Systematic Review of Occupational Therapy and Mental Health Promotion, Prevention, and Intervention for Children and Youth

Marian Arbesman; Susan Bazyk; Susan M. Nochajski

doi:10.5014/ajot.2013.008359

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Research Article | November 2013

Systematic Review of Occupational Therapy and Mental Health Promotion, Prevention, and Intervention for Children and Youth

Marian Arbesman; Susan Bazyk; Susan M. Nochajski

Author Affiliations

Article Information

American Journal of Occupational Therapy, November/December 2013, Vol. 67, e120-e130. doi:10.5014/ajot.2013.008359

Abstract

We describe the results of a systematic review of the literature on children’s mental health using a public health model consisting of three levels of mental health service: universal, targeted, and intensive. At the universal level, strong evidence exists for the effectiveness of occupation- and activity-based interventions in many areas, including programs that focus on social–emotional learning; schoolwide bullying prevention; and after-school, performing arts, and stress management activities. At the targeted level, strong evidence indicates that social and life skills programs are effective for children who are aggressive, have been rejected, and are teenage mothers. The evidence also is strong that children with intellectual impairments, developmental delays, and learning disabilities benefit from social skills programming and play, leisure, and recreational activities. Additionally, evidence of the effectiveness of social skills programs is strong for children requiring services at the intensive level (e.g., those with autism spectrum disorder, diagnosed mental illness, serious behavior disorders) to improve social behavior and self-management.

The objectives of this review were to systematically search the literature and critically appraise and synthesize the applicable findings to address the following focused question: What is the effectiveness of activity-based interventions for mental health promotion, prevention, and intervention with children and youth? The interventions include those focused on peer and social interaction, compliance with adult directives and social rules and norms, and participation in productive and task-focused behavior.

Statement of the Problem

Historically, interventions in the area of children’s mental health tended to focus narrowly on services provided to children with diagnosed mental illness provided in psychiatric settings (Bazyk, 2011). More recent efforts have used a public health model to expand the scope of services. According to Bazyk (2011), children’s mental health services using the public health model focus on helping all children develop and maintain mental health, and occupational therapy practitioners provide such services to all children, both with and without identified mental health problems. These services promote occupational performance in areas of occupation, including education, play, leisure, work, social participation, activities of daily living (ADLs), instrumental activities of daily living, and sleep and rest, within a variety of environments, such as school, home, community, and health care settings (American Occupational Therapy Association [AOTA], 2008). Systematic reviews of children’s mental health research strengthen the current knowledge of the efficacy of practices used by occupational therapy practitioners for all children and youth, not just those with diagnosed mental illness.

Background

The mission of public health is to create a society in which people can be healthy (Institute of Medicine, 1988). This mission is accomplished by “creating the expertise, information and tools that people and communities need to protect their health—through health promotion, and prevention of disease, injury and disability” (Centers for Disease Control and Prevention, 2013). The World Health Organization (2001) and national leaders in the field of children’s mental health have advocated for a public health approach to mental health emphasizing the promotion of mental health as well as the prevention of and intervention for mental illness (AOTA, 2010a, 2010b; Bazyk, 2011). The public health model of mental health includes three major levels of service:

Tier I: universal, or whole-population, programs provided to all children, including those with or without mental health or behavioral problems or other disabilities and illnesses
Tier II: targeted, or selective, services designed to support children and youth who have learning, emotional, or life experiences that place them at risk of engaging in problematic behavior or developing mental health challenges
Tier III: intensive services provided to children and youth with identified mental, emotional, or behavioral disorders that limit their participation in needed and desired areas of occupational performance (AOTA, 2008; Miles, Espiritu, Horen, Sebian, & Waetzig, 2010).

Guided by the emerging focus of occupational therapy on wellness and health promotion, the philosophical basis of the profession, and the importance of engagement in meaningful occupations and activities, occupational therapy practitioners can play a vital role in providing services in all three tiers.

Because a public health approach to mental health involves the provision of promotion, prevention, and intensive interventions, it is important to make distinctions among these practices. Mental health promotion interventions focus on competence enhancement—that is, on building strengths and resources in the whole population (Barry & Jenkins, 2007). Prevention interventions have been developed over the past two decades and have traditionally focused on reducing the incidence and seriousness of problem behaviors and mental health disorders (Barry & Jenkins, 2007; Catalano, Hawkins, Berglund, Pollard, & Arthur, 2002). Early prevention programs tended to focus primarily on reducing risk factors (e.g., family history of substance abuse, poverty). Current approaches, however, recognize the importance of minimizing mental health problems by enhancing protective factors as well (e.g., social and emotional competencies, clear standards for behavior; Miles et al., 2010). Intensive individualized interventions are provided to diminish the effects of an identified mental health problem and assist the child in reaching an optimal state of functioning. Intervention at this level is often dependent on the specific mental health problem or formal diagnosis (Miles et al., 2010).

Method

This systematic review examined studies that evaluated the effects of occupation- and activity-based intervention on peer and social interaction, compliance with adult directives and social rules and norms, or productive or task-focused behaviors (including ADLs) for children and youth at the universal, targeted, and intensive tiers. These areas were chosen by a consensus group of occupational therapy practitioners with mental health expertise, who felt that these were the most representative of psychosocial components that predict participation in school and in the home and community. In other words, these mental health experts believed that children who were able to interact in peer and social environments or comply with adult directives and engage in task behavior were more likely to successfully participate in school and in the home and community environments.

An evidence-based perspective is based on the assumption that scientific evidence of the effectiveness of occupational therapy intervention can be judged to be more or less strong and valid according to a hierarchy of research designs, an assessment of the quality of the research, or both. This review used standards of evidence developed in evidence-based medicine that standardize and rank the value of scientific evidence for biomedical practice using the following grading system (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996):

Level I: Systematic reviews, meta-analyses, randomized controlled trials
Level II: Two groups, nonrandomized studies (e.g., cohort, case control)
Level III: One group, nonrandomized (e.g., before and after, pretest and posttest)
Level IV: Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V: Case reports and expert opinion that include narrative literature reviews and consensus statements.

To conduct the systematic review, reviewers evaluated research studies published in the peer-reviewed scientific literature according to their quality (scientific rigor and lack of bias) and levels of evidence. An initial review conducted in 2003 covered articles published between 1980 and 2002 (Jackson & Arbesman, 2005). An updated review included articles published between 2003 and 2009. In addition, more recent articles were included covering the period 2010–2012 that were recommended by occupational therapy practitioners with mental health expertise. Specific inclusion criteria were as follows:

The article was published in either a peer-reviewed journal or a peer-reviewed evidence-based review since 1980 in the English language.
The age range of study participants was 3 to 21 yr.
The intervention described in the study was embedded in activities and within the domain of occupational therapy, although it did not have to be a common occupational therapy intervention or administered by an occupational therapist or occupational therapy assistant.
Outcomes measured in the study included social or peer interactions or compliance with adult directives or social rules and norms (including ADLs).
The article provided Level I, II, or III evidence.

The following articles were excluded: presentations and conference proceedings, non–peer-reviewed literature, dissertations and theses, articles about participants who were younger than age 3 yr, and articles that provided Level IV and V evidence.

Reviewers, AOTA staff, and the AOTA project methodology consultant first identified search terms, and the advisory group reviewed them. For the updated review, additional search terms were added to reflect changes in terminology that had taken place since the first review. Search terms for the reviews included activities, activities of daily living, bullying, friendship, health, leisure, out-of-school activities, play, promotion/wellness, recreation, resiliency, school mental health, stress, and transition. A medical research librarian with experience in completing systematic review searches conducted all updated searches. Reviewers searched MEDLINE, ERIC, EMBASE, Evidence-Based Medicine Reviews, and PsycINFO; OTseeker was included in the updated review.

The AOTA methodology consultant completed the initial review of the database search results. The updated review was completed in part through an academic partnership with the third author (Susan M. Nochajski) and master’s students in occupational therapy at the University at Buffalo, State University of New York, and in part by the AOTA consultant (Marian Arbesman). The team of reviewers also scanned the bibliographies of articles selected for review. After the literature search, reviewers then evaluated the quality of the studies and ranked them according to level of evidence.

The strength of the evidence is based on the guidelines of the U.S. Preventive Services Task Force (2012) . The designation of strong evidence includes consistent results from well-conducted studies, usually at least two randomized controlled trials (RCTs). A designation of moderate evidence is based on one RCT or two or more studies with lower levels of evidence. In addition, some inconsistency of findings across individual studies might preclude a classification of strong evidence. The designation of limited evidence may be based on few studies, flaws in the available studies, and some inconsistency in the findings across individual studies. A designation of mixed evidence may indicate that the findings were inconsistent across studies in a given category. A designation of insufficient evidence may indicate that the number and quality of studies are too limited to make any clear classification.

Only selected articles from the systematic review are mentioned in this article and included in the reference list. Table 1 summarizes the objective, design and participants, interventions and outcome measures, results, and limitations of six articles that helped answer the focused questions and were representative of the results of the systematic reviews.

Results

A total of 124 articles were included in the earlier and updated reviews. Although the reviews included published literature from both occupational therapy and other related fields, all studies provided evidence within the scope of occupational therapy practice. Seventy-seven of the articles (62%) were classified as Level I evidence, 27 (22%) were classified as Level II studies, and 20 (16%) were classified as Level III studies.

Tier 1: Evidence for Universal Programs

We identified three themes within Tier 1: social skills programming; health promotion programs; and play, leisure, and recreation activities. Within the social skills theme, strong evidence was provided by a Level I meta-analysis that whole-school and social–emotional learning programs improve social and emotional skills (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011). Strong evidence from a Level I meta-analysis (Wells, Barlow, & Stewart-Brown, 2003) indicates that programs adopting a whole-school approach, implemented continuously for more than a year and focused on the promotion of mental health as opposed to the prevention of mental illness, can be successful. A Level I meta-analysis (Durlak, Weissberg, & Pachan, 2010) provided strong evidence that children participating in after-school programs that incorporate a goal of either social skills or other personal skills can improve social behaviors and reduce problem behaviors. Strong evidence from another Level I meta-analysis (Kraag, Zeegers, Kok, Hosman, & Abu-Saad, 2006) showed that interventions with a problem-solving component can improve coping strategies.

The evidence is moderate that parent education improves child compliance (Wahler & Meginnis, 1997 —Level I RCT). Moderate evidence also indicates that parent education that is part of a multicomponent school program prevents aggressive behaviors in at-risk kindergarteners (Walker et al., 1998 —Level I RCT). A Level I systematic review (Ttofi & Farrington, 2009) provided strong evidence that school-based antibullying programs were effective in reducing bullying and victimization by approximately 20% compared with control programs. The authors reported that the most important components of the antibullying program were parent education, improved playground supervision, and classroom management.

The second theme within Tier 1 includes universal programs related to health promotion. Subthemes identified within health promotion were stress management, health literacy, education to prevent back injury, yoga, and childhood obesity programs. Strong evidence was provided by a Level I meta-analysis (Kraag et al., 2006) that school-based stress management and coping skills programs for children in Grades 3–8 can reduce stress and improve coping skills. A Level I RCT (Pinto-Foltz, Logsdon, & Myers, 2011) provided evidence that mental health literacy programs for adolescents can improve their knowledge of and attitudes about mental illness.

Moderate evidence from two Level I systematic reviews (Birdee et al., 2009; Galantino, Galbavy, & Quinn, 2008) indicates that yoga improves physical fitness and cardiorespiratory health. A Level II nonrandomized controlled trial (Berger, Silver, & Stein, 2009) provided limited evidence that inner-city elementary students participating in an after-school yoga program had fewer negative behaviors in response to stress than control participants. A Level I meta-analysis (Waters et al., 2011) provided strong evidence that childhood obesity programs affect body mass index, particularly for children aged 6–12 yr.

The third theme in Tier 1 was interventions related to play, recreation, and leisure. Subthemes were addressed in recreational programs focusing on individual interests of participants, structured arts programs primarily using drama, and recreational activity programs that stressed cooperation and team building. A Level I systematic review (Daykin et al., 2008) and one Level II nonrandomized controlled trial (Wright et al., 2006) provided moderate evidence that participation in performing arts activities improves social interaction and social skills. Limited evidence from 1 Level II nonrandomized controlled trial indicates that participation in performing arts programs can reduce emotional problems (Wright et al., 2006). A Level I RCT (McNeil, Wilson, Siever, Ronca, & Mah, 2009) provided moderate evidence that the use of recreation facilitators in after-school programs can increase participation in physical activity. Limited evidence from a Level II nonrandomized study (Jones & Offard, 1989) indicates that skill-based activity groups for children and adolescents can reduce involvement with the legal system but provided insufficient evidence that such groups improve behavioral outcomes. A Level I RCT (Kutnick & Brees, 1982) supplied moderate evidence that teaching cooperation skills in elementary-age children can increase cooperation and reduce competitive behavior. Moderate evidence from 1 Level I RCT (Ebbeck & Gibbons, 1998) indicates that team-building activities during physical education can improve self-concept.

Tier 2: Evidence for Targeted Interventions

Tier 2 targeted interventions included the same themes as Tier 1: social skills; health promotion; and play, leisure, and recreation. The populations studied included children and adolescents who were rejected by their peers, were at risk for behavioral problems or aggressive behaviors, had learning disabilities or attention deficit hyperactivity disorder (ADHD), had intellectual impairments or developmental delays, and were teenage mothers.

Strong evidence from 3 Level I RCTs indicates that social skills training for disliked or rejected children and adolescents improves social interaction, peer acceptance, and social standing (Bierman & Furman, 1984; Csapo, 1986; Morris, Messer, & Gross, 1995). Six studies provided strong evidence that social skills programming for at-risk, aggressive, or antisocial children and adolescents improves attention, peer interaction, and prosocial behaviors and reduces aggressive, delinquent, and antisocial behaviors (Conduct Problems Prevention Research Group, 2007 —Level I RCT; Dubow, Huesmann, & Eron, 1987 —Level II nonrandomized controlled trial; Kazdin, Bass, Siegel, & Thomas, 1989 —Level I RCT; Lochman & Wells, 2004 —Level I RCT; Ohl, Mitchell, Cassidy, & Fox, 2008 —Level II nonrandomized controlled trial; Waddell, Hua, Garland, Peters, & McEwan, 2007 —Level I systematic review).

Three studies provided strong evidence that social skills programming for children and adolescents with learning disabilities and ADHD improves communication and social and functional skills and reduces problem behaviors (Drysdale, Casey & Porter-Armstrong, 2008 —Level I RCT; Lamb, Bibby, & Wood, 1997 —Level III before-and-after study; Wiener & Harris, 1997 —Level I RCT). Four studies provided strong evidence that social and life skills programs for children with intellectual impairments and developmental delays improve life skills, conversation turn-taking, initiation of social interaction, self-management, and compliance and decrease problem behaviors and aggression (Carter & Hughes, 2005 —Level I systematic review; Kingsnorth, Healy, & Macarthur, 2007 —Level I systematic review; Shechtman, 2000 —Level I RCT; Wade, Carey, & Wolfe, 2006 —Level I RCT). Strong evidence from a Level I systematic review (Coren & Barlow, 2001) indicates that parenting programs for teenage mothers and their children result in improved mother–infant interaction; parental attitudes and knowledge; and maternal mealtime communication, self-confidence, and identity.

In the theme of health promotion, 3 studies examined the effects of yoga. Moderate evidence from a Level I RCT reported in a Level I systematic review (Birdee et al., 2009) showed that gastrointestinal symptoms were reduced in adolescents with irritable bowel syndrome after participation in a yoga program. Limited evidence (Benavides & Caballero, 2009 —Level III before-and-after study) indicates that yoga for youth at risk for Type 2 diabetes resulted in increased weight loss and improvements in self-esteem. A Level II nonrandomized controlled trial (Powell, Gilchrist, & Stapley, 2008) provided limited evidence that a program of yoga, massage, and relaxation for children with behavioral difficulties resulted in improvements in self-confidence and increased communication. A Level I RCT (Hernandez-Guzman, Gonzalez, & Lopez, 2002) provided moderate evidence that a guided imagery program with withdrawn or rejected first graders in Mexico resulted in increased socialization when imagery was combined with rehearsal of coping strategies.

Moderate evidence from a Level I RCT (Gebert et al., 1998) showed that a multicomponent training program for children and adolescents with asthma that included relaxation, social activities, and sports resulted in improved knowledge about asthma. A Level I RCT (McPherson, Glazebrook, Forster, James, & Smyth, 2006) provided limited evidence that taking part in an interactive computer game resulted in improved knowledge about asthma, increased internal locus of control, and fewer absences from school at 6 mo compared with a control condition. Moderate evidence from a Level I RCT (Christian & D’Auria, 2006) indicates that a life skills management program for children with cystic fibrosis can improve peer support and social competence and decrease loneliness.

The third theme for Tier 2 targeted interventions is play, leisure, and recreation. Three studies provided strong evidence that play groups for abused or neglected children can improve play skills, self-esteem, and positive feelings and reduce solitary play and behavior problems (Fantuzzo et al., 1996 —Level I RCT; Tyndall-Lynd, Landreth, & Giordano, 2001 —Level II nonrandomized controlled trial; Udwin, 1983 —Level I RCT). Strong evidence also indicates that play and music activities for children with intellectual and language impairments can improve social skills and attention to peers (Robertson & Ellis Weismer, 1997 —Level I RCT; Schery & O’Connor, 1992 —Level II nonrandomized controlled trial; Sussman, 2009 —Level II repeated measures with participants serving as their own controls). Strong evidence also indicates that participating in recreation, leisure, and physical education programs results in improved social interaction (Carter & Hughes, 2005 —Level I systematic review; Santomier & Kopczuk, 1981 —Level I RCT).

Tier 3: Evidence for Intensive Interventions

The focus of Tier 3 is on children and adolescents who require intensive mental health interventions. The evidence in this tier falls into two themes—interventions targeted to social skill development and those that focus on play, leisure, and recreation. The populations within this tier have diagnoses of mental illness, severe behavior disorders, and autism spectrum disorders (ASD).

Strong evidence from a Level I meta-analysis (Machalicek, O’Reilly, Beretvas, Sigafoos, & Lancioni, 2007) indicates that social skills interventions involving self-management strategies, changes in instructional content, and differential reinforcement can have a positive impact on social behavior, social competence, and self-management in children with ASD. Two meta-analyses provided mixed evidence (Lee, Simpson, & Shogren, 2007; Machalicek et al., 2007) that social skills training improves self-management in school-age children with ASD.

Other studies reported improvements in social behaviors using more specific interventions. Moderate evidence indicates that a friendship skill group can improve social and friendship skills in children with ASD (Laugeson, Frankel, Mogil, & Dillon, 2009 —Level I RCT). Limited evidence was found that video modeling or direct group instruction improved prosocial behaviors and social interaction (Kroeger, Schultz, & Newsom, 2007 —Level II nonrandomized controlled trial). Strong evidence shows that Lego^® social skills groups can improve social interaction and reduce social difficulties in elementary-age children with ASD (LeGoff, 2004 —Level II nonrandomized controlled trial; LeGoff & Sherman, 2006 —Level II nonrandomized controlled trial; Owens, Granader, Humphrey, & Baron-Cohen, 2008 —Level I RCT). Moderate evidence (Wood et al., 2009 —Level I RCT) indicates that cognitive–behavioral therapy (CBT) reduced parent-reported anxiety symptoms in children with autism, and limited evidence (Epp, 2008 —Level III pretest–posttest design) shows that CBT strategies used in combination with art activities and games improved assertive behaviors and reduced hyperactivity and problem behaviors. Moderate evidence indicates that a social communication intervention that included joint attention can result in improvements in language and adaptive behavior (Aldred, Green, & Adams, 2004 —Level I RCT).

Other studies explored social skills intervention for children and youth with diagnosed mental illness or serious behavior disorders, including schizophrenia, depression, anxiety, conduct disorders, and severe behavior or emotional disorders. Strong evidence indicates that social skills interventions can improve social behaviors for children with these clinical conditions. Baker, Lang, and O’Reilly (2009) found in a Level I systematic review that video modeling improved peer interaction and on-task behavior and reduced inappropriate behavior. Similar results were noted in a Level I meta-analysis by Cook and colleagues (2008), who reported that social skills training had a medium effect size for adolescents with serious behavior disorders, particularly for modeling, social–cognitive procedures, and operant procedures. Butler, Chapman, Forman, and Beck (2006 —Level I review) used meta-analytic techniques to evaluate the effectiveness of CBT and found large effect sizes when CBT was used for childhood depressive and anxiety disorders. Effect sizes for childhood somatic disorders were moderate.

The two populations studied within the theme of play, leisure, and recreation were children and adolescents with ASD and children with severe behavior disorders. The evidence is inconclusive that play activities for children with autism can increase play and cooperative behaviors (Schleien, Mustonen, & Rynders, 1995 —Level III before-and-after study; Schleien, Rynders, Mustonen, & Fox, 1990 —Level III before-and-after study). A Level I systematic review (Gold, Wigram, & Elefant, 2006) and a Level I RCT (Kim, Wigram, & Gold, 2008) provided strong evidence that music-related activities (singing, listening to music, playing an instrument) can improve nonverbal and verbal communication skills and reduce problem behaviors in children with autism. The evidence is insufficient that a program (Instrumentalism in Occupational Therapy) focused on identifying one’s life mission can improve participation in occupations by adolescents with emotional and behavioral difficulties (Ikiugu & Ciaravino, 2006 —Level III pretest–posttest mixed design).

Discussion and Implications for Practice, Education, and Research

The results of the systematic review provide a wealth of evidence supporting a strength-based approach for all children and youth, targeted services for at-risk groups and populations, and an individual client impairment–focused model of practice for children and youth with identified mental health challenges. The evidence also provides support for an occupation- and activity-based approach that can be used with children and youth at all three tiers in a wide range of environments (e.g., school, home, community) and contexts.

The results at the Tier 1 universal level provide occupational therapy practitioners with strong evidence to support providing occupation- and activity-based interventions in many areas, such as social–emotional learning programs and schoolwide programming to prevent bullying. Occupational therapy practitioners working in schools and after-school programs should consider incorporating a social skills component because the evidence is strong that activity-based social skills interventions improve social behaviors and reduce problem behaviors. In the area of health promotion, school-based stress management programs have been shown to reduce stress and improve coping skills in children in Grades 3–8 and should be incorporated into school and after-school programs.

At the universal level, occupational therapy practitioners can also play a role in improving participation in activities such as performing arts programs. A recent report by the National Endowment for the Arts (Catterall, Dumais, & Hampden-Thompson, 2012) indicated that children and adolescents from low socioeconomic backgrounds who participate in arts programming either at school or in extracurricular programs achieve better academic success in school.

At the targeted level, the evidence is strong that social and life skills programs are effective for a wide range of at-risk children and youth such as aggressive or rejected youth and teenage mothers. In addition, the evidence is strong that children with intellectual impairments, developmental delays, and learning disabilities benefit from social skills programming and play, leisure, and recreational activities. Occupational therapy practitioners are the ideal professionals to provide these types of programs because they have a wealth of knowledge about the challenges for these children and adolescents and about activity-based programming.

The evidence for the effectiveness of social skills programs is also strong for children requiring services at the intensive level. Occupation- and activity-based social skills programs are effective in helping children with ASD improve social behavior and self-management. In addition, social skills programs are effective in improving social behaviors for children and adolescents with a diagnosed mental illness or serious behavior disorder.

Findings from this systematic review cover many aspects of occupational therapy practice for children’s mental health and demonstrate scientific rigor. The review involved systematic methodologies and incorporated quality control measures. The review included 124 articles, and 84% described Level I and II evidence, indicating that the evidence is of very good to high quality. The articles included in the systematic review, however, have several overarching limitations: small sample sizes; wide variation in interventions, diagnoses, clinical conditions, and outcomes measured; and the use of self-report outcome measures. Depending on the level of evidence, some studies lacked randomization or a control group or provided limited statistical reporting. In addition, a wide range of diagnoses, clinical conditions, and types of interventions may have been included in the meta-analyses and systematic reviews incorporated in this review.

Occupational therapy academic programs have a long history of incorporating mental health practice into curricula. Occupational therapy practitioners are well prepared not only to identify mental health problems but also to understand how to assess and provide interventions to children and youth needing intensive services. The information provided in this systematic review, however, takes a broader approach in emphasizing mental health promotion and prevention interventions for children and youth without diagnosed mental illness. It is important for academic programs to prepare students through coursework and fieldwork experiences to apply a public health model of children’s mental health at the universal, targeted, and intensive levels in both school- and community-based settings. This systematic review shows that occupational therapy practice can expand into a public health model while using occupation- and activity-based approaches.

Although much of the evidence to date, as reported in this systematic review, was published by researchers outside the field of occupational therapy, it is critical for occupational therapy practitioners to use this evidence to support practice and future research in each tier. For example, when developing new programs focusing on social skills; play, leisure, and recreation; or health promotion, practitioners can use summaries of evidence to document the benefits of such programs. In addition, practitioners need to commit to generating evidence-based findings to support services provided at the universal, targeted, and intensive levels. At the universal level, practitioners can collaborate with teachers and administrators in assessing school climate or whole-class social–emotional learning after the implementation of whole-school programming. Collecting pre- and posttest scores on social skills measures when implementing small group intervention to targeted at-risk students is another way to obtain evidence to evaluate intervention outcomes. Finally, clear documentation of student outcomes after individualized services provides evidence regarding the effects of intervention for individual students. Occupational therapy practitioners also can agree to collaborate with colleagues and participate in any large-scale RCTs conducted at their setting.

The findings of this systematic review have the following implications for occupational therapy practice:

Strong evidence was found that Tier I occupation- and activity-based interventions in many areas, such as social–emotional learning programs, schoolwide programming to prevent bullying, and after-school programs, are effective in improving social skills.
The evidence is strong that social and life skills programs for Tier II are effective for a wide range of at-risk children and youth, such as those who are aggressive or rejected and teenage mothers.
Strong evidence indicates that children with intellectual impairments, developmental delays, and learning disabilities benefit from social skills programming and play, leisure, and recreational activities.
The effectiveness of occupation- and activity-based programs at Tier III to improve social behavior and self-management is supported for children with ASD and for children and adolescents with diagnosed mental illness or serious behavior disorders.

Acknowledgments

We thank Aarti Rego Pereira, Rachel Acquard Eising, Jessica Williams Hoffarth, Sara Zarinkelki, Kelly Todd, Diana Minardo, and Kyleen King, who were graduate students at the University at Buffalo, for their assistance in reviewing abstracts and articles for this review. We also thank Deborah Lieberman, Program Director, AOTA Evidence-Based Practice Project, for her guidance and support during the process of this review.

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