RAPID REVIEW

Occupational therapy interventions for

AUTHORS
Janke van der Walta Autism Spectrum Disorders - a Rapid
https://orcid.org/0000-0001-5012-0121
Madri Engelbrechtb
Review
https://orcid.org/0000-0002-4606-7572
Hester van Biljonc
http://orcid.org/0000-0003-4433-6457
Shaheed M. Soekerd ABSTRACT
https://orcid.org/0000-0001-5382-1855

AFFILIATION Introduction: This rapid review aimed to synthesise evidence for

aDivision of Occupational Therapy, Department occupational therapy intervention in the management of autism
of Health and Rehabilitation Sciences, Faculty of
Medicine and Health Sciences, Stellenbosch spectrum disorders. The review forms part of a series of rapid reviews
University, South Africa commissioned by the Occupational Therapy Association of South Africa
bCentre for Disability and Rehabilitation Studies, to help inform decision making as South Africa prepares for a new health
Department of Global Health, Faculty of system.
Medicine and Health Sciences, Stellenbosch Method: Level I and II research studies published from 2017 - 2022 were
University, South Africa considered for inclusion. Electronic database searches were conducted
cWork-Link Vocational Rehabilitation Practice,
on the Cochrane database. The identified records were screened in
Johannesburg, South Africa
dDepartment of Occupational Therapy, University Rayyan according to inclusion and exclusion criteria. Quality assessment
of the Western Cape, South Africa of the selected articles was done with the CASP appraisal tool. Data were
extracted to a custom Microsoft Excel® worksheet and analysed
quantitatively by percentage/frequency and qualitatively by thematic
CORRESPONDING AUTHOR analysis of statements.
Janke van der Walt
Email: [email protected] Results: Thirty-eight records were selected. These included 30
systematic reviews and eight randomised controlled trials. Twelve
intervention domains across four age groups were identified with sensory
KEYWORDS
Autism, intervention, occupational therapy, rapid integration and social skills interventions most frequently examined.
review, policy support Interventions were delivered across various venues, including mediation
and technology (e.g., telehealth interventions). A number of different
HOW TO CITE THIS ARTICLE outcome measures were used.
Van der Walt J, Engelbrecht M, Van Biljon H, Conclusion: There is evidence to support the effectiveness of
Soeker, SM. Occupational Therapy interventions
for Autism Spectrum Disorder. a Rapid Review. occupational therapy interventions for autism spectrum disorder across
South African Journal of Occupational Therapy. the lifespan for twelve different domains.
Vol 24 No 1. April 2024. DOI: https://doi.org/
Implications for practice
10.17159/2310-3833/vol54no1a9
•Occupational Therapists are involved in the provision of therapy
DATA AVAILABILITY intervention across all age groups for people with ASD.
Upon reasonable request, from corresponding •Intervention can successfully take place in a clinic setting, but also at
author home or through means of technology.
ARTICLE HISTORY •There is growing evidence for sensory integration therapy or
Submitted: 26 August 2023 techniques when considering functional outcomes when treating
Reviewed:6 February 2024 people with ASD.
Revised: 13 February 2024 •There is a lack of Level I and II research in the form of randomised
Accepted: 14 February 2024 control trials and systematic reviews regarding ASD intervention in
sub-Saharan Africa.
EDITOR
Blanche Pretorius
https://orcid.org/0000-0002-3543-0743
INTRODUCTION
FUNDING This rapid review was performed as part of a series of reviews by an
The Occupational Therapy Association of South appointed task team, initiated by the Occupational Therapy Association
Africa (OTASA) requested the authors to do this of South Africa (OTASA). The aim of the rapid review project is to provide
rapid review and they were remunerated by the
association. evidence for the role of occupational therapy intervention for specific
conditions in preparation of moving towards a National Health Insurance
Published under an International Creative Common LIsence 4.0 (NHI) system in South Africa1. This review was guided by the autism
standard operating protocol for occupational therapy as compiled by the
OTASA standard protocol group2.
The focus of this review is on autism spectrum disorders. Autism
ISSN On-line 2310-3833 spectrum disorder (ASD) is a complex neurological disorder,

SA Journal of Occupational Therapy SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 74
characterised by impairments of reciprocal social interaction, was steered by the methods guide for rapid reviews for Covid-
verbal and non-verbal communication, as well as preference 19 medicine reviews1⁹, and a practical guide to rapid reviews
for repetitive stereotyped activities, behaviours and interests. by the World Health Organization2⁰. The research question
To diagnose ASD, symptoms must be present before the age investigated was: What ASD-related evidence exists for
of three years, but last throughout the lifespan. Autism occupational therapy intervention across the human lifespan?
spectrum disorder is described as level 1, 2 or 3 by severity of The research population was defined as any person with ASD
social communication impairments and repetitive restrictive across the lifespan. “Intervention” included any form of
patterns of behaviour and the level of severity depends on the treatment that involves occupational therapists as
level of support required3,⁴. intervention/programme developers, organisers, researchers
The World Health Organization (WHO) reports a global or facilitators. Assessment methods were not included in this
prevalence of autism at 1%⁵, while systematic reviews of review.
global prevalence figures reflect a prevalence of between
Study designs
0.6%⁶ and 0.65 %⁷. An updated systematic review⁸ indicates
Only level I and II studies*were considered for the review and
an increased global prevalence of 0.03% from 2012 onwards,
included systematic reviews and randomised controlled trials.
possibly due to increased awareness about the condition and
Qualitative designs and other reviews such as scoping or
earlier identification. Systematic and scoping reviews found no
literature reviews were excluded.
records of prevalence studies conducted in sub-Saharan
Africa, including South Africa⁹,1⁰. Considering the absence of Search approach
prevalence data in South Africa, Pillay et al. performed a Searches were conducted online through use of the library at
search of all the children with a primary or secondary Stellenbosch University. Cochrane library and Medline were
diagnosis of ASD in schools in the Western Cape of South used as search engines; however, the Medline search was
Africa, resulting in a broad rate of 0.08%11.The lack of more aborted due to no new records found when compared to the
extensive and comprehensive data complicates service Cochrane search. The search string used was: “Autism OR
delivery and intervention for ASD in South Africa1⁰ . Autism Spectrum Disorder OR ASD AND Occupational
Occupational therapists enable individuals and Therapy OR occupational therapist” Inclusion criteria were:
communities to participate in daily life activities through level I or II studies*, peer-reviewed publications, published
engagement in occupations relevant to them, or by modifying between January 2017 and December 2023, available in
the occupation or environment12. De Schipper et al., in their English and full text available. Conference proceedings,
systematic review of the literature, identified numerous reports, theses, etc., were not included.
categories on the International Classification of Functioning, References were saved online in Mendeley21, an online
Disability and Health (youth version) core sets for ASD when personalised reference database and referencing tool. All
considering ability and disability in ASD13, affirming the references were transferred to the webtool Rayyan.ai to assist
importance of occupational therapists within a larger with the screening process22.
intervention team1⁴. The need for occupational therapy services
for adults with ASD are less frequently reported on, although Study selection
services include involvement in the areas of sensory Two researchers firstly screened the records on Rayyan.ai by
integration1⁵, vocational rehabilitation services1⁶, driving title and abstract, while a third researcher resolved any
training1⁷ and social skills1⁸. conflicts. The selected records underwent full text screening
This study examines global evidence-based occupational by the primary investigator, while a second researcher
therapy intervention for ASD across the lifespan to inform screened 20% of the full text articles. A third reviewer
policy makers as we move towards a new NHI system in resolved any uncertainties.
South Africa. Rapid reviews are used to inform health decision Data extraction
makers both timeously and cost effectively, while still A custom Microsoft Excel® worksheet was designed to extract
maintaining methodological rigor1⁹,2⁰. Rapid reviews proved data under the following headings: author; study title; study
very valuable during the Covid-19 pandemic to inform the design; population (gender, age, geographical location,
government, clinicians and patients about strategic evidence setting); intervention method; comparisons; outcomes. The
to make crucial decisions. These reviews take an average of headings “comments” and “statements” were added to allow
five to twelve weeks to complete, however during an for any important information to be recorded which was not
emergency, such as the Covid-19 pandemic, the timeframe covered under the previous headings.
was much shorter i.e. seven to ten days to complete a
review1⁹,2⁰. Appraisal of study quality
METHODOLOGY The quality of studies was appraised using the Critical
Scope and question Appraisals Skills Program (CASP) Randomised Controlled Trial
The OTASA rapid review task team consisted of four Standard Checklist, or CASP checklist for systematic reviews 23.
occupational therapists with clinical and academic experience Points for each question were awarded to obtain an informal
in the various fields of practice. The first author was the score per record as follow: Yes = 1; Not clear = 0.5 and No = 0.
principal researcher for this review and was assisted by
* Level I studies include RCTs and systematic reviews of RCTs with or without
theother authors during all phases of the review. The review
meta-analysis. Level II include systematic reviews of a combination of RCT’s and
quasi-experimental studies with or without meta-analysis.

75 SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 SA Journal of Occupational Therapy
Evidence analysis 43 duplicates were removed through the Rayyan.ai screening
Data were analysed by percentage and frequency tool, 2305 records were screened by title and abstract. The
predominantly for quantitative reporting. Additional first screening eliminated 2050 records, while the full text
information recorded under the statements/comments version of eight records could not be accessed. This resulted in
sections were grouped together through thematic analysis. full text screening of 250 records. At this stage, the research
Statements were filtered by method of deduction and only team agreed to only include records identified from 2017 -
statements that were not already represented quantitatively 2022, rather than for ten years due to sufficient records
were selected for reporting. identified in this timespan. Records from the previous five
years were found to be well-represented in the systematic
RESULTS
reviews from 2017 - 2023. The PRISMA diagram2⁴ (Figure 1,
Search results
below) illustrates the screening and selection process.
From the Cochrane search, 2348 records were identified. After

Figure 1 Prisma Diagram2⁵

SA Journal of Occupational Therapy SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 76
Study design and quality Study locations were not reported for all studies. Among
The included records comprised thirty systematic reviews and those reported, most studies were conducted in the United
eight RCTs. A full description of studies can be seen in Table I States of America (n = 6), Northern Europe (n = 5), Australia
(below). All included studies were of acceptable quality with (n = 5) and Asia (Japan, China, Taiwan) (n = 4). Studies were
scores of above 7/10 for systematic reviews and above 8/11 for also reported in Canada (n = 2), Brazil (n=1), New-Zealand (n
RCTs on the CASP. Systematic reviews reported studies over = 1) and Egypt (n = 1).
the timespan of 1967 to 2021.

Table I Records included in the reiew

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80 SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 SA Journal of Occupational Therapy
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Population
Studies included in this review either focused on occupational Table II Domains of intervention by age groups
therapy interventions for people with ASD and/or caregivers
and/or employers of people with ASD. Ultimately, the aim of
the occupational therapy interventions was always to improve
the quality of life of the person with ASD. Ages were covered
at a range from birth to late adulthood. Guided by the OTASA
standards of practice for ASD document2 studies were divided
into age group categories of: early years (0- 3 years) (n = 19);
childhood (3 – 12 years) (n = 29); adolescents (15- 22 years) (n
= 25) and adulthood (23 years and up) (n = 10).
Interventions
Twelve different domains of occupational therapy
intervention were identified across all included studies. The
sensory domain included any form of intervention aimed at
sensory integration, modulation or stimulation, including
Ayers sensory integration®, and was most frequently reported
on (n = 12) together with the social skills domain (n = 12)
which included specialised programs such as KONTAKT®2⁶
and PEERS®⁵⁸. Further domains included behavioural (n = 9);
educational (n = 9); mediated (n = 9); cognitive (n = 8); play/
leisure (n = 8); activities of daily living (n = 7); technology (n =
4); motor skills (n = 3), sleep (n = 2) and work (n = 2) domains. Thematic analysis
When considering age groups by domains (Table II, Common themes were identified through thematic analysis
adjacent), studies examining the work domain only covered and can be summarised as follows:
the adolescent to adult age range, while motor skills were Studies reported on many specialised programs and
covered up to the adolescent age range. The play/leisure techniques for ASD involving occupational therapists, for
domain mostly refers to the occupation of play among the which supplementary specialised training isrequired2⁶,2⁷,3⁰,31,33,
early years, child and adolescent age group (n = 7), with only ⁴3,⁵3,⁵⁵,⁵⁸,⁶⁰.
one study that included adult leisure. All other domains were However, a combination of approaches and techniques are
studied over all age groups. often necessary to reach desired outcomes⁴1,⁴2,⁵⁰,
andinterventions involving technology, such as robots and
Intervention venue telehealth, require multidisciplinary involvement2⁷,⁵⁹.
The studies that reported venues included clinic or therapy Caregiver/parent mediated intervention hold many benefits
environments, community centres, schools, tertiary for individuals with ASD, the caregivers and cost-effective
institutions, places of work and home environments as study/ service delivery and evidence suggest that gains can occur
intervention venues. within a relatively short time span, however more research is
needed in this regard2⁸,3⁶,⁴⁶,⁴⁷,⁴⁹,⁵⁰. There is a lack of research on
Outcome measures
specific academic support for students with ASD2⁹. In general,
A vast number of different and diverse outcome measures
more high-quality trials with participation-focused outcome
were reported in systematic reviews and RCT’s. These
measures are needed to support clinicians involved in the
included standardised assessments, questionnaires, checklists,
management of ASD 32. Studies yielded many and diverse
surveys and rating scales. The specific outcome measures
outcome measures and approaches, which complicates
used for RCT’s are reported in Table I (page 77).
evidence comparison3⁸,3⁹,⁵⁹.

82 SA Journal of Occupational Therapy / Volume 54 Number 1, April 2024 SA Journal of Occupational Therapy
DISCUSSION developing methods of practice to use in sub-Saharan Africa
Research considering occupational therapy interventions for over the past decade⁶⁵ and further research in this area, in
ASD is well-represented in the literature over the time period support of ASD interventions are indicated. Mediated
2017 - 2022 as covered in this rapid review, including 30 interventions, often co-occurring with the use of technology,
systematic reviews. Good quality RCT’s are less frequently brings intervention within homes and schools and involve
represented, as also found in other systematic reviews31,32. families and/or teachers3⁶. Specialised programs are often
Records included in this review are predominantly from high- used and require post qualification training e.g., Kontakt®2⁶ or
income countries, with no records from low-income countries PEERS®⁴⁸,⁵⁸, for social skills; DIR®/floortime31 and Ayers
and limited records from upper-middle-income countries⁶1 i.e., sensory integration®⁵⁵.
China⁴⁶,⁶⁰ and Brazil⁵⁹. South Africa is classified as an upper-
Limitations
middle-income country and can thus most closely associate
Only level I and II studies were included in this review, so
with these studies, however, no studies from South Africa or
limiting the inclusion of lower quality studies specific to sub-
sub-Saharan Africa matched the criteria for this review.
Saharan Africa and South Africa that may reveal area-specific
Although records include interventions across the lifespan,
interventions for ASD.
occupational therapy intervention is most frequently
There is an overlap in academic and clinical practitioner
described for children (3 – 12 years), followed by early years
input with regards to therapy intervention for ASD. Therapists
(0 – 3 years) and adolescents (13 – 22 years), and much less
and researchers are often not defined by role in research
frequent for adults over 23 years of age. Novak et al⁵⁰ listed 39
papers. This complicated the accuracy of the screening
different effective interventions for children with a range of
process and records might have been missed.
disabilities in their systematic review, concluding that parents
have many choices when considering therapy intervention. Ethics
While early intervention for ASD is essential⁶2, in their Only articles from peer-reviewed journals were considered for
systematic review, Lorenc et al1⁸ reiterates the importance of the review and the quality and bias of selected records were
more evidence-based research for interventions for adults tested using the CASP rating tool. Ethical clearance was not
with ASD, and specifically for adults without intellectual required as the study did not require primary data collection.
disabilities. Services are usually focussed on mental health,
which can only be accessed if a problem develops, rather than CONCLUSION AND RECOMMENDATIONS
having access to preventative services. Furthermore, studies Evidence from around the globe suggests that occupational
focus on younger adults (below 40 years of age)1⁸. Considering therapy plays an integral part in the management of ASD
that ASD is a life-long condition, the focus on the provision of across at least 12 domains and across all ages. ASD
occupational therapy intervention for middle, adult and older intervention is a specialised area for which post qualification
adult age groups is an area that needs attention by training is required when considering specific programmes
researchers. and techniques; however, promising evidence also exists for
When considering ages by intervention, it makes sense that mediation, use of technology and task-sharing approaches
researchers give more consideration to sensory which makes intervention more accessible to all.
integration3⁰,⁴3,–⁵1-⁵3,⁵⁵ and parent mediated intervention2⁸,33, There is a gap in and need for ASD research within South
3⁶,⁴⁶,⁴⁷,⁴⁹ in the younger years, while social skill interventions Africa to establish reliable data and to determine current
are mainly considered in the childhood and adolescent intervention processes, including occupational therapy
years2⁶,⁴⁶,⁵⁴,⁵⁸,⁶⁰. Interventions related to work and driving are involvement in South Africa. Global evidence for occupational
only considered in late-adolescent years and adult years1⁶,1⁸. therapy interventions should be considered with caution
Nevertheless, twelve different intervention domains for ASD against the unique challenges South Africa faces with regards
with occupational therapy involvement were identified in this to diversities, socio-economics, rurality, co-morbidities and
review across the lifespan, which coincides with the large the current and proposed health systems.
range of functional impairments that could occur with ASD13. Author contributions
In a systematic review of 406 clinical trials, Provenzani et All four authors (Janke van der Walt, Madri Engelbrecht,
al identifies the vast number of outcome measures used
63
Hester van Biljon and Shaheed M. Soeker contributed
within ASD research as a barrier when comparing studies⁶3. substantially to the design of the study and the screening
This was reflected in the current review, however, with twelve process. Janke van der Walt analysed and interpreted the data
different domains of intervention, a variety of outcome with the support of the other authors as critical reviewers.
measures is to be expected. The authors recommend greater Janke van der Walt wrote the article which was revised by the
consensus regarding outcome measures in ASD research, this other three authors. All authors agreed on the final content as
could be considered across the individual domains and age presented.
groups identified.
Access to occupational therapy interventions is described Conflicts of Interest
across a range of locations, indicating an openness to The authors have no conflict of interest to declare.
accessible intervention. A systematic review investigating non- REFERENCES
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