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Occupational Therapy OT

| 6 May 2024

A Guide to Occupational Therapy for Autism

Autism spectrum disorder (ASD) 1 is a neurodevelopmental condition characterized by impaired social communication skills, restricted and repetitive behaviors and isolated areas of interest. Approximately one in 36 children in the United States are diagnosed with ASD, which can be recognized as early as age two but is typically detected after age five. 2

Early diagnosis and intervention can greatly improve outcomes for people with autism. 3 One primary mode of intervention is occupational therapy (OT) for autism , which can play a unique role in helping individuals with ASD live more fully and independently.

What Is Occupational Therapy?

Occupational therapy is a field of healthcare that holistically treats people who have injuries, disabilities or other conditions, including autism. In this practice, occupational therapists (OTs) help patients develop, recover or maintain their ability to engage in meaningful daily activities, including effective communication.

OTs often begin the process by communicating directly with the patient and family to understand the patient’s individual needs. They assess the patient’s physical, sensory, emotional and cognitive abilities before developing reasonable goals and a treatment plan. The OT then usually works with the patient for several sessions or longer term to help them progress toward their goals.

The Role of Occupational Therapy for Autism Spectrum Disorder Treatment

Occupational therapy for autism evaluates the current developmental levels of children and adults with ASD, and aims to improve their ability to self-regulate emotions and participate in social interactions. 4 Through interventions, an OT for autism can help individuals build strength and overcome limitations.

What Is Occupational Therapy for Autism?

To evaluate a patient, the OT may use screening tools such as an ASD checklist, a sensory profile, the Childhood Autism Rating Scale (CARS, or diagnosis criteria set forth in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). 5 ,6 When observing the patient, an OT for autism will consider the following skills 6 :

• Social: Interactions with others, emotion regulation, behavior, desire for personal space, eye contact and aggression
• Communication : Speech and non-verbal communication
• Cognitive: Attention span and stamina
• Sensory : Responses to stimuli, sensory seeking and sensory defensiveness
• Motor: Posture, balance and manipulation of small objects

Common Occupational Therapy Interventions for Autism

After completing an evaluation, the OT for autism works with the patient and family to develop an intervention plan and treatment goals. Occupational therapy autism interventions may include 7 :

• Sensory integration and sensory-based strategies
• Mental health and wellness treatment
• Emotional development and self-regulation strategies and programs
• Peer groups, social participation and play activities
• Self-care routines to help with daily activities such as bathing, feeding and grooming
• Motor development techniques
• Supporting an adolescent’s transition into adulthood and helping them build skills to enter the workforce
• Cognitive behavioral approaches to support positive behaviors

Benefits of Occupational Therapy for Autism

The main goal of occupational therapy for autism is to improve a patient’s quality of life. Through interventions, an OT for autism can help people with ASD gain independence and 8 :

• Focus on academic tasks
• Communicate appropriately
• Maintain and foster relationships
• Work with others to achieve a common goal or purpose
• Learn to delay gratification
• Express emotions in a healthy, productive way and manage self-regulation
• Become more independent and confident
• Feel less anxious

How to Find an OT for Autism

Contact a patient’s school or physician to find a qualified occupational therapist. When choosing an OT for autism to work with a child or adult, look for someone who is willing to 9 :

• Conduct a comprehensive diagnostic evaluation and create written goals for treatment
• Offer one-on-one treatment in a sensory-rich setting
• Provide an intensive treatment program that encourages family members to participate
• Ask questions and encourage the patient and family to do the same

Occupational therapy for autism can help people at all points along the spectrum develop the skills to communicate better and participate in meaningful daily activities. OT for autism practitioners are uniquely positioned to provide treatment that can help individuals with autism succeed .

Want to know more about our OT programs?

Occupational therapy is a rewarding career path that allows for the opportunity  to help people of all ages manage physical and cognitive disabilities and differences. Ready to learn more about how to become an OT and assist those with autism? Learn more about graduate occupational therapy programs at the University of St. Augustine for Health Sciences (USAHS).

USAHS is a leading choice for aspiring OTs. We offer two graduate occupational therapy programs:a Master of Occupational Therapy (MOT) and Doctor of Occupational Therapy (OTD) . Expert faculty practitioners, compassionate support, cutting-edge technology, progressive learning models and a flexible curriculum are a few of our outstanding traits. Our enrollment team is here to help you determine which degree fits your lifestyle, preferences and personal and professional goals.

The entry-level occupational therapy master’s degree program at the Dallas, Texas, campus has applied for accreditation and has been granted Candidacy Status by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association (AOTA), located at 6116 Executive Boulevard, Suite 200, North Bethesda, MD 20852-4929. ACOTE’s telephone number c/o AOTA is (301) 652-AOTA and its web address is www.acoteonline.org. The program must have a preaccreditation review, complete an on-site evaluation and be granted Accreditation Status before its graduates will be eligible to sit for the national certification examination for the occupational therapist administered by the National Board for Certification in Occupational Therapy (NBCOT). After successful completion of this exam, the individual will be an Occupational Therapist, Registered (OTR). In addition, all states require licensure in order to practice; however, state licenses are usually based on the results of the NBCOT Certification Examination. Note that a felony conviction may affect a graduate’s ability to sit for the NBCOT certification examination or attain state licensure.

Students must complete 24 weeks of Level II fieldwork within 24 months following completion of all prior didactic portions of the program

• “Autism diagnosis criteria: DSM-5,” Autism Speaks, https://www.autismspeaks.org/autism-diagnosis-criteria-dsm-5
• “Autism statistics and facts,” Autism Speaks, https://www.autismspeaks.org/autism-statistics-asd
• Lonnie Zwaigenbaum, et al., “Early Identification and Interventions for Autism Spectrum Disorder,” Pediatrics, 2015;136(Supplement_1):S1-S9. https://pediatrics.aappublications.org/content/136/Supplement_1/S1
• Anne V. Kirby, Lisa Morgan, Claudia Hilton, “Autism and Mental Health: The Role of Occupational Therapy,” The American Journal of Occupational Therapy, 2023;77:2, https://research.aota.org/ajot/article/77/2/7702170010/24066/Autism-and-Mental-Health-The-Role-of-Occupational
• American Psychiatric Association, “Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR),” Psychiatry Online, https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
• Payal Pawar, “Occupational Therapy for Autism – Assessment and Intervention,” Occupational Therapy {OT}. https://occupationaltherapyot.com/occupational-therapy-autism/
• Scott Tomchek, et al., “Occupational Therapy Interventions for Adolescents With Autism Spectrum Disorder,” American Journal of Occupational Therapy, 2016;71:1, https://research.aota.org/ajot/article/71/1/7101395010p1/6264/Occupational-Therapy-Interventions-for-Adolescents
• “How Does Occupational Therapy Benefit A Child with Autism?” Applied Behavior Analysis Programs Guide,  https://www.appliedbehavioranalysisprograms.com/faq/how-does-occupational-therapy-benefit-a-child-with-autism/
• “Choosing an Occupational Therapist,” STAR Institute, https://www.spdstar.org/basic/choosing-an-occupational-therapist

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Home » Autism Therapies and Treatments » Benefits, Uses, and Importance of Occupational Therapy for Autism

Benefits, Uses, and Importance of Occupational Therapy for Autism

By   Katherine G. Hobbs, AA

May 24, 2024

What is occupational therapy?

The role of occupational therapy for autism is to help the child participate in the things they want and need to do through the therapeutic use of everyday activities. (“About Occupational Therapy,” 2019) Occupational therapy takes a holistic approach to the client’s wellbeing. It addresses the physical, psychological, and cognitive aspects of the clients’ functionally. Clients are assessed in all their environments. You can expect assessments in your home, school, in the community, and virtually. (Gee, Nwora, & Peterson 2018) 

What an occupational therapist does

According to the Bureau of Labor Statistics, “Occupational therapists treat patients who have injuries, illnesses, or disabilities through the therapeutic use of everyday activities.” (“Occupational Therapists: Occupational Outlook Handbook,” 2019). Your child’s occupational therapist will assess his/her abilities and help him/her reach his/her full potential. The occupational therapist will tailor his/her approach to your child’s learning style. Younger children might learn best through play and role-plays. An older child might learn better through role-play, community mentors, or using apps to assist with executive planning.

In Volume 71 of the American Journal of Occupational Therapy , a study was published explaining how a 17-year-old boy with autism utilized occupational therapy. In this case study, Jimmy utilized group-based social skills training, video modeling, and participating in an interest-based culinary club to practice his social skills. After attending individual sessions three times per month with his school-based occupational therapist, Jimmy increased his attendance in the culinary club from 25 to 90 percent over the course of a semester. He also gained the skills to prepare meals and earned an internship in the food industry. Jimmy works with a friend from his social group with whom he shares similar interests (Tomchek, Koenig, Arbesman, & Lieberman, 2017).

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Occupational therapy assessment for autism

When an occupational therapist assesses your child, he/she will typically start with a discussion with you (and your child, if appropriate) about your child’s goals. The therapist might also ask your child’s teacher for input. The therapist might visit your child’s home or school for further observation. He/she will assess your child’s capabilities and challenges. You should bring a copy of your child’s Childhood Autism Rating Scale and sensory profile.

Once the occupational therapist has a clear understanding of your child’s goals and abilities, he/she will create a comprehensive intervention plan. The therapist might make recommendations for adaptive equipment. If so, the therapist will train you and your child to use the equipment. Depending on your child’s needs, communication devices , visual supports , or adaptive educational equipment might be appropriate. According to the American Occupational Therapy Association, “occupational therapy practitioners have a holistic perspective, in which the focus is on adapting the environment to fit the person, and the person is an integral part of the therapy team.” (“About Occupational Therapy,” 2019).

Occupational therapy interventions for autism

Your child’s occupational therapist will provide interventions, as necessary, to address social skills, communication, sensory processing, and behavior . Deepam Pawar and Payal Mehta Pawar, occupational therapists in India, explain that they provide interventions to help their clients respond to sensory input. Common interventions include sensory integration, motor developmental activities, and play activities to boost cognition and perception skills. Sensory integration therapy helps children to “register, modulate, and act on sensory input…[sic] The occupational therapist uses different sensory strategies to promote self-regulation and motor planning.” They also utilize interventions to help children: regulate arousal level, decrease distractibility, decrease anxiety, and improve the performance of activities of daily living (Pawar & Pawar, 2017).

Occupational therapy activities for autism

Occupational therapy activities range from play-based to skills-based tasks. Depending on your child’s goals and abilities, occupational therapy might consist of individual sessions, group sessions, or a mixture of both. Some common activities the Pawars practice with their clients include proprioceptive and vestibular sensory integration activities such as:

• Push, pull games like tug of war
• Wheelbarrow walking
• Playdough/theraputty that offers high resistance
• Ropes or dynamic ladder climbing
• Theraband activities
• Sand play for tactile sensitivity

Children in group sessions might dance or play games such as musical chairs (Pawar & Pawar, 2017). Your child’s occupational therapist will teach you how to help your child practice these activities at home.

Speech and occupational therapy for autism

In addition to occupational therapy, speech therapy might be beneficial for your child with autism. Speech-language pathologists work closely with occupational therapists. The overlap in their practices includes helping clients with feeding, swallowing, cognition, posture, and language learning difficulties. If your child struggles to communicate verbally, your child’s occupational therapist will likely recommend enlisting the help of a speech-language pathologist.

The Speech Pathology Graduate Program organization explains that while both occupational therapists and speech-language pathologists are concerned with a child’s ability to communicate verbally, their approaches and focuses are different. An occupational therapist’s main area of focus will be the child’s attention span and social abilities. They might teach sound creation skills but also focus largely on socialization exercises and sensory integration therapy. A speech-language pathologist will focus on building language-learning skills and teaching the child to form sounds and build them into words and sentences (“How Occupational Therapy is Used to Complement SLP,” 2019).

Speech therapy might be appropriate for your child if he/she is completely nonverbal, has trouble with pronunciation, or postural issues that affect enunciation. Your child’s occupational therapist will likely have recommendations for speech-language pathologists in your area. If your child receives services through a hospital, you might be able to have joint appointments with both providers as necessary. If this is not possible, your child’s providers should be in frequent contact to collaborate on your child’s care plan.

Effectiveness of speech therapy and occupational therapy for children with autism

A study published in Issue 12 of the Journal of Pakistan Psychiatric Society examined the effectiveness of speech and language therapy for children with autism spectrum disorders. While the study had a small sample size of only two children, it evaluated them for six and a half months. At the beginning of the study, the children were evaluated by a psychologist and a speech-language pathologist and assigned scores on the Childhood Autism Rating Scale (CARS). After six months of speech and language therapy, both children’s scores went up. The first child’s score raised to 2.23/.651 (M/SD) from an original score of 2.67/.816 (M/SD). The second child began with a score of 2.50/.462 (M/SD) and finished with a score of 2.03/.399 (M/SD). The study concluded that “speech and language therapy helps [sic] to enhance speech, vocabulary, verbal and [sic] non-verbal communication as well as sentence building in children with [sic] ASD.” (Batool & Ijaz, 2015)

What are the benefits of occupational therapy for autism?

A second study published in Volume 66 of the Australian Occupational Therapy Journal sought to prove the effectiveness of occupational therapy for children with disabilities. The study included children with a range of diagnoses, several of whom have autism. The researchers found 39 effective occupational therapy interventions. Top-down approaches “confer larger clinical gains than bottom-up approaches, when aiming to improve a child’s function.” Researchers also noted that involving parents in a child’s occupational therapy is “effective and worthwhile.” (Novak & Honan, 2019).

The role of occupational therapy for parents of children with autism

Your child’s occupational therapist might recommend that you participate in the therapy with your child. This can be beneficial so that you are on the same page as your child and his/her care provider. Playing an active part in your child’s sessions will help you implement the therapy at home.

Karen Razon, an occupational therapist in Orlando, Florida, explained in her article published in Issue 74 of Autism Parenting Magazine that parents with high-stress levels might benefit from occupational therapy. Razon explains that occupational therapists view “an emotionally-overwhelmed parent though a holistic pair of glasses.” An occupational therapist can help parents improve their physical, emotional, spiritual, or social wellbeing. “Whether it be helping parents find coping mechanisms that fit their family lifestyle, creating weekly routine that schedules ‘spouse-time’ or ‘alone-time’ while meeting their child’s needs, or searching for local parental support groups ,” Razon says that occupational therapists can help parents find balance in their life (Razon, 2019). She suggests asking your child’s occupational therapist for advice or a referral to an occupational therapist for yourself. A psychologist might also be an appropriate fit for some parents.

How can you advocate for occupational therapy for your child with autism?

If you have decided to pursue occupational therapy for your child with autism, you will likely need a referral from your child’s pediatrician or psychologist. If your child is on private insurance, you will need to contact your insurance company for approval before seeking occupational therapy. Most companies have a list of approved providers available online. If your child is on Medicaid, his/her caseworker should be able to provide you with a list of in-network providers. Providers affiliated with research or teaching hospitals might be able to offer your child access to newer technologies or research studies. Private practice or small clinic-based providers might be able to offer more individualized attention due to smaller caseloads. Interviewing several occupational therapists is essential to find the best provider.

References:

About Occupational Therapy. (2019). Retrieved October 28, 2019, from https://www.aota.org/About-Occupational-Therapy.aspx .

Batool, I., & Ijaz, A. (2015). Journal of Pakistan Psychiatric Society. Retrieved October 28, 2019, from http://jpps.com.pk/article/effectivenessofspeechandlanguagetherapyforautismspectrumdisorder_2455.html .

Gee, Bryan M., et al.  Occupational Therapy’s Role in the Treatment of children with autism Spectrum Disorders . 5 Nov. 2018, https://www.intechopen.com/books/occupational-therapy-therapeutic-and-creative-use-of-activity/occupational-therapy-s-role-in-the-treatment-of-children-with-autism-spectrum-disorders . Accessed 28 Oct. 2019.

How Occupational Therapy is Used to Complement SLP. (2019). Retrieved October 28, 2019, from https://www.speechpathologygraduateprograms.org/occupational-therapy/ .

Novak, I., & Honan, I. (2019, April 10). Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/1440-1630.12573 .

Occupational Therapists: Occupational Outlook Handbook. (2019, September 4). Retrieved October 28, 2019, from https://www.bls.gov/ooh/healthcare/occupational-therapists.htm .

Pawar, P. M., & Pawar, D. (2017, April 23). Occupational Therapy for Autism – Assessment and Intervention. Retrieved from https://occupationaltherapyot.com/occupational-therapy-autism/ .

Razon, K. (2019, October 21). Interesting Ways Occupational Therapy Can Help Parenting Stress. Retrieved October 28, 2019, from https://www.autismparentingmagazine.com/occupational-therapy-help-stress/ .

Tomchek, S., Koenig, K. P., Arbesman, M., & Lieberman, D. (2017, January 1). Occupational Therapy Interventions for Adolescents With Autism Spectrum Disorder. Retrieved October 28, 2019, from https://ajot.aota.org/article.aspx?articleid=2593025 .

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Home > Honors College > Honors Theses > 3603

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Case study - the outcomes of occupational therapy for an autistic teen.

Molly Boyle , Western Michigan University Follow

Date of Defense

Date of graduation.

Occupational Therapy

First Advisor

Michelle Suarez

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Ben Atchison

autism, independence, autonomy, occupational therapy

This study sought to understand the outcomes of occupational therapy through interviews of a person with autism spectrum disorder (defined below), their family, and an occupational therapist. By interviewing each of these people, this study aimed to examine the impact of occupational therapy on the autonomy and independence of a young adult with autism and his family.

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Boyle, Molly, "Case Study - The Outcomes of Occupational Therapy for an Autistic Teen" (2022). Honors Theses . 3603. https://scholarworks.wmich.edu/honors_theses/3603

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Autism spectrum disorder: How can occupational therapists support schools?

• PMID: 31401850
• DOI: 10.1177/0008417419838904

Background.: Children with autism spectrum disorder (ASD) face multiple occupational challenges in their school, and school staff need additional support to increase their participation.

Purpose.: The aim of this study is to identify how Response to Intervention (RTI) could be used by occupational therapists to support school personnel who work with children with ASD.

Method.: In a descriptive qualitative study, three discussion groups were undertaken with occupational therapists and school staff members in Quebec, Canada, to identify the main concerns regarding the participation of children with ASD in school activities as well as the actions to consider when attempting to increase school-related abilities.

Findings.: School staff members are primarily concerned with frequent outbursts and limited autonomy, along with low motivation and anxiety in children with ASD in diverse school activities and contexts. The actions identified provide guidelines for school and occupational therapist selection, the process to follow, collaborative practices, and support required.

Implications.: A practice model is presented for occupational therapists who seek to develop school capacity to support the participation of children with ASD.

Keywords: Besoins; Ergothérapie; Intervention-level model; Modèle en paliers d’intervention; Needs; Occupational therapy; Participation; Schools; Écoles.

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• Listening to teachers: Views on delivery of a classroom based sensory intervention for students with autism. Mills C, Chapparo C. Mills C, et al. Aust Occup Ther J. 2018 Feb;65(1):15-24. doi: 10.1111/1440-1630.12381. Epub 2017 Oct 12. Aust Occup Ther J. 2018. PMID: 29023760
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Case Studies

Case study 1.

• Special school

Child’s name & age: AB, 12

Main areas of concern: Playing with private parts, poking bottom, smearing faeces, refusal to have hair cut, refusal to go to dentist

Case study 2

• Mainstream primary

Child’s name & age: CD, 5

Main areas of concern: Does not stay in seat, cannot complete work, very rough with classmates, refuses to sit for circle time, occasionally hits and bites staff

Case study 3

• Mainstream post-primary

Child’s name & age: EF, 13

Main areas of concern: Inconsistent attendance at school, increasing incidence of school refusal, minimal friendships, refusing to leave house

Case study 4

Child’s name & age: GH, 9

Main areas of concern: Biting his hand, banging his head, hitting and biting staff, high frequency of repetitive behaviours (pacing, flapping hands in front of eyes), eating non-food items

Case study 5

Child’s name & age: IJ, 16

Main areas of concern: Sensory over-responsive, Aggressive and negative outbursts during transport to and from School and in the classroom

Case study 6

Child’s name & age: KL, 13

Main areas of concern: Selective mutism in school, refusal to complete work; and to participate in class and sometimes to sit in class. Sensory over responsive, particularly with tactile and auditory input.

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Efficacy and Safety of Stem Cell Therapy in Children With Autism Spectrum Disorders: A Systematic Review and Meta-Analysis

1 The First Clinical Medicine College of Gannan Medical University, Ganzhou, China

2 Subcenter for Stem Cell Clinical Translation, First Affiliated Hospital of Gannan Medical University, Ganzhou, China

3 School of Rehabilitation Medicine Gannan Medical University, GanZhou, China

4 Ganzhou Key Laboratory of Stem Cell and Regenerative Medicine, GanZhou, China

Zhengwei Zou

5 Clinical Medicine Research Center, First Affiliated Hospital of Gannan Medical University, Ganzhou, China

Minhong Zhang

6 Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China

7 Key Laboratory of Biomaterials and Biofabrication in Tissue Engineering of Jiangxi Province, Gannan Medical University, Ganzhou, China

Associated Data

The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author.

There is insufficient evidence regarding the efficacy and safety of stem cell therapy for autism spectrum disorders. We performed the first meta-analysis of stem cell therapy for autism spectrum disorders in children to provide evidence for clinical rehabilitation.

The data source includes PubMed/Medline, Web of Science, EMBASE, Cochrane Library and China Academic Journal, from inception to 24th JULY 2021. After sifting through the literature, the Cochrane tool was applied to assess the risk of bias. Finally, we extracted data from these studies and calculated pooled efficacy and safety.

5 studies that met the inclusion criteria were included in current analysis. Meta-analysis was performed using rehabilitation therapy as the reference standard. Data showed that the Childhood Autism Rating Scale score of stem cell group was striking lower than the control group (WMD: −5.96; 95%CI [−8.87, −3.06]; p < 0.0001). The Clinical Global Impression score consolidated effect size RR = 1.01, 95%CI [0.87, 1.18], Z = 0.14 ( p = 0.89), the effective rate for The Clinical Global Impression was 62% and 60% in the stem cell group and the control group, respectively. The occurrence events of adverse reactions in each group (RR = 1.55; 95%CI = 0.60 to 3.98; p = 0.36), there was no significant difference in the incidence of adverse reactions between the stem cell group and the control group.

Conclusions

The results of this meta-analysis suggested that stem cell therapy for children with autism might be safe and effective. However, the evidence was compromised by the limitations in current study size, lacking standardized injection routes and doses of stem cells, as well as shortages in diagnostic tools and long period follow-up studies. Hence, it calls for more studies to systematically confirm the efficacy and safety of stem cell therapy for children with autism spectrum disorders.

Introduction

Autism spectrum disorder (ASD) is a group of neurodevelopmental disorders characterized by social deficits, communication inabilities and stereotypic behaviors ( 1 ). The incidence is estimated to be 1–2% of all children, according to the U.S. Centers for Disease Control and Prevention ( 2 ). Despite its increasing prevalence ( 3 , 4 ), the etiology of ASD is not fully understood yet, which can be interpreted as including both genetic and environmental factors ( 5 ). The processes of inflammation and immune activation may act to modify the risk of ASD gene expression or destruct process of typical neural development in ASD ( 6 ). ASD patients are a heterogeneous group with different symptom characteristics ( 7 ), thus there is no definitive treatment for ASD patients ( 8 ).

Given the potential effects of sustained immune disorders and inflammation in ASD and known paracrine ( 9 ), homing ( 10 , 11 ), immunomodulatory ( 12 ) and multi-directional differentiation capacity ( 13 , 14 ) of stem cells, they are receiving attention as a potential therapeutic approach. Growing numbers of research reports have confirmed the efficacy and safety of stem cell therapy with different methods including autologous bone marrow mononuclear cells ( 15 – 17 ), fetal stem cells ( 18 ), human cord blood mononuclear cells ( 19 ) and umbilical cord mesenchymal stem cells ( 20 ) in patients with autism. However, the great mass of these case reports or case series studies are limited to a few geographical regions, thus fail to provide sufficient guidelines for clinical decisions. Moreover, these studies have several shortcomings, such as small sample size, non-standard control groups, non-standard assessment scale and short-term follow-up. Most importantly, when we began this study, there was no systematic evidence-based medical review demonstrating the efficacy and safety of stem cell therapy for ASD.

Collectively, we aim to rigorously screen and extract all preclinical trial data on stem cell therapy for autism, objectively evaluate and summarize evidence concerning the effectiveness of stem cell therapy for autism symptoms through systematic review and meta-analysis.

The study design was developed by the steering group, followed by the standard Cochrane Neonatal Review Group methods and PRISMA reporting guidelines. We have already submitted a registration application at Prospero (CRD42021285384, https://www.crd.york.ac.uk/prospero/ ).

Children and adolescents (age 0–18 years) were diagnosed with autism, regardless of region, gender, or race.

Intervention

Multiple kinds of stem cells interventions on children with autism were investigated within the current systematic review and meta-analysis, with no limitations on injection times, administration route and dose. Studies of stem cells in combination with other treatments, such as antipsychotic drugs, are also being considered.

Comparisons

Rehabilitation therapy includes sensory integration therapy, auditory training, behavioral intervention, occupational therapy, speech therapy and music therapy.

The main indicators are the scores of Clinical Global Impression (CGI) and Childhood Autism Rating Scale (CARS) or any other evaluation tools suitable for ASD in the corresponding studies.

Study Types

Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) were included in this study, both paralleled or crossover. For trials that had a crossover design, we included all the data before and after the crossover.

Data Sources

The following English and Chinese databases were searched from their inception to 24th JULY 2021: PubMed/Medline, Web of Science, EMBASE, Cochrane library, China Academic Journal (through China National Knowledge Infrastructure [CNKI], [WanfangData], [Cqvip], [SinoMed]) and Clinicaltrials.gov. A detailed illustration of search strategies is available in Supporting information 1 (S1. Search Strategy). No date restrictions or language restrictions are used for retrieval. Finally, references were tracked and included in the study to ensure that no RCTs and CCTs were missed by the search strategy.

Study Selection

All prospective controlled clinical studies of stem cell therapy on autism patients were included, as were trials in which stem cells were part of a complex intervention. We excluded qualitative studies, uncontrolled trials, case studies and case series, as well as trials that developed between different cell types, and studies that failed to provide detailed results.

Data Extraction and Quality and Validity Assessment

Two independent reviewers evaluated the retrieved studies for inclusion and assessed the methodological quality of included studies. Elements extracted included study characteristics (author, country, publication year and experimental design), participant characteristics (sex, age range and diagnostic criteria), intervention details (types of cells, dose ranges, administration and frequency), outcome measurement, follow-up time and adverse reactions. The risk of bias was assessed using the Review Manager 5.3. The disagreements were thrashed out by the two reviewers.

Data Analysis

Data entry and analysis were performed using Review Manager 5.3 software. The data required for meta-analysis were obtained by direct input or indirect calculation based on the original data (The data of CARS can be obtained directly, and the effective improvement number of CGI needs to be calculated based on the total efficiency provided in the original text multiplied by the number of each group, like Dawson et al .'s study). When studies of multiple intervention groups are compared, the “shared” control group is split equally in each comparison ( 21 ) and the weighted average difference (WMD) and risk ratio (RR) were used to compare continuous variables (CGI and CARS) and dichotomous variables (Adverse events) respectively. All results obtained were reported with 95% confidence intervals (CI). Heterogeneity among studies was determined by Q test and I 2 statistics (I 2 equals or exceeds 50%, p < 0.05 is considered to have greater heterogeneity). The random effect model or mixed effect model was selected according to the size of heterogeneity. With high heterogeneity, sensitivity analysis or subgroup analysis was used to detect the source of heterogeneity; if the source of heterogeneity cannot be found, a descriptive analysis was conducted.

Results of the Search

A flowchart describing the selection of eligible trials is presented in Figure 1 . A total of 137 articles from 9 databases were retrieved: Web of Science ( n = 15) databases, PubMed/MEDLINE ( n = 12), Cochrane ( n = 7), Embase ( n = 36), CNKI ( n = 11), Wan fang Data ( n = 30), Cqvip ( n = 19), Sino Med ( n = 4), Clinicaltrials.gov ( n = 3). We also included 1 latest research reports through citation searching to ensure that the retrieved literature includes all the studies in the published meta-analysis ( 26 ). Finally, 5 studies were included within our meta-analysis.

The inclusion flow chart of the literature was retrieved.

Characteristics of the Studies

The characteristics of the included studies are listed in Table 1 . Diagnosis criteria were performed mainly through the Diagnostic and Statistical Manual of Mental Disorders-4 (DSM-4) (60.0%) or Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) (40.0%) criteria. The 5 studies comprised 3 RCTs and 2 CCTs, sample sizes ranged from 36 to 180. A total of 325 subjects were included in the systematic review and meta-analysis, 319 of whom were analyzed for safety, including 265 males and 54 females. However, in Dawson's study ( 27 ), two pilot participants and 2 participants were found to be ineligible [bipolar disorder ( n = 1), the primary caregiver does not speak English ( n = 1)] after randomization, thus were excluded from the efficacy analysis. Collectively, only 315 subjects were included in the efficacy analysis.

Summary of clinical studies of stem cells therapy for autism spectrum disorders.

RCT, randomized controlled trial; CCT, controlled clinical trail; DSM,Diagnostic and Statistical Manual of Mental Disorders; BMMSC, bone marrow mesenchymal stem cell; MNCs, mononuclear cells; MSCs, mesenchymal stem cells; CB, cord blood; UCMSCs, umbilical cord mesenchymal stem cells; AUCB,autologous umbilical cord blood; DMSO, Dimethyl sulfoxide; CARS, childhood autism rating scale; CGI, Clinical Global Impression; VABS, Vineland Adaptive Behavior Scales; PDDBI, The PDD Behavior Inventory; EOWPVT, Expressive One-Word Picture Vocabulary Test; ABC, Autism Behavior Checklist; ROWPVT, receptive one word picture vocabulary test; M, month; W, week .

Methodological Quality

The Figures 2 , ​ ,3 3 showed the assessment results of bias risk and methodological suitability of the included studies. Studie by Dawson et al was considered high quality and low risk of bias. Lv et al . 's study was high risk in the field of random sequence generation and have “Some concerns” in multiple domains that substantially lowers confidence in the result. The other three studies should be considered “Some concerns” according to Cochrane's book in their one or two domains.

Risk of bias and applicability concerns.

Meta-Analysis

Five eligible articles were meta-analyzed using a random effects model, with CARS ( Figure 4 ) and CGI ( Figure 5 ) as primary and secondary indicators to evaluate the effectiveness of stem cell therapy for autism, and adverse reactions as safety indicator ( Figure 6 ).

CARS forest plot included in the study.

CGI forest plot included in the study.

Forest plot of adverse events.

As can be seen from the forest diagram in Figure 4 , heterogeneity test p = 0.14; I 2 = 42%, indicating moderate heterogeneity. Data showed that the CARS score of the stem cell group was significantly lower than the control group [WMD: −5.96; 95% CI (−8.87, −3.06); p < 0.0001] ( Figure 4 ). A higher score of CARS refers to severe disease. Overall, our results showed that the stem cell group had better efficacy in ASD treatment than the control group. In addition, sensitivity analysis was conducted to eliminate outliers in another intervention group (Lv 2013b) of Lv et al .'s study and the results were found to be stable (WMD: −7.08; 95%CI [−9.46, −4.70]; p < 0.0001; heterogeneity test p = 0.53; I 2 = 0%).

We found that the forest plot of CARS had moderate heterogeneity. According to the results of the methodological quality assessment, we concluded that the research quality of Lv et al .'s study was low. Afterward, we conducted a subgroup analysis based on the methodological quality, and found that the combined results of CARS in the high-quality group were stable [WMD: −6.37; 95%CI (−9.11, −3.63); p < 0.00001, heterogeneity test p = 0.55; I 2 = 0] ( Figure 7 ). The results of Lv et al . 's study showed high heterogeneity and instability in the low-quality group [WMD:−4.83; 95% CI (−13.78, 4.12); p = 0.29; heterogeneity test p = 0.02; I 2 = 82%] ( Figure 7 ). Therefore, Lv et al .'s study might be the source of heterogeneity. The results in Figure 5 show no significant difference in CGI. Consolidated effect size RR = 1.01, 95%CI [0.87, 1.18], Z = 0.14 ( p = 0.89), the effective rate for CGI was 62 and 60% in the stem cell group and the control group, respectively. Heterogeneity test I 2 = 0%, p = 0.72, indicating no heterogeneity.

CARS Forest plot of subgroup analysis.

The forest plot in Figure 6 reflects the occurrence events of adverse reactions in each group [RR = 1.55; 95%CI = (0.60, 3.98); p = 0.36; Figure 6 ], there was no significant difference in the incidence of adverse reactions between the stem cell group and the control group, with heterogeneity test p = 0.28; I 2 = 22%. Based on the forest map, we have visual outliers. The sensitivity analysis found that the study of Dawson et al was an outlier and the cause of heterogeneity. Whereas, after Dawson et al 's study was excluded, the results were more stable [RR = 4.70; 95%CI = (0.90, 24.63); p = 0.07; Heterogeneity test p = 0.95; I 2 = 0%].

Stem cells are defined as tissue units of biological systems which is responsible for the regeneration and development of organs and tissues. Stem cells are capable of self-renew and differentiate into multiple cell line ages, therefore, these cells can also be units that evolve through natural selection ( 28 , 29 ). Hematopoietic stem cells were primarily discovered and used for the treatment of blood-system failure induced by nuclear radiation ( 30 ). In recent years, the clinical results show that stem cells have shown promising effects in a variety of chronic and difficult diseases, such as spinal cord injury ( 31 – 34 ), graft-vs. -host disease (GVHD) ( 35 , 36 ), diabetes and complications ( 37 – 39 ), stroke ( 40 , 41 ), etc . As expected, more and more researchers are attempting to determine the efficacy of stem cell therapy for ASD.

Martínez ( 26 ) published the first systematic review and meta-analysis of stem cell therapy for autism in September 2021, but they included uncontrolled studies in the analysis to compensate for the insufficient number of studies. Especially in the studies within the control group, they only extracted data from the intervention group, which might reduce the clinical guiding significance of the conclusion that stem cell therapy significantly improves scales in patients with ASD. Our study demonstrates that stem cell therapy for children with autism appears to be safe and effective. CARS - the primary outcome measurement confirmed the efficacy, whereas, the secondary outcome measurement—CGI, showed no difference between stem cells and control treatment. Furthermore, Bieleninik, Ł ( 42 ) found total costs of ASD including health services costs and societal costs, were estimated to be around 2834 EUR in 2 months by analysis with 5 European countries and 4 non-European countries. However, the median total charges and costs for stem-cell transplant hospitalization were $270,198 and $92,717 from 2002 to 2015 ( 43 ). Given the persistence of autism, the hospitalization cost also increased dramatically. Therefore, it is extremely important to make the expensive stem cell therapy to gain greatly therapeutic effect. Currently, stem cell treatments for autism is mostly considered a new mean of clinical trials and have just been conducted in only a few places. It is urgent to form the standardized treatment methods and improve the curative effect before that they are popularized in clinical practice.

We can glimpse from the included studies where future autism stem cell therapy needs to be standardized. Firstly, we noted that the doses of cell injections in the included studies were varied. In Sharifzadeh's study ( 22 ), subjects received a total of 0.5-1 × 10 8 cells in the first injection and 0.3-0.5 × 10 8 cells in the second injection. In other studies ( 19 , 24 , 25 , 44 ), subjects received injections ranging from 2 × 10 6 /kg to 2.5 × 10 7 /kg cells at a time. Different doses of cell injection may account for the inconsistent efficacy. Owing to these limited studies, we could not analyze the influence of dosage on the efficacy and safety of stem cell injections. Secondly, there are two ways of cell injection: intravenous injection and intrathecal injection. Intravenous infusion of cells may limit the homing effect, cells could be trapped in organs such as lungs, heart, liver or kidney and get blocked by the blood-brain barrier, which might reduce the therapeutic effect on ASD ( 45 , 46 ). Furthermore, only two studies were followed up for 12 months, such a short period is not conducive to observing progress in the improvement of core symptoms of autism. Previous studies have suggested improvements observed after 12-month and 18-month follow-up, particularly in the Clinical Global Impression Scale ( 17 , 27 , 46 ). The CGI rating scale has been widely used in psychiatry to evaluate the degree of symptom and therapeutic efficacy, and the Improvement (CGI-I) scale is used to assess the extent a patient has improved or worsened following an intervention, but they are non-ASD specific ( 47 ), which might explain why there was no significant difference in the CGI scores between the two groups. Additionally, ASD is a complex neuropsychiatric disorder with substantial phenotypic and genetic heterogeneity ( 48 ), reducing the impact of heterogeneity on treatment and evaluation studies is quite important. Moreover, there are multiple sources of stem cells, and the therapeutic effects of stem cells from different sources may vary. Lv ( 19 ) and Liu ( 44 ) suggest that compared with the control group, the effect of cord blood mononuclear cells (CBMNC) transplantation was significant, however, the combination of CBMNC and umbilical cord mesenchymal stem cells (UCMSCs) had a greater therapeutic effect than CBMNC alone. The small sample size of included studies is also a problem that cannot be ignored. As mentioned above, there are many studies in the field of stem cell therapy for autism that have directly or indirectly demonstrated its effectiveness. However, they did not meet the criteria for inclusion in our analysis and were not meta-analyzed, but their results were equally important.

Overall, the major limitations of the included studies were small sample size, non-specific outcome measures, treatment regimens were not uniform, and lacking adequate follow-up.

In conclusion, the use of stem cells to treat children with autism may be effective and safe, but we believe that the current evidence is in-sufficient, the conclusions are based on studies that do not have a uniform treatment protocol. Besides, due to the high cost of stem cell therapy and the lack of widespread clinical application, guardians of children with autism need to be discreetly about enrolling in clinical trials of stem cell treatments for autism. It is urgent to establish a standardized treatment protocol through a large number of trials, such as the most suitable stem cell type, administration method and dose need to be screened; the post-treatment evaluation of stem cell therapy need to be improved. These may lead to the discovery of stem cell therapy for autism and its pathogenesis, thus further improving the therapeutic effect. We expect stem cell therapy to be used in the clinical treatment of autism and have significant therapeutic effects, but it is still a lot of work to be done before this can happen.

Data Availability Statement

Author contributions.

JQ: conceptualization, writing-reviewing and editing, data extraction, and assessing the risk of bias. ZL: conceptualization, writing-reviewing and editing, data extraction, and assessing the risk of bias. JY: writing-original draft, study selection, research retrieval, and statistical analysis. MZ: study selection, research retrieval, and statistical analysis. LL: study selection, and data extraction. ZZ: writing-reviewing and data extraction. ZH: assessing the quality of studies. LZ: article revision and grammar revision. YL: writing-original draft and statistical analysis. All authors contributed to the article and approved the submitted version.

The authors are grateful for the financial support received from the Foundation of Jiangxi Educational Committee (GJJ180791). The Science and Technology Project of Jiangxi Provincial Health Commission (20191079). The Open Project of Key Laboratory of Prevention and treatment of cardiovascular and cerebrovascular diseases, Ministry of Education (XN201913). The Foundation of Technology Innovation Team of Gannan Medical University (TD201806). Key Project Foundation of Gannan Medical University (ZD201831). First Affiliated Hospital of Gannan Medical University, Doctor Start-up Fund (QD076), and Jiangxi Provincial Natural Science Foundation (20212BAB206075).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We thank the two colleagues who put forward advices for this study, Junming Chen and Dongmiao Han.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fped.2022.897398/full#supplementary-material

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