Evidence-Based Practice Guidelines for Children with Autism Spectrum

Disorder (ASD)Bryden Giving, MAOT, OTR/LEmail: bgiving@pieofmn.com

*All information shared within this presentation is a culmination of recommendations from a multitude of professional organizations, systematic

reviews, and governmental bodies including: the American Occupational Therapy Association, Wisconsin Health Department, National Professional Development Center on Autism Spectrum Disorder, Academy of Pediatrics,

and the Cochrane Collaboration

* None of the presented information are opinions expressed by the presenter

What is Evidence-Based Practice?

• Evidence-based practice (EBP) is the implementation of knowledge from clinical and professional expertise, patient-client unique circumstances and values, and best research evidence into current practice (Law & MacDermind, 2014; Straus, Richardson, Glasziou, & Haynes, 2005; Wong et al., 2014)

• EBP is associated with better outcomes and is more cost-effective than non-EBP approaches (Shin, Randolph, & Rauch, 2010; Straus et al., 2005)

• The primary goal of EBP is to utilize research evidence to decrease the use of ineffective health-care practices and ensure you are providing ethical, effective, and best treatment (Baker & Tickle-Degnen, 2014; Law & MacDermind, 2014; Straus et al., 2005)

• Providing EBP is a highly valued ideal of the American Occupational Therapy Association (AOTA) (American Occupational Therapy Association, 2017; Gillen et al., 2017)

BestResearch Evidence

Professional And Clinical

Expertise

Patient / Client Unique

Values andCircumstances

EBP and Occupational Therapy for Children with ASD

• The range of cost in 2011 in medical expenses for treating children with ASD was between 12 billion and 60 billion dollars, which places an ethical pressure on practitioners to provide evidence-based interventions (Centers for Disease Control and Prevention, 2016)• Evidence-based interventions are practices or programs that have peer-reviewed, documented

empirical evidence of effectiveness and the greatest potential to achieve targeted outcomes (Law & MacDermind, 2014; Straus, Richardson, Glasziou, & Haynes, 2005; Wong et al., 2014)

• EBP is framework for how interventions and health-care methods are being evaluated by payers; it’s the gold standard for reimbursement of services, especially with our shift to PDPM (AOTA, 2019; Shin, Randolph, & Rauch, 2010; Straus et al., 2005) • All areas of health care are emphasizing strong links between research and practice (Shin, Randolph, & Rauch, 2010;

Straus et al., 2005)

Details on Evidence LevelsSuggested recommendations are based on available evidence and content experts’ clinical expertise regarding the value of using the interventions. Criteria for level of evidence and recommendations (A, B, C, I, D) are based on standard language (U.S. Preventive Services Task Force, 2012). Criteria are as follows:

Recommendation / Evidence Level

Description

A Strong evidence that practitioners should routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and that benefits substantially outweigh cost and time.

B Moderate evidence that practitioners should routinely provide the intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial

C Weak evidence that the intervention can improve outcomes. It is recommended that the intervention be provided selectively based on professional judgement and patient preferences. There is at least moderate certainty that the net benefit is small.

I Insufficient evidence to determine if practitioners should routinely be providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harm cannot be determined. There is no reason to assume these interventions are effective. Other interventions should be considered.

D Recommend that practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

Adapted from Tomcheck & Koenig, 2016

Interventions for Social Skills, Social Communication, Restricted and Repetitive Behaviors, Play performance, and Leisure Participation

Task analysis to promote a child's participation in social interaction (A) [AFIRM, 2019]

Group-based social skills training programs in both clinic-based and contextual settings to improve social skills (A)

PECS to improve social communication (A)

Naturalistic strategies (e.g., antecedent-based intervention, reinforcement) to improve joint attention (A)

Behavioral techniques to improve participation in occupations (A)

Early Start Denver Model to improve social communication, play performance, and leisure participation (A)

Adapted from Tomcheck & Koenig, 2016

Interventions for Social Skills, Social Communication, Restricted and Repetitive Behaviors, Play performance, and Leisure Participation

Cognitive Behavioral Intervention (CBI) teaches learners to examine their own thoughts and emotions, recognize when negative thoughts and emotions are escalating in intensity, and then use strategies to change their thinking and behavior (A) [AFIRM, 2019; Wisconsin Department of Health Services, 2016]

GemIIni Systems to improve functional communication, social performance, and play (A) [AFIRM, 2019; Wisconsin Department of Health Services, 2016]

Structured play groups to increase play performance (A) [AFIRM, 2019]

Treatment and Education of Autistic and Communication Related Handicapped Children (TEACCH) to improve play performance and leisure participation (B)

Social Stories to address behavioral difficulties, teach social skills, and promote functional communication (B) [Collet-Klingenberg & Franzone, 2008]

Activity-based interventions to improve social skills (B)

Parent-mediated interventions (e.g., parent-mediated communication-focused treatment, Autism 1-2-3) and imitation to improve social communication (B)

Adapted from Tomcheck & Koenig, 2016

Interventions for Social Skills, Social Communication, Restricted and Repetitive Behaviors, Play performance, and Leisure Participation

Computer-based interventions (social skills training, virtual reality, video modeling, and collaborative computer work) to improve social skills (B)

Naturalistic behavioral interventions (e.g., milieu therapy, functional communication training, and pivotal response training) to improve social communication (B)

Developmental interventions (e.g., relationship-based or floor time) to improve social communication (B)

Parent-mediated interventions (e.g., parent-mediated communication-focused treatment, Autism 1-2-3) and imitation to improve social communication (B)

Recess intervention, leisure group, and Social Stories to improve leisure participation (B)

Adapted from Tomcheck & Koenig, 2016

Interventions for Social Skills, Social Communication, Restricted and Repetitive Behaviors, Play performance, and Leisure Participation

Social Communication, Emotional Regulation and Transactional Support (SCERTS) to prompt child-initiated communication in everyday activities aiming to help children learn and spontaneously apply functional skills (C) [Wisconsin Department of Health Services, 2016]

Hyperbaric Oxygen Therapy (HBOT) to improve core symptoms of Autism and associated symptoms of Autism (I) [Wisconsin Department of Health Services, 2016]

Sensory-motor interventions to improve social communication (I)

DIR / Floortime to improve a child‘s participation in play performance and socio-emotional relationships (I) [Wisconsin Department of Health Services, 2016]

Brain Balance to improve the occupational participation of children with ASD (I)

Vision Therapy to improve a child‘s participation in play, education, ADLs, and functional communication (I)

PLAY Project to promote a child‘s joint attention, social skills, and play performance (I) [Wisconsin Department of Health Services, 2016]

Adapted from Tomcheck & Koenig, 2016

Interventions For Sensory Integration and Sensory-Based Interventions

Qigong massage to improve self-regulatory behaviors and reduce tactile abnormalities, autism symptoms, and parental stress (A)

Sensory-adapted dentist office environment to reduce distress, pain, and sensory discomfort for children with ASD (B)

ASI to address individualized goal areas with measurement by Goal Attainment Scaling (B)

Multisensory activities to improve occupational performance and behavior regulation (B)

Yoga to improve emotional regulation, decrease emotional distress, and improve self-soothing for adolescents (C)

ASI to improve sleep, adaptive skills, Autism features, and sensory processing (C-I)

Sensory diets integrated into child routines to meet sensory needs (I) [Wong et al., 2014]

Adapted from Tomcheck & Koenig, 2016

Reflex integration therapies (e.g., MNRI) to improve functional outcomes and sensory processing difficulties (I) [Wisconsin Department of Health Services, 2016]

Sound therapies (Therapeutic Listening, The Listening Program, Auditory Integration Training, Integrated Listening Symptoms) to improve behavioral regulation and sensory processing (Cochrane Collaboration, 2019; Wisconsin Department of Health Services, 2016); sound therapies to improve a child’s participation in daily activities and occupations (AOTA, 2015) [I]

Dynamic seating to improve in-seat and on-task behavior and engagement (I)

Wilbarger Protocol (e.g., brushing) to promote the occupations of children with ASD (I) [Weeks, Boshoff, & Stewart, 2012]

Weighted vests to support improved behavior or performance in daily activities (D)

Adapted from Tomcheck & Koenig, 2016

Craniosacral Therapy to improve functional outcomes and sensory processing difficulties (I) [Wisconsin Department of Health Services, 2016]

Interventions For Sensory Integration and Sensory-Based Interventions

Interventions for Performance in ADLs, IADLS, and Education

Task analysis to improve a child's participation in ADLS, IADLs, academic tasks, and motor skills (A) [AFIRM, 2019]

Visual supports to enhance a child's performance in ADLs, IADLs, and academic tasks (A) [AFIRM, 2019]

Video modeling and technology-enhanced visual supports and prompting to increase function in ADL performance (A)

Antecedent-based Intervention (ABI) can be used to decrease an identified interfering behavior and increase engagement by modifying the environment (A) [AFIRM, 2019]

Naturalistic Intervention (NI) consists of applying principles of behavior during a learner's everyday routines and activities to increase a target behavior or decrease an interfering behavior (A) [AFIRM, 2019]

Discrete Trial Training (DTT) consists of an adult-directed, massed trial instruction, reinforcers, and clear contingencies and repetition to teach a new skill or behavior (A) [AFIRM, 2019]

Adapted from Tomcheck & Koenig, 2016

Discrete Trial Training (DTT) consists of an adult-directed, massed trial instruction, reinforcers, and clear contingencies and repetition to teach a new skill or behavior (A) [AFIRM, 2019]

Cognitive-behavioral approaches to improve function in the areas of ADLs and IADLs (B)

Treatment and Education of Autistic and Communication Related Handicapped Children (TEACCH) to improve emotional regulation, functional communication, and sensory processing (B)

Curriculum-based handwriting interventions (e.g., Handwriting Without Tears, Write Start Program, Size Matters Handwriting Program) can elicit improvements in legibility (B) [Engel, Lillie, Zurawski, & Travers, 2018]

Sequential Oral Sensory (S.O.S.) Approach to feeding to increase a child’s food repertoire and address food selectivity challenges (C) [Reinoso, Carsone, Powers, & Bellare, 2018]

CO-OP approach to improve ADL and IADL function (C)

ASI to reduce caregiver assistance needed for self-care skills (C)

Interventions for Performance in ADLs, IADLS, and Education

Adapted from Tomcheck & Koenig, 2016

Implications for Practice Summary (Tomcheck & Koenig, 2016)

• Moderate to strong evidence supports the following intervention approaches:1. TEACCH and task analysis for addressing a variety of occupations2. Group-based social skills training to enhance social skills3. Discrete trial training and video modeling to enhance functional performance in daily activities4. PECS, joint attention, naturalistic strategies, ESDM, and parent-mediated strategies to facilitate social communication

development, play, and participation in ADLS and IADLs5. Video modeling, visual supports, and prompting to increase functional independence in ADLs6. Multisensory activities and social stories to improve occupational performance and behavior regulation7. Cognitive-behavioral and behavioral approaches (e.g., reinforcement, antecedent-based intervention) to improve

function in ADL and IADL occupations8. Activity-based interventions to improve occupational performance

• Interventions with limited or poor evidence:1. Listening programs (Therapeutic Listening, The Listening Program, Auditory Integration Training, Integrated

Listening Symptoms)2. Weighted vests to improve behavior and sensory regulation3. Wilbarger Protocol4. Reflex integration programs5. Brain Balance6. Yoga to improve emotional regulation7. Dynamic seated to improve attention

• Treatment methods with poor or limited evidence should be used sparingly by practitioners. If a therapist perceives a potential benefit selects one of these methods, the client’s family should be informed of the limitations in evidence and anypossible risks.

An Evidence-Based Perspective (Kielhofner & Taylor, 2017)

1. Level 1: Systematic reviews of the literature, meta-analyses, and randomized controlled trials (RCTs)

2. Level II: Cohort study3. Level III: Case-control study4. Level IV: Case report5. Level V: Expert opinions

*The number of research articles existing to support the efficacy of an intervention is irrelevant; the research articles must contain high quality research (primarily Level I) *

Tips for Reading a Research Paper (Greenhalgh, 2014)

1. Was the research article found in a published peer-reviewed journal?2. Does the literature review contain published research or just expert opinions and reviews?3. What is the strength/level of evidence? What type of study was completed? (Evidence pyramid)4. Does the research study have a small, medium, or large sample?5. Does the research focus on children with autism spectrum disorder and their occupations?6. Does the study have experimental and control/comparative groups that are clearly defined?7. What outcomes were used to capture the interventions’ effect and how often were they used?8. Does the research report statistically significant effects of the practice for individuals with ASD for at

least one outcome variable?9. Were the creators of the intervention involved or were there any conflicts of interest?

Is My Practice Evidence-Based? (Greenhalgh, 2014)

1. Have I identified and prioritized the clinical, psychological, social, and other problem(s), taking into account the patient’s perspective?

2. Have I sought evidence (from systematic reviews, guidelines, clinical trials, and other sources) pertaining to problem area?

3. Have I assessed and taken into account the completeness, quality, and strength of the evidence?4. Have I presented the pros and cons of different options to the patient’s families and incorporated their

preferences in to the final recommendation? (Clearly communicate benefits and risks of an intervention if the evidence is questionable or low)

5. Have I evaluated the evidence of different interventions in terms of occupational performance and participation outcomes?

Helpful Links and Resources• Open Journal of Occupational Therapy (OJOT) - https://scholarworks.wmich.edu/ojot/ • Journal of Occupational Therapy Education (JOTE)- https://encompass.eku.edu/joteAccess• Wisconsin Treatment Intervention Advisory Committee has a list of popularly used interventions to treat children with ASD

and their evidence level - https://tiac.wisconsin.gov/summary-determinations-regarding-level-evidence.htm• AOTA Membership!

Ø Access to American Journal of Occupational Therapy (AJOT), British Journal of Occupational Therapy (BJOT), and Canadian Journal of Occupational Therapy (CJOT)

• Registered with NBCOT?Ø Access to research journal libraries of ProQuest and RefWorks

• AOTA’s EBP sectionØ Link to Autism Spectrum Disorder section - https://www.aota.org/Practice/Children-Youth/Evidence-based/EBP-

ASD.aspxØ Critically Appraised Topics (CATs) are regularly added and can be downloaded as a pdf

• The Cochrane Collaboration - http://www.cochrane.org/index.htmØ The Cochrane Collaboration provides accurate, up-to-date information regarding the effects of healthcare. It creates and

disseminates systematic reviews of healthcare treatments, including those regarding children with ASD. The Cochrane Collaboration promotes the examination of evidence in the form of studies and clinical trials.

• The Autism Focused Intervention Resources and Modules (AFIRM) project has translated evidence-based practices identified by Wong et al. (2015) into online learning modules.Ø The practices can be found at https://autismpdc.fpg.unc.edu/evidence-based-practices

• OT Seeker is a database that contains abstracts of systematic reviews, randomized controlled trials and other resources relevant to occupational therapy interventions - http://www.otseeker.com

1. Autism Focused Intervention Resources and Modules (AFIRM) Team. (2015). AFIRM modules. Chapel Hill, NC: National Professional Development Center on Autism Spectrum Disorder, FPG Child Development Center, University of North Carolina. Retrieved from https://afirm.fpg.unc.edu/node/137

2. American Occupational Therapy Association (AOTA). (2015). Critically appraised topic: Evidence for sound therapies for children with autism spectrum disorder. Retrieved from https://www.aota.org/Practice/Children-Youth/Evidence-based/CAT-ASD-Sound.aspx.

3. American Occupational Therapy Association (AOTA). (2017). Evidence-based practice & research. Retrieved from https://www.aota.org/Practice/Researchers.aspx4. American Occupational Therapy Association (AOTA). (2019). Payment for Value Based OT: Implications for Quality and Practice. Retrieved from

https://www.aota.org/Practice/Manage/value.aspx.5. Baker, N., & Tickle-Degnen, L. (2014). Evidence-based practice: integrating evidence to inform practice. In B. A. B. Schell, G. Gillen, & M. E. Scaffa (Eds). Willard and Spackman's Occupational

Therapy (12th ed., pp. 398-412). Philadelphia: Lippincott Williams & Wilkins.6. Centers for Disease Control and Prevention. (2016). Autism spectrum disorder. Retrieved from http://www.cdc.gov/ncbddd/autism/data.html#references7. Cochrane Collaboration (2019). http://www.cochrane.org/8. Collet-Klingenberg, L., & Franzone, E. (2008). Overview of social narratives. Madison, WI: The National Professional Development Center on Autism Spectrum Disorders, Waisman Center,

University of Wisconsin.9. Engel, C., Lillie, K., Zurawski, S., & Travers, B. G. (2018) Curriculum-based handwriting programs: A systematic review with effect sizes. American Journal of Occupational Therapy, 72,

7203205010. https:/doi.org/10.5014/ajot.2018.02711010. Gillen, G., Lieberman, D., Stutzbach, M., & Arbesman, M. (2017). Five interventions/assessments our clients should question. OT Practice, 22(15), 19-20. Retrieved

from https://www.aota.org/~/media/Corporate/Files/Secure/Publications/OTP/2017/OTP-Volume-22-Issue-15-bridge-obstacles.pdf11. Greenhalgh, T. (2014). How to read a paper: The basics of evidence-based medicine. Cichester, West Sussex: John Wiley & Sons.12. Griffin, W., & AFIRM Team. (2017). Autism focused intervention resources & modules (AFIRM). Retrived from https://affirm.fpg.unc.edu/node/13713. Kielhofner, G., & Taylor, R. R. (2017). Research in occupational therapy: Methods of inquiry for enhancing practice. Philadelphia: F.A. Davis Company.14. Law, M., & MacDermind, J. (2014). Introduction to evidence-based practice. In M., Law & J. C., MacDermind (Eds.), Evidence-Based Rehabilitation: A Guide to Practice (3rd ed., pp. 1-14).

Thorofare, NJ: SLACK.15. Reinoso, G„ Carsone, B„ Weldon, S., Powers, J„ & Bellare, N. (2018). Food selectivity and sensitivity in children with Autism Spectrum Disorder: A systematic review defining the issue and

evaluating interventions. New Zealand Journal of Occupational Therapy, 65(1), 36-42.16. Straus, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2005). How to practice and teach EBM. Evidence-Based Medicine. Third edition. Elservier, 13-29. doi:10.1177/104973150629616717. Shin, J., Randolph, G. W., & Rauch, S. D. (2010). Evidence-based medicine in otolaryngology, part 1: The multiple faces of evidence-based medicine. Otolaryngology – Head and Neck Surgery,

142, 637-646. doi:10.1016/j.otohns.2010.01.01818. Tomchek, S. D., & Koenig, K. P. (2016). Occupational therapy practice guidelines for individuals with autism spectrum disorder. Bethesda, MD: AOTA Press, The American Occupational Therapy

Association.19. Watling, R., Miller Kuhaneck, H., Parham, L. D., & Schaaf, R. (2018). Occupational therapy practice guidelines for children and youth with challenges in sensory integration and sensory processing.

Bethesda, MD: AOTA Press.20. Weeks, S., Boshoff, K., & Stewart, H. (2012). Systematic review of the effectiveness of the Wilbarger protocol with children. Pediatric Health, Medicine, and Therapeutics, 2, 79–89. 21. Wisconsin Department of Health Services. (2016). Summary of determinations regarding levels of evidence. Retrieved from https://tiac.wisconsin.gov/summary-determinations-regarding-level-

evidence.htm.22. Wong, C., Odom, S. L., Hume, K. Cox, A. W., Fettig, A., Kucharczyk, S., ... Schultz, T. R. (2014). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder.

Retrieved from http://autismpdc.fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/2014-EBP-Report.pdf.

References