Background
It is unclear whether atypical patterns of facial expression production metrics in autism reflect the dynamic and nuanced nature of facial expressions across people or a true diagnostic difference. Furthermore, the heterogeneity observed across autism symptomatology suggests a need for more adaptive and personalized social skills programs. Towards this goal, it would be useful to have a more concrete and empirical understanding of the different expressiveness profiles within the autistic population and how they differ from neurotypicals.

Methods
We used automated facial coding and an unsupervised clustering approach to limit inter-individual variability in facial expression production that may have otherwise obscured group differences in previous studies, allowing an “apples-to-apples” comparison between autistic and neurotypical adults. Specifically, we applied k-means clustering to identify subtypes of facial expressiveness in an autism group (N = 27) and a neurotypical control group (N = 57) separately. The two most stable clusters from these analyses were then further characterized and compared based on their expressiveness and emotive congruence to emotionally charged stimuli.

Results
Our main finding was that a subset of autistic adults in our sample show heightened spontaneous facial expressions irrespective of image valence. We did not find evidence for greater incongruous (i.e., inappropriate) facial expressions in autism. Finally, we found a negative trend between expressiveness and emotion recognition within the autism group.

Conclusion
The results from our previous study on self-reported empathy and current expressivity findings point to a higher degree of facial expressions recruited for emotional resonance in autism that may not always be adaptive (e.g., experiencing similar emotional resonance regardless of valence). These findings also build on previous work indicating that facial expression intensity is not diminished in autism and suggest the need for intervention programs to focus on emotion recognition and social skills in the context of both negative and positive emotions.

Abstract: This study aims to investigate the relationship between binge-watching addiction and family, emotional, conduct, cognitive and anger control problems, hyperactivity, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)-ADHD Index, DSM-IV-Inattention, and DSM-IV-Hyperactivity Impulsivity in a large sample of healthy Turkish adolescents. The association between binge-watching behavior addiction and mood disorders in healthy adolescents was examined in this cross-sectional study conducted in Turkey. Participants completed both measures, The Binge-Watching Addiction Questionnaire and The Conners-Wells' Adolescent Self-Report Scale. An online survey of 189 adolescents was conducted. One hundred fourteen subjects (60.3%) were categorized into the binge-watcher group. Results showed important positive associations between binge-watching behavior and emotional, conduct, cognitive problems, and DSM-IV-Inattention. The conducted analysis showed an important association between high frequency of binge-watching and emotional problems (p < 0.001), conduct problems (p = 0.012), cognitive problems (p = 0.001), and inattention (p < 0.001). These findings contributed to our comprehension of adolescents' psychological correlates of television viewing behavior. Further researches on the relationship between extreme binge-watching and psychiatric disorders of adolescents are recommended.

Au Québec, les enfants d’âge préscolaire ayant un trouble du spectre de l’autisme (TSA) reçoivent des services d’intervention comportementale intensive (ICI) par le biais des établissements du réseau de la santé et des services sociaux. L’intensité et la précocité, ainsi que le recours à des stratégies d’intervention spécifiques découlant des principes de l’analyse appliquée du comportement caractérisent l’ICI. La sélection des stratégies les plus appropriées pour chaque enfant est une étape essentielle du processus d’intervention. Plusieurs éléments sont susceptibles d’influencer cette décision. Les caractéristiques individuelles des enfants et les priorités de leur famille en sont des exemples. Cette étude s’intéresse à la façon dont les équipes cliniques opèrent ce processus d’individualisation. Plus spécifiquement, elle vise une meilleure compréhension de la façon dont les dispensateurs de services réalisent cette étape de l’intervention et l’identification des facteurs pris en compte, dans le cadre de services offerts dans la communauté. Pour ce faire, un devis qualitatif est proposé. Dix superviseures cliniques de programmes ICI de trois établissements du réseau de services publics québécois ont partagé leur expérience dans le cadre d’entretiens. Les résultats suggèrent que la prise de décision concernant les stratégies à privilégier implique plusieurs facteurs, et ce, à différents niveaux. En effet, le discours des superviseures met d’abord l’accent sur l’enfant et sa famille. De plus, il intègre des facteurs contextuels plus larges, notamment les environnements disponibles et les personnes qui appliquent l’intervention. Les résultats soulèvent la question de la formation et du soutien à offrir aux équipes d’intervention afin de faciliter le processus d’individualisation de l’ICI.

L’entraînement et l’attribution de chiens d’assistance pour les enfants qui présentent un trouble du spectre de l’autisme (TSA) gagnent en popularité. Les bienfaits documentés concernent tant les aspects physiologiques que comportementaux : diminution du stress et de l’anxiété, augmentation des interactions sociales, développement du langage, entre autres éléments. Toutefois, les facteurs explicatifs de ces bienfaits sont peu documentés. Objectif : La présente étude explore l’effet différencié de l’introduction d’un chien d’assistance dans les familles d’enfants autistes âgés entre cinq et neuf ans, selon le degré de sévérité des déficits liés au TSA. Méthode : Un nombre de 91 parents d’enfants ayant reçu un chien d’assistance de la Fondation Mira ont rempli un questionnaire sur le niveau de fonctionnement de l’enfant en différents domaines un mois avant et trois mois après l’attribution de leur chien. Les résultats ont été étudiés en fonction de la sévérité des symptômes de l’enfant, établi à l’aide de la traduction en français de la Childhood Autism Rating Scale (CARS) (Schopler et al., 1980), par Bernadette Rogé (1989). Résultats : En se basant sur les réponses au questionnaire, les enfants présentant des symptômes d’autisme allant de moyens à sévères semblent bénéficier davantage et de manière significative de la présence du chien d’assistance que les enfants plus légèrement atteints. Discussion : La sévérité de l’autisme pourrait être prise en compte lors des démarches d’obtention d’un chien d’assistance afin de mieux accompagner les familles vivant avec un enfant ayant un TSA. Cet article explore les concepts théoriques sous-jacents aux effets du chien selon différents domaines de vie, afin de contribuer à l’amélioration continue et le développement de meilleures pratiques dans le dans le champ d’étude du TSA et du chien d’assistance.

Lorsqu’un parent assure les soins d’un enfant ayant un trouble du spectre de l’autisme (TSA), il fait face aux stresseurs quotidiens de la prise en charge d’un enfant, auxquels s’ajoutent ceux liés à l’autisme. Dans l’ensemble, ces parents rencontrent un niveau de stress parental plus élevé que les parents d’enfants non autistes ou présentant certaines particularités développementales. Dans une étude précédente, l’agrégation d’indices physiologiques et psychologiques obtenus chez 71 mères a mené à l’identification de trois profils de stress parental, montrant une adaptation distincte. Des entrevues semi-structurées ont été effectuées auprès de ces mères. Cet article présente le résultat de l’analyse qualitative d’entrevues menées auprès de mères dans chacun des profils identifiés (n:12). Les résultats montrent que les trois profils de stress parental se distinguent au niveau des caractéristiques des enfants, de la perception des mères à propos du soutien social offert par les professionnels et par l’entourage, de leur utilisation des stratégies de coping, en plus de l’ampleur et de la diversité des conséquences négatives auxquelles ces mères font face quotidiennement. Qualifiés de profils détaché, épuisé ou rencontrant un stress aigu, les différences entre les trois profils de stress sont discutées, illustrant une réalité complexe. La description de cette hétérogénéité dans le vécu de stress parental apporte une contribution novatrice à la recherche actuelle en fournissant des leviers d’intervention adaptés au vécu respectif.

Au Québec, les enfants d’âge préscolaire ayant un trouble du spectre de l’autisme (TSA) reçoivent des services d’intervention comportementale intensive (ICI) par le biais des établissements du réseau de la santé et des services sociaux. L’intensité et la précocité, ainsi que le recours à des stratégies d’intervention spécifiques découlant des principes de l’analyse appliquée du comportement caractérisent l’ICI. La sélection des stratégies les plus appropriées pour chaque enfant est une étape essentielle du processus d’intervention. Plusieurs éléments sont susceptibles d’influencer cette décision. Les caractéristiques individuelles des enfants et les priorités de leur famille en sont des exemples. Cette étude s’intéresse à la façon dont les équipes cliniques opèrent ce processus d’individualisation. Plus spécifiquement, elle vise une meilleure compréhension de la façon dont les dispensateurs de services réalisent cette étape de l’intervention et l’identification des facteurs pris en compte, dans le cadre de services offerts dans la communauté. Pour ce faire, un devis qualitatif est proposé. Dix superviseures cliniques de programmes ICI de trois établissements du réseau de services publics québécois ont partagé leur expérience dans le cadre d’entretiens. Les résultats suggèrent que la prise de décision concernant les stratégies à privilégier implique plusieurs facteurs, et ce, à différents niveaux. En effet, le discours des superviseures met d’abord l’accent sur l’enfant et sa famille. De plus, il intègre des facteurs contextuels plus larges, notamment les environnements disponibles et les personnes qui appliquent l’intervention. Les résultats soulèvent la question de la formation et du soutien à offrir aux équipes d’intervention afin de faciliter le processus d’individualisation de l’ICI.

Objective: The purpose of this study was to describe the implementation of universal suicide risk screening in pediatric neurodevelopmental disabilities (NDD) medical clinics, analyze demographic and clinical characteristics of eligible patients, describe outcomes of positive screenings, and describe factors that influenced participation in screenings.

Methods: A suicide risk screening protocol was developed and implemented for medical clinic patients aged 8 to 18 years. Registered nurses screened patients using the "Ask Suicide-Screening Questions" tool during triage. Positive screenings were referred for further assessment and mental health management. Demographics and clinical data were extracted from medical records using retrospective chart reviews.

Results: During the 6-month study period, 2961 individual patients presented for 5260 screening eligible patient visits. In total, 3854 (73.3%) screenings were completed with 261 (6.8%) positive screenings noted. Screenings were declined in 1406 (26.7%) visits. Parents of children with cognitive impairments were more likely to decline screening. Clinics serving children with autism spectrum disorder had higher rates of positive screenings compared with all other clinic attendees. Seventy-two of 187 children (38.5%) with positive screenings were identified and referred to outpatient mental health referrals. Seven (2.5%) of these children required acute psychiatric treatment.

Conclusion: Routine screening, identification of increased suicide risk, and referral to mental health care among children with NDD are feasible. It remains unclear whether variation in rates among youth with and without NDD may indicate true differences in suicide risk or cognitive impairments or reflect psychiatric comorbidities. High rates of declined participation may have influenced identification of children with NDD and suicide risk. Preliminary findings identified groups of children with NDD at heightened risk for suicidal ideation and behavior. Further research is needed to assess the validity of suicide risk screening tools in children with neurodevelopmental disorders.

Table des matières:

Page 02: Comment supporter les apprentissages chez les enfants autistes?
Page 06: L'expression émotionnelle des jeunes enfants autistes diffère-t-elle des enfants neurotypiques? L'importance du contexte!
Page 08: Évaluation des tout-petits: L'importance d'une approche multi-méthodes et alliant différentes perspectives
Page 11: Comportements restreints et répétitifs en autisme: comment ils évoluent?
Page 13: Diagnostics associés dans l'enfance des personnes diagnostiquées autistes.

Background
Phosphatase and tensin homologue (PTEN) is a cancer suppressor gene. Constitutional mutations affecting this gene are associated with several conditions, collectively termed PTEN hamartoma tumour syndromes (PHTS). In addition to hamartomas, PTEN aberrations have been associated with a range of non-tumoural phenotypes such as macrocephaly, and research indicates possibly increased rates of developmental delay and autism spectrum disorder (ASD) for people with germline mutations affecting PTEN.

Method
A systematic review of literature reporting behavioural and psychological variables for people with constitutional PTEN mutations/PHTS was conducted using four databases. Following in-depth screening, 25 articles met the inclusion criteria and were used in the review. Fourteen papers reported the proportion of people with PTEN mutations/PTHS meeting criteria for or having characteristics of ASD and were thus used in a pooled prevalence meta-analysis.

Results
Meta-analysis using a random effects model estimated pooled prevalence of ASD characteristics at 25% (95% CI 16–33%), although this should be interpreted cautiously due to possible biases in existing literature. Intellectual disability and developmental delay (global, motor and speech and language) were also reported frequently. Emotional difficulties and impaired cognitive functioning in specific domains were noted but assessed/reported less frequently. Methods of assessment of psychological/behavioural factors varied widely (with retrospective examination of medical records common).

Conclusions
Existing research suggests approximately 25% of people with constitutional PTEN mutations may meet criteria for or have characteristics of ASD. Studies have also begun to establish a range of possible cognitive impairments in affected individuals, especially when ASD is also reported. However, further large-scale studies are needed to elucidate psychological/behavioural corollaries of this mutation, and how they may relate to physiological/physical characteristics.

Background
Imitation skills play a crucial role in social cognitive development from early childhood. Many studies have shown a deficit in imitation skills in children with autism spectrum disorders (ASD). Little is known about the development of imitation behaviors in children with ASD. This study aims to measure the trajectories of early imitation skills in preschoolers with ASD and how these skills impact other areas of early development.

Methods
For this purpose, we assessed imitation, language, and cognition skills in 177 children with ASD and 43 typically developing children (TD) aged 2 to 5 years old, 126 of which were followed longitudinally, yielding a total of 396 time points.

Results
Our results confirmed the presence of an early imitation deficit in toddlers with ASD compared to TD children. The study of the trajectories showed that these difficulties were marked at the age of 2 years and gradually decreased until the age of 5 years old. Imitation skills were strongly linked with cognitive and language skills and level of symptoms in our ASD group at baseline. Moreover, the imitation skills at baseline were predictive of the language gains a year later in our ASD group. Using a data-driven clustering method, we delineated different developmental trajectories of imitation skills within the ASD group.

Conclusions
The clinical implications of the findings are discussed, particularly the impact of an early imitation deficit on other areas of competence of the young child.

Background
RASopathies are genetic syndromes that result from pathogenic variants in the RAS-MAPK cellular signaling pathway. These syndromes, which include neurofibromatosis type 1, Noonan syndrome, cardiofaciocutaneous syndrome, and Costello syndrome, are associated with a complex array of medical and behavioral health complications. Despite a heightened risk for social challenges and autism spectrum disorder (ASD), few studies have compared different aspects of social behavior across these conditions. It is also unknown whether the underlying neuropsychological characteristics that contribute to social competence and socially empathetic (“prosocial”) behaviors differ in children with RASopathies as compared to children with nonsyndromic (i.e., idiopathic) ASD.

Methods
In this cross-sectional, survey-based investigation, caregivers of preschool and school-aged children with RASopathies (n = 202) or with idiopathic ASD (n = 109) provided demographic, medical, and developmental information about their child, including psychiatric comorbidities. For children who were able to communicate verbally, caregivers also completed standardized rating scales to assess social competence and empathetic behavior as well as symptoms of hyperactivity/inattention and emotional problems.

Results
As compared to children with idiopathic ASD, children with RASopathies were rated as demonstrating more resilience in the domain of empathy relative to their overall social competence. Similarities and differences emerged in the psychological factors that predicted social behavior in these two groups. Stronger communication skills and fewer hyperactive-impulsive behaviors were associated with increased empathy and social competence for both groups. Greater emotional challenges were associated with lower social competence for children with RASopathies and stronger empathy for children with idiopathic ASD. Among children with RASopathy and a co-occurring ASD diagnosis, socially empathetic behaviors were observed more often as compared to children with idiopathic ASD.

Conclusions
Findings suggest that the development of social behavior among children with RASopathies involves a distinct pattern of strengths and weaknesses as compared to a behaviorally defined disorder (idiopathic ASD). Identification of areas of resilience as well as behavioral and social challenges will support more targeted intervention.

Background
Attention deficit hyperactivity disorder (ADHD) is a common childhood behavioral condition that globally affects an average of around 5% of children and is associated with several adverse life outcomes. Comorbidity with autism spectrum disorder (ASD) is highly prevalent. Pharmacological treatment for ADHD symptoms has been shown to be effective. However, the prevailing perception is that children with ADHD and concomitant ASD symptoms report poorer efficacy and more side effects. This has been supported by studies on this population, but prospective studies directly comparing children with ADHD and different levels of ASD symptoms are lacking. We aimed to assess if children with ADHD and concomitant ASD symptoms differ regarding effects and side-effects of pharmacological ADHD treatment compared to children with ADHD without ASD traits. This is to our knowledge the second study to directly compare the effect of ADHD medication between ADHD patients with different levels of ASD symptoms.

Methods
In a non-randomized, observational, prospective cohort study, 323 patients aged 6 to 17 years who were diagnosed with ADHD and starting pharmacological treatment were divided into two groups: one with high level of ASD symptoms (ASD group, N=71) and one with low level of ASD symptoms (non-ASD group, N = 252). Treatment outcome was measured as ADHD symptoms, and evaluated using the Swanson, Nolan and Pelham Teacher and Parent ADHD rating scale-version IV (SNAP-IV). Side-effects were evaluated using the Pediatric Side Effects Checklist (P-SEC), at 3 months follow-up.

Results
From baseline to 3 months, there was no significant difference in neither treatment effect nor number of clinically significant adverse events experienced between the ASD group and the non-ASD group.

Conclusions
Our results did not implicate that ADHD patients with concomitant ASD symptoms have decreased treatment effect of ADHD medication than patients with ADHD without concomitant ASD symptoms. Neither did the results support that ADHD patients with ASD symptoms experienced significantly more side-effects than ADHD patients without ASD symptoms. Although, we did not analyze different medications separately, this is in line with the only previous study directly comparing methylphenidate treatment in children with or without ASD.

Background and aims
Humans communicate primarily through spoken language and speech perception is a core function of the human auditory system. Among the autistic community, atypical sensory reactivity and social communication difficulties are pervasive, yet the research literature lacks in-depth self-report data on speech perception in this population. The present study aimed to elicit detailed first-person accounts of autistic individuals’ abilities and difficulties perceiving the spoken word.

Methods
Semi-structured interviews were conducted with nine autistic adults. The interview schedule addressed interviewees’ experiences of speech perception, factors influencing those experiences, and responses to those experiences. Resulting interview transcripts underwent thematic analysis. The six-person study team included two autistic researchers, to reduce risk of neurotypical ‘overshadowing’ of autistic voices.

Results
Most interviewees reported pronounced difficulties perceiving speech in the presence of competing sounds. They emphasised that such listening difficulties are distinct from social difficulties, though the two can add and interact. Difficulties were of several varieties, ranging from powerful auditory distraction to drowning out of voices by continuous sounds. Contributing factors encompassed not only features of the soundscape but also non-acoustic factors such as multisensory processing and social cognition. Participants also identified compounding factors, such as lack of understanding of listening difficulties. Impacts were diverse and sometimes disabling, affecting socialising, emotions, fatigue, career, and self-image. A wide array of coping mechanisms was described.

Conclusions
The first in-depth qualitative investigation of autistic speech-perception experiences has revealed diverse and widespread listening difficulties. These can combine with other internal, interpersonal, and societal factors to induce profound impacts. Lack of understanding of such listening difficulties – by the self, by communication partners, by institutions, and especially by clinicians – appears to be a crucial exacerbating factor. Many autistic adults have developed coping strategies to lessen speech-perception difficulties or mitigate their effects, and these are generally self-taught due to lack of clinical support.

Implications
There is a need for carefully designed, adequately powered confirmatory research to verify, quantify, and disentangle the various forms of listening difficulty, preferably using large samples to explore heterogeneity. More immediate benefit might be obtained through development of self-help and clinical guidance materials, and by raising awareness of autistic listening experiences and needs, among the autistic community, communication partners, institutions, and clinicians.

Background and aims
Play-based interventions are used ubiquitously with children with social, communication, and language needs but the impact of these interventions on the mental health of this group of children is unknown. Despite their pre-existing challenges, the mental health of children with developmental language disorder (DLD) and autism spectrum disorder (ASD) should be given equal consideration to the other more salient features of their condition. To this aim, a systematic literature review with meta-analysis was undertaken to assess the impact of play-based interventions on mental health outcomes from studies of children with DLD and ASD, as well as to identify the characteristics of research in this field.

Methods
The study used full systematic review design reported to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (PRISMA prisma-statement.org) with pre-specified inclusion criteria and explicit, transparent and replicable methods at each stage of the review. The study selection process involved a rigorous systematic search of seven academic databases, double screening of abstracts, and full-text screening to identify studies using randomised controlled trial (RCT) and quasi-experimental (QE) designs to assess mental health outcomes from interventions supporting children with DLD and ASD. For reliability, data extraction of included studies, as well as risk of bias assessments were conducted by two study authors. Qualitative data were synthesised narratively and quantified data were used in the metaanalytic calculation.

Main contribution
A total of 2,882 papers were identified from the literature search which were double screened at the abstract (n  =  1,785) and full-text (n  =  366) levels resulting in 10 papers meeting the criteria for inclusion in the review. There were 8 RCTs and 2 QEs using 7 named play-based interventions with ASD participants only. Meta-analysis of 5 studies addressing positive mental health outcomes (e.g. positive affect and emotional functioning) found a significant overall intervention effect (Cohen's d = 1.60 (95% CI [0.37, 2.82], p = 0.01); meta-analysis of 6 studies addressing negative mental health outcomes (e.g., negative affect, internalising and externalising problems) found a non-significant overall intervention effect (Cohen's d = 0.04 -0.17 (95% CI [-0.04, 0.51], p = 0.88).

Conclusions
A key observation is the diversity of study characteristics relating to study sample size, duration of interventions, study settings, background of interventionists, and variability of specific mental health outcomes. Play-based interventions appear to have a beneficial effect on positive, but not negative, mental health in children with ASD. There are no high quality studies investigating the efficacy of such interventions in children with DLD.

Implications
This review provides good evidence of the need for further research into how commonly used play-based interventions designed to support the social, communication, and language needs of young people may impact the mental health of children with ASD or DLD.

Dans l'autisme, la transition vers l'âge adulte est très souvent un moment difficile. Difficile tout d'abord pour la personne concernée, mais aussi éprouvante pour ses proches.. Cette période s'inscrit en effet dans un contexte de transformations personnelles et contextuelles, où il va s'agir de s'adapter, de modifier ou de fabriquer des environnements nouveaux.. Les transformations personnelles concernent tout à la fois les modifications neuropsychologiques et somatiques observées durant l'adolescence, que les évolutions cliniques du trouble, dans lesquelles on note souvent l'apparition de nouvelles associations avec d'autres psychopathologies (anxiété, dépression...). Et, pour certains sujets, beaucoup plus rares, c'est aussi l'annonce d'un diagnostic tardif, avec toutes ses conséquences.. Mais l'entrée dans l'âge adulte, c'est aussi une profonde modification de l'environnement du sujet : recherche d'une formation ou d'un emploi, d'un logement, d'un partenaire. Ces contraintes, surdéterminées par le poids des normes sociales, vont nécessiter la mise en place de soutiens, de programmes, d'interventions qui vont mobiliser les parents, la fratrie, mais aussi les employeurs, les personnels éducatifs, et parfois nécessiter des aménagements législatifs et sociétaux concernant ce que certains nomment un « handicap ».. Ce livre, à partir d'une revue de la littérature internationale centrée sur ce thème, et même si beaucoup d'articles concernent l'autisme sans déficience intellectuelle, aborde toutes ces questions.. Il n'y a pas à ce jour de réponses « clés en main ». Chaque pays, parfois chaque région apporte son lot de solutions. Mais, dans tous les cas, une synthèse méritait d'être proposée aux personnes concernées ou intéressées par cette problématique..

The prevalence of sleep dysfunction is considerably higher in the autistic population than in the non-autistic. Similarly, the incidence of sensory reactivity differences in autism exceeds that in the neurotypical population. The basis of sleep disorders in autism is multifactorial, but sensory integration/processing concerns may play a role. Research that investigates this interplay for autistic individuals is limited but vital. In this scoping review, we examined literature addressing the following research question: What is the relationship between sleep and sensory integration/processing in autism? We included articles if they were peer-reviewed, English or Spanish, purposefully addressed sensory integration/processing differences, were sleep focused and included autism as the primary diagnosis or population. Articles were excluded if the language was not English or Spanish, research was conducted with animals, they were non-peer-reviewed, the primary population was not autistic, the sensory focus reflected a specific sensorineural loss (e.g., blindness, or deafness), there was not a clear inclusion of sensory integration/processing or sleep. We searched six databases and included all citations from the inception of each database through June 2021. The search strategy identified 397 documents that were reduced to 24 included articles after exclusion criteria were applied. The majority of studies we identified characterized the relation between sleep and sensory integration/processing differences in autism. Investigators found multiple sleep concerns such as bedtime resistance, sleep anxiety, delayed sleep onset, night awaking, and short sleep duration in autistic individuals. Identified sensory concerns focused on reactivity, finding hyper- and hypo-reactivity as well as sensory seeking across sensory domains. Co-existence of sleep concerns and sensory integration/processing differences was frequently reported. Few intervention studies showed a clear sensory focus; those that did emphasized pressure, movement, touch, and individual sensory preferences/needs. Swimming programs and massage showed promising results. No studies were of high quality. At a minimum, there is a co-existence of sensory reactivity differences and sleep concerns in autistic children, and possibly autistic adults. The relationship between poor sleep and sensory integration/processing differences is complex and multi-faceted, requiring additional research. Interventions that purposefully include a central sensory component have not been well studied in autistic children or adults. Overall studies with greater rigor and purposeful use of sensation and sensorimotor supports as a component of intervention are needed. This study was not funded.

Background: Carers report unmet need for occupational therapy services addressing sensory difficulties in autism, yet insufficient evidence exists to recommend a therapeutic approach.

Objectives: Our aim was to determine the clinical effectiveness and cost-effectiveness of sensory integration therapy for children with autism and sensory difficulties across behavioural, functional and quality-of-life outcomes.

Design: We carried out a parallel-group randomised controlled trial, incorporating an internal pilot and a process evaluation. Randomisation utilised random permuted blocks.

Setting and participants: Children were recruited via services and self-referral in Wales and England. Inclusion criteria were having an autism diagnosis, being in mainstream primary education and having definite/probable sensory processing difficulties. Exclusion criteria were having current/previous sensory integration therapy and current applied behaviour analysis therapy.

Intervention: The intervention was manualised sensory integration therapy delivered over 26 weeks and the comparator was usual care.

Outcomes: The primary outcome was problem behaviours (determined using the Aberrant Behavior Checklist), including irritability/agitation, at 6 months. Secondary outcomes were adaptive behaviour, functioning and socialisation (using the Vineland Adaptive Behavior Scales); carer stress (measured using the Autism Parenting Stress Index); quality of life (measured using the EuroQol-5 Dimensions and Carer Quality of Life); functional change (according to the Canadian Occupational Performance Measure); sensory processing (determined using the Sensory Processing Measure™ at screening and at 6 months to examine mediation effects); and cost-effectiveness (assessed using the Client Service Receipt Inventory). Every effort was made to ensure that outcome assessors were blind to allocation.

Results: A total of 138 participants were randomised (n = 69 per group). Usual care was significantly different from the intervention, which was delivered with good fidelity and adherence and minimal contamination, and was associated with no adverse effects. Trial procedures and outcome measures were acceptable. Carers and therapists reported improvement in daily functioning. The primary analysis included 106 participants. There were no significant main effects of the intervention at 6 or 12 months. The adjusted mean difference between groups on the Aberrant Behavior Checklist - irritability at 6 months post randomisation was 0.40 (95% confidence interval -2.33 to 3.14; p = 0.77). Subgroup differences in irritability/agitation at 6 months were observed for sex of child (intervention × female = 6.42, 95% confidence interval 0.00 to 12.85; p = 0.050) and attention deficit hyperactivity disorder (intervention × attention deficit hyperactivity disorder = -6.77, 95% confidence interval -13.55 to -0.01; p = 0.050). There was an effect on carer stress at 6 months by region (intervention × South England = 7.01, 95% confidence interval 0.45 to 13.56; p = 0.04) and other neurodevelopmental/genetic conditions (intervention × neurodevelopmental/genetic condition = -9.53, 95% confidence interval -18.08 to -0.98; p = 0.030). Carer-rated goal performance and satisfaction increased across sessions (p < 0.001), with a mean change of 2.75 (95% confidence interval 2.14 to 3.37) for performance and a mean change of 3.34 (95% confidence interval 2.63 to 4.40) for satisfaction. Health economic evaluation suggests that sensory integration therapy is not cost-effective compared with usual care alone.

Limitations: Limitations included variability of the intervention setting (i.e. NHS vs. private), delay for some receiving therapy, an error in administration of Vineland Adaptive Behavior Scales and no measurement of comparator arm goal performance.

Conclusions: The intervention did not demonstrate clinical benefit above standard care. Subgroup effects are hypothesis-generating only. The intervention is likely to be effective for individualised performance goals, although it is unclear whether effects were in addition to standard care or were maintained.

Future work: Further investigation of subgroup effects is needed.

Trial registration: This trial is registered as ISRCTN14716440.

Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 29. See the NIHR Journals Library website for further project information.

Importance: Autism spectrum disorder (ASD) is a neurological condition characterized by impairments in social interaction, communication, and behavior. Occupational therapy practitioners use creative arts interventions for children with ASD, but relevant evidence for these interventions is lacking.

Objective: To provide occupational therapists evidence of the benefit of creative arts interventions for children with ASD by evaluating treatment efficacy and connecting the evidence with the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4).

Data Sources: We searched peer-reviewed articles in six databases: CINAHL, Cochrane, PubMed, Ovid, PsycInfo, and Scopus. Eighteen articles published between 2000 and 2020 met Level 1b or 2b evidence criteria and were retrieved for full review; 15 were included in this scoping review.

Study Selection and Data Collection: We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to extract data. Inclusion criteria were as follows: (1) Level 1b or 2b study; (2) quantitative data; (3) published in English; (4) population of children (ages <18 yr); (5) primary diagnosis of ASD; and (6) creative arts intervention in the forms of drawing, painting, or coloring; music; or theater.

Findings: Creative arts interventions benefited children with ASD in two OTPF–4 areas (process and social interaction) pertaining to the Performance Skills domain and one OTPF–4 area (body functions) pertaining to the Client Factors domain. We found similar effects for group and individual intervention sessions, and significant improvements required multiple sessions.

Conclusions and Relevance: Our findings provide evidence for the efficacy of creative arts interventions to enhance occupation-based outcomes for children with ASD.

What This Article Adds: Our findings support occupational therapy practitioners’ use of creative arts interventions to improve OTPF–4-based client factors and process and social interaction skills for children with ASD.