic people in different contexts. Although there is only emerging evidence in the inclusion of autistic people's strengths, interests, and perspectives to guide occupational therapy interventions, such practices can enhance the delivery of neurodiversity-affirming and trauma-informed practices. In addition, evidence is needed to support participation in activities of daily living (ADLs) for autistic youths. We recommend the use of strengths-based language to describe autistic people and the use of environmental adaptations, care partner education, and coaching to enhance occupational therapy service delivery. Plain-Language Summary: The literature is sparse regarding neurodiversity-affirming and trauma-informed practices for autistic youths, as well as for participation in activities of daily living (ADLs). These Practice Guidelines provide new information on positive mental health development; self-determination; ADLs, instrumental ADLs, play, and leisure occupations for children, adolescents, and adults; person-centered planning for adolescents and adults; and rest and sleep. Information on health management is also provided. 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). However, we respect the use of person-first language and have made a conscious decision to include research articles that have used this language.

Associations Among Daily Living Skills, Motor, and Sensory Difficulties in Autistic and Nonautistic Children.

IMPORTANCE: Motor and sensory challenges are commonly reported among autistic individuals and have been linked to challenges with daily living skills (DLS). To best inform clinical intervention, greater specificity in how sensory and motor challenges relate to DLS is needed. OBJECTIVE: To evaluate the relationship between combined sensory and motor scores and DLS performance among autistic and nonautistic children and to explore associations between motor scores and performance on specific DLS items. DESIGN: Descriptive design. SETTING: University research lab. PARTICIPANTS: Autistic children, nonautistic children with no family history of or diagnosis related to autism, and nonautistic children with a family history of or diagnosis related to autism (ages 6-10 yr; N = 101). All participants communicated verbally. INTERVENTION: None. Outcomes and Measures: Parent-report measures of DLS and sensory features and standardized assessments of motor performance. RESULTS: Findings indicated a strong relationship between motor difficulties and all domains of DLS. At the item level, motor skills were associated with occupations of dressing, bathing, health management, cleaning up and organization, meal preparation and clean-up, education, and safety. Combined sensory and motor measures better predicted DLS than sensory or motor measures alone. CONCLUSIONS AND RELEVANCE: Children with motor and sensory challenges are likely to experience challenges with a diversity of occupations, which is important given the prevalence of motor and sensory challenges among autistic children and among children with other neurodevelopmental conditions. Therapeutic interventions that account for or address these motor challenges and associated sensory features are likely to further enhance DLS. What This Article Adds: A combination of motor challenges and sensory features better predict DLS than either motor or sensory challenges alone. In addition, motor challenges in children are most highly associated with DLS challenges in the domains of dressing, bathing, cleaning, education, safety, health, and meal preparation. Occupational therapists can use this information when considering how the results of sensory and motor assessment may guide clinical intervention in autistic and nonautistic children.

Quality-of-Life Discrepancies Among Autistic Adolescents and Adults: A Rapid Review.

IMPORTANCE: Quality of life (QoL) is a core outcome of occupational therapy, but it is decreased among autistic adolescents and adults. This is the first review of QoL from an occupational therapy standpoint. OBJECTIVE: To identify self-reported QoL differences between autistic and nonautistic samples; investigate sex differences in QoL among autistic people; examine consistency in QoL among autistic people across age, intellectual disability (ID), and self- versus proxy-report method; and appraise occupational therapy-related interventions addressing QoL among autistic people. DATA SOURCES: Articles published in peer-reviewed journals between 2010 and 2020, located through Academic Search Ultimate, PubMed, and OTseeker, along with the American Journal of Occupational Therapy, British Journal of Occupational Therapy, Canadian Journal of Occupational Therapy, and Australian Occupational Therapy Journal. Study Selection and Data Collection: Article samples consisted of at least 20% autistic females and used self-reported QoL measures. Qualitative research was excluded, as well as studies with participants younger than age 13 yr. Twenty-seven articles qualified (3 Level 1B, 13 Level 3B, and 11 Level 4). FINDINGS: Autistic adolescents and adults demonstrated decreased self-reported QoL compared with nonautistic peers across age and ID presence. One article compared sex differences in QoL among autistic people. Interventions improved QoL among autistic people. CONCLUSIONS AND RELEVANCE: Autistic adolescents and adults demonstrate decreased QoL in comparison with nonautistic peers. Questions remain related to sex differences in QoL among autistic people, an area for future research. Multiple evidence-based approaches to improve QoL in the autistic population are relevant to occupational therapy practice. What This Article Adds: Self-reported QoL among autistic adolescents and adults is clearly lower than among their nonautistic counterparts. This article provides information on multiple interventions related to occupational therapy to improve QoL among autistic people.

The relation between specific motor skills and daily living skills in autistic children and adolescents.

Introduction: Motor skill difficulties are common in autistic children and are related to daily living skills (DLS). However, it remains unclear which specific motor tasks are most likely to impact overall DLS. This study sought to fill this gap. Methods and results: In 90 autistic children and adolescents (ages 6-17 years), we found that fine/manual motor tasks, like drawing or folding, demonstrated significant medium-sized relations with DLS, even after accounting for IQ and sensory features, whereas tasks in the areas of bilateral coordination, upper-limb coordination, and balance only related to DLS (small effect sizes) prior to accounting for IQ and sensory features. When looking at an overall balance score, we found that IQ significantly interacted on the relation between overall balance and DLS. Discussion: These results further demonstrate the particular importance of fine/manual motor skills for DLS in autistic youth, even when accounting for IQ and sensory features. Indeed, accounting for sensory features strengthened the relations between fine/manual motor skills and DLS. Our findings provide evidence of the impact of cognitive factors on the relation between balance and DLS, indicating that it may be that autistic individuals with lower IQs experience relations between balance and DLS that are different than their peers with higher IQs. Our findings support the benefit of considering individual motor skills rather than domain-level information when assessing ways to promote DLS in autistic youth. The results further shed light on the importance of fine motor skills, as well as the unique relationship of balance and DLS in autistic individuals with lower IQs.

Role of autonomic, nociceptive, and limbic brainstem nuclei in core autism features.

Although multiple theories have speculated about the brainstem reticular formation's involvement in autistic behaviors, the in vivo imaging of brainstem nuclei needed to test these theories has proven technologically challenging. Using methods to improve brainstem imaging in children, this study set out to elucidate the role of the autonomic, nociceptive, and limbic brainstem nuclei in the autism features of 145 children (74 autistic children, 6.0-10.9 years). Participants completed an assessment of core autism features and diffusion- and T1-weighted imaging optimized to improve brainstem images. After data reduction via principal component analysis, correlational analyses examined associations among autism features and the microstructural properties of brainstem clusters. Independent replication was performed in 43 adolescents (24 autistic, 13.0-17.9 years). We found specific nuclei, most robustly the parvicellular reticular formation-alpha (PCRtA) and to a lesser degree the lateral parabrachial nucleus (LPB) and ventral tegmental parabrachial pigmented complex (VTA-PBP), to be associated with autism features. The PCRtA and some of the LPB associations were independently found in the replication sample, but the VTA-PBP associations were not. Consistent with theoretical perspectives, the findings suggest that individual differences in pontine reticular formation nuclei contribute to the prominence of autistic features. Specifically, the PCRtA, a nucleus involved in mastication, digestion, and cardio-respiration in animal models, was associated with social communication in children, while the LPB, a pain-network nucleus, was associated with repetitive behaviors. These findings highlight the contributions of key autonomic brainstem nuclei to the expression of core autism features.

Sensorimotor Features and Daily Living Skills in Autistic Children With and Without ADHD.

Attention-deficit/hyperactivity disorder (ADHD) commonly co-occurs in autistic children. However, additional research is needed to explore the differences in motor skills and sensory features in autistic children with and without ADHD, as well as the impacts of these factors on daily living skills (DLS). This observational study sought to fill this gap with 67 autistic children (6.14-10.84 years-old), 43 of whom had ADHD. Autistic children with ADHD demonstrated higher sensory features and lower motor skills than autistic children without ADHD. In examining autism and ADHD features dimensionally, we found that overall sensory features, seeking, and hyporesponsiveness were driven by both autism and ADHD features, whereas motor skills, enhanced perception, and hyperresponsiveness were driven by only autism features. Additionally, in using these dimensional variables of autism and ADHD features, we found that differences in motor skills, sensory and autism features, but not ADHD features, impact DLS of autistic children, with autism features and motor skills being the strongest individual predictors of DLS. Together, these results demonstrate the uniqueness of motor skills and sensory features in autistic children with and without ADHD, as well as how autism features, sensory features, and motor skills contribute to DLS, emphasizing the importance of a comprehensive understanding of each individual and complexities of human development when supporting autistic children.

Brainstem white matter microstructure is associated with hyporesponsiveness and overall sensory features in autistic children.

BACKGROUND: Elevated or reduced responses to sensory stimuli, known as sensory features, are common in autistic individuals and often impact quality of life. Little is known about the neurobiological basis of sensory features in autistic children. However, the brainstem may offer critical insights as it has been associated with both basic sensory processing and core features of autism. METHODS: Diffusion-weighted imaging (DWI) and parent-report of sensory features were acquired from 133 children (61 autistic children with and 72 non-autistic children, 6-11 years-old). Leveraging novel DWI processing techniques, we investigated the relationship between sensory features and white matter microstructure properties (free-water-elimination-corrected fractional anisotropy [FA] and mean diffusivity [MD]) in precisely delineated brainstem white matter tracts. Follow-up analyses assessed relationships between microstructure and sensory response patterns/modalities and analyzed whole brain white matter using voxel-based analysis. RESULTS: Results revealed distinct relationships between brainstem microstructure and sensory features in autistic children compared to non-autistic children. In autistic children, more prominent sensory features were generally associated with lower MD. Further, in autistic children, sensory hyporesponsiveness and tactile responsivity were strongly associated with white matter microstructure in nearly all brainstem tracts. Follow-up voxel-based analyses confirmed that these relationships were more prominent in the brainstem/cerebellum, with additional sensory-brain findings in the autistic group in the white matter of the primary motor and somatosensory cortices, the occipital lobe, the inferior parietal lobe, and the thalamic projections. LIMITATIONS: All participants communicated via spoken language and acclimated to the sensory environment of an MRI session, which should be considered when assessing the generalizability of this work to the whole of the autism spectrum. CONCLUSIONS: These findings suggest unique brainstem white matter contributions to sensory features in autistic children compared to non-autistic children. The brainstem correlates of sensory features underscore the potential reflex-like nature of behavioral responses to sensory stimuli in autism and have implications for how we conceptualize and address sensory features in autistic populations.