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.

Partners in Care: Consumer Experiences With Professional Services.

Consumer experience is a key driver of successful health and education outcomes. Yet, the key factors influencing consumer experiences with care are not fully understood. The aim of this study was to understand, from the perspective of people receiving health care or education services, factors that determine positive and negative experiences with care. We interviewed people who received services, including occupational therapists, and analyzed recordings of the interviews using content analysis. Themes emerged from positive experiences with care on a continuum from "Acknowledges Me" to "Shares Problem Solving." Themes from negative experiences were also on a continuum from "Lacks Curiosity" to "Disregards." A fifth theme emerged from occupational therapists, describing "transformational insights" regarding how their personal experiences receiving care affected their practice. The findings from this study align with core OT constructs and advances understanding of authentic partnerships with people receiving professional services.

Partners in Care: Consumer Experiences with Professional ServicesThis study sought to understand, from the perspectives of people receiving services, factors that determine positive and negative experiences with care. We interviewed people who received health care or educational services, which are two settings where occupational therapists practice. We analyzed the interviews by identifying experiences participants had receiving care and grouping those experiences into common themes. Participants generally associated positive experiences with provider actions that recognized and validated their perspective and experiences or that partnered with the person in planning for their care. Participants associated negative experiences with provider actions that prioritized procedural care over individualization, or that actively disregarded the person which created feelings of shame, anger, and despondency. Occupational therapists in our study who received care shared similar experiences to people who were not trained as health care providers. Our findings highlight the importance of partnering with people receiving care, which is often at odds with training on expert models of care provision. We suggest that partnering in care is a skill set that providers need to cultivate through ongoing reflection and mentorship.

Interventions for Developing Positive Mental Health in Autistic Individuals (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 or improve positive mental health for autistic1 individuals.

Interventions That Foster Self-Determination in Autistic Individuals (2013-2021).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's (AOTA'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 a systematic review that examined interventions to support and improve self-determination for autistic1 individuals.

"A different environment for success:" a mixed-methods exploration of social participation outcomes among adolescents on the autism spectrum in an inclusive, interest-based school club.

Background: Adolescents on the autism spectrum often experience challenges participating socially in inclusive education. The majority of school-based social supports focuses on social skills training, although research shows that students on the spectrum prefer activity-based social groups over social instructions. Thus, activity-based school clubs incorporating student interests may support social participation. Method: This mixed-methods study explored the preliminary social participation outcomes of adolescents on the spectrum in an inclusive Maker Club at three public schools. The quantitative phase examined longitudinal social behavior rates throughout the school club among students (n = 12). The qualitative phase interviewed six teachers in three schools (n = 6) to explore teacher perceptions of student social outcomes compared to general classrooms and program outcomes associated with the programs. Results: Mixed-effects modeling revealed increased social response rates and social reciprocity over time in both students on the spectrum and non-autistic peers without any group differences. Teachers reported that students on the spectrum engaged more socially than in general classrooms and attributed the positive outcomes to activities encouraging shared interests and the flexible social environment. Conclusions: Inclusive school clubs incorporating shared interests and joint activities among students may socially support students on the spectrum in inclusive education.

Improving Executive Functions Using the Engineering Design Process: A Peer-Mediated Problem-Solving Approach for Autistic Adolescents.

Executive functions-specifically, problem-solving skills-are crucial for school success. Challenges in these functions faced by autistic adolescents are often unrecognized or viewed through a behavioral lens that requires correction or normalization. A lack of development of higher order problem-solving skills leads to increased instances of secondary mental health issues, creating further behavioral and social challenges. We propose using the Engineering Design Process (EDP), a flexible, cyclical, top-down, self-sustaining approach that uses peer mediation to teach group problem-solving skills. We then position this cycle within existing occupational therapy models to demonstrate its adaptability and flexibility, describe the distinct features of this problem-solving strategy, and present a real-world case study in which the EDP is used as a problem-solving approach in an after-school program. The EDP develops crucial social and interpersonal skills using interest-driven occupations and can be organically used as a group strategy. This article uses the identity-first language autistic people. This nonableist language describes their strengths and abilities and is a conscious decision. This language is favored by autistic communities and self-advocates and has been adopted by health care professionals and researchers (Bottema-Beutel et al., 2021, Kenny et al., 2016).

Exploring the role of interpersonal contexts in peer relationships among autistic and non-autistic youth in integrated education.

The double empathy problem theory posits that autistic social difficulties emerge from an interpersonal misalignment in social experiences and expectations between autistic and non-autistic people. Supporting this, emerging research reveals better social outcomes in interactions within than across neurotypes among autistic and non-autistic people, emphasizing the need to examine the role of the interpersonal context in autistic social outcomes. However, research on peer relationships among autistic youth primarily focuses on individual characteristics in isolation from the interpersonal context. To address this, this preliminary study explored the effects of student-peer neurotype match on peer relationships among autistic and non-autistic youth in an integrated educational setting. We plotted the peer relationship networks among youth in a school club based on systematic observations of peer interactions over eight 45-min sessions. Descriptive network statistics (node degree and strength) showed that both autistic and non-autistic youth had more and stronger peer relationships with their same- than cross-neurotype peers. Assortativity coefficients revealed a tendency for youth to connect with peers of the same neurotype, rather than with peers with similar social popularity or activity. We further modeled the effects of student-peer neurotype match on peer relationships using exponential random graph models. The findings suggested that student-peer neurotype match predicted the total strength of peer relationships above and beyond the effects of student neurotype, individual heterogeneity in social popularity and activity, and the tendency of mutuality in social relationships. We discussed the strengths and limitations of this study and the implications for future research and inclusion practice.

Experiences of Students, Teachers, and Parents Participating in an Inclusive, School-Based Informal Engineering Education Program.

Many youth on the autism spectrum possess interests and strengths for STEM-related postsecondary pathways, yet there are few research-based programs to support those interests and competencies including complex problem solving and social communication. This qualitative study explored the experiences and perceived outcomes of students, teachers, and parents participating in an inclusive, strength-based, extracurricular engineering design program entitled the IDEAS Maker Club. Twenty-six students, 13 parents, and nine teachers in the program completed interviews and program logs while researchers conducted classroom observations over 2 years. Thematic analysis identified five common themes: (1) positive student experience and engagement, (2) skills acquisition, (3) development of interest in STEM and related careers, (4) social relationships and community, and (5) safe spaces that supported self-determination.

Exploring interpersonal and environmental factors of autistic adolescents' peer engagement in integrated education.

LAY ABSTRACT: Peer engagement is essential but often challenging for autistic students in integrated education, especially for adolescents. Although peer engagement is bidirectional and context-dependent, research has largely focused on individual characteristics rather than the interpersonal and environmental factors affecting peer engagement. This mixed-methods study examined peer interactions over a school year among 17 adolescents (seven were autistic) in an inclusive school club at a public middle school in the Northeastern United States. The study began with a quantitative phase identifying sessions in which each student was socially engaged with peers more or less often than usual for them. We then qualitatively compared the social interactions and contexts between sessions where each participant experienced high and low peer engagement. Thematic analysis revealed four themes regarding contextual supports and barriers to autistic peer engagement: (1) peer engagement is a participatory process where a student and their peer(s) navigate mutual understanding, shaped by both student and peer social characteristics, openness, and involvement; (2) student-peer synchronicity, such as shared interests or compatibility of social styles, was essential to autistic peer engagement; (3) peer engagement can be supported by activities facilitating joint engagement and exploration of mutual interests; (4) classroom interventions emphasizing strengths can support peer engagement, while normative behavioral standards without peer education on individual differences and diversity can perpetuate peers' negative perceptions of autistic difficulties. The findings have implications for better inclusive practice to support autistic social participation by modifying the peer environments, activities, and classroom interventions.

Shifting Focus From Impairment to Inclusion: Expanding Occupational Therapy for Neurodivergent Students to Address School Environments.

Social participation in schools is critical to student academic and psychosocial outcomes. Neurodivergent students, however, often experience environmental barriers to social participation, such as lack of awareness and negative attitudes among peers and school staff, including teachers. Although authentic social participation is composed of dynamic interactions between a person and the external environments, occupational therapy's role in addressing student social participation primarily focuses on internal social characteristics. Barriers within school environments often remain unaddressed, with no clear role for occupational therapy practitioners. We advocate an expansion of occupational therapy's role to address school environments, especially the social, physical, and policy aspects, to promote social participation and inclusion. We also discuss the need for change and present a framework guiding intervention in school environments.

Peer preferences and characteristics of same-group and cross-group social interactions among autistic and non-autistic adolescents.

LAY ABSTRACT: Autistic students often experience challenges in peer interactions, especially for young adolescents who are navigating the increased social expectations in secondary education. Previous research on the peer interactions of autistic adolescents mainly compared the social behaviors of autistic and non-autistic students and overlooked the peers in the social context. However, recent research has shown that the social challenges faced by autistic may not be solely contributed by their social differences, but a mismatch in the social communication styles between autistic and non-autistic people. As such, this study aimed to investigate the student-and-peer match in real-world peer interactions between six autistic and six non-autistic adolescents in an inclusive school club. We examined the odds of autistic and non-autistic students interacting with either an autistic peer, a non-autistic peer, or multiple peers, and the results showed that autistic students were more likely to interact with autistic peers then non-autistic peers. This preference for same-group peer interactions strengthened over the 5-month school club in both autistic and non-autistic students. We further found that same-group peer interactions, in both autistic and non-autistic students, were more likely to convey a social interest rather than a functional purpose or need, be sharing thoughts, experiences, or items rather than requesting help or objects, and be highly reciprocal than cross-group social behaviors. Collectively, our findings support that peer interaction outcomes may be determined by the match between the group memberships of the student and their peers, either autistic or non-autistic, rather than the student's autism diagnosis.