Interventions enhancing daily living skills for children with Autism Spectrum Disorder. : A systematic Literature Review from 2010-2020.

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Interventions enhancing daily living

skills for children with Autism

Spectrum Disorder

A systematic Literature Review from 2010-2020

Nikolopoulos Marios

One-year master thesis 15 credits Supervisor: Ingallill Gimbler Berglund

Interventions in Childhood

Examinator

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SCHOOL OF EDUCATION AND COMMUNICATION (HLK) Jönköping University

Master Thesis 15 credits Interventions in Childhood Spring Semester 2020

ABSTRACT

Author: Nikolopoulos Marios

Interventions enhancing daily living skills for children with Autism Spectrum Disorder. A systematic Literature Review from 2010-2020.

Pages: 29

Activities of daily living (ADL) are fundamental to participation in daily life. Even if participation is necessary for person’s well-being and development, individuals with disabilities often are not par-ticipating in basic life domains. Children with autism spectrum disorder (ASD) can have an impact on many basic functional areas such as daily living skills. The daily living skills (DLS) contain the ability of children to participate in activities such as personal hygiene, dressing, household chores and money management that are important prerequisites for self-sufficiency and autonomy. The aim of this systematic literature review was to investigate the existence and the outcomes of inter-vention programs which can enhance daily living skills for children with autism spectrum disorder. A search for peer-reviewed articles evaluating such intervention programs and published between 2010 and 2020 was performed. The search in several databases resulted in eight articles. The findings were grouped based on the kind and the target activity of each intervention program. Most of the identified studies have reported effective outcomes using various intervention programs for the improvement of DLS such as picture prompting, video prompting, video-game training, self-mon-itoring, behavioural training and therapeutic horseback riding aiming in activities such as hygiene, clothing, cooking and money management. The International Classification of Functioning, Disa-bility and Health, version for Children and Youth (ICF-CY) and the Occupational Therapy practice framework were used as a base for the discussion after the analysis. Despite the number of studies found, not enough research has been done to describe and evaluate interventions enhancing the performance in ADL. The findings of this review may serve as a resource for future researchers, who are working with children in need of special support.

Keywords: autism spectrum disorder, activities of daily living, children and adolescents, occupational ther-apy, systematic literature review

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1 Introduction

Children with autism spectrum disorder (ASD) often face difficulties in multiple areas of occu-pation. They struggle to cope with the demands of daily life and complete activities of daily living in many contexts (Liss et al., 2006). According to Jasmin et al. (2009), both parents and professionals have reported that children with ASD have delayed performance of self-care and face difficulties with feeding and toileting. Two theoretical frameworks will be used in order to clarify the relationship between theory and practice: “The Occupational Therapy Practice Framework” and the “ICF-CY”.

Within the Occupational Therapy Practice Framework, occupational therapy is defined “as the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhance or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings” (American Occupational Therapy Association, 2014). Occupational therapists use their knowledge to design the appropriate occupation-based intervention plans. This combination consists of the transactional relationship among the per-son, the engagement in valuable occupations and the context. According to American Occupa-tional Therapy Association (2014), the intervention plans aim to facilitate change or growth in client factors (body functions, body structures, values, beliefs, and spirituality) and skills (mo-tor, process, and social interaction) needed for successful participation.

The ICF-CY (International Classification of Functioning, Disability and Health Chil-dren & Youth Version) provides a framework for health that demonstrates relationships among the six core domains: the presence of a health condition, body structures and functions, activity performance, participation, environmental factors and personal factors (World Health Organi-zation, 2007). The everyday life participation of individuals with a need of special support is directly connected with the outcomes of education and health services. Even if participation is necessary for person’s well-being and development, individuals with disabilities are not partic-ipating in essential life domains such as in leisure activities, domestic life and school to the extent that their typically functioning peers do (United Nations Convention on the Rights of Persons with Disabilities, 2006). ICF-CY provides an approach for understanding children’s functioning as a complex relationship between the health condition, environmental and personal factors in order to find the activity limitations and participation restrictions, which may have been experienced. Several factors are ranging from personal and environmental factors that can work as barriers for a child in need of special support. Therefore, the focus of outcomes of

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2 education and health services for individuals with a need of special support is strongly related to their engagement in everyday life situations (UNCRPD, 2006).

2 Background

The theoretical frameworks of this study constitute the ICF-CY (WHO, 2007) and the Occupa-tional Therapy practice framework (American OccupaOccupa-tional Therapy Association, 2014) as have been mentioned above. The key concepts within this paper will focus on interventions related to functioning-quality of life, Activities of Daily Living (ADL) and children- adoles-cents with Autism Spectrum Disorder.

2.1 Autism Spectrum Disorder and Quality of life

Recent studies indicated that an estimated 1 in 76 children has autism spectrum disorder (Cen-ters for Disease Control and Prevention, 2015). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) criteria, an individual must show significant deficits in social skills and interaction within multiple contexts to be diagnosed with ASD (American Psy-chiatric Association, 2013). There are several levels of ASD, depending on the type and func-tional impacts. The social communication deficits and the restrictive and repetitive patterns of behaviour are the core factors of diagnosis. Additionally, many people with ASD also show comorbid disabilities, such as intellectual disability, sensory processing disorders and psychi-atric diseases (Ben-Sasson et al., 2007). Because of these issues, ASD is associated with limi-tations in occupational domains such as activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, and sleep (APA, 2013).

Participation of children with ASD is assessed using different assessments, for example, the Child Assessment of Participation and Enjoyment (CAPE) and Activities Card. Preschool and school-aged children with ASD participate in fewer daily activities across all participation domains, such as self-care, leisure, play, social interaction, and education, compared to their peers (LaVesser & Berg, 2011). Interestingly, among a population of High Functional ASD, differences were found in some aspects of participation, such as diversity, social aspects, and location of activities. In contrast, no differences were found in other aspects of participation, such as enjoyment and preferences between them and their peers without developmental disa-bilities (Potvin et al., 2013). To broaden understanding of participation in daily life activities of children with ASD, various child characteristics and their associations with participation were

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3 studied. Gender, age, and autism severity predict participation, diversity and intensity (Little et al., 2014). A child’s behaviour difficulties were reported as the main reason for non-participa-tion among preschoolers (LaVesser & Berg, 2011). Sensory processing issues and executive functions also limit participation (Reynolds et al. 2011).

2.2 Activities of Daily living

Throughout developmental process for children with ASD, health professionals evaluate ADL skills and try to promote autonomy in these occupations. Because the impairments can influence many functional areas, skills development for Activities of daily living (ADLs) and Instrumen-tal Activities of daily living (IADL) is needed. Interventions involve the improvement in ADLs such as feeding, dressing, and personal hygiene. These activities are often priorities for parents of children with ASD because they increase independent living of a child and decrease the need for personal assistance in the home and community. ADLs are essential in daily life participa-tion (AOTA, 2014), however, IADLs can promote participaparticipa-tion in more complicated tasks and activities in the home and community (AOTA, 2014). IADLs comprise occupations which are necessary for independent living in the future. It includes activities such as meal preparation, shopping, home maintenance, and communication management, for example, cell phones. These skills promote opportunities for increased autonomy and self-efficacy for youth with ASD, as well as allow them to further participate in educational process (Weaver, L., 2015).

Through the educational procedure, youth can follow pathways to develop life skills and become active members of society. It is necessary to enrich therapists’ knowledge with supports and strategies which are effective in achieving those outcomes, in order to find the appropriate interventions to facilitate a purposeful and effective academic experience (Dunn et al. 2012). The successful educational experiences could make youth with ASD gain functional skills for employment in the future. Many professionals have tried to develop interventions aiming to increase participation and independent functioning in daily occupations applying a variety of methods. The understanding of the effectiveness of interventions aimed at improving performance in ADLs, can be used as a guide for treatment of people with ASD and lead to increased application of evidence-based practice (Weaver, L., 2015).

2.2.1 Daily living skills

The most vital prerequisites for self-sufficiency and autonomy are related to the daily living skills (DLS) in activities such as personal hygiene, dressing, meal preparation, completing household chores, following safety rules and money management (Sparrow, Cicchetti, & Balla,

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4 2005). The existing evidence has shown that adolescents with disabilities who can inde-pendently perform feeding and dressing skills have more possibilities to be engaged in higher education, work, or preparation for work, after high school than adolescents with limited skills (Wagner et al. 2003). Likewise, enhanced DLS are associated with increased independence and sustained community employment for individuals with ASD (Chan et al., 2017). One of the major concerns for parents of children with disabilities is the promotion of a safe and productive life (Bilgin & Kucuk, 2010), and the ability to independently perform Daily Living Skills (DLS). These two factors can contribute to a person’s inclusion, meaningful participation in society and to an overall better quality of life (Carnahan et al., 2009).

Additionally, children and adolescents with limited DLS express the need to rely on oth-ers for support, which usually comes from their family memboth-ers. As a consequence, this need becomes a significant predictor of both lower levels of family quality of life (Gardiner & Iarocci, 2015) and higher levels of parental distress (Tomanik, Harris, & Hawkins, 2004). Evi-dence supports that the DLS of children are associated with a reduction in parenting stress, regardless of children’s developmental level, autism symptom severity and problem behaviours (Green & Carter, 2014). However, excluding very few cases, research on adaptive functioning and DLS in ASD has mostly been performed in the USA or other western countries, and very little is known regarding other parts of the world (Valenti et al., 2010).

2.3 ICF-CY Framework

Participation constitutes an important part of functioning. According to the biopsychosocial model and as the ICF-CY defines, the functioning of children is a complex relationship with a health condition, environmental and personal factors (Figure 1). This relationship can lead pro-fessionals to find the activity limitations and participation restrictions, which children may have experienced (WHO, 2007). A possible diagnosis of Autism Spectrum Disorder (ASD) requires that the difficulties in social communication and interaction have an important clinical role, and they influence social, occupational and other important areas of functioning. In addition, stere-otyped, repetitive and restricted behaviour patterns that present in the early developmental pe-riod are crucial. Researchers have proved that the professionals use the ICF-CY ( WHO, 2007) in ASD and they consider ICF-CY (WHO, 2017) categories from all areas of the biopsychoso-cial model in the assessment and intervention process when they work with young children with ASD (Castro & Pinto, 2013).

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5 The ICF and ICF-CY provide methods for classifying functioning within four key com-ponents of the biopsychosocial model, that is body functions, body structures, activities and participation, and environmental factors. These components are structured in categories with up to four levels of increasing detail. Basically, the first level provides only a general overview of the areas of functioning that are included in the classification model. The total number of the categories that ICF and the ICF-CY contain is over 1400. That means that together provide a holistic classification of functioning. However, the content, in its current, complete form, can-not apply for daily clinical use or research purposes. For example, many categories are irrele-vant if applied to any health condition.

Figure 1. The framework of the International Classification of Functioning, Disability – Child and Youth version (ICF-CY) (WHO, 2007).

2.4 Occupational Therapy Practice Framework: Domain and Process

The purpose of a framework is to provide a theoretical base on which to build a system or a concept (American Heritage Dictionary of the English Language, 2003). The Occupational Therapy Practice Framework: Domain and Process describes the ground theory of occupational

Health Condition (disorder or disease) Activity Body functions / Body structures Participation Environmental Factors Personal Factors

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6 therapy practice and make clear the basic concepts for a common understanding of the profes-sion. The engagement in occupation aims to achieve health, well-being, and participation in life and that statement describes the domain and process of occupational therapy in its fullest sense. In addition, this process determines the profession’s belief that active engagement in occupation promotes and maintains health and participation. The term occupation refers to the daily life activities in which people engage. Occupations are meaningful, purposeful and they occur in a context. They are influenced by the interaction between individual’s factors, performance skills, and performance patterns. Occupations can engage the performance of multiple activities for integration and can lead to various results. The Framework identifies a wide range of occupa-tions categorized as ADLS, IADLs, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2014). (Figure 2). All aspects of the domain, including occupations, client factors, performance skills, performance patterns, and context and environment, are equally valued and they interact together in order to affect the client’s occupational identity, health, well-being, and participation in life.

Figure 2. Aspects of the domain of occupational therapy: All aspects of the domain transact to support engagement, participation, and health (AOTA, 2014).

Occupations Client factors Performance skills Performance patterns

Contexts and environments Activities of daily

liv-ing (ADLs)

Values, beliefs and spirituality

Motor skills Habits Cultural

Instrumental activities of daily living

(IADLs)

Body functions Process skills Routines Personal

Rest and sleep Body structures Social interaction skills

Rituals Physical

Education Roles Social

Work Temporal

Play Virtual

Leisure

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2.5 Intervention programmes

Given this breadth and depth of performance limitations, professionals need to utilize a range of interventions and educational programmes to children and adolescents with ASD. In early interventions of these children, occupational therapists often focus on enhancing children’s sen-sory processing, sensorimotor performance, social–behavioral performance, self-care and play-ing participation. In older children and adolescents, occupational therapy goals mainly focus on independence in the community through the improvement of social and behavioral perfor-mance. In most occasions, occupational therapists work as members of a multidisciplinary team of professionals who assess, plan, and implement the child’s program (Case-Smith & Arbesman, 2008). Previous research recognizes the importance of an individualized approach and has shown the efficacy of a range of different approaches, differing both theoretically and practically. However, a clear superiority of one approach over another has not been shown (Greenspan, Wieder & Simons, 1998). The treatment procedure its vital to start as earlier as possible and should be as completed and intensive as possible. Intervention follows a reliable assessment of child’s characteristics and skills in different fields. The social isolation and the limitation of cognitive function and behaviour is very common in children with ASD. Early intervention is fundamental to prevent situations like these, planning intervention for develop-ment (Magiati, Charman, & Howlin, 2007).

Special autism services are increasingly provided by American governments. However, community mental health centres in America serve a low percentage of the children with ASD (Bryson et al., 2008). It’s basic to be mentioned that health service conditions may differ not only across countries but within the same country. The older age of diagnosis and the inacces-sibility to treatment can cause a delay in developmental process. Because of the unavailability of daily-accessible services, the beginning of the intervention comes in second place. As a mat-ter of fact, children are often taken in for treatment in late infancy or adolescence or not treated at all, although the early intervention should be the rule. Facing this scenario, the parents’ as-sociations are playing a growing role in promoting local initiative to implement special autism treatment centres (Valenti et al., 2010).

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2.6 Rationale

Occupational Therapists focus on the ability of children with ASD to function within a variety of contexts, like home, school, and community environments. The support on the development of their daily living skills is essential because as children develop, the parents gradually transfer the responsibility for managing the tasks of daily life to them (Kao et al., 2014). The result of this responsibility shift is that the child manages to cope with all these components of important daily life tasks. The basic features of autism such as poor socializing, inadequate awareness of others’ perceptions and difficulties in generalizing of skills from one context to another, may make it more difficult for these people to take responsibility for vital tasks. Additionally, there is no sufficient evidence regarding the way that impairments and functional skills change over time and the relationship of those changes to independent living outcomes for individuals with ASD (Kao et al., 2014). Better daily living skills (DLS) are associated with increased independ-ence and positive functional outcomes in ASD (Kilincaslan et al., 2019).

3 Purpose of the systematic review and research

questions

The purpose of this systematic literature review is to describe the intervention programs which can enhance daily living skills, for children with ASD in school age. The research questions are:

- What kind of intervention programs aim to support daily living skills? - What are the outcomes of those intervention programs?

4 Method

To identify research on the purpose of this study, a systematic literature review was performed.

Systematic reviews are a type of literature review that are designed to provide a complete, comprehensive summary of current evidence relevant to a research question. It is characterized by clearly stated questions, uses systematic methods to collect data and synthesize findings qualitatively or quantitatively. Through the search and collection method, researcher also de-fine inclusion/ exclusion criteria and quality assessment criteria (Jesson, Matheson, & Lacey, 2011).

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4.1 Search procedure

The database search for this systematic literature review took place in January 2020. All the searches were limited to scholarly articles published in English language. The search words that were used in the database PsycINFO were ("children" OR "kids" OR "youth" OR "teen-agers" OR "adolescents" OR "child") AND ("activities of daily living" OR "Adl" OR "Iadl") AND ("Autism" OR "Asd" OR "Autism spectrum disorder") AND "Effect*". This search re-sulted with 20 articles. The search words that were used in the database ERIC were ("children" OR "kids" OR "youth" OR "teenagers" OR "adolescents" OR "child") AND ("activities of daily living" OR "Adl" OR "Iadl") AND ("Autism" OR "Asd" OR "Autism spectrum disorder") AND "Effect*". In this search, 17 articles were found. The search words were used in database Pubmed were ("children" OR "kids" OR "youth" OR "teenagers" OR "adolescents" OR "child") AND ("activities of daily living" OR "Adl" OR "Iadl") AND ("Autism" OR "Asd" OR "Autism spectrum disorder") AND "Effect*". This search result in 43 articles. The search words that were used in database CINAHL ("children" OR "kids" OR "youth" OR "teenagers" OR "adolescents" OR "child") AND ("activities of daily living" OR "Adl" OR "Iadl") AND ("Autism" OR "Asd" OR "Autism spectrum disorder") AND "Effect*". This search yielded 37 articles see flowchart 1.

4.2 Inclusion/exclusion criteria

Inclusion and the exclusion criteria which was used for the screening were established based on the research questions. The participant, interest, comparison and outcome (PICO) frame-work was used in order to determine the exact components necessary for the aim of this review. The PICO formulation is an accepted mechanism used in systematic reviews to frame a review question about an intervention programme and outline inclusion and exclusion criteria. The PICO format helps to operationalise systematic and consistent approaches to selection of items for inclusion independent of either the direction or nature of results or factors empirically known to influence the direction or interpretation of results (Booth, Cantrell, Preston, Cham-bers & Goyder, 2015).

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10 Table 1. Inclusion/ Exclusion criteria

Inclusion Exclusion

Population

Children with Autism Spectrum Disorder aged 5-18, Parents, Health Professionals

Infants 0-5, Adults 18+

Interest

Autism spectrum disorder with or without in-tellectual disability

ADHD, Down Syndrome, DCD, Dyspraxia, Learning disabilities, Developmental Delays, Cerebral Palsy

Comparators

Typically development children or no com-parators

Non-typically development children

Outcome

Activities of Daily Living, daily living skills, everyday functioning, task performance

Social engagement, Motor skills, Cognitive skills

Publication

Research articles published in peer-reviewed journals

Documents that are not peer-reviewed, book chapters, systematic reviews

Year

2010-2020 Older research

The participants included were children or adolescents diagnosed with Autism Spectrum Disorder within the age range 5-18 years. The topic of interest included the diagnoses of autism spectrum disorder with or without intellectual disability. Other possible diagnoses or comor-bidities (ADHD, Down Syndrome, DCD, Dyspraxia, learning disabilities, Developmental De-lays, Cerebral Palsy) were not included within this research review because the mentioned di-agnosis can importantly differ if there are additional difficulties. The optional comparison group are children or adolescents who are typically functioning without any diagnosis. The outcome

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11 criteria included interventions and relations about Occupational engagement, functioning, de-velopment, independency, quality of life, task performance, Activities of Daily Living. The publication type of inclusion criteria were research articles which were published in peer-re-viewed journals. Articles which were published between 2010-2020 were only included in order to have the most recent information concerning the topic. An extraction form with inclusion and exclusion criteria is shown in the Table 1 above.

4.3 Selection process

A detailed overview of the search process and article selection can be observed in the flow chart below (Flowchart 1).

_Identif ic ati on Sc re ening E lig ibility Inc lude d Eric 17 PubMed 43 20

Total number of records from combined databases (n= 118)

Records screened by title and abstract (n= 118)

Records excluded following the exclusion criteria (n=68)

Records screened by in-clusion criteria (n= 50)

Number of duplicates removed (n=31)

Full text articles assessed for eligibility (n=19)

Records exluded (n=11)

Total number of records included (n=8)

CINAHL 37 PsycINFO 20

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12 Articles collected in databases ERIC, PsycINFO, CINAHL and Pubmed were imported to Zotero, a reference management software to manage bibliographic data and related research materials and facilitate the screening process in systematic literature review. Then, the articles (n=118) were screened through title and abstract contents based on inclusion and exclusion criteria. A total of 68 articles were excluded based on the exclusion criteria. Next, duplicate articles were exluded (n=31). Duplicate articles consisted of articles which were found more than once in databases searching. The rest of the articles (n=19) were then assessed through full text readings for eligibility based also on the inclusion criteria (Table 1) and the quality assessment protocol (Appendix 1 and 2). When the articles were deemed to be low quality or not did adhere to the inclusion criteria, they were excluded (n= 11) leaving a total of 8 articles in the study. A total of 8 articles were finally included in this research.

In order to assess the quality of the articles, two assessment protocols were used. The quality assessments for this study was taken from the CASP (Critical Appraisal Skills Pro-gramme, 2018). These checklists were designed to be used as educational pedagogic tools, as part of a workshop setting, therefore we do not suggest a scoring system. The core CASP check-lists (randomised controlled trial & systematic review) piloted from health care professionals in 1994 and a group of experts gathered to develop and pilot the checklist which it would be used. Over the years overall adjustments have been made to the format, but a recent survey of checklist users reiterated that the basic format continues to be useful and appropriate. Due to the existence of both qualitative and quantitative design, two different checklists were used for each type of study. The articles which used mixed methods were assessed from both quality assessment checklists. Five of the articles were considered to have good quality (>70% of the quality criteria fulfilled) and three articles were of moderate quality (>50% and <70% of the quality criteria fulfilled). None of the final included articles was of low quality (<50% of the quality criteria fulfilled) (Appendix 3).

4.4 Ethics

Systematic reviews are frequently read and cited in documents that influence educational policy and practice. Hence, ethical issues associated with what and how systematic reviews are pro-duced and used have serious implications. According to Zawacki-Richter et al. (2019) there are guiding principles which were followed in the particular systematic review and consisted of six

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13 phases: an appropriate epistemological orientation, identifying an appropriate purpose search-ing for relevant literature, evaluatsearch-ing, interpretsearch-ing and distillsearch-ing evidence from selected reports and constructing connected understandings for the reader.

4.5 Data analysis

After data extraction, the last step of methodology was the data analysis. The studies assigned with an identification number (see Table 2.), to be used as a reference for the continuing of review. General information about studies and intervention programs were described first, men-tioning the country of conducting and the methodology design. A narrative synthesis was then undertaken to report the findings. To answer the first research question, descriptions of inter-vention programs and the activities of daily living which each program focuses were analysed. Then, a categorization of intervention’s content for children with ASD was considered with respect to the domains of function on the International Classification of Functioning, Disability and Health (WHO, 2007). The term “content” describes the means of intervention, the fre-quency and the sample. To answer the second research question, outcomes of the intervention programs were analysed in different groups. Contents that were recognized as covering similar constructs and topics were grouped in the same group, as well as outcomes that were recognized as similar constructs. The outcomes of chosen interventions were analysed divided into three groups depending on the methods and measurements were used to assess the outcomes.

5 Results

5.1 Overview

Eight articles were identified that answered the research questions according to the inclusion criteria. They evaluated interventions supporting daily living skills, such as cooking, dressing, laundry, either by observing a change in outcomes from pre- to post- intervention. These articles were published between 2010 and 2020 in journals related to health, education and science. A short overview of the studies can be found in Table 2, while some additional information about the studies, is included in Appendix. Most of the studies which are included in this systematic literature review, were set in USA. Only one of the eight studies conducted in Taiwan and one in China. Six studies evaluated individual interventions aimed at adolescents and children (1, 3, 4, 5, 6, 7), one study evaluated group intervention aimed at adolescents (2) and one study

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14 evaluated interventions aimed at children with the implication of parents in educational process (8).

Two studies were quantitative studies (2, 3) and six were mixed methods studies (1, 4, 5, 6, 7, 8). Four studies (1, 3, 4, 5) had an experimental group enrolled in an intervention from the beginning- baseline phase until the end of the intervention phase with pre-tests and post-tests. The other four studies (2, 6, 7, 8) had also an experimental group with baseline condition, intervention condition but they also evaluated the follow-up condition to investigate the sus-tainability of the effect. The results are categorized based on the daily living skill and the activ-ity which is examined, the content of intervention and the outcomes of each intervention.

The sample was diverse. Firstly, because there is a wide variation in the type and sever-ity of symptoms people with autism experience and secondly because the range of age (5-18) was also wide. In three studies (5, 6, 7) the intervention programs were focused on young chil-dren (6-12 years old), in one study (1) the intervention programs were focused on elementary school aged children (12-15 years old) and two studies (2, 4) focused on adolescents (15-18 years old). Furthermore, two studies (3, 8) included ages from various levels. Regarding the severity of autism spectrum disorder and the functional level of the sample, there were different levels too. Five studies (1, 4, 5, 6, 7) included participants with mild-moderate autism disorder, one study (2) included participants with high functioning autism disorder, while 2 studies (3, 8) included various levels of autism disorder. Six out of eight studies (1, 3, 4, 5, 6, 7) applied interventions on children directly, one study (2) combined children and parents, while one study (8) did the intervention to the parents training them in relation with their children DLS.

5.2 Intervention activities

In most of the studies researchers used interventions focused on a specific task/activity. The studies are listed in the Table 2. The basic activities which were described can be divided in three basic categories such as Hygiene: morning routine (which includes making a bed, wash-ing hands, washwash-ing face, washwash-ing teeth and toiletwash-ing) and shower trainwash-ing, Clothwash-ing: dresswash-ing, laundry, folding clothes, tying shoes, Cooking: cooking a pasta with or without microwave, dishwashing and Social skills: money management.

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15 Table 2. Focused ADL of each intervention.

Two out of eight studies (3,4), did not focused on a specific activity but they described inter-ventions to improve skills which can be useful for many activities of daily living. These skills were the adaptive skills through horse-riding (3) and on-task behavior using activity schedule on the iPod touch (4).

5.3 Content of interventions

The content of interventions includes the description of the aim, the sample and the materials that the professionals used to intervene. What did they do and how? The ICF-CY (WHO, 2007) was used to divide the content into two themes: Activity/Participation and Body functions/ Body structures.

Reference no.

Activity of Daily living Intervention

1 Fold clothes and Cook microwave pasta Vivo picture prompting and video prompting strategies

2 Morning Routine, cooking, laundry, money management

STRW (Surviving and Thriving in the Real World)

3 Adaptive skills Therapeutic horseback riding

4 Activity schedule and On-task behavior Self- reinforcement on the iPod touch

5 Tying shoes Video prompt-models and backward

chaining

6 Shower training Kinect-based training videogame

7 Dishwashing Self- monitoring intervention

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16 Table 3.

Reference Aim Intervention Duration

1. Enhance independent functioning skills and learn DLS.

Picture prompts: Children follow a power point presentation with pictures which describe each step they have to do in a specific task.

Video prompts: Children follow a power point presentation with filmed vid-eos which describe each step they have to do in a specific task.

10-12 Sessions for 6 weeks

2. Explore and evaluate the feasibility of STRW group intervention on the acquisi-tion of DLS (morning routine, kitchen/cooking, laundry and money man-agement).

Group intervention to adolescents and parents:

Adolescents: Each week, one DLS was targeted through didactics,

discus-sion, demonstration, and in vivo practice using empirically based strategies (e.g. behavioural, technology, video modelling)

Parents: Each week, parents were taught how to utilize strategies (e.g. visual

strategies, technology, modelling, prompt fading, and incorporating special interests) to both promote practice of DLS by their adolescent and generalize the DLS to home and community environments.

90 min. sessions for 10 weeks

3. Evaluate the effects of Therapeutic horse-back riding (THR) in core areas of func-tioning.

Every THR lesson followed the same routine: put riding helmet on, sit and wait on the bench, mount horse, teaching a new skill, game or activity to practice the new skill, dismount horse, groom horse, and put away equip-ment.

10/1-h weekly ses-sions

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17 4. Assess the independent on-task remaining

and completion when using self-reinforce-ment compared to teacher-delivered rein-forcement.

The intervention includes activity schedules and the use of portable technol-ogy by presenting schedules on an iPod touch, which was used to teach vo-cational, leisure, and functional living skills

6 weekly sessions

5. Integrate video segments as prompt model with backward chaining to teach children shoe tying.

A series of video recordings were prepared to provide prompt models as part of the backward chaining procedure. The number of steps needed increased as training moved back through the chain. Each child observed a cartoon selected based on their preference.

3 x 10–15 min. learn-ing sessions

6. Examine if game technology is effective to teach independently shower.

The game-based training is an interactive technology approach between hu-man and computer, in which a Kinect gesture recognition technology en-gages the child in a play procedure in order to promote his or her target be-haviors.

25-40 min./ 21 sessions (11 weeks)

7. Evaluate the independent completion of dishwashing in home setting.

The intervention condition consisted of two main phases: (a) dishwashing instruction: washing bowls and (b) self-monitoring instruction: self-record-ing of the individual’s dishwashself-record-ing from video tapself-record-ings.

1 month / daily basis

8. Teach parents to deliver VP to their chil-dren with ASD using an iPad.

A Microsoft Power-Point presentation described the purpose and rationale of the training, outlined intervention procedures, and guided the instruction. Parents were given this presentation in the form of a guide. Video prompting segments used in the children’s intervention were created using an iPad 3G and transferred to the Picture Scheduler application on the same iPad.

3 times per week / 5-7 weeks

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18 As has been already mentioned, various functional levels and age were existed in the sample. However, apart from differences, some important similarities were found. Most of the interventions (1, 2, 4, 5, 6, 7, 8) used technology to accomplish their goals. Four studies (1, 2, 5, 7, 8) used video prompting combined with other techniques such as backward chaining and self-monitoring. One study (6) used game technology and one used activity schedules in iPod touch. Interestingly, one study (1) conducted a comparison between the effectiveness of video and picture prompts when used for teaching daily living skills in adolescents with ASD. Visu-alized pictured programmes were used in two other studies (4, 7).

5.3.1 Body functions/ Body structures

Methods were used to improve DLS for children and adolescents with ASD focus on the body functions and structures. The horseback riding (3) was focused on development in three core areas functioning: self-regulation behaviors, adaptive skills, and motor skills in school-age chil-dren and adolescents. The sessions consisted of activities and exercises that addressed physical, psychological, cognitive, and social skills. Additionally, the self-reinforcement (4) was one of the intervention methods that was focused on body functions and structures. Self-reinforcement is an important part of self-development and self-management training, although it has received little attention in the literature. The purpose of this study was to assess whether individuals with ASD remained on-task for longer durations and completed tasks independently when using self-reinforcement compared to teacher-delivered self-reinforcement

5.3.2 Activities/ Participation

The technology methods which have been described above as well as The Surviving and Thriv-ing in the Real World (STRW) (2) method of intervention aimThriv-ing to improve DLS for children and adolescents with ASD focused on activities/ participation. The STRW was a group inter-vention to adolescents and parents which was combined behavioural and technology strategies in order to achieve the acquisition of DLS. The strategies included: didactics, discussion, demonstration, and in vivo practice using empirically based strategies (e.g. behavioural, tech-nology, video modelling) for the adolescents and for the parents there was a teaching on how to utilize strategies (e.g. visual strategies, technology, modelling, prompt fading, and incorpo-rating special interests) to promote the improvement of DLS. More specifically, the intervention targeted four areas: morning routine, kitchen/cooking, laundry and money management.

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5.4 Outcomes of intervention

Intervention outcomes were operationalized as a change from pre-intervention (baseline condi-tion) to post intervention (intervention condicondi-tion) and follow-up (maintenance) condition, if it was existed. Different methods and various measurement instruments were used to assess the outcomes. A brief description of the different measurements and results in relation to the target activity has been presented in Table 4. The fact of different methods and measurement made it challenging to categorize and compare them, however, three groups have been created based on the type of each study’s results. The first includes the studies which compare the perfor-mance scores of the assessment tools through the different intervention conditions (2,3). The second includes the studies which compare the percentage of the correct independent perfor-mance through the different intervention conditions (1, 4, 6, 7) and the third includes the studies which estimate the efficacy, presenting the effect sizes (5, 8).

5.4.1 Pre and post-test assessment tools score

The Vineland Adaptive Behavior Scales, Second Edition (Vineland -II), Goal Attainment Scal-ing (GAS) and Vineland Adaptive Behavioral Scales II- Interview edition (VABS-II) are the assessment tools which were used in the studies which compared the performance scores in ADL (2,3). A more detailed description of these assessment tools can be found in the Appendix 5. In study no. 2, the Vineland-II was used and the raw scores on the three Vineland-II DLS subdomains corresponding to the targeted skills taught in STRW and the results were the fol-lowing: from baseline to post-treatment, the paired sample t tests revealed statistically signifi-cant improvement in the raw scores on the Domestic subdomain (t(6) = 2.85, p = 0.03, d = 1.1) and DLS domain (t(6) = 2.86, p = 0.03; d = −1.3), from baseline to follow-up, the paired sample t tests revealed statistically significant improvement in the raw scores on the Community sub-domain (t(6) = 4.41, p = 0.005; d = 1.7) and DLS sub-domain (t(6) = 3.880, p = 0.01; d = 1.5), while from post-treatment to follow-up, there were no significant changes in the raw scores on the Vineland-II DLS domain and subdomains. The GAS also was used in study no. 2 and the results were the following: from baseline to post-treatment, paired sample t tests revealed statistically significant improvement in the mean item score in all four areas and in the total score, from baseline to post-treatment, paired sample t tests revealed statistically significant improvement in the mean item score in all four areas, from baseline to follow-up, paired sample t tests re-vealed statistically significant improvement in the mean item score in all four areas and in the total score, while from post-treatment to follow-up, there were no significant changes in the mean item scores in the four areas and total score of the GAS. Overall, the results of STRW

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20 intervention were promising, especially given that high-functioning adolescents with ASD have significant DLS deficits (e.g. Duncan and Bishop, 2013) that are not typically addressed through school or clinical services. The VABS-II was used in study no. 3. The results comparing base-line and post-THR assessments for the VABS-II, significant improvements were observed for the Adaptive Total score (p = 0.001) and the Daily Living raw score (p = 0.011).

5.4.2 Pre and post-intervention percentages of correct independent performance Regarding the second category which includes the studies (1, 4, 6, 7) which compare the per-centage of the correct independent performance through the different intervention conditions, the study no. 1 compared the effects of Video prompting and Picture prompting interventions and they concluded that both prompting systems were effective in developing independent re-sponding for participants with ASD. However, the video prompting was more effective than picture prompting and more specifically the one of the two participants engaged in more inde-pendent correct responding when the video prompting condition was used (M = 91%) than with the picture prompting condition (M = 83%). The second participant also had higher independent correct responding when the video prompting materials were used (M = 90%) than in the picture prompting condition (M = 76%). In study no. 4, the researchers tried to assess whether individ-uals remained on task longer durations and completed tasks independently when they use self-reinforcement compared to teacher-delivered self-reinforcement. Results of this study demonstrated high percentages of on-task behavior and schedule completion in both self-reinforcement and teacher-delivered reinforcement. More specifically, the percentage of intervals with on-task be-haviour of the three participants increased from 14%, 13% and 11% (baseline condition) to 100% for all of them (intervention condition) and they maintained the same on task behaviour through the follow-up condition.

In study no. 6, the purpose was to examine whether game technology is an effective way to teach adolescents with ASD to take a shower independently. The results indicated that the proposed system, in conjunction with operant conditioning strategies, can facilitate the progress of children with ASD taking a shower independently. For the six participants, the rate of im-provement in taking a shower independently was 33%, 62%, 72%, 88%, 191% and 193%. Fi-nally, in study no.7 the researchers utilized a self-monitoring intervention to increase independ-ent task completion of dishwashing at home for three elemindepend-entary-aged children with ASD. The results indicated that all three children acquired self-monitoring, improved dishwashing skills and maintained both skills at a high level without supervision one week after the completion of

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21 the intervention. More precisely, during baseline and without the use of the self-recording, the first participant completed the dishwashing task with 25% (two steps), the second with 0–12% (one step) accurate, while the third did not complete any steps accurately during baseline probe trials. The mastery criterion for dishwashing was 100% accuracy in probe trials for three con-secutive days. The three children achieved the mastery criterion on dishwashing in 23, 12, and 11 days.

5.4.3 Effect sizes

The third category includes the studies which present effect sizes (5,8). In study no. 5, the re-searchers tried to extend the prior research by integrating video prompting with backward chaining and evaluating the treatment in an experimental design. The study demonstrated the successful application of video prompt-modelling with backward chaining to teach the complex skill of shoe tying, nevertheless the data of baseline and treatment conditions indicated medium effects for all the three participants. The effect size calculations for the first participant shown NAP= .7841, p= .0044, for the second participant NAP= .7500, p= .0007 and the third NAP= .8571, p= .0000. Lastly, the study no. 8 included both parents and children. The purpose of that study was to evaluate the effects of behaviour skills training with follow-along coaching to teach parents to deliver video prompting using an iPad to teach DLS to their children with ASD. The study indicates that behaviour skills training packages can be used to teach parents to de-liver evidence-based practices effectively and efficiently to the children, since the Tau-U scores for the three participants were 1.00, 0.83, and 1.00 and the omnibus Tau-U score was 0.95. These individual data indicate that the parent-delivered intervention ranged from effective to very effective.

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References Intervention Outcome

Target Measurement Results

1 Vivo picture prompting and video prompting strategies

Fold clothes and Cook microwave pasta

Task analytic data sheet with correct and incorrect perfor-mance

Both strategies were effective.

Effectiveness: Video prompting > Picture prompting

2 STRW (Surviving and Thriving in the Real World)

Morning Routine, cook-ing, laundry, money man-agement

Vineland II, GAS Vineland- II and GAS: Significant improvement from baseline to post-treatment, but no significant changes from post-treatment to follow-up.

3 Therapeutic horseback riding Adaptive skills VABS-II VABS-II: Significant improvements in Adaptive, Communication, So-cial and Daily Living raw score.

4 Self- reinforcement on the iPod touch and Teacher delivered re-inforcement

Activity schedule and On-task behaviour

Independent schedule comple-tion, 30s momentary time sam-pling procedure

High percentages of on-task behavior and schedule completion in both self-reinforcement and teacher-delivered reinforcement.

5 Video prompt-models and back-ward chaining

Tying shoes Checklist based on the research protocol

Medium effect sizes. Good treatment in promoting skills acquition but extensive number of teaching trials.

6 Kinect-based training video-game

Shower training Data sheet designed to record the task chain

The rate of improvement in taking shower independently was raised for all the participants.

7 Self- monitoring intervention Dishwashing Checklist based on the research All three children improved dishwashing, acquired self-monitoring and maintained both skills without supervision after one week. Their parents also very satisfied.

8 Parent delivery video prompting Making a bed, cooking a pasta, tying shoes

Checklist based on the research protocol

Τhe parents implemented consequence strategies inconsistently. How-ever, they were successful with the implementation of the VP prepara-tion and intervenprepara-tion. Children completed the steps of their DLS with high accuracy, and these skills maintained following the removal of the intervention.

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6 Discussion

The findings of this systematic review indicate the existence of evidence which support the feasibility and effectiveness of daily living skills intervention programs. The common target of the studies was to enable children and adolescents with ASD to participate in activities of daily living in a home as well as school setting. Although previous evidence has documented the important relation between DLS and functional independence (Katsiana, Sinodinou and Strpakos, 2019) this review found limited number of studies with interventions with goal to im-prove daily living skills in an effective way in this specific population. However, most of the existing treatment procedures were medium or high effective in promoting skill or activity ac-quisition for the participants in a short or long space.

Previous studies have also examined various approaches to improve skills for children with ASD and the results about interventions that are most frequently used are common with the results of this study. Hong et al. (2013) identified video modelling, behavioural in vivo procedures, visual cues, and audio cuing. Video modelling involves the children watching vid-eos of behaviours either from others or from themselves engaging in the target behaviours (Charlop-Christy et al. 2000), behavioural in vivo procedures which include prompting, rein-forcement, modelling, chaining, and shaping (Mayer, Sulzer-Azaroff & Wallace, 2012)., visual cues include visually based strategies, such as visual activity schedules (Ganz et al. 2008) and audio cueing which providing verbal prompts from the instructor to the individual (Allen et al. 2012). The interventions mentioned are also included in this study with an emphasis on video prompts-video modelling and visual cues, showing a high effectiveness. Research indicates that individuals with autism have difficulties to receive information that is presented only vocally, while the visual stimuli tends to be stronger in learning procedure (Van Laarhoven et al. 2010). The use of visual seems to enhance instruction and has brought in positive outcomes for these individuals when completing multi-step tasks independently (Wong et al. 2013).

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6.1 The role of parents

As can been seen, two out of the eight studies (2, 8) which are included in this systematic review used the parents as a basic or complementary part in the therapy process, pointing to positive outcomes in both studies. Parents seems to be the most important people in the life of a child with ASD. They have a direct influence from the crucial first few years until the whole child-hood and teenage years. Their role in the social setting of the child and therefore in the support, relationships, stimulation and services that are accessed is significant (Viljoen et al., 2019).

An important number of studies have been conducted to examine the effects of parent-implemented intervention and they indicated a positive effect for most parents regarding the increasing of the parental knowledge, skills, and performance (Koegel, Bimbela and Schreib-man, 1996; SchreibSchreib-man, Kaneko, Koegel, 1991). Furthermore, one way parents can contribute to their children’s development is to help them gain DLS by becoming fluent in the application of parent-implemented interventions (PII). PII are practices in which therapists teach the parents intervention procedures in order to deliver part, or all, of the given intervention to their own children (Wong et al. 2013). The use of PII has been reported to promote successful outcomes such as effective communication, joint attention and appropriate mealtime behaviors (Naj-dowski et al. 2010) among children with ASD (Cruz‑Torres et al. 2019). The PII practice in-cludes mainly instructions, modeling, coaching and performance feedback from the profession-als. In total, these instructional methods are known as Behavior Skills Training and they are considered as a successful way for teaching parents of children with ASD and other develop-mental disabilities, how to promote appropriate behaviors (Mueller et al. 2003). Interestingly, research suggest that the achievement of the desired outcomes for the child’s participation and performance provide benefits in parents’ life too (Osborne et al. 2008, Schwichtenberg and Poehlmann 2007).

According to ICF, the environmental factor, which include the social and physical struc-ture, affects the person directly as well as indirectly. For example, the impact of the medication that targets body function is a direct affect, while our perceptions of the activity context are an indirect effect. However, the person also affects the environment through engagement in activ-ities within places (Batorowicz, King, Mishra and Missiuna, 2015). This phenomenon can be described by the transactional relationships between the person and the context in which people are involved causing changes to both the individual and the environment over time (Mallinson & Hammel, 2010). Therefore, effective approaches to support parents and families of children

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23 with ASD and factors associated with positive parent and family outcomes need to be identified to improve the quality of life for families, parents, and children with ASD (Estes et al. 2013).

6.2 Activity-centered or skill-centered intervention?

Most of the intervention programs included in this review are based on occupation-focused practices, rather than skill-focused intervention. More specifically, out of the eight studies with intervention programs, only one focused on skill-centered strategies (3). This study included therapeutic horse-riding lessons to teach or practice new skills for children with ASD and the outcomes indicated significant improvements for the adaptive, the communication, the social and the daily living raw score. Research suggests adaptive behavior as a very closely related factor for social functioning and independent living (Farley et al. 2009, Kanne et al. 2011). Adaptive behavior characterizes the individual’s ability to convert cognitive functions to typical performance skills of daily activities (Sparrow et al. 1984). These skills are developing inde-pendently, and they include everyday skills, such as the effective communication and partici-pation in community activities. Well-developed adaptive skills are necessary to independent functioning (Klin et al. 2007). The measure of adaptive behaviour skills with the most common use is the Vineland Adaptive Behavior Scales (Sparrow et al. 2005) and can been detected in the current review, too.

On the other hand, from a top-down perspective, the daily living skills enhancement can be focused through participation in occupation-focused practices, coaching parents and other similar approaches (Gillen & Greber, 2014, Palisano et al. 2012). Some of the previous evidence suggest the use of the term activity- or occupation-based intervention to describe this approach, presenting the common points as below: “Choosing activities according to the child’s interests, Teaching individual goals embedded in routines and planned activities, Teaching functional and generalizable skills, Using before and after behaviour stimuli which have natural and mean-ingful relations with behaviours and environment” (Pretti-Frontczak and Bricker, 2004). The term occupation, as it is used in the Occupational Therapy practice framework (AOTA, 2014), refers to the daily life activities in which people engage. Occupations have purpose, meaning, and perceived utility to the individuals. Therefore, they are influenced by the interaction among client factors, performance skills, and performance patterns. The child’s interests consist one of the basic components, so there is a need for involving them in multiple occupations-activities of their preference. Besides, the occupational therapy process is the client-centered delivery of occupational therapy services and the practitioners use the collaboration with clients when they

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24 engage in clinical reasoning (AOTA, 2014). In addition, the occupational outcome, except from the terms of occupational performance and occupational engagement are connected to occupa-tional rights that encompass inclusive participation in everyday occupations, too. The concept of occupational rights (Hammell 2008) is complementary to the concept of occupational science which supports that humans are occupational beings who need and want to engage in doing, being, becoming, and belonging.

Nevertheless, focusing on the participation of children in everyday life from a system theoretical perspective, the ICF-CY defines participation as ‘involvement in a life situation’, therefore the intervention process might include both occupation performance and skill’s de-velopment. Taking into consideration the diagnoses of ASD as a health condition and the ac-tivity limitations and participation restrictions as the deficits in daily living skills, an interven-tion plan should include changes in both activities and skills regarding personal factors. The individual’s deficit is classified as a result of many different aspects, therefore ICF suggests interventions which can be used in a more holistic way in order to enhance participation (WHO, 2007).

6.3 Methodological issues

In this section, the most important methodological issues of the included studies will be high-lighted. Although positive results have been reported, the quality of research designs and quality of the evidence of studies on those interventions focusing on daily living skills for individuals with ASD have not been investigated in depth. Most of the intervention programs included in this review have not described in detail some interventions. Furthermore, there are several thoughts about the generalizing of the results from studies identified in this review to broader contexts, because of the sample. The size of the sample was small in most of the studies and as it can been observed, it was only consisted of participants with medium to high functioning autism. Thus, there is a difficulty to evaluate the daily living skills intervention programs for children with low functioning autism.

In general, most of the existing studies comprised children with high functioning autism spectrum disorder (HFASD) and did not control for the severity of symptoms of autism (Ros-enberg, Moran and Bart, 2017). Because of their severe communicative and cognitive limita-tions, these children are a hard-to-research population (King, 2013), and the feasibility of stand-ardized tests for these children is limited compared to children with HFASD. However, Little,

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25 Sideris, Ausderau and Baranek (2014) have identified that autism severity is one of the most important factors which predict participation diversity and intensity. Children with low func-tioning autism spectrum disorder (LFASD) present motor dysfunction which is a barrier for the performance and generalization of routine daily activities such as dressing, eating, drawing, playing (Fabbri-Destro et al., 2013).

6.4 Strenghts and Limitations

The research literature offers strong positive evidence for occupational therapists to use com-prehensive, individualized analysis of the child’s performance to develop the intervention strat-egies. The research evidence also supports the use of family-centered and the interdisciplinary approaches. Many of the studies used skill-based or activity-based interventions such as those implemented by health care therapists. The results of this analysis will assist readers in evalu-ating intervention effectiveness in a more clear and accurate way.

The limitations of this systematic review are based on the design and methods of this systematic review, including a small number of studies. The particular review shows that stud-ies about enhancing daily living skills are carried out basically in developed countrstud-ies, which it follows the inclusion criteria but could have been influenced by the choice to restrict the search to empirical English-language articles published in peer-reviewed journals. Consequently, the identified intervention strategies could be applied to only developed countries. Furthermore, another limitation has to do with the criterion that only studies involving samples without any comorbidities except intellectual disability are selected. That means that children and adoles-cents with some usual comorbidities, such as sensory processing disorders were excluded. Alt-hough relations between sensory responses and DLS remain to be explored, the DLS require sensory interaction and the effects of sensory sensitivity, or sensory avoiding could be interest-ing to be explored (Jasmin et al., 2009). Mental health issues also consist a very common char-acteristic of the children and adolesents with ASD, as have been demonstrated by evidence (Hofvander et al., 2009, Leyfer et al, 2006, Simonoff et al. 2008), but they were also excluded from the study sample.

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6.5 Future research

Every profession makes use of theories to underlie and explain its practice. However, there is a need of testing these explanations through research. Research is the primary tool by which the-ory can be corrected and refined so that can be improved and provide useful explanations for practice. As experts in childhood occupations, one of the suggestions for future research is to critical examine and make assumptions regarding the mechanisms of development. There is still a debate between skill-based and activity-based interventions which is important to be ad-dressed in order to approach the needs of children with developmental challenges in an evi-dence-based manner. Moreover, it would be useful for the future researches to include a larger sample for various countries using ADL measurements in different contexts and environments of the children themselves. The cognitive level measurements or IQ scores of participants also are essential in order to explore the relationship between DLS and cognitive level. Finally, sen-sory integration approaches should be the focus of future research evidence considering that sensory-based techniques have moderate to strong evidence of effectiveness but minimal re-search evidence.

7 Conclusion

To conclude, as it becomes apparent the necessity of research regarding the enhancing of DLS for children with ASD is a very important issue in order to improve the clinical training and the impact on practice. There is a need to take into consideration all the factors which may influence everyday life. Most of the identified studies have reported effective results using various inter-vention programmes for the improvement of DLS such as picture prompting, video prompting, videogame training, self-monitoring, behavioural training and therapeutic horseback riding. The ICF-CY while analyzing the most important components, highlighted the environ-mental factor as crucial. All professionals involved within pediatric rehabilitation should have an up-to-date and realistic view of a family’s needs in order to provide an effective service provision to the child and as an extension to the whole family. The Occupational Therapy prac-tice framework focuses on the ability of children with ASD to function within a variety of con-texts, like home, school, and community environments through the provision of purposeful and meaningful occupations, such as personal hygiene, dressing and feeding.

Most existing studies comprised children with moderate and high functioning autism spectrum disorder (HFASD) and did not control children with a more severe levels of symptoms

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27 even if the severity is a vital feature which predict participation diversity and intensity. This systematic review has certain limitations and not enough research has been done generally to evaluate the intervention strategies in a holistic way, however, provides a useful overview of interventions aimed at enhancing DLS and can offer guidance in planning such intervention programs.

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