Interventions for Social Participation for Autistic Adults (2013–2020)

Abstract

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 on social participation interventions and participation outcomes for autistic 1 adults.

Full Systematic Review Question

This systematic review addressed the question “What are the interventions within the scope of occupational therapy to address participation in activities of daily living, instrumental activities of daily living, rest and sleep, work, education, play, leisure, social participation, and health management among autistic people over the age of 18?”

Current Theme Reported

The main themes of the studies included in this systematic review brief are social participation and instrumental activities of daily living (IADL) participation.

Clinical Scenario

Social and community participation for autistic individuals has the potential for increasing quality of life and life satisfaction (Cameron et al., 2022). Social participation may also contribute to a sense of inclusion and belonging within society (Jones et al., 2022). However, social participation among autistic individuals is often limited by lack of opportunity, lack of choice, and unwelcoming social environments (Orsmond et al., 2013; Jones et al., 2022). For occupational therapy practitioners, social participation involves supporting physical, social, and cultural capacities and contexts (Ideishi, 2013) as well as creating opportunities and self-determined choices by the individual (Renwick et al., 2019; White et al., 2018).

Summary of Key Findings

Twelve articles were reviewed that focused on social participation and IADL participation (Table 1). Social participation articles were further divided into themes based on the type of intervention and outcomes. Key themes were (a) the Program for the Education and Enrichment of Relational Skills (PEERS) for Young Adults intervention, (b) structured planning with peer mentoring interventions focused on increasing social participation in the community, and (c) manualized interventions focused on social communication and engagement. An additional theme focused on IADL independence and participation in context (i.e., exercise, shopping). The strength-of-evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018). We used the Oxford Centre for Evidence-Based Medicine (2009) levels of evidence for this review. For single-subject research design studies, the level of evidence and quality assessment were done using methodology from Romeiser Logan et al. (2008).

Table 1.

Evidence Table for Interventions for Social Participation and IADLs for Autistic Adults

Author YearLevel of EvidenceRisk of Bias (RoB)CountrySetting	Intervention	Improvement
Theme 1: Social Participation
Subtheme 1: PEERS for Young Adults intervention, a caregiver-assisted social skills training program. One Level 1b and one Level 2b studies used PEERS for Young Adults intervention to improve social participation. Moderate strength of evidence supports this type of intervention. Risk of bias for these studies was moderate.
McVey et al. (2016) Level 1b—RCT RoB Moderate Country United States Setting Community	Participants N = 47, intervention = 24, waitlist control = 23; mean age 20.9 yr, 25% female; ASD, parent report of social difficulties, English fluency, no history of mental disorder or sensory/physical impairments; ADOS-G 6 or higher; Kaufman BIT-2 Verbal IQ 70 or higher. Intervention PEERS for Young Adults—PEERS is a caregiver-assisted social skills training program that aims to improve social engagement and social skills as a basis for social participation. Delivery Method Group young adult sessions with concurrent caregiver sessions. Dose 90-min sessions once per week for 16 wk.	Between Groups Intervention group had significant improvement in parent-rated social skills and youth self-reported social participation. Within Group Significant improvement.
Laugeson et al. (2015) Level 2b—RCT RoB Moderate Country United States Setting Community	Participants N = 17, intervention = 9, delayed control = 8; mean age 20.4 yr, 24% female; ASD diagnosis from licensed mental or medical professional; social problems reported by caregiver; willing to participate; caregiver fluent in English; IQ > 70; scored ≥26 on AQ Intervention Weekly group didactic lessons of the PEERS for Young Adults intervention, a caregiver-assisted social skills program for young adults without intellectual disability. Delivery Method Social skills group Dose 90-min sessions once per week for 16 wk.	Between Groups Intervention group had significant improvement in youth and parent-rated social engagement and knowledge of specific social skills. Within Group Significant improvement
Wyman & Claro (2020) Level 2b—prepost RoB Moderate Country United States Setting School	Participants N = 63, ASD = 29, CD=34; mean age: 18.7 yr, 20.7% female, students between the ages of 16 and 21 with ASD or CD. Intervention PEERS School-based curriculum Delivery Method Social skills group Dose 45-min sessions twice weekly for 16 wk.	Between Groups No significant differences postintervention on the QSQ-A as an outcome measure of social participation (students’ self-reported number of hangouts [invited to or hosted] with their peers outside of school and names of the people who attended the hangouts).
Subtheme 2: Social Planning and Frequency of Participation in Community Activities Two Level 4 SSRD studies used a structured social planning intervention to increase the frequency of participation in community activities. There is low strength of evidence for this type of intervention. Risk of bias for these studies was moderate.
Ashbaugh et al. (2017) Level 4—SSRD RoB Moderate Country United States Setting University clinic	Participants N = 3; mean age: 21.5 yr; 66.6% female; DSM-4 or DSM-5 ASD; student in higher education setting; 18–25 yrs.; speak in full syntactically correct sentences; no history of violence or aggressive behaviors; demonstrated social difficulties by self-report or observation Intervention One-on-one structured social planning sessions reviewing daily log with a clinician and one-on-one support for social activities with a peer mentor. Delivery Method Individual sessions in a university clinic Dose Weekly 60-min sessions for 10 wk	Descriptive Findings All three participants increased the number of social activities they participated in per week.
Koegel et al. (2013) Level 4—SSRD RoB Moderate Country United States Setting University clinic	Participants N = 3; mean age 22.3 yr; 0% female; DSM-4 Asperger’s Syndrome Intervention One-on-one social planning sessions and reviewing daily log based on student’s interests with a clinician Delivery Method Intervention sessions were implemented on a university campus in a clinic room at the University Autism Center. Social activities took place in each student’s natural settings on the university campus. Dose Weekly 60-min sessions for 33 wk	Descriptive Findings All three participants increased the number of social activities they participated in per week. Self-reported increase in satisfaction with college experience, peer interactions, number of friends and confidence in peer conversations.
Subtheme 3: Manualized interventions for social communication and engagement Three studies used manualized interventions to improve social communication and engagement within the context of social group activities. Moderate strength of evidence supports this type of intervention. Risk of bias for these studies was low to moderate.
Akabogu et al. (2020) Level 1b—RCT RoB Moderate Country Nigeria Setting Not identified	Participants N = 86; mean age of treatment group: 23.7 yr; 62.8% female; DSM-4-TR for ASD; low social participation; willingness to participate; available to attend intervention; English as primary language Intervention LEI that included language education intervention techniques, cognitive behavioral techniques, rational emotive techniques, and social coping techniques. Delivery Method Small group sessions Dose 28 sessions (2 hr each) implemented over 14 wk (56 hr total).	Between Groups There was a significant increase in social participation among young adults who were exposed to the LEI at posttest and 4-mo follow-up on the Social Participation Questionnaire.
Morgan et al. (2014) Level 2b—pilot RCT RoB Low Country United States Setting Not identified	Participants N = 28; mean age 25 yr; 8% female, met diagnostic criteria for ASD; verbal IQ above 70 with a GED or a special education or regular high school diploma Intervention Interview Skills Curriculum which is a 12-wk manualized group intervention to increase social pragmatics skills necessary for job interviews. Delivery Method Group intervention Dose 90-min sessions one time per week for 12 wk.	Between Groups Significantly larger gains in social–pragmatic skills were observed during a mock job interview in the intervention group over the control group.
Oswald et al. (2018) Level 2b—pilot RCT RoB Moderate Country United States Setting Clinic	Participants N = 44 (n = 28 treatment); mean age: 25.1 yr; 30% female; community diagnosis of ASD based on multiple scales, completion of high school, spoken language, and no evidence of psychosis or behavioral/conduct problems that would be disruptive or dangerous Intervention ACCESS Program with a social coach caregiver or close relative). Key components included three CBT and psychoeducation-based modules on (1) stress and anxiety coping; (2) self-determination; and (3) adaptive and social skills module. Concurrent social coach groups covered the above topics and provided psychoeducation on how to facilitate the use and generalization of skills and concepts learned by individuals in group. Delivery Method Group Dose Nineteen 1.5-hr weekly lessons.	Between Groups There were significant improvements in participants’ global adaptive functioning as reported by social coaches. There were also significant changes in the ABAS Conceptual Composite.
Theme 2: Independence performing IADLs
Three Level 4 SSRD studies used individualized interventions to improve independence performing an activity of daily living. There is low strength of evidence to support this intervention. Risk of bias was moderate to high in these studies.
Bassette et al. (2020) Level 4—SSRD RoB Moderate Country United States Setting Personal training studio	Population N = 3; ages 17, 19, and 21 yr old; 33% female; all competed in Special Olympics powerlifting competitions; no health/medical issues; diagnosis of ASD; parent report benefit in physical activity; parent perception of ability to engage in intervention. Intervention App-based video models that were commercial or customized using adolescents with autism doing the exercises. Narration included, verbal praise included, similar backdrop. Delivery Methods Individual intervention delivered in a personal training studio Dose Variable	Descriptive Findings Increase in physical activity, the number of exercise and workout tasks completed independently.
Luiselli et al. (2020) Level 4—SSRD RoB Moderate to High Country United States Setting Residential school	Participants N = 1; 18-yr-old female with ASD and global developmental delay. Intervention Participated in group home prebedtime activities. Faded bedtime intervention with graduated earlier bedtimes and 30-min observations for sleeping. Delivery Method Individual in residential school for students with neurodevelopmental disabilities. Dose 120 days.	Descriptive Findings Hours to sleep onset decreased and hours of continuous sleep increased during the intervention period and were maintained at 1-mo follow-up.
Burckley et al. (2015) Level 4—SSRD RoB Moderate Country United States Setting Grocery store	Participants N = 1; 18-yr-old female. Intervention Watching a video modeling of a shopping task followed by doing the shopping task Delivery Method Individual in grocery store. Dose 80 sessions with iPad video modeling sessions at session 15, 40, 55.	Descriptive Findings Increase in the percentage of steps in the shopping task that were completed independently and without prompting.

Note. ABAS = Adaptive Behavior Assessment System; ACCESS = Acquiring Career, Coping, Executive control, Social Skills; ADOS-G = Autism Diagnostic Observation Schedule-Generic; ASD = autism spectrum disorder; AQ = Autism Spectrum Quotient; CBT = cognitive behavioral therapy; CD = cognitive deficit; DSM = Diagnostic and Statistical Manual of Mental Disorders; GED = general equivalency degree; IADL = instrumental activities of daily living; IQ = intelligence quotient; LEI = Language education intervention; PEERS = Program for the Education and Enrichment of Relational Skills; QSQ-A = Quality of Socialization Questionnaire-Adolescent; RCT = randomized controlled trial; RoB = risk of bias; SSRD = single-subject research design.

Bottom Line for Occupational Therapy Practice

Moderate strength of evidence supports structured interventions such as PEERS to increase social participation and social skill acquisition. Moderate strength of evidence supports other customized manualized interventions delivered in the context of social settings that contribute to increased social communication and engagement for young autistic adults. Moderate to low strength of evidence supports individualized interventions to increase independent performance of IADL. There is low strength of evidence for single-subject research designs with small samples for individualized interventions focused on social activity planning to increase frequency of social activity participation.

Occupational therapy practitioners can contribute to programs and multidisciplinary teams that provide individualized and/or group training to facilitate meaningful social participation. Occupational therapy practitioners can help identify an individual’s goals and priorities, analyze occupational performance within the context of desired social and community activities, and contribute to customized person, task- or environment-based interventions, modifications, or accommodations. Though supported by a lower strength of evidence, interventions delivered using different individualized supports (i.e., technology, peer mentoring, and activity schedule) in context of the occupation fall within the scope of occupational therapy. Studies included in this systematic review were determined to have outcomes that measured social participation, and studies that focused on skill acquisition outside of authentic participation settings were excluded. The evidence reviewed is limited by the lack of attention to the engagement of autistic adults as stakeholders in the research process and limited information about whether individual study goals and outcomes were stakeholder generated. Studies of occupational therapy interventions and outcome measures that explicitly identify self-determined outcomes capturing meaningful social participation, quality of and satisfaction with participation are needed to expand the evidence base for occupational therapy practices and outcomes.