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.

Flourishing and Functional Difficulties among Autistic Youth: A Confirmatory Factor Analysis.

The International Classification of Functioning, Disability, and Health for Children and Youth outlines body structures and functions and activities and participation to fully describe elements that support or detract from participation. While flourishing has gained attention in recent literature, research also points to the role of functional difficulties among autistic youth in influencing participation. Clearly, function is a multi-dimensional and complex construct and likely consists of both indicators of flourishing and functional difficulties. We used data from the National Survey of Children's Health (NSCH) from 2016 to 2020 to identify aspects of flourishing functional difficulties to achieve the following aims: (1) Investigate the factor structure of flourishing and functional difficulties among autistic youth ages 10-17 years; and (2) examine the extent to which child variables (i.e., sex, age, race, ethnicity, autism severity, poverty) are associated with flourishing and functional difficulties. Autistic children (n = 2960) between the ages of 10 and 17 years were included. We used confirmatory factor analysis followed by a multivariate general linear model (GLM) to examine the association between child variables and factors. Results indicated a six-factor structure (medical conditions, instrumental activities of daily living, activities of daily living, social competence, behavioral control, and school motivation) with good model fit (root mean square error of approximation = 0.08 [p = 0.926], comparative fit index = 0.94, Tucker-Lewis index = 0.91). Multivariate GLM showed that child factors were differentially and significantly associated with factors of functional difficulties and flourishing. Current findings suggest that 16 items measured by the NSCH result in a six-factor structure of flourishing and functional difficulties among autistic youth. A comprehensive approach to capture function among autistic youth must assess aspects of flourishing and difficulties.

Development and Validation of Telehealth Competency Questionnaire-Provider.

Background: Given the rapid increase in telehealth utilization, health care providers are being increasingly trained to deliver services virtually. However, there are limited measures available to assess the extent to which structured trainings influence competency domains associated with telehealth delivery. Methods: The authors developed the Telehealth Competency Questionnaire-Provider (TCQ-P) using a multistep process, including a literature review and expert reviewers. Using two datasets, we used exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to validate and refine the tool, respectively. The final version contained 17 items. Model fit was evaluated using the comparative fit index (CFI) (>0.90), Tucker-Lewis index (TLI) (>0.80), standardized root mean square residual (SRMR) (<0.08) and root mean square of error of approximation (RMSEA) (<0.08). Results: Participants included n = 701 in the exploratory study and n = 721 in the confirmatory study. Two items were revised, and one item was deleted as a result of the EFA, and the CFA of 17 number of items supported a 3-factor model (i.e., Evaluation, Rapport, Troubleshooting). Model fit was good, with CFI = 0.984, TLI = 0.978, RMSEA = 0.051, and SRMR = 0.035. Discussion: The TCQ-P measures three essential domains of telehealth competency, which is essential for future health care providers. The measure may be used to assess telehealth training outcomes.

Race and Ethnicity Reporting in Occupational Therapy Research Among Autistic Youth.

Historically marginalized racial and ethnic groups are underrepresented in autism research broadly; however, patterns of inclusion in occupational therapy research are unknown.In this secondary data analysis, we examined race and ethnicity reporting across articles included in a systematic review of evidence related to occupational therapy practice with autistic individuals <18 years (2013-2021).Two team members reached >90% interrater coding agreement in race and ethnicity reporting across articles in ADLs/IADLs, education/work, play, sleep, and social participation in clinics, homes/communities, and schools.Intervention outcomes of ADL/IADLs (66.7%) and play (66.7%) had low rates of reporting, while social participation in schools (100%) and education/work (100%) had higher rates of reporting. Sample diversity was greatest among research in schools and most limited in clinic-based settings.Systemic racism that limits individuals' participation in occupational therapy research perpetuates racial and ethnic health inequities among autistic children and adolescents.

Who is included in occupational therapy research among autistic youth?In research that guides occupational therapy practice with autistic youth, we need an understanding of the participants that were included in the research. Historically marginalized racial and ethnic groups are typically not included in the research, so we examined articles that informed occupational therapy practice for autistic youth. We found that different areas of intervention (e.g., play, education/work) had different rates of reporting. The most diverse samples were included in schools and were most limited in clinic-based settings. This is important because systemic racism can influence occupational therapy research and practice.

Occupational Therapy After Breast Cancer Reconstructive Surgery: A Predictor for Opioid Prescriptions.

Occupational therapy practitioners have a unique and vital role among interprofessional health care teams toward facilitating occupational participation among breast cancer survivors. This study investigated the relationship between acute medicine occupational therapy services after breast cancer reconstructive surgeries (BCRS) and a number of prescription refills 90 days after surgery. This retrospective study ran binary logistic regression analyses on 562 women after BCRS for refills of opioid and non-opioid medication. Both models were statistically significant, χ2(7df) = 23.001, p = .002; χ2(7df) = 32.312, p < .001, indicating the ability to distinguish who received opioid or non-opioid refills, respectively. While younger age was a significant predictor across both models, occupational therapy was only significant for opioid refills; each was associated with fewer refills. Early occupational therapy treatment after BCRS is associated with fewer opioid prescriptions 90 days after surgery, therefore enhancing occupation throughout this timeframe is beneficial.

Clinic-Based Interventions to Support Social Participation for Autistic Children and Adolescents (2013-2021).

Systematic review briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings from clinic-based studies to support social participation for autistic1 children and adolescents (birth to 18 yr).

Interventions to Support Social Participation for Autistic Children and Adolescents in Schools (2013-2021).

Systematic review briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings to support social participation in school contexts for autistic1 children and adolescents (birth to 18 yr).

Interventions to Support Participation in Sleep for Autistic Children and Adolescents (2013-2021).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings from the systematic review on interventions to support participation in sleep for autistic1 children and adolescents (birth to 18 yr).

Interventions to Support Participation in Education for Autistic Students (2013-2021).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings from the systematic review on interventions to support autistic1 children and youth (up to 18 yr old) and focuses on participation in education settings.

Interventions to Support Participation in Play for Autistic Children and Youth (Dates of Review: 2013-2021).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings to support participation in play for autistic1 children and adolescents (birth to 18 yr).

Interventions to Support Participation in Basic and Instrumental Activities of Daily Living for Autistic Children and Adolescents (2013-2021).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings from the systematic review on interventions to support participation in basic and instrumental activities of daily living by autistic1 children and adolescents (birth to 18 yr).

Interventions to Support Social Participation for Autistic Children and Adolescents in Homes and Communities (2013-2021).

Systematic review briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings to support social participation for autistic1 children and adolescents (birth to 18 yr) in homes and communities.

A comprehensive analysis of adverse events in the first 30 days of phase 1 pediatric CAR T-cell trials.

The tremendous success of chimeric antigen receptor (CAR) T cells in children and young adults (CAYAs) with relapsed/refractory B-cell acute lymphoblastic leukemia is tempered by toxicities such as cytokine release syndrome (CRS). Despite expansive information about CRS, profiling of specific end-organ toxicities secondary to CAR T-cell therapy in CAYAs is limited. This retrospective, single-center study sought to characterize end-organ specific adverse events (AEs) experienced by CAYAs during the first 30 days after CAR T-cell infusion. AEs graded using Common Terminology Criteria for Adverse Events were retrospectively analyzed for 134 patients enrolled in 1 of 3 phase 1 CAR T-cell trials (NCT01593696, NCT02315612, and NCT03448393), targeting CD19 and/or CD22. A total of 133 patients (99.3%) experienced at least 1 grade ≥3 (≥Gr3) AE across 17 organ systems, of which 75 (4.4%) were considered dose- or treatment-limiting toxicities. Excluding cytopenias, 109 patients (81.3%) experienced a median of 3 ≥Gr3 noncytopenia (NC) AEs. The incidence of ≥Gr3 NC AEs was associated with the development and severity of CRS as well as preinfusion disease burden (≥ 25% marrow blasts). Although those with complete remission trended toward experiencing more ≥Gr3 NC AEs than nonresponders (median, 4 vs 3), nonresponders experiencing CRS (n = 17; 37.8%) had the highest degree of NC AEs across all patients (median, 7 vs 4 in responders experiencing CRS). Greater understanding of these toxicities and the ability to predict which patients may experience more toxicities is critical as the array of CAR T-cell therapies expand. This retrospective study was registered at www.clinicaltrials.gov as NCT03827343.

CD22 CAR T-cell associated hematologic toxicities, endothelial activation and relationship to neurotoxicity.

BACKGROUND: Hematologic toxicities, including coagulopathy, endothelial activation, and cytopenias, with CD19-targeted chimeric antigen receptor (CAR) T-cell therapies correlate with cytokine release syndrome (CRS) and neurotoxicity severity, but little is known about the extended toxicity profiles of CAR T-cells targeting alternative antigens. This report characterizes hematologic toxicities seen following CD22 CAR T-cells and their relationship to CRS and neurotoxicity. METHODS: We retrospectively characterized hematologic toxicities associated with CRS seen on a phase 1 study of anti-CD22 CAR T-cells for children and young adults with relapsed/refractory CD22+ hematologic malignancies. Additional analyses included correlation of hematologic toxicities with neurotoxicity and exploring effects of hemophagocytic lymphohistiocytosis-like toxicities (HLH) on bone marrow recovery and cytopenias. Coagulopathy was defined as evidence of bleeding or abnormal coagulation parameters. Hematologic toxicities were graded by Common Terminology Criteria for Adverse Events V.4.0. RESULTS: Across 53 patients receiving CD22 CAR T-cells who experienced CRS, 43 (81.1%) patients achieved complete remission. Eighteen (34.0%) patients experienced coagulopathy, of whom 16 had clinical manifestations of mild bleeding (typically mucosal bleeding) which generally subsided following CRS resolution. Three had manifestations of thrombotic microangiopathy. Patients with coagulopathy had higher peak ferritin, D-dimer, prothrombin time, international normalized ratio (INR), lactate dehydrogenase (LDH), tissue factor, prothrombin fragment F1+2 and soluble vascular cell adhesion molecule-1 (s-VCAM-1). Despite a relatively higher incidence of HLH-like toxicities and endothelial activation, overall neurotoxicity was generally less severe than reported with CD19 CAR T-cells, prompting additional analysis to explore CD22 expression in the central nervous system (CNS). Single-cell analysis revealed that in contrast to CD19 expression, CD22 is not on oligodendrocyte precursor cells or on neurovascular cells but is seen on mature oligodendrocytes. Lastly, among those attaining CR, grade 3-4 neutropenia and thrombocytopenia were seen in 65% of patients at D28. CONCLUSION: With rising incidence of CD19 negative relapse, CD22 CAR T-cells are increasingly important for the treatment of B-cell malignancies. In characterizing hematologic toxicities on CD22 CAR T-cells, we demonstrate that despite endothelial activation, coagulopathy, and cytopenias, neurotoxicity was relatively mild and that CD22 and CD19 expression in the CNS differed, providing one potential hypothesis for divergent neurotoxicity profiles. Systematic characterization of on-target off-tumor toxicities of novel CAR T-cell constructs will be vital as new antigens are targeted. TRIAL REGISTRATION NUMBER: NCT02315612.

A Telehealth Delivered Toilet Training Intervention for Children with Autism.

BACKGROUND: Independence in toileting is a vital skill, yet toilet-training interventions for children with autism are limited. OBJECTIVES: We investigated the acceptability and preliminary efficacy of a hybrid telehealth intervention that used synchronous individualized coaching sessions and asynchronous online educational materials to support parents in toilet training their children with autism. METHOD: Participants included 34 families of children with autism ages 2 to 8 years. Measures were administered at pre- and postintervention (10-12 weeks) and included the Toileting Behavior Questionnaire, Goal Attainment Scaling, and Canadian Occupational Performance Measure. RESULTS: Twenty-five families completed all intervention procedures. Parents found the intervention highly acceptable and reported significant improvements in child toileting behaviors; however, families accessed the asynchronous intervention materials at a low rate. CONCLUSION: A parent coaching model delivered through telehealth may be a promising method to increase toileting independence among families of young children with autism.

Enhancing Telehealth Competency: Development and Evaluation of Education Modules for Older Adults.

Despite a rapid increase in telehealth utilization, older adults disproportionately experience disparities to services. To promote telehealth accessibility among this population, there is a need for specific training to increase user perceived competency. For this sequential mixed-methods study, we designed telehealth education modules through consultation with older adults. We then evaluated their impact on older adults' perceived telehealth competency. To solicit feedback on preliminary modules, we administered a semi-structured interview to a sample (n = 5) of older adults; then, we assessed the revised modules' impact on perceived competency among a sample of older adults (n = 53). Participants critiqued the preliminary training materials as having limited information on telehealth privacy and advised increasing the accessibility of design. Those that completed the revised modules demonstrated significant improvements in perceived telehealth competence. Telehealth training modules may be a promising method to increase perceived telehealth competency among older adults.

Telehealth Interventions to Promote Health and Behavior-Related Outcomes in Adolescents with Autism Spectrum Disorder.

This systematic review examined the effectiveness in a hybrid telehealth model for adolescents with autism spectrum disorder (ASD), exploring the evidence base, methodology, and outcomes of health and behavior-related interventions for adolescents with ASD. The 11 included studies (a) were quantitative, (b) evaluated interventions delivered through a hybrid telehealth model (i.e., combined remote intervention with minimal in-person procedures), (c) measured health and behavior-related outcomes, and (d) considered adolescence as ages 12 through 25 years. The studies were a mixture of designs, methods, and outcome measures, and participant numbers were extremely low. Results demonstrated an overall lack of empirical evidence on the efficacy of hybrid-delivered interventions for adolescents with ASD, and more studies are needed to explore their effectiveness.

Telehealth Competency Questionnaire-Consumer: Psychometric Validation of a Client-centered Measure.

To effectively access telehealth services, individuals must possess certain competencies; yet, telehealth consumer focused measures are limited. The purpose of this study was to describe the development and validation of the Telehealth Competency Questionnaire - Consumer (TCQ-C). Among a sample of adults with chronic health conditions (n=134), findings showed that the TCQ-C is comprised of one factor that accounts for 66.6% of the variance, and internal consistency of subscales are good (range α = 0.80-0.87) and may be used for clinical or research purposes. The TCQ-C demonstrated moderate concurrent validity with the Telehealth Usability Questionnaire-Usability subscale (r = 0.728, p<.001), and significantly discriminates between adults >65 years and those younger as well as those with and without previous telehealth experience. The TCQ-C is a psychometrically sound instrument to evaluate baseline competencies among telehealth consumers so that education, research, and clinical practices are tailored to increase effective engagement between clients and providers.

Initial characterization of print awareness in unhoused children.

This study provides an initial understanding of print awareness, a foundational literacy skill, in a group of 12 unhoused children at two shelters in a large urban setting. Children ranged in age from 4;1 to 8;0, representing grades associated with learning to read (i.e., pre-kindergarten to second grade). Findings indicate that the majority of children in this sample were significantly delayed in their acquisition of print awareness skills. Caregivers were surveyed regarding their beliefs about supporting literacy development and what would be beneficial for helping them in this area. Responses indicated that almost all caregivers believed that some literacy development should occur outside of the school setting and that it would be helpful if they (the caregivers) were taught both what skills to teach and how to teach them.