Systematic Review of Occupational Therapy and Mental

Health Promotion, Prevention, and Intervention

for Children and Youth
Marian Arbesman, Susan Bazyk, Susan M. Nochajski

MeSH TERMS
 activities of daily living
 adolescent health services
 child health services
 mental health services
 occupational therapy
 public health practice
 socialization

We describe the results of a systematic review of the literature on childrens 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 socialemotional 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.
Arbesman, M., Bazyk, S., & Nochajski, S. M. (2013). Systematic review of occupational therapy and mental health promotion,
prevention, and intervention for children and youth. American Journal of Occupational Therapy, 67, e120e130. http://
dx.doi.org/10.5014/ajot.2013.008359

Marian Arbesman, PhD, OTR/L, is Consultant,

Evidence-Based Practice Project, American Occupational
Therapy Association, Bethesda, MD; President,
ArbesIdeas, Inc., 19 Hopkins Road, Williamsville, NY
14221; and Adjunct Assistant Professor, Department of
Rehabilitation Science, University at Buffalo, State
University of New York; ma@ArbesIdeas.com
Susan Bazyk, PhD, OTR/L, FAOTA, is Professor,
Occupational Therapy Program, School of Health
Sciences, Cleveland State University, Cleveland, OH.
Susan M. Nochajski, PhD, OTR/L, is Director,
Professional and Graduate Studies, Department of
Rehabilitation Science, Occupational Therapy Program,
University at Buffalo, State University of New York.

he 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 childrens 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), childrens 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 childrens mental
health research strengthen the current knowledge of the efficacy of practices

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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 healththrough 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 childrens 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 enhancementthat 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

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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 20102012 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, nonpeer-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, outof-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 masters 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 metaanalysis that whole-school and socialemotional 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

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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 problemsolving 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., 1998Level 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 38 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 612 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, 1987Level
II nonrandomized controlled trial; Kazdin, Bass, Siegel, &
Thomas, 1989Level I RCT; Lochman & Wells, 2004
Level I RCT; Ohl, Mitchell, Cassidy, & Fox, 2008Level
II nonrandomized controlled trial; Waddell, Hua, Garland,
Peters, & McEwan, 2007Level I systematic review).
Three studies provided strong evidence that social
skills programming for children and adolescents with

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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, 1997Level III
before-and-after study; Wiener & Harris, 1997Level 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, 2005Level
I systematic review; Kingsnorth, Healy, & Macarthur,
2007Level I systematic review; Shechtman, 2000Level
I RCT; Wade, Carey, & Wolfe, 2006Level 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
motherinfant 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, 2009Level 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 (HernandezGuzman, 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 &
DAuria, 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., 1996Level I RCT; Tyndall-Lynd, Landreth, &
Giordano, 2001Level II nonrandomized controlled
trial; Udwin, 1983Level 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,
1997Level I RCT; Schery & OConnor, 1992Level
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, 2005Level I systematic review; Santomier &
Kopczuk, 1981Level 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 themesinterventions
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,
OReilly, 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, 2009Level I RCT). Limited evidence
was found that video modeling or direct group instruction
improved prosocial behaviors and social interaction (Kroeger,
Schultz, & Newsom, 2007Level 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,

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2004Level II nonrandomized controlled trial; LeGoff &

Sherman, 2006Level II nonrandomized controlled trial;
Owens, Granader, Humphrey, & Baron-Cohen, 2008
Level I RCT). Moderate evidence (Wood et al., 2009Level
I RCT) indicates that cognitivebehavioral therapy (CBT)
reduced parent-reported anxiety symptoms in children with
autism, and limited evidence (Epp, 2008Level 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, 2004Level 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
OReilly (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 (2006Level 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, 1995Level III
before-and-after study; Schleien, Rynders, Mustonen, &
Fox, 1990Level 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 ones life
mission can improve participation in occupations by

adolescents with emotional and behavioral difficulties (Ikiugu

& Ciaravino, 2006Level III pretestposttest 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 impairmentfocused
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 socialemotional 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 activitybased 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 38 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 atrisk 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.

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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 childrens
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 childrens mental health at the
universal, targeted, and intensive levels in both schooland 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 evidencebased 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
socialemotional 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 occupationand activity-based interventions in many areas, such
as socialemotional 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 selfmanagement is supported for children with ASD and
for children and adolescents with diagnosed mental
illness or serious behavior disorders. s

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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