**9. Recreation and sports**

face a demanding environment at school [183-185]. Presentation methods for educational materials must be modified to meet the challenges of students with autism, such as their ability to communicate, view and manipulate educational materials, and move about the school. Occupational therapists work closely with teachers to promote the highest level of function possible for a child with autism pursuing educational goals like fine and gross motor skills

Occupational therapists use screening, assessment, and clinical observation tools and strat‐ egies to analyse why child with autism is having functional and sensory difficulties in educational settings not to establish interventions in school settings. During their interventions occupational therapists use some of the standardized tests like Sensory Profile [189, 190], Bayley Scales of Infant Development-II [191], Peabody Developmental Motor Scale [192], Bruininks-Oseretsky Test of Motor Proficiency [193], and Pediatric Evaluation of Disability

If the standardized tests are not appropriate, occupational therapist can give descriptive reports without using standardized scales. It is important to compare the child's performance with the previous scores than the normative sample. Occupational therapists can use play based performance profiles like Hawaii Early Learning Profile or Transdisciplinary Play-Based Assessment [194]. Additionally ecological/environment inventories should be used to evaluate child with autism within a variety of educational environments (classroom, garden, sports area etc.), curricular expectations; tools/instruments to help gather relevant information; whether the team needs expansion to obtain needed information [195, 196]. And also to determine and work with the educational team to determine functional strengths and challenges and providing information to design instructional programs of the student with autism. Occupa‐ tional therapist should try to become familiar with the individual education plan [194-196].

Occupational therapists use direct or indirect services for students with autism in school settings. Occupational therapy interventions purposes are to help students with autism to gain independence in daily living activities, feeding and oral functions, play skills, task organization and completion, written communication skills, hand function, sensory integration (process‐ ing), visual perception, campus/school mobility, participating on a regular and timely basis, using tools and supplies, participating in activities throughout school settings. Also when skill and strength cannot be developed or improved, occupational therapy offers creative modifi‐ cations and adaptations for carrying out development-appropriate activities [195, 196].

In school practice, occupational therapists work with students, teachers, families, classes, schools, and school districts. Occupational therapists are experts at identifying ways to engage students with autism in educational activities and supporting them to develop competence in

and attention skills [185-188].

182 Autism Spectrum Disorder - Recent Advances

Inventory Test [82] in school setting [194].

**8.1. Assessment**

**8.2. Intervention**

their roles as students.

Recreation, a participation domain of the International Classification of Functioning Disability and Health (ICF), includes involvement in formal and informal activities such as play, sports, going to the theatre, crafts and tourism [197]. Leisure in occupational therapy is described as one of the occupational areas that cover recreational activities. *Leisure* is defined as "'A nonobligatory activity that is intrinsically motivating and engaged in during discretionary time, that is, time not committed to obligatory obligations such as work, self-care, or sleep'" [99]. Engagement in challenging and intrinsically motivating recreation and leisure activities is considered as an important part of development of children and young people [198]. These activities are reported to have positive impacts on physical and mental health, reduce behav‐ ioural and emotional disorders, facilitate becoming friends, widen interest areas of child and increase life satisfaction of family [199-202].

Besides being pleasant, recreational activities improve the life quality of individuals with autism, develop their social communication and acceptance, reduce inappropriate behaviours, improve fine and gross motor skills and helps in attainment of social skills [203]. Findings of studies on participation of children with autistic disorders in physical activities and sports activities show that sports and physical activities may create opportunities for social interac‐ tion, reduce repetitive movements and contribute in development of motor performance and physical suitability as well as self management skills [204-207].

Studies show that children with autism have more limited participation in recreational activities when compared with their peers with typical development or those in other disability groups [208-211]. Core impairments of autism spectrum disorders (i.e., communication impairments, social deficits, and abnormal restrictive, repetitive and stereotyped behaviours) and other features related with disorder (e.g. motor skills differences and maladaptive behaviour) affect recreational participation [212]. Another significant factor is sensory integration problems experiences by individuals with autism. It's reported that children with autism and sensory difficulties participate in recreational activities less and prefer more informal (not structured) and home activities [213]. Besides all these individual features, the impact of family and environmental factors are also described. The interplay is noted among the child's impairments, the family's style, preferences, and demands, as well as environmental or community-based limitations in restricting a given child's ability to participate in an array of recreational activities [199]. Studies show that participation of families in recreational activities positively affect child's participation [214]. Furthermore, it's observed that number of accessible services in society is parallel to participation in these activities [199]. Another factor is acceptance perceived from family, friends and neighbours. Families of children with developmental delay and behavioural problems may discontinues activities outside home as a response to negative reactions of people against the noise and temper tantrums of child [215]. As a conclusion, holistic perspective is important.

Individuals with autism are in need of programs structured and organized with proper support to reveal their recreational interests and to improve their leisure skills [203]. Therefore interdisciplinary teamwork is an important issue. Considering multifaceted factors that affect participation in recreational activities, strong cooperation of families and professionals are required in the planning and implementation of intervention [208]. Occupational therapists are important both with their expertise in occupational participation and their knowledge on sensory integration interventions for participation of individuals with autism in recreational activities. Occupational therapists point out exploration and participation in leisure activities, which are one of the occupational areas. Leisure exploration refers to identifying interests, skills, opportunities, and appropriate leisure activities. Leisure participation is planning and participating in appropriate leisure activities; maintaining a balance of leisure activities with other areas of occupation; and obtaining, using, and maintaining equipment and supplies as appropriate [65].

#### **9.1. Assessment**

Occupational therapy assessment with an occupation-based, family-centred and top-down approach starts with an interview with the family and self-report. Family's perspective on interests and skills of child, life style, economical status, their access to social and community resources should be recorded. Ideally, leisure assessments should be made in the natural settings of the child whenever possible. Interview and observation made in this setting are important to assess physical, social, cultural, attitudinal or organizational environment factors which affect leisure participation of the child and to evaluate child's performance skills. It is important for the therapist to observe motor, process and social interaction skills and attitudes of the child against others during activities with peers [185].

Paediatric Activity Cart Shorting (PACS), Children's Assessment of Participation and Enjoy‐ ment (CAPE), Canadian Occupational Performance Measure (COPM) are some of the exam‐ ples of standardized methods that can be used in the assessment of recreational interests and skills of the child [85, 216, 217]. It is important to assess the sensory integration skills of the child and impact of these skills on activities, to define strategies to meet the needs of the child and to create sensory friendly settings. Therefore Sensory Profile (SP) is a standardized scale used in defining sensory difficulties of child [29].

#### **9.2. Intervention**

Occupational therapists give trainings to families, friends and teachers on how to facilitate participation of individual besides teaching the most needed skills for participation of children in selected leisure activity. Additionally they give training on use of adaptive equipment required for activities and make environmental modifications.Participation of children with deficits in activities together with their peers without deficits is important for both groups. Some of the study results show that peer support programs are useful for both groups. Structuring recreational activities where children with autism can be together with children with typical development can be an effective for proper modeling and social integration of children with autism and for the positive attitude changes in others [218, 219].

One of the most important highlight of recreation and leisure activities is that they are "intrinsically motivated". Neurobiological studies show that limbic system which orchestrates motivation and drive in brain is not adequately developed in individuals with autism. According to sensory integration theory by Ayres, purposeful sensory-based activities may increase natural inner drive. Therefore, carefully selected sensory-based activities may help finding activity meaningful and purposeful and sustaining participation [220, 221].

Virtual Reality (VR) technology is an important tool to widen leisure activity spectrum of intellectual and developmental disability population. Easy changeability of virtual environ‐ ments, adaptation and scaling of difficulty of task according to the skills of the individual can be considered as advantages of VR [222]. Furthermore, it increases motivation and leads to positive impacts on the participation of individuals. In the intervention, its integration to home routine as a recreational activity is considered to be useful.
