International Journal of Speech-Language Pathology

ISSN: 1754-9507 (Print) 1754-9515 (Online) Journal homepage: http://www.tandfonline.com/loi/iasl20

Does occupational therapy play a role for

communication in children with autism spectrum
disorders?

Michèle L. J. Hébert, Eva Kehayia, Patricia Prelock, Sharon Wood-Dauphinee

& Laurie Snider

To cite this article: Michèle L. J. Hébert, Eva Kehayia, Patricia Prelock, Sharon Wood-Dauphinee
& Laurie Snider (2014) Does occupational therapy play a role for communication in children
with autism spectrum disorders?, International Journal of Speech-Language Pathology, 16:6,
594-602

To link to this article: http://dx.doi.org/10.3109/17549507.2013.876665

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 International Journal of Speech-Language Pathology, 2014; 16(6): 594–602

Does occupational therapy play a role for communication in children

with autism spectrum disorders?

MICHÈLE L. J. HÉBERT1,2, EVA KEHAYIA1,2, PATRICIA PRELOCK3,

SHARON WOOD-DAUPHINEE1 & LAURIE SNIDER1,4
1McGillUniversity, Montreal, QC, Canada, 2Jewish Rehabilitation Hospital-CRIR, Laval, QC, Canada,
3Universityof Vermont College of Medicine, Burlington,VT, USA, 4and Montreal Children’s Hospital-CRIR,
Montreal, QC, Canada
Downloaded by [University of Sydney Library] at 10:24 09 October 2015

Abstract
This study investigates occupational therapy for early communication in children with autism spectrum disorders (ASD).
The research explored the role of occupational therapists in supporting children with ASD to become better communicators
by considering their inter-professional collaboration with speech-language pathologists. Convenience samples of 21 clinical
occupational therapists and speech-language pathologists were recruited to participate in semi-structured audio-recorded
focus groups, using a qualitative design. Distinct views included a child-centred focus from speech-language pathologists,
whereas occupational therapists spoke of the child through societal viewpoints, which later pointed to occupational thera-
pists’ proficiency in enabling skill generalization in ASD. An equal partnership was consistently reported between these
clinicians, who identified the same objectives, shared strategies, joint treatments, and ongoing collaboration as the four
main facilitators to inter-professional collaboration when treating children with ASD. Three unique roles of occupational
therapy comprised developing non-verbal and verbal communication pre-requisites, adapting the setting, educating-
partnering-advocating for the child, and providing occupation-based intervention. These three themes meshed with the
discipline-specific occupational therapy domains represented in the Person–Environment–Occupation framework. When
working in inter-professional collaboration, speech-language pathologists and occupational therapists agree that occupa-
tional therapy is indispensable to early intervention in enabling communication in ASD.

Keywords: Autism spectrum disorders (ASD), Early childhood, Intervention.

Background and rationale children with ASD through collaboration with

Autism spectrum disorders (ASD) are highly prevalent,
complex, and lifelong neurodevelopmental disorders
(Center for Disease Control, 2012). Children with
ASD experience mild-to-severe difficulties in com-
munication, social, and behavioural development
(American Psychiatric Association, 2013). Clinicians
including occupational therapists and speech-
language pathologists screen, evaluate, and provide
therapy to children who are at risk for or who have
ASD (Chakrabarti & Fombonne, 2001). Paediatric
occupational therapists are members of medical
diagnostic and early intervention teams who are
trained to enable activities of daily living such as
feeding, sleeping, and self-care, which are necessary
to thrive, yet can be significant challenges for these
children (Canadian Association of Occupational
Therapists, 2006; Clark, Miller-Kuhaneck, & Watling,
2004). Occupational therapy can also support
parents and other professionals in order to minimize
maladaptive or unwanted behaviours (Clark et al.,
2004). Their approach is a comprehensive focus on
children’s engagement and participation in meaning-
ful occupations in the home, school, community, and
society as a whole (CAOT, 2008).
The ability to communicate is a key challenge
for children with ASD (Prelock & Nelson, 2012).
Communication skills are pre-requisites to meeting
many early occupational needs, where childhood
occupations refer to daily routines such as commu-
nication, play, socialization, learning, and integration
in society (Clark et al., 2004; Townsend & Polatajko,
2007). Compared to children with a physical dis-
ability, whose developmental objective may be to
learn to walk, goals for children with ASD typically
relate to communication and social interaction.
Pre-requisites for communication, including joint

Correspondence: Michèle L. J. Hébert, McGill University, School of Physical and Occupational Therapy, 3654 Promenade Sir-William-Osler, Montreal,
Quebec, Canada H3G 1Y5. Email: michele.lj.hebert@mail.mcgill.ca
ISSN 1754-9507 print/ISSN 1754-9515 online © 2014 The Speech Pathology Association of Australia Limited
Published by Informa UK, Ltd.
DOI: 10.3109/17549507.2013.876665
 Occupational therapy for early communication in ASD
attention, object permanence, listening, comprehen-
sion, and symbolic play begin to develop during
critical periods in infancy and early childhood
(Rogers & Dawson, 2010). There is a critical period
or an optimal timeframe during which developmen-
tal and behavioural changes can easily occur, capital-
izing on maximal brain plasticity (Doidge, 2007).
In fact, a growing body of literature and empirical
evidence on ASD speaks to the effectiveness of
early intensive educational–behavioural–relationship-
based intervention for communication during these
critical periods (Mundy & Neal, 2001; Paul, 2008;
Prelock & Nelson, 2012; Rogers & Dawson, 2010).
A collaborative inter-professional framework is
essential for professionals working with children who
experience complex developmental issues, such as
may be found in ASD (CAOT, 2008; D’Amour &
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Oandasan, 2005; Health Canada, 2006). High-risk
infants in need of resuscitation are among the few
childhood populations for whom inter-professional
collaborative practices have been studied more
extensively in the past decade (Brodsky, Gupta,
Quinn, Smallcomb, Mao, Koyama, et al., 2013).
Regarding the provision of services to children or
adults who have ASD, recent investigations exam-
ined attitudes and barriers to inter-professional col-
laboration and practice in the healthcare system
(Loutzenhiser & Hadjistavropoulos, 2008; Werner,
2011). However, to date, there have been no studies
exploring the role of occupational therapists in
explicitly facilitating communication in this young
population, and there is no information on inter-
professional collaboration between speech-language
Figure 1. Four-stage investigation to develop a questionnaire.
595
pathologists and occupational therapists when
treating these children. The current research begins
to address this gap.
Purpose and objectives
In order to understand paediatric clinicians’ views
on the roles and practices of occupational therapy
in developing communication in children with ASD,
we pursued two objectives: (1) to explore occupa-
tional therapists’ role in supporting communication
with this population when in an inter-professional
collaborative context with speech-language patho-
logists; and (2) to identify emerging themes from
their views.
Method
This study is one step in the first stage of a larger
four-phase study whose purpose was to develop a
valid, reliable, self-administered, bilingual ques-
tionnaire to be used thereafter in a Canada–US
survey designed to examine occupational therapy
practice for supporting early communication in
young children with ASD, within a context of
inter-professional collaboration (IPC) with speech-
language pathologists. Figure 1 summarizes this
four-phase investigation, emphasizing the present
study, which are the focus group discussions. The
development of an instrument was started prior to
running the focus group discussions, and field test-
ing of the instrument followed once development
 596 M. L. J. Hébert et al.
was complete. This process is briefly presented in
the next paragraph.
Instrument development and field testing
To begin, questionnaire items were generated following
a comprehensive review of the literature, consulta-
tion with experts, and by extracting content from the
focus group discussions. Then, the face and content
of the questionnaire were validated, as was the test
re-test reliability. This field testing served to mini-
mize bias and maximize response rate on the
questionnaire by following systematic survey design
methods including Dillman’s (2007) evidence-based
Tailored Design Method. Ethical approval was
obtained from the ethics review boards at McGill
University and the University of Vermont for all
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study phases, and English and French informed
consent forms were signed by participants. The
following two sections present details about the focus
group participants and procedures.
Participants
Two convenience samples of occupational therapists
(n ⫽ 12) and two of speech-language pathologists
(n ⫽ 9) in Vermont and Montreal, who had seen
young children with ASD within the past 12 months,
were included (Table I). The four focus groups com-
prised six anglophone and six francophone occupa-
tional therapists, respectively, as well as seven
anglophone and two francophone speech-language
pathologists (13 anglophone participants, eight fran-
cophone participants). French-speaking groups were
included to examine whether or not linguistic or cul-
tural differences affected responses. Speech-language
pathologists were invited because of their expertise
in speech, language, and communication.
Procedures
To achieve the research objectives, a total of 21 occu-
pational therapists and speech-language pathologists
participated in audio-recorded, semi-structured
focus groups. To minimize cross-discipline influence,
groups were discipline-specific and language-
specific. Open-ended questions probed the participants
Table I. Study participants.
Anglophones (VT)
Method
Participants OT SLP
4 focus groups* 6 7
Face validation 0 0
Content validation 4 0
Test re-test testing 8 0
Pilot study total 18 7 4
VT, Vermont; QC, Quebec; OT, occupational therapists; SLP, speech-language pathologists.
*The focus group participants are the focus of this study and manuscript.
about their opinion of important elements for the
development of early communication in children
with ASD, and about the perceived role of occupa-
tional therapists in supporting early communication
alone and when in collaboration with speech-
language pathologists.
Data analyses
Given the qualitative nature of this investigation,
focus group transcriptions were interpreted quali-
tatively using thematic analyses (Butler-Kisber,
2011). This method was chosen because of its
systematic yet flexible approach to reducing data by
following data categorization and validation steps.
Group discussions were transcribed and revised
by an outside reviewer to ensure there were no
omissions. Transcriptions were transformed into
statements, first by sorting statements into catego-
ries, then reducing the statements to eliminate
redundancies. Next, these categorized and reduced
statements were examined to identify emerging
themes. For example, the transcription statement
about occupational therapists who
generally speaking, can see things much broader than
a lot of other people. (Occupational therapists) are
not quite as compartmentalized … (They) see the big
picture and how different pieces fit together
was categorized as global holistic intervention, and
later reduced to expertise in occupation-based inter-
vention, as presented in depth in the results section.
French statements were translated into English, to
determine if cultural differences emerged. The final
statements were then transformed into questionnaire
items while maintaining, as closely as possible, the
phrasing used by the participants. Questionnaire
items are not presented in this manuscript, as this
investigation focuses on findings from the focus
group discussions alone rather than on questionnaire
items for the international survey as a whole.
Results
General findings from the focus groups are presented
in three parts, followed by emerging themes. The three
parts comprise participant input on (1) important
Francophones (QC)
Layperson OT SLP Layperson
0 6 2 0 21
4 0 0 4 8
0 3 0 0 7
0 9 0 0 17
18 2 4 53
 Occupational therapy for early communication in ASD
elements of communication development in ASD,
(2) the role of occupational therapy for communica-
tion, and (3) occupational therapy—speech-language
pathology inter-professional collaboration for this
young population. Emerging themes, additional
findings, and interpretation conclude this section.
Elements of communication development in ASD
No cultural differences were noted across the French
and English group responses. In fact, views were
relatively consistent within and across languages and
disciplines. In general, larger groups generated more
discussion, dynamics, and exchanges, whereas
smaller groups tended towards a sooner rather than
later consensus among participants, even though
they were reminded that there were no right or wrong
answers. Focus group participants were first asked to
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reflect on elements that they felt were imperative to
early communication development in children with
ASD. Most of the elements raised by clinicians were
pre-requisites previously identified in the literature.
These included developing an interest and motiva-
tion to communicate, the ability to orient toward a
communicative partner, access to language, joint
attention, socialization, pragmatics, vocabulary,
semantics, and play. The Supplementary Appendix
details available online at http://informahealthcare.
com/doi/abs/10.3109/17549507.2013.876665 the
questions asked relative to these topics and examples
of statements. Seven elements not previously reported
in the literature as critical elements to developing
early communication in children with ASD were: the
child’s social appetite, intestinal stability, the level of
family stress and regulation, a safe environment, a
wider community understanding, the consistent use
of communication modes by adults, and advocating
for the child and their family. Given that the initial
intent of the focus groups was to generate question-
naire items for a survey, these elements were consid-
ered for inclusion in the questionnaire.
Role of occupational therapy in supporting
communication
Participants were then asked to reflect on the role of
occupational therapy in enabling early communica-
tion in children with ASD. Most focus group state-
ments supported the belief that facilitating early
communication in youngsters with ASD is a shared
goal, with equal partnership between occupational
therapists and speech-language pathologists. The
following are sample focus group statements.
One (profession) almost doesn’t go without the other.
In an ideal world, OT-SLP work must be done. We
are indispensable.
Speech-language pathologists and occupational
therapists shared views about the effectiveness of
paediatric occupational therapy, and clinicians also
597
voiced their opinion about the degree of necessity
of occupational therapy for early communication
development as follows:
… for our work to be effective … thank goodness I’m
not alone in working on communication, because it
would be strictly useless. Sensory needs must absolutely
be addressed … before being able to continue.
Occupational therapists can play a role at all
levels …. They are “100%” needed for early
communication.
Furthermore, to streamline participant under-
standing of their type of IPC practice, the catego-
ries of multi-disciplinary, inter-disciplinary, and
trans-disciplinary practice were defined (Paul &
Peterson, 2001). Multi-disciplinary practice implies
that neither objectives nor strategies are shared by
different disciplines. Inter-disciplinary practice
means that only objectives are shared. Trans-
disciplinary practice infers that both objectives and
strategies are shared. So, while the majority of views
defended egalitarian roles, one speech-language
pathologist expressed belief in a lesser degree of a
shared role for early communication. This view-
point reflected multi-disciplinary practice rather
than inter-disciplinary or trans-disciplinary prac-
tice. While there was initial hesitation about equally
shared roles, in the end consensus was noted.
I’d find it difficult to calculate it 50–50. I’d like to
think that the SLP has a much greater role in the
development of communication, but it’s true, if we
don’t work on the availability of the child, we’re sort
of working for nothing.
Overall, participants agreed that occupational
therapy plays an “indispensable” role when children
with ASD do not yet communicate or communicate
with difficulty.
Inter-professional collaborative practice: Occupational
therapy–speech-language pathology
Along these same lines, participating clinicians were
asked to describe the inter-professional collaboration
(IPC) between occupational therapy and speech-
language pathology in supporting communication in
children with ASD. Both disciplines recognized the
value of IPC, while highlighting the facilitators and
obstacles to optimal collaboration. Six main facilita-
tors emerged: having access to one another, sharing
goals, sharing strategies, being in constant collabora-
tion, providing joint-treatments, and depending on
one another’s individual expertise. These facilitating
factors were included in the questionnaire. At an orga-
nizational level, some participants pointed out the
importance of shared beliefs, and minimizing person-
nel turnover by fostering long-term relationships:
The flexible co-ordination of policies and procedures in
time and space … from higher up … administratively
 598 M. L. J. Hébert et al.
… that there is a common structure, global way of
doing things, similar line of thought, global perspective
of the intervention … (minimizing) lots of … changes
in interventionists … ensuring a continuum in time
will facilitate this (collaboration).
At a professional practice level, clinicians indicated:
It takes frequent and sustained collaboration …
consultation on a regular basis.
Knowing one another’s profession, the role each
one plays. Also knowing the approaches used by one
(professional) as much as the other (professional);
the approaches to language of other professionals.
Concepts of having a collaborative mindset and a
trusting relationship were suggested as a means to
facilitate the dependency on one another’s expertise.
One statement that portrays this IPC ingredient
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was:
You can’t tell who’s who. There’s no role distinction.
When you get working with people who you are com-
fortable with, who … want to get to the same end …
when you can find people you can trust to be ok with
change.
When speaking of IPC specifically for young
children with ASD, four of the six IPC ingredients
were stressed: shared objectives, shared strategies,
joint-treatments, and ongoing collaboration. A state-
ment that represented this common belief in both
disciplines was:
… Very often I’m providing the motor components
and she might be providing more of the directed
speech, but then there may be times where …
I might be looking like the speech therapist and
she’s looking like an OT. I think boy isn’t that nice
that you can share those roles and not get upset
about it.
Several participants voiced a strong opinion that,
when compared to multi-disciplinary or inter-
disciplinary models, trans-disciplinary collaborative
practice is optimal for very young children with
ASD. We do not yet know if differential experiences
in IPC, clinical setting, funding source, or other
factors explain the type of early intervention
implemented. The results of our survey may allow
us to better understand what factors explain the
use of different treatment approaches within the
context of IPC.
Emerging themes
Three themes emerged from the analyses of focus
group statements about the role of occupational
therapists in facilitating early communication: (1)
centredness on the child, (2) emphasis on ensuring
contextual support, and (3) expertise in occupation-
based intervention.
Theme 1
The first theme, centredness on the child, empha-
sized occupational therapy expertise in developing
early communication pre-requisites in children
with ASD, a newly identified role for occupational
therapists. Pre-requisites include joint attention,
motor competencies, as well as other pre-linguistic
requirements, as exemplified by these participants’
statements:
work done … to maintain the child in a state of
arousal, a functional state, which allows the imple-
mentation of means that promote the development
of communication.
If we don’t take care of sensory and self-regulation
elements … we’ll miss out on communication
elements all together.
Also, for a child that doesn’t have enough verbal,
… (occupational therapists) introduce visual commu-
nication, all the motor work for … gestural commu-
nication. For pre-requisites, motor imitation ...
Cognitive elements; cognition.
Biting as a means of communicating was one
example of an unwanted behaviour that …
OT can minimize and fill (the child’s) need in a more
functional way.
Some participants suggested that occupational
therapy additionally plays a role in fostering verbal
communication by providing:
… the muscle tone, trunk strength, trunk control, the
oral musculature, looking at all the physical and
sensory things that are required in order to speak.
A speech-language pathologist added:
If a child is dyspraxic, sometimes we as speech-
language pathologists use techniques where we need
to touch the child. But if the child is very tactile
defensive, all the work that can be done in OT to
desensitize the child at a tactile level … allowing us
to approach, touch, help, and give facial guides … for
some sound production. The OT can help us.
Finally, clinicians highlighted how occupational
therapy can facilitate a child’s motivation to com-
municate:
The more he has interests, the more reasons he will
have to communicate.
I think that to develop communication, … we have
to know (the children’s) play interests. The occupa-
tional therapist can help discover their interests.
In essence, there was consensus that the fewer pre-
cursors to language that children have, the more the
role of occupational therapy is important.
The less the child has pre-requisites, the more indis-
pensable is the OT … joint attention, visual contact,
 Occupational therapy for early communication in ASD
the more the role of the OT is primordial … in terms
of communication.
These opinions recognized the indispensable role
that OT applies on a number of child-specific
domains, including early communication, play,
socialization, daily living, sensory and motor com-
petencies, as well as prevention or reduction of
maladaptive or unwanted behaviours.
Theme 2
Statements about the second theme represented two
distinct contextual support angles: physical and
human supports. One statement that summed up
this contextual theme was “transactional supports”,
which is defined in the literature as the empower-
ment of parents and professionals by providing them
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with tools and education, as well as the adaptation
of the child’s setting (Prizant, Wetherby, Rubin, &
Laurent, 2003).
Theme 2: Physical supports. Participants shared that
occupational therapists are flexible and adapt chil-
dren’s physical space and material by “using modal-
ities, rooms, the setting, chairs, tables, balls, swings”
and “… their … talents to help with communication
through … social stories ... pictures”.
Moreover, occupational therapists reportedly
create opportunities for socialization,
… in small groups … (which is) a good way … to set
up (communication) development.
OTs developed social skills programs in collabora-
tion with speech-language pathologists and educators.
But the programs were mainly started by OTs, because
social skills are based a lot on self-regulation. So, the
expression of emotions, emotional self-regulation …
comes back to fostering … a favourable pre-disposition
for the child to communicate, and understand the
meaning of (the child’s) environment.
Given that their work is frequently in natural envi-
ronments, occupational therapy intervention was
said to lead to the successful enablement of early
communication.
Theme 2: Human supports. In terms of occupational
therapy enabling children with ASD to communicate
by providing human context support to parents,
fellow clinicians, and organizations, occupational
therapists were said to do so by considering the “…
state of stress of the family” and “what their level of
regulation or dis-regulation is”, and
… educating other team members (and parents) on
different techniques that might be helpful or other
things to try with their child.
Across all four focus groups, a child and family
advocacy role was highlighted, with statements about
599
their collaboration with, and education of other pro-
fessionals and parents. Both participating disciplines
reported that occupational therapists are well posi-
tioned and qualified to advocate for these children
and their parents’ rights to, for example, prevent bul-
lying, foster communication, and facilitate their inte-
gration in society. In summary, children can develop
communication when
… surrounded by sensitive people about the child’s
needs … (where there’s a) wider community under-
standing that communication isn’t just verbalization.
Thus, the role of occupational therapists in
education, advocacy, and partnership for children
with ASD repeatedly arose as important, while
considering both family and interventionist needs
and supports.
Theme 3
In the third theme, occupational therapy expertise in
providing occupation-based intervention was under-
lined. This theme overlaps with the aforementioned
two themes, given occupational therapy’s specific
and contextual perspective through the occupation
of the child, allowing occupational therapists to be
uniquely positioned to intervene. Occupational ther-
apists consider childhood occupation in all life con-
texts such as participation and integration in the
home, daycare, school, community, and society.
Early communication and play are two childhood
occupations that were highlighted by participants. In
terms of early communication, one statement was:
The more the child is in contact with that vocabulary
..., the more he will manipulate it, the more he
will use it to play or to accomplish his daily living
activities.
Clinicians under-scored the role of occupational
therapy in assessing, developing, and incorporating
play in treatment, which is a fundamental childhood
occupation that directly relates to communication.
Participants described that with an occupational
therapy
evaluation of the handicapping situation … (of) the
daily impact … (occupational therapists) bring (the
child) to participate in age appropriate activities; (they
identify) what is missing for this child to function in
his group, be well in his body, be comfortable.
Moreover,
OTs play a lot with children … the whole play aspect
is developed in OT.
One clear overarching message was that
OTs, generally speaking, can see things much broader
than a lot of other people. (Occupational therapists)
 600 M. L. J. Hébert et al.
are not quite as compartmentalized … (They) see the
big picture and how different pieces fit together.
Further findings and discussion of results
From a perspective of shared knowledge, both occu-
pational therapists and speech-language pathologists
brought forward the anatomical, functional, and
neurodevelopmental elements of early communica-
tion, such as oral control, praxis, arousal level, con-
centration, receptive and expressive language.
However, the two disciplines differed in their descrip-
tions of early pre-requisites to communication.
Speech-language pathologists emphasized develop-
ment-specific speech and language elements such as
vocabulary, pragmatics, semantics, morphology, and
syntax. In contrast, occupational therapists reported
more on family- and community-centred compo-
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nents. For instance, occupational therapists empha-
sized the central role of the family on following
through on communication modes and their open-
ness to using almost any means to facilitate their
child’s communication. Occupational therapists also
spoke about contextual elements impacting commu-
nication, which were not typically described by
speech-language pathologists. Examples of contex-
tual components included the child’s access to a safe
environment, setting up opportunities to practice or
use communication, having role models, and educat-
ing all team members in using techniques. Even
more broadly, occupational therapy participants
considered that living within an understanding and
supportive community, as well as being served by
well-trained interventionists, were important ele-
ments to the development of early communication.
To summarize, speech-language pathologists defined
early communication in ASD with a child-centred
focus, whereas occupational therapists’ definition
was grounded in a more comprehensive view of
examining childhood occupation, from the child’s
perspective, to that of the family, support networks,
and society.
Although there was some initial concern by speech-
language pathologists that occupational therapists
would have a role in enabling communication, in the
end, all focus group discussions revealed that both
occupational therapists and speech-language pathol-
ogists believe in the valuable contribution of occu-
pational therapy to communication in ASD. Once
language develops, speech-language pathologists
appear to have a more critical role in communica-
tion. Birth to 6 years of age was proposed as an
essential time for occupational therapy engagement
in enabling early communication. This belief con-
cords well with the clinical knowledge and experi-
ence of occupational therapy in enabling children to
play and socially interact, while minimizing and
preventing maladaptive or unwanted behaviours.
The National Autism Center Standards Report
(2009) stresses that working in the natural setting
and creating natural learning opportunities are
important elements of evidenced-based practice for
children with ASD. Transferring what is learned
across different settings, people, behaviours, and
responses leads to generalization, yet achieving gen-
eralized use of skills is a significant and pervasive
challenge for children with ASD (Rogers & Dawson,
2010; Whalen, 2009). All four focus groups in this
study attested to the contributory expertise of occu-
pational therapists in enabling children’s learning in
natural settings. Several statements pointed to the
inherent ability of occupational therapists to treat
children in their home, daycare, and community
contexts. Therefore, although working in the natural
setting is not reserved for occupational therapists,
their role in creating opportunities for peer play,
fostering naturalistic teaching, and enabling skill
generalization in children with ASD is a natural part
of occupational therapy practice. In this sense, the
contribution of occupational therapy to enabling
early communication is more relevant than previ-
ously acknowledged.
When examining more closely the speech-language
pathology and occupational therapy comments in
the present study, interesting patterns emerged. The
three previously presented emerging themes mir-
rored an occupational therapy practice framework:
the Person Environment Occupation (PEO) frame-
work (Law, Cooper, Strong, Stewart, Rigby, & Letts,
1996). The PEO framework is taught worldwide to
students and licensed professionals in occupational
therapy. The PEO concepts represent occupational
therapists’ unique expertise in eliciting one’s balance
through the person, and their occupations in their
environment (Law et al., 1996). The person concept
considers factors such as childhood diagnosis, age,
developmental level, function, and other personal
traits. Given this domain, the first emerging theme
about centredness on the child fits well in the person-
related concept of the PEO framework. In fact, per-
son concepts that were identified about occupational
therapists’ centredness on the child with ASD include
non-verbal and verbal communication pre-requisites
including joint-attention, arousal, emotional regula-
tion, muscle tone, motor control, co-ordination,
imitation, sensory processing, and motivation.
Second, the environment-related concept of the
PEO model matches the second theme emphasizing
contextual supports. Environment, in the PEO frame-
work, considers assessing space, time, and people
dynamics to identify needs for environmental adap-
tation and/or modification. Adapting and modifying
an environment includes physical and human sup-
ports, which are consistent findings in our study.
Indeed, contextual supports that were identified
encompassed both physical and human supports.
Occupational therapists are proficient in adapting
settings to foster communication, creating oppor-
tunities for early communication, and fostering
learning situations with the family and early
 Occupational therapy for early communication in ASD
interventionists. Occupational therapists do so, on
one-hand, by providing treatment in natural settings,
using creative means, and modalities. On the other
hand, they educate and advocate for the child with
ASD and their parents to prevent bullying, and
facilitate a community-wide awareness that commu-
nicating is more than verbalizing. This unique occu-
pational therapy approach enables the child with
ASD to generalize skills taught.
Lastly, focus group statements underlined com-
munication, play, socialization, conversation, social
interactions, social participation, and integration,
that are childhood occupations, as represented in the
top portion of the PEO framework (Figure 2). These
occupations are in fact the core of this investigation,
which leads us to the third theme of occupation-
based intervention expertise. This practice framework
suggests that occupational therapists are experts in
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assessing and treating the three domains of person–
environment–occupation, and in determining how these
domains interact with and impact on what is most
meaningful to the person. Occupational therapy
assessment and intervention of person–environment–
occupation, aim to enable a person’s quality-of-life by
optimizing the balance between these three concepts.
Thus, occupational therapy expertise in providing
occupation-based intervention can arguably repre-
sent the optimization of balance between person,
environment, and occupation. Figure 2 depicts our
adaptation of the PEO framework, and how the three
emerging themes can be embedded into the person–
environment–occupation domains for children with
ASD. The consistency between the three themes and
the PEO framework is underlined by clinician
comments about occupational therapy education,
advocacy, and partnership roles for children with
ASD and their families. It is becoming clear that
university and continuing education for occupational
therapy students and professionals are filtering into
Figure 2. Themes embedded in the PEO practice framework for
children with ASD. Adapted from the Person–Environment–
Occupation framework (Law et al., 1996).
601
clinical practice for children with ASD. Knowledge
transfer from undergraduate status to clinical
practice status may be occurring in occupational
therapists who treat children with ASD.
Future research directions
The immediate next question to answer is what com-
munication early interventions are occupational
therapists using today with children who have
ASD? Therefore, as a subsequent step, a Canada–US
survey was completed, which aimed to define
occupational therapy intervention to enable early
communication in children with ASD, and to explain
early intervention considering occupational therapy
inter-professional collaboration practices with speech-
language pathologists. The results are currently being
analysed.
Focus group study limitations
Most participants worked in inter-disciplinary or
trans-disciplinary practice models suggesting that
volunteer bias may have been present. This limitation
may be explained by the fact that participation was
on a voluntary basis, and the announcement to
participate in this study included the terms “inter-
professional collaboration between the occupational
therapist and the speech-language pathologist for
communication in toddlers with autism”, which
likely attracted those with a particular interest in this
clinical practice framework. The survey is currently
being completed and will serve to more objectively
describe practice in this area.
Conclusion
Due to the complexity of ASD, paediatric clinicians
recognized the value of shared professional roles in
intervening early to help young children with ASD
to become better communicators. When defining the
specific role of occupational therapists to facilitate
communication with these children, unexpected yet
important results were found. Consensus was
obtained about the “indispensable” role of occupa-
tional therapy in developing early communication
due to their unique expertise in occupation-based
intervention. Expertise in occupation-based inter-
vention is founded in three discipline-specific
domains: occupational therapy expertise in person,
environment, and occupation (PEO). Interestingly,
these three domains were identified in the focus
groups. For expertise in occupation-based interven-
tion to be present, the PEO framework suggests that
a balance between these three domains is optimized.
Indeed, both speech-language pathologists and
occupational therapists agree that occupational
therapy is in a pertinent position to optimize this
balance for early communication in children with
 602 M. L. J. Hébert et al.
ASD due to occupational therapy expertise in
assessing and treating PEO factors and interactions.
Additionally, occupational therapy plays a particular
role in facilitating communication pre-requisites.
Along these same beliefs, clinicians consistently
described occupational therapists’ inherent profi-
ciency in enabling the generalization of skills in chil-
dren with ASD thanks to their innate skill in creating
natural contexts for learning, from individual through
societal perspectives. In turn, occupational therapists
were said to be specialists in empowering parents of
children with ASD and early interventionists through
child–family–interventionist advocacy, education,
and partnership. Consequently, when children with
ASD are treated by occupational therapists in
collaboration with speech-language pathologists,
they may more readily learn to communicate,
participate, and integrate in our world. In essence,
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occupation-based intervention expertise was revealed
as the central cause for appropriateness of occupa-
tional therapy with this childhood population.
Acknowledgements
This study was possible thanks to McGill University,
the University of Vermont, the Jewish Rehabilitation
Hospital and CRIR, the Canadian Institute of
Health Research, the Mental Lexicon Project, Judith-
Kornbluth Gelfand Paediatric Fellowship, Canadian
Occupational Therapy Foundation, Eleanor Côté
Foundation, and participants in Quebec and
Vermont. Underlined is the valuable support of
graduate students, faculty members, as well as
family and friends.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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