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A. is an eight-year-old boy who attends a special school for children with social, emotional and behavioural difficulties. He has a diagnosis of autism.

Case study on Anxiety

B. is a fourteen year old girl and attends an autism unit within a mainstream school. She is very anxious and can be negative about her achievements and talents.

Case study on Class/Homework

C. is a twelve year old boy who is at secondary school. He is doing well at school but finds homework stressful.

Case study on Concentration & Attention

D. is a six year old boy who attends a mainstream primary school. He has a diagnosis of autism and attention deficit hyperactivity disorder (ADHD).

Case study on Emotional Regulation

E. is a ten year old boy who attends a social communication class within a mainstream school.

Case study on Group Work

G. is a ten year old boy with autism, he has recently moved to a special school setting. He previously attended a mainstream school and spent a lot of his time in an individual classroom due to behavioural difficulties.

Case study on Teenage Years

I. is 15 years old. He has a diagnosis of autism and attends a mainstream post primary school. He enjoys Art, ICT and Mathematics and has been provided with a classroom assistant for 20 hours per week.

Case study on Time Management

J. is an 18 year old student at Post Primary.

Case study on Transitions

K. is six years old and attends a special school. He has difficulties with transitions which cause him stress.

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A Case Study of Autism: Paul, 3 Years Old

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Arun was brought for consultation with Dr. A M Reddy by his parents. He was about 4 years old, the second child to the parents. Even while he was being brought into the room, we could hear his loud wailing. It took some time for the child to calm down and later we could observe that the child was very restless. He was running around the room, pulling down cushions and generally creating chaos in the room and mother was quite harried in trying to control him. He was diagnosed with ASD (Autism Spectrum Disorder).

What is ASD?

Autism or Mutinism as it was earlier known was thought primarily to affect communication skills but with more studies, it was understood that autistic children display a wide range of symptoms, hence the word “spectrum” was added to Autism disorder. Autism is a complex neurodevelopmental disorder which affects a person’s social behavior and communication skills.

Why it occurs?

The exact reason why ASD occurs is not known but many risk factors have been identified like age of the parents, poor ovulation, infections or exposures to harmful chemicals or radiation during pregnancy, thyroid, diabetes type of hormonal disorders, birth injuries, infections in childhood, vaccinations, etc.

What are its symptoms?

As its name suggests, ASD displays a myriad of symptoms but some of the common symptoms of ASD is lack of speech. While some children have no speech, in some children speech that was developed before may regress. Many of them do not prefer to mingle with children of their age group. Repetitive action, physical restlessness, inability to understand emotions, mood swings like sudden bouts of excitement, crying without any reason, are few symptoms displayed by many autistic children.

Aggressive behaviors like self-harming, head-banging, tantrum-throwing, biting/pushing others, destructiveness, can be displayed by few. Response to name call, having sustained eye contact, unable to understand commands, stereotypical actions and stimming are some of the common symptoms exhibited by many.

Coming back to the case of Arun, a detailed case history was noted down by our doctors, a summary of which is given below.

He is the second child and the age difference between both the siblings is seven years. After the first child was born, the mother developed hypothyroidism for which she was on thyroxine 50 mcg daily tablets. No history of abortions or contraceptive use was reported. Father was apparently healthy. The age of the parents was 35 and 38 years respectively during conception. She conceived naturally and pregnancy was apparently uneventful. But on deeper probing few differences were found out between both the pregnancies.

While during the first pregnancy the parents were in India, but during second there were in the United States. She was advised to continue with the same dosage of thyroxine and during 6-7 months of the pregnancy, she was given flu and T Dap vaccine. The child was born of emergency C – section as the water broke early. The birth cry was normal and seemingly the child was progressing well but after his first birthday, the child had a bout of severe gastrointestinal infection when they visited India where he was hospitalized for three days and given medicines.

Parents were worried that he seems to put everything in his mouth and his favorite items were paper, cloth, wall plaster. His demands have to be met, else he used to become very upset. Emotional connectivity towards parents was less. He would not follow simple commands and it was becoming increasingly difficult for the parents to manage him. With therapies, his eye contact improved a little and was able to follow a few simple commands but the progress was slow.

He was a picky eater and liked crunchy foods. His bowels were constipated and he was not yet toilet trained. He was given Cuprum Sulph 10 M and was kept on regular follow up.

On the next visit to Dr. A M Reddy Autism Center , the parents complained that their child developed itching on the skin but his restlessness reduced slightly. The medication was continued for about three months during which the child’s anger reduced by 30%, his eye contact improved and he was no longer constipated. His itching too reduced in the meanwhile. A second dose was repeated and about six to seven months of treatment, he started saying few words, tantrum-throwing reduced and his habit of putting everything in the mouth was gone.

The dose was repeated in 50M potency. After about a year and half of treatment, he started interactive communication, giving relevant answers to questions and was doing much better. On the advice of Dr. A M Reddy, they placed him in normal school and he is doing well.

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Original research article, “i just want to stay out there all day”: a case study of two special educators and five autistic children learning outside at school.

• 1 Department of Education and Wellness, Elon University, Elon, NC, United States
• 2 Department of Psychology, University of Cambridge, Cambridge, United Kingdom

School is often stressful for autistic students. Similarly, special educators are susceptible to burnout because of the unique demands of their jobs. There is ample evidence that spending time outside, particularly in nature, has many positive effects on mental, emotional, and physical wellbeing. In this case study of two special educators and five autistic students in a social skills group at an elementary school in the southeastern United States, we sought to identify the effects of moving the class outside several times per week. Findings indicated that while there were challenges, the autistic children experienced numerous affordances that supported development toward achieving Individualized Education Plan goals. Moreover, there were also notable positive effects for the special educators. We found that even with little prior experience, learning outside is possible and beneficial to everyone involved.

Introduction

The first time Jacob, an autistic 1 elementary student with selective mutism, ventured into an outdoor environment at his rural school, he spoke to his friend while they were in the midst of an activity. His special education teachers were shocked. They told us they had never heard him verbalize anything due to selective mutism, an anxiety disorder that inhibits individuals from speaking in certain social situations despite an ability to speak in more familiar or comfortable settings ( American Psychiatric Association, 2013 ). As the year progressed and Jacob went outside more often with his social skills class, he spoke spontaneously with greater frequency, sometimes asking questions and interacting with his peers. Toward the end of the year, Jacob approached a brick wall near the outdoor learning environment that the class was using that day. He noticed a spider spinning a web on the wall. “Look at this!” he called to his friends. Several other children in the group gathered around, and they discussed what the spider was doing and why it was there. Jacob was an active participant in the conversation, engaged and curious.

Since Jacob was a participant in our case study, we were able to observe the ways that he and his autistic peers interacted with their teachers, with each other, and with the environment. Autism is a neurodevelopmental condition that consists of several typical behaviors or traits. These include repetitive, stereotyped behaviors and difficulties or impairments with social interaction and communication ( World Health Organization, 1992 ; American Psychiatric Association, 2013 ). As it is a spectrum, the needs, abilities, and outcomes of autistic individuals varies greatly. There is limited research on how nature might affect autistic children, especially at school, but there are many anecdotal accounts, which is what inspired our investigation. Higashida (2007) , an autistic Japanese teenager who communicates through a letterboard and computer, shared that nature has the ability to alter his emotions: “Just by looking at nature, I feel as if I’m being swallowed up into it … Nature calms me down when I’m furious and laughs with me when I’m happy” (p. 124). Gordon (2013) wrote about a non-speaking autistic four-year-old child spelling his name for the first time ever while outside using sticks as props. The teacher in Gordon’s article believes that spending time outdoors every day helps children with additional needs accomplish tasks previously believed to be beyond their capabilities. Brewer (2016) highlighted two schools in England that offered opportunities for students with additional education needs to spend time outdoors. According to a teacher at one of the schools, being outside is calming and stress-relieving, especially for autistic students. James (2018) , a British forest school leader, felt so strongly regarding the benefits he saw from taking autistic people into nature that he authored Forest School and Autism: A Practical Guide to encourage others to follow suit. James wrote that there is a lack of research available supporting the use of outdoor spaces with autistic people despite the wealth of anecdotal accounts, including those he details in his book.

Evidence continues to mount that spending time in nature is good for everyone (e.g., Chawla, 2015 ; Williams, 2017 ). While there are numerous studies that demonstrate benefits for typically developing children and adults (e.g., Wells and Evans, 2003 ; Fjørtoft, 2004 ; Swarbrick et al., 2004 ; Morita et al., 2007 ; Berman et al., 2008 ; Abraham et al., 2010 ; Berman et al., 2012 ; Kuo et al., 2018a ), there is limited research on the effects of nature for those with autism. Moreover, using outdoor environments as an accommodation to support autistic students at school is understudied. Therefore, in this case study of two special educators and five autistic students in a social skills group, we addressed the following research questions: What are the challenges and affordances of outdoor learning for autistic children? What are the special educators’ perspectives on outdoor learning with autistic children?

Literature Review

There is growing interest in the use of outdoor environments to benefit children. For instance, the North American Association for Environmental Education (2017) reported that there were 250 nature-based preschools and kindergartens in the United States, a notable increase. Learning outside can serve various educational purposes. The Institute for Outdoor Learning (n.d.) emphasizes “discovery, experimentation, learning about and connecting to the natural world, and engaging in environmental and adventure activities,” which can happen through multi-day trips, residential experiences, and adventure sports. Relatedly, nature-based learning (NBL) is “an educational approach that uses the natural environment as the context for learning” ( Chawla, 2018 , p. xxvii). Forest School (FS) is one example of NBL. The Forest School Association, 2011 , a professional body in the United Kingdom, provides six principles to guide and support FS practitioners. For example, FS takes place in an immersive wooded or natural environment, and learning is child-led. Recent research suggests that FS may facilitate feelings of affinity or ownership over natural spaces, thus encouraging pro-environmental behaviors ( Harris, 2021 ). NBL can, in practice, look many different ways. Access to an immersive wooded or natural environment is not necessary, however. Outdoor learning can occur in urban areas where children explore sidewalks, subways, stores, and parks (e.g., Whitlock, 2020 ).

The effects of engaging with nature are diverse. There are benefits to mental health, including lower stress levels ( Wells and Evans, 2003 ; Morita et al., 2007 ), improved social and emotional wellbeing ( Abraham et al., 2010 ; Berman et al., 2012 ), and feelings of belonging and sense of self ( Swarbrick et al., 2004 ; Cummings and Nash, 2015 ). Interpersonal skills seem to be positively impacted ( Dillon et al., 2005 ), including increased expressions of sympathy toward others and the environment ( Barthel et al., 2018 ). Even nearby nature has notable implications for cognition, intelligence, and development in both educational and residential contexts. Wells (2000) found that, in a study of low-income families with children aged 7–12 years old, moving from a “low naturalness” area to a “high naturalness” area had significant effects for child cognitive function. Similarly, Wells and Evans (2003) , using a four-item naturalness scale, reported that nearby nature may be a buffer for stressful life events for children with a mean age of 9.2 years in rural residential contexts. In a study of adults in Australia, Astell-Burt and Feng (2019) reported that higher amounts of tree canopy (30%) as well as total green space were associated with lower psychological distress and better general health. Bijnens et al. (2020) found that residential green space could have positive impacts on intelligence for children ranging in age from 7 to 15 years old in urban settings.

The benefits of nature for educational purposes have also been documented. Dadvand et al. (2015) , in their study of over 2,500 7 to 10-year-olds in Barcelona, suggested the possibility of improvements in cognitive development associated with surrounding greenness, particularly greenness of schools. Kuo et al., 2018b studied grass and tree cover in a sample of over 318 public schools in Chicago in relation to achievement on state-level assessments. Tree cover was related to academic achievement, particularly for math, while grass cover was not related. Thus, the presence of green spaces in and around schools seems to offer benefits to children. Additionally, Kuo et al., 2018a concluded that classroom engagement from 9 to 10-year-old children increased following lessons that took place in nature, suggesting the potential for what the authors refer to as “refueling in flight” for student focus. This reinforces Kuo et al.'s (2019) sentiment that “it is time to take nature seriously as a resource for learning and development” (p. 6). Considering the existing research, could the same be true for engaging autistic students with nature?

The accommodations and supports each autistic individual requires, if any, are highly variable. A large number of interventions exist to address supposed impairments in autistic populations; these include commonly known interventions such as Applied Behavior Analysis ( Baer et al., 1968 ), TEACHH (Treatment and Education of Autistic and Communications - Handicapped Children; Mesibov et al., 2005 ), and intensive interaction ( Nind and Hewett, 1988 ). The type of intervention or support that an autistic school-age child will receive is dependent on the specifications of that individual's Individualized Education Plan (IEP); the IEP, when used correctly, serves as a roadmap of interventions and supports to attain specific, measurable goals ( Blackwell and Rossetti, 2014 ). Difficulties with social interactions, for example, may prompt the use of an intervention like a social skills group. Group social skills training involves the teaching and practice of social skills among peers. This is the context of our case study. The worthwhileness of such an intervention for targeting the social skills of autistic children remains unclear, with some evidence of effectiveness ( Hotton and Coles, 2016 ) and other authors concluding that the intervention has little impact ( Bellini et al., 2007 ); despite this, the teaching and practicing of social skills in a group setting remains a common practice in special education ( DeRosier et al., 2011 ).

School experiences can be difficult for autistic children, leading to increased mental health issues and additional support needs. Due to the differences or difficulties in social communication common in autistic people, interactions with peers can be complex and challenging, causing stress and anxiety. Autistic children are also more likely to be bullied at school because of their behavioral differences ( Rowley et al., 2012 ). In fact, autistic children and teenagers are more likely to experience bullying and victimization than typically developing peers and peers with intellectual disability. Additionally, autistic children may experience gaps in academic achievement as well due to social impairments and other difficulties not related to intellect or ability ( Estes et al., 2011 ). It is not surprising, then, that mental health issues are more prevalent among the autistic population than the general population, with some researchers reporting estimates of 20% of the autistic population experience co-occurring anxiety disorders ( Lai et al., 2019 ). Confounded with the usual difficulties of childhood and adolescence, school can be a tumultuous time for autistic students.

One potential avenue of support for autistic individuals that is underutilized and understudied is the use of outdoor environments. While there is extensive research showing that time spent in nature offers benefits for wellbeing, particularly mental health, and even cognition and intelligence in typically developing populations or those with attention deficit hyperactivity disorder (ADHD), there is far less research on what nature might offer autistic people, especially children. According to Blakesley et al. (2013) , gardening projects, summer camps, field visits, and animal therapy have shown to have positive effects for autistic children; however, more research on the potential of outdoor learning for autistic children at school is needed.

The research that does exist is promising. Bradley and Male (2017) interviewed four autistic children, ages 6–8 years old, who participated in FS as well as their parents. Despite the small sample size, several benefits were identified from the interviews; these included friends/friendship development, challenges and risk taking, learning outcomes, and experiencing success. Zachor et al. (2016) utilized quantitative methods to study the impact of an outdoor adventure program on the autistic symptomatology of 51 autistic children between the ages of 3–7 years, with findings indicating a reduction of symptomatology after participation in the outdoor group when compared to a control group. Additionally, Li et al. (2019) interviewed caregivers of autistic children in China, who ranged in age from 4 to 17 years old, and “identified multiple sensory-motor, emotional, and social benefits of nature for children with autism” (p. 78). The findings from these three studies demonstrate that learning outdoors may need to be considered an accommodation and intervention for autistic children. Further evidence, especially in a school context, would bolster the research base and potentially lead to nature-based accommodations for autistic children.

Theoretical Framework

This study is framed by the theory of stress recovery put forward by Ulrich et al. (1991) . Stress recovery theory (SRT) suggests that following a bout of stress, individuals who are exposed to natural settings are able to reduce that stress more quickly than those who were not exposed to natural settings, demonstrated even at a parasympathetic level. The authors noted that the idea of stress recovery occurring in natural settings is not a new one; it has been documented throughout history, including in evolutionary theories. Stress reduction has also been observed in a study using nature sounds rather than visual natural scenes ( Alvarsson et al., 2010 ). Decades of research show that natural settings contribute to decreased stress and associated mental health issues ( Wells and Evans, 2003 ; Morita et al., 2007 ; Abraham et al., 2010 ; Berman et al., 2012 ).

SRT has also been applied in a sample of 18 11-year-olds, some of whom were considered to have “bad” behavior. Roe and Aspinall (2011) measured mood and reflection on personal development before and after a typical indoor lesson and a FS session. The authors reported that greater positive behavioral change occurred after time in the forest environment, suggesting that the restorative potential of nature may have been at play. Additionally, SRT underpinned work conducted by Shao et al. (2020) in which 26 elementary-aged children performed first an electronic gardening task followed by a real-life horticultural activity. Various physiological measurements (e.g., heart rate variability and skin conductance) indicated that the children experienced positive impacts from the real-life horticultural activity, including a decrease in sympathetic nervous activity. Thus, SRT has been applied to work with a range of ages, including younger children.

As previously noted, autistic individuals have a more difficult school experience. Additionally, the levels of mental health issues among the autistic population is much higher than that of typically developing peers ( Lai et al., 2019 ). It is likely that those challenging and sometimes traumatic school experiences are among several factors contributing to increased mental health issues among school-age autistic children. Due to its significant and continued impact upon wellbeing and various outcomes, the school experience and associated mental health issues should be of focus for teachers, caregivers, counselors, interventionists, and other practitioners who engage with this population. Stress recovery offered by educational activities occurring in nature could be beneficial, then, by mitigating the stressful experiences of attending school or interacting socially with others.

Research Methods

As a case study, this is a preliminary investigation of a phenomenon over which we had little control ( Yin, 2017 ). According to Miles et al. (2019) , a case is “a phenomenon of some sort occurring in a bounded context” (p. 44). Thus, our case is a social skills group consisting of two special educators and five autistic students who used both indoor and outdoor environments at an elementary school in the southeastern United States. Furthermore, this is an exploratory case study given that it was not intended to test a particular hypothesis ( Yin, 2017 ). As noted by Hancock and Algozzine (2011) , exploratory case studies serve as a prelude for more expansive investigations that might seek to confirm a hypothesis or work with a concept in a more in-depth manner. Given the small sample size, our findings are not generalizable.

The case study was carried out at a public K-5 elementary school with approximately 600 students, an estimated 47% of whom are eligible for free or reduced price lunch. The school, which we will call Belington Elementary (pseudonym), has a special education department consisting of two teachers, both of whom participated in this study. They provide both push-in and pull-out support for students with IEPs, and they also co-facilitated a 30-min social skills group with five autistic students every day.

The purpose of this social skills group was to offer guidance and practice for communicating and interacting with peers through a variety of lessons. Sometimes the teachers provided direct instruction regarding specific concepts. For example, the teachers might read a book in which one of the characters demonstrates emotion regulation, or they might facilitate a matching activity that required students to align particular situations, as stated by the teacher, to the coordinating emotions that the individual in the fictional situation was likely feeling. Sometimes the teachers prompted the students to engage with each other through games and free play. For example, the teachers invited the students to build well-known international monuments using materials found outside in small groups, which required cooperation and collaboration. Social skills interventions are commonly used for autistic children, particularly those in mainstream environments, as they teach the social interaction behaviors that would be considered “typical” in society. The behaviors may include maintaining eye contact, reducing atypical speech patterns, and expressing interest in what other conversation partners are saying ( White et al., 2010 ). Social skills training programs have been reported to be effective in targeting perceived “deficits” or differences in social interaction (e.g., Kamps et al., 1992 ; Webb et al., 2004 ; Cappadocia and Weiss, 2011 ).

There were four outdoor environments generally used by the teachers for this case study (see Figure 1 ). First was a small pavilion situated very close to the school building. Next to the pavilion was a small garden, but it was overgrown and not actively used by anyone at the school. The second area was referred to as “the outdoor classroom” and was located in a more open area next to the school. The outdoor classroom consisted of several picnic tables under a large covering. Both the pavilion and the outdoor classroom were located just outside the door from the special education classroom, which both teachers shared. The third area was the playground, blacktop, and field located at the back of the school. Finally, there was a nature trail that led to a small clearing in a wooded area. There were wooden benches that formed a circle in the clearing. Accessing the nature trail required a slightly longer walk out of the building, across the parking lot, and over a small patch of grass. For the purposes of our research, we considered the pavilion, outdoor classroom, and playground/blacktop/field areas to be sites for outdoor learning; activities that took place in the nature trail and clearing in the wooded area were considered NBL due to the more immersive setting.

FIGURE 1 . Belington elementary campus. A = Indoor Classroom, B = Outdoor Classroom, C = Pavilion, D = Playground and Blacktop Area, E = Nature Trail, F = Forest Classroom

Participants

Participants included two special educators and five autistic students. The teachers, Mrs. Barrett and Ms. Smith (pseudonyms), were both in the early stages of their careers in special education. While Ms. Smith graduated from university two years prior, Mrs. Barrett worked for over 10 years in several other education and childcare contexts before seeking a special education qualification. Both teachers had minimal experience taking autistic children outside the classroom and no formal training or experience with outdoor learning. The social skills group was composed of five students from 2nd, 3rd, and 4th grades. All of them identified as male and white, had autism diagnoses, and spoke English as their first language. Basic descriptive information regarding the participants can be found in Table 1 .

TABLE 1 . Participant information.

Data Collection

A total of 31 visits were carried out, with 26 observations taking place outside and 5 taking place indoors. One visit was completed at the end of January while 7–8 visits were completed per month from February to May. Visits were typically on Mondays and Wednesdays, though seven of the visits were on other days of the week due to events at the elementary school, which meant the class was unable to meet, or to observe the children indoors. The 30-minute social skills classes met in the afternoon each day during the last lesson block of the day. At the start of the study, the teachers agreed among themselves that they would take the children outside on Mondays and Wednesdays. This plan sometimes changed due to weather or a change in lesson plans. Thus, the decision regarding which days to go outside was predetermined, but the teachers had the autonomy to make adjustments day-to-day. We did not observe the students during other subjects.

Field notes were handwritten when at the school and later typed on a shared document. We elaborated on the field notes on the shared document, which resulted in longer narratives. We also tracked the frequency of certain behaviors exhibited by three of the students (Curtis, Jacob, and Tracy; pseudonyms) in our field notes. The target behaviors were related to the IEP goals for each student; the purpose of focusing on IEP goals was to observe if an outdoor environment facilitated any progress or development in regards to those particular goals. Behavior frequency was noted throughout the entire class period, with tally marks indicating the presence of the target behavior. Further details denoting the content of the behaviors were recorded as well. For example, if Curtis asked a question, we would write down what he asked. The decision to track behaviors for only three of the five students was made due to the other two children’s IEP goals. That is, their goals were generally conversation-related but difficult to track using frequencies. Thus, we focused on tracking behaviors of three students with goals that could be more easily quantified.

Finally, we conducted semi-structured interviews with both teachers at the beginning, middle, and end of the data collection period. Interviews lasted 30–45 min and were carried out in person at the school. The first two interviews were with each teacher separately (i.e., two interviews for each) and the final interview was with both teachers together in an effort to provide a space for reflection and discussion between them. In the first interview, questions focused on their previous experiences working with children (both indoors and outdoors), their own relationship with nature, their feelings about incorporating outdoor learning, and their initial impressions or observations of their first few sessions outdoors. The second interview included questions regarding outdoor lesson planning inspiration, how the teachers felt the group was managing with outdoor lessons, how they themselves were impacted by taking their lessons outside, any difficulties they encountered, and how they were beginning to use outdoor learning with their other groups throughout the day. The final interview focused on reflections from both teachers regarding the challenges they faced throughout the experience and what they felt they did to be successful in outdoor environments. All interviews were audio recorded and transcribed.

Data Analysis

We followed Miles et al.'s (2019) guidance regarding qualitative data analysis. To start, we conducted two phases of coding on the interviews and field notes. Coding served to categorize like pieces of data. The first cycle of coding utilized several of the many types of coding, including descriptive, in vivo , and emotions coding. The purpose of the first cycle of coding was to summarize two of the available data sources. The second cycle of coding served to identify patterns in those codes. Codes were then grouped together into categories or themes.

Next, we completed a round of jottings. Jottings documented our thinking as we analyzed the data. These brief notes were written directly into the interview and field note documents to ensure continuity between the data that prompted the thought and the thought itself. Following the use of jottings, analytic memoing then served to “synthesize (descriptive summaries of data) into higher level analytic meanings” ( Miles et al., 2019 , p. 97). Beyond just noting thoughts about the data, analytic memos extend and connect various data with theory and researcher perception.

To formalize and organize our thoughts and findings, we produced assertions and propositions based on all sources of data. According to Miles et al. (2019) , assertions are declarative statements while propositions are conditional statements that serve to predict. These statements allowed us to look at the findings comprehensively and better determine the entire picture of what occurred throughout the study, based upon the available data. To summarize and conclude the process, we carried out a within-case analysis to describe what occurred within the single case of focus in our study.

Limitations

Case studies, particularly those that are exploratory and utilizing within-case analysis, are not generalizable as they focus in depth on one particular case to better understand some aspect of that case. More time observing the participants and conducting the study over a longer period of time would have given us a more robust set of data. Finally, the special educators in this case study were not experts in outdoor learning and had very limited experience taking students outside. Therefore, the challenges and affordances we found may be unique to this context.

When Mrs. Barrett and Ms. Smith agreed to participate in this case study, we had to rely on their willingness, creativity, and resilience to regularly use outdoor environments with their social skills group. Our first research question pertained to the effects of being outside on autistic students, but the second research question about special educators’ perceptions of outdoor learning was perhaps more significant. Mrs. Barrett and Ms. Smith decided what days they would go outside, where on the school campus they might go, what concepts and topics to integrate into their lessons, whether they were adequately meeting IEP goals, and how to respond to autistic students’ needs during transitions and disruptions to their routines. They were the conduits for the entire case study. If for any reason they were not comfortable using outdoor environments, we would not have been able to observe their students.

Neither of the special educators had significant prior experience or training with NBL. During our first interview, Ms. Smith said that she had not used the outdoor environments at her school very often, “just taking them out a few times last year.” She continued, “I would take them out to the outdoor classroom... sometimes on a nice sunny day” but confessed she did not have “a lot of experience incorporating, like, outdoor instruction or environmental education.” When we asked what inspired her to use the outdoor environments a few times, she said,

I thought that was really cool, and I kind of wanted to explore them too, um, just 'cause I knew we had a trail. I knew we had the outdoor classroom there for a reason, and I enjoyed it outside, especially like when the weather was nicer, and I figured it was a fun break for my students, too.

Even without much prior experience or training, both Ms. Smith and Mrs. Barrett found going outside to be appealing enough to participate in this study, and their comfort levels increased the more they used the outdoor environments. Mrs. Barrett noted during her second interview, “We were kind of hesitant before (about) going outside,” but then quickly followed with, “Now that we (are more) experienced... it's just like, calmer. It's peaceful. I just want to stay out there all day.” Both special educators found that outdoor environments offered more than just a fun break for students.

Before we began observing the social skills group, Ms. Smith and Mrs. Barrett shared with us the general IEP goals for their five autistic students. In an email, they highlighted the specific skills they would be working on during the study:

• Engaging in appropriate conversation with others (listening to others, asking relevant questions, using a “social filter”)

• Using “appropriate verbalizations” to express feelings and needs rather than shutting down or using aggressive/physical behaviors

• Identifying others’ perspectives and feelings

• Identifying the problem in a social situation and creating a solution to meet both party’s needs (problem-solving skills)

• Completing non-preferred tasks

• Asking for a break when frustrated

• Demonstrating verbal control in different social situations

They also stressed that there was not a set curriculum that they were required to follow, which allowed them the flexibility of creating their own lessons in ways that would meet their students’ needs and IEP goals. In fact, they were used to developing their own curriculum. “Last year we didn’t have any type of curriculum (provided),” they wrote in the email, “so we pulled from a lot of online resources.” From the beginning, Mrs. Barrett and Ms. Smith were both cautiously optimistic about regularly using outdoor environments with their autistic students. Their lack of experience and training was not insurmountable. Rather, they displayed a growth mindset throughout the study. This was especially apparent in the lessons they developed.

The first outdoor lesson we observed took place in the blacktop area just outside of their classroom (location D on Figure 1 ). The main objective was to support students’ identification of emotion states, so Ms. Smith wrote “happy,” “sad,” “angry,” and “afraid” on four distinct spaces on the blacktop in chalk. The students were then tasked with drawing pictures or writing words with chalk that they associated with the emotion words. The spaces for drawing were approximately five feet away from each other; the children worked in pairs, rotating to the various spaces as the lesson progressed. Throughout the lesson, students were observed laughing and smiling. Some children found nearby rocks on the ground and threw them toward the field while they were taking breaks from drawing. At the end of the activity, everyone sat on the ground in a circle to summarize what they learned. The students were largely engaged in the activity, though some noted that sitting on the hard ground hurt their hand or that the cracks in the asphalt got in the way of their drawing. Despite the colder weather on this day, the only comments about feeling cold came from adults present.

During the second outdoor lesson we observed, the children were noticeably different in their expressions of emotion and interactions with one another compared to their behavior at the start of the class indoors. When observation began at the start of class, before the group had moved outside, the children were being kept on the carpet because the teachers felt they were not following instructions to be quiet and still. Once outside, the activity, which involved running to various parts of the playground to select an emotion word that described the scenario being read aloud (e.g., happy, sad, angry), prompted smiles, laughter, happy screaming, and talking among the students. This was true for Jacob as well, which caused Ms. Smith to comment that she’d never before seen Jacob speak to peers unprompted during an activity.

Several days later, they took a book about emotion regulation outside to the picnic tables to read as a group. While Ms. Smith read aloud, many of the students moved their bodies, tapping on the tables and alternating between standing and sitting. At one point during the lesson, Jacob was moving around rocks and items he found on the ground. Ms. Smith asked a question specifically addressed to him in what appeared to be an attempt to re-engage him in the story. During the following outdoor lesson, the group reviewed the book. Then, to enhance their understanding of the book, Mrs. Barrett and Ms. Smith showed the students a container of bubbles, pulled out the plastic wand, and blew a few into the air. The bubbles were meant to indicate feelings of anger that eventually build up until they pop. The students provided answers to the question, “What makes you angry?” and then were to chase a bubble and “pop” it. Jacob and Tracy in particular seemed to enjoy the opportunity to run after and pop bubbles, as they laughed and smiled throughout this portion of the activity. Mark seemed eager to help Ms. Smith with blowing the bubbles.

During the next outdoor lesson, the concept was advanced further through the use of a liter bottle of soda. The lesson began with a discussion of what they learned about being angry or frustrated from the bubble popping activity. During this review, Tracy and Jacob were moving around, displaying stimming behaviors, and standing up. The teachers shook the bottle to indicate the process of getting angry. The bottle was then opened, and some of its contents spilled out, much to the delight of the children. This prompted a conversation about what strategies could have been used to prevent the spill. The students suggested taking a break while shaking the bottle to allow the fizzing to calm down, which they demonstrated with another bottle of soda. They waited a few minutes after shaking the bottle, and the students discussed whether this was a long enough break to prevent another explosion. During this portion of the lesson, Tracy was corrected by the teachers for not paying attention. This was then related to strategies that they could use to defuse anger. These strategies were demonstrated through the use of skits; the students were put into two groups and tasked with acting out a situation where someone was upset and had to employ a strategy to diffuse their anger. The children largely participated in the skits, though Tracy commented that he was cold and spent some time zipping and unzipping his jacket. Additionally, Jacob was not taking part in this activity, as he was slightly away from the group, touching one of the gazebo’s columns. This was not acknowledged by the teacher.

Continuing with the theme of emotion regulation, another activity on a particularly warm and sunny day included four hula hoops with colors coordinating to the Zones of Regulation, an emotional control system created by Leah Kuypers. The four colors help to categorize different emotions, with blue indicating low alertness, green indicating calm states, yellow indicating elevated emotions, and red indicating extremely elevated emotions. One of the teachers read a scenario, and the children responded by moving to the hula hoop that corresponded to the regulation zone they felt was represented by the scenario. For instance, one scenario was, “Tommy was walking to his table in the cafeteria when he dropped his tray of food. All of his food went on the ground. What zone do you think Tommy was in when this happened?” At first, all of the children moved together, seeming to make the same decisions. Eventually, students broke off and made their own choices about what zone matched best. Throughout the activity, Alex appeared to be dancing as he participated. When students did choose a hula hoop that no one else went to, the teachers asked them to justify their choice, prompting a discussion. For instance, toward the end of the activity, Jacob broke off from the group and went to a different hoop than his peers. The teachers then asked him to explain why he made that choice.

After several months of incorporating outdoor environments into their instruction, the teachers planned a series of lessons to develop teamwork skills. During an indoor class lesson, the students began to work on a small group project. The groups were tasked with building well-known structures out of Legos (e.g., Statue of Liberty, Sphinx, Great Wall of China). The next day, the class took their Lego projects outside to work at the outdoor classroom under the pavilion. Several classes later, the teachers told the students that they would be repeating the same process of building famous structures in small groups; this time, though, the students would be utilizing whatever natural materials they could find outside. Over the course of several outdoor lessons, the students, in their groups, brainstormed what types of materials they would need, where they could get those materials outside, and how they would build the structures. One day was spent on the nature trail collecting materials in a bucket to take back inside. Then, several lessons, both indoor and outdoor, were spent creating their structures. The outdoor lessons to prepare for making a famous structure out of natural materials were interspersed with indoor lessons teaching, reviewing, and discussing what teamwork looks like. That is, concepts were taught inside that were then immediately incorporated into outdoor activities, creating an indoor-outdoor transfer of skills and knowledge.

The aforementioned are only a small sample of the lessons planned and executed by Ms. Smith and Mrs. Barrett for their social skills group with autistic students. Table 2 presents details about all of the lessons that were observed during the study.

TABLE 2 . Descriptions of lessons.

Our analysis of the data revealed the challenges experienced by the special educators and their students, the adaptations the teachers made in response to the challenges, and the affordances for everyone in the case study.

Not surprisingly, taking autistic children into new learning environments has its challenges. To begin, there were several reasons why the teachers, who taught at a school with several well-developed outdoor spaces, had never utilized these locations before. The main barrier was timing; the teachers had only 30 min with their social skills group and were hesitant to use some of that limited time to travel to and from the outdoor environments. Once the teachers tried taking their group out, they realized that “it didn’t take as long to get out there as I thought it would.” Importantly, they used that transition time effectively, as we explain below, incorporating it into their lesson so that travel time was not “wasted” time.

Once the group started going outside more regularly, the teachers found that an additional barrier was the weather; more specifically, a lack of appropriate clothing and footwear for adverse weather conditions sometimes stopped the class from going outside. On one day, the teachers changed the plans to go outside “because it was raining and cold, and we didn't want anybody getting sick.” Another day, the class decided to stay inside because one of the students had new shoes on and didn’t want to get them muddy on the nature trail.

Over the course of the study, the teachers also came to realize that not all of the outdoor spaces available to them were equal. That is, the class had several options, including a pavilion close to the school that had a view of the front parking lot, where buses and parents would line up at the end of the school day; the playground, blacktop, and field behind the school that had a view of a road; and the nature trail and outdoor classroom that was secluded from any views of the road or the school. Ms. Smith quickly found that “they’re able to focus more when we're in areas further away from the road.” Both teachers agreed that the students were less “distracted” when they were in the nature trail and forest classroom, leading them to prefer taking the students there.

It seems that this preference was shared by the students as well; during one lesson, Ms. Smith told the students they would be going to the pavilion, and several students groaned and expressed that they felt that space was boring because “it’s just land.” When outside at the pavilion or on the field that had views of the road, there were several instances of children becoming noticeably “distracted” when large trucks passed by, often commenting on what they saw. Additionally, several of the children experienced anxiety related to knowing what time it was and having sufficient time to prepare for going home. Thus, when the class was at the outdoor pavilion and the students could see parents and buses arriving for pickup, this anxiety increased and became disruptive to the lesson.

Despite the clear barriers that existed, the teachers persisted in incorporating outdoor learning into their social skills class. This persistence necessitated a willingness by the teachers to adapt accordingly.

Adaptations

On a larger scale, both teachers underwent a transition in their approach to teaching this particular social skills group. As mentioned previously, neither teacher had experience taking children, particularly autistic children, outside for educational purposes. Throughout the study, both became more confident and comfortable with taking autistic children, and children with other additional needs, into outdoor environments. They became so comfortable, in fact, that they began taking children from their other groups, including reading and math support groups, outside. This was not an expectation of the study; rather, the teachers noticed the effects on themselves and their students and were compelled to try it on their own.

In a more literal sense, the importance of transitions to the success of the group’s outdoor lessons was quickly apparent. An initial apprehension existed with both teachers regarding the amount of time that would be spent walking to the outdoor environments in use for that lesson. Because of this, the teachers often opted for closer locations when going outside, such as the playground, grass field behind the school, or pavilion that was right next to the building; the students often complained when they were told this was their destination for the day, however. Additionally, there were downsides to these more easily accessible outdoor environments such as proximity to roads and parking lots and the presence of other classes. This challenged the teachers to find a way to access a more secluded outdoor location and deliver a meaningful lesson within the 30-minute time frame of the class session.

To do this, Ms. Smith found that transition time could be effectively harnessed so that the five-minute walk to the more secluded outdoor environment on the nature trail became a feasible option for the class. During several sessions, Ms. Smith used the time spent walking back into the building to have individual “check-outs” with the students. Describing her thought process for doing this, Ms. Smith said, “That’s why I was like, let’s just do individual check-outs as we walk back instead, where I just talk to them one-on-one, because they’re not listening to each other as a group … I just checked in with a couple as we walked to ask them, ‘Hey, do you think you met your goal today, and how did you do that?’ I talked to at least three or four of them.” On trips from the building out to the nature trail, the teachers sometimes explained rules, procedures, and expectations for the day, told the class what the planned activity was, or asked individual students what emotion regulation zone they felt they were in at that time. On other days, transition time was used to play “I Spy” to encourage students to pay attention to their surroundings. With their newfound realization of the impact that effective transitions can have, both teachers felt that “trying to plan for those transitions” during lesson planning was particularly crucial to increasing the chances for success.

While we offered the teachers support with brainstorming ideas and developing lesson plans, they did not ask for this help and were insistent on using their own ideas. To start, the teachers often opted to take the lessons they would use indoors and simply move them to an outdoor environment. For instance, they did this several times with read-aloud books and post-reading discussions. Early in the study, Ms. Smith mentioned that she was “very comfortable taking indoor activities outside. But I don’t necessarily feel like I’m great at using what’s outside for the lesson.” After observing this, we found that lessons could be categorized in four ways: indoor lessons delivered inside, indoor lessons that are simply moved into an outdoor setting, indoor lessons that are adapted to utilize some element of the outdoor setting, and lessons designed for use only outdoors.

An added difficulty was the topic that this particular group needed to cover: social skills. Ms. Smith found this more difficult as “social skills was something like, I don't know if I was, if I would say I was necessarily, like, really taught how to teach necessarily.” In an effort to utilize the outdoors for social skills lessons more effectively, the teachers found that it was easiest to search for one of those elements -- outdoor learning or social skills -- and then adapt the idea they’ve found to include the other element. Thus, they avoided the frustration of trying to find ideas for “social skills lessons outdoors,” which may not readily exist online.

To source ideas for their outdoor lessons, the teachers utilized online searches and platforms like Pinterest as well as asking their colleagues for input, and they had success with these methods. Lesson planning required a learning curve, though, as Ms. Smith noted that she had to realize that “it’s okay to, like, go back to something that's worked because it's familiar and it's good … good for them, too. Because I think some, at the beginning, I was just feeling pressured to like come up with something new every time, too.” Additionally, the teachers had to remember that going outside meant they were able to utilize an entirely new set of materials. Ms. Smith found that her “normal frame of mind is worksheets. Videos … maybe a game inside. But now, it's like I need to think about a different space, different materials and what not.” With this, Ms. Smith demonstrated how she adapted her approach to lesson planning during the study.

Adaptations were evident throughout the five months of the study. For instance, the teachers learned that their class responded best when new concepts were introduced indoors and follow-up activities were conducted outside, rather than trying to teach new concepts in the outdoor environment. The teachers believed that this was the case because “when you’re outside, you don’t want to just be sitting and listening. They’re ready to move and be active.” Allowing for movement and physical activity -- taking advantage of having more space outdoors -- was another key to success for the class as the teachers focused on “trying to incorporate more movement, so we've done a lot of games.” Additionally, understanding that lessons don’t have to be complicated to be impactful meant that outdoor lessons felt more approachable for the teachers. Ms. Smith stated that “coming up with your own ideas is a little bit easier now. Like, just thinking of the spaces that we have and … just it's easier to think about. I was like, ‘Well, we can take a walk outside,’ like even just something as simple as taking a walk outside to see all the different places.”

The teachers also expressed that flexibility, both in carrying out lesson plans and in expectations, was key when taking their autistic students outside. For instance, on one day that was intended to be an indoor lesson, the class took a vote to decide where they would prefer to work; four of the students voted to work outside, so the class moved locations and simply took the indoor lesson into the outdoor classroom. This happened quite frequently, as Ms. Smith noted that the class was spending more time outside than what was required from the study because “the kids have been asking to.” During another lesson, Mrs. Barrett realized that she had forgotten one of the key materials, a small whiteboard, inside. She adapted the lesson to account for this, having the children act out the scenarios she was going to draw instead, resulting in a successful lesson.

While the class certainly discussed and adhered to rules and procedures for being outside in order to keep all of the students as safe as possible, the expectations that students were held to evolved as the class spent more time outside. Certain behaviors were discouraged in any setting, such as interrupting teachers or classmates by speaking out of turn. Others, however, were allowed in the outdoor space as the teachers noticed that they adapted their own attitudes toward what constituted acceptable behavior while outdoors. Mrs. Barrett admitted that, when taking the class outside, she was “more flexible with [them]... I don’t expect them to sit still.” She also shared that while she still expected students to listen to her as she teaches, those specific listening behaviors that she is looking out for are also different outside, noting that “I can tell. I can say, ‘Okay. So who … ’ And they say it right back. I know they're listening.” Additionally, observations of the class and teachers indoors showed that sitting still and showing body language that was indicative of focus on the teacher were expectations; children who deviated from these expectations were given reminders of “proper” behavior. When outdoors, however, bodily movement became more accepted, with Mrs. Bartlett sharing, “One chose to sit on the boardwalk and the other three sat on the bench. Well, one started off on the bench and he went off, under the bench. Like, okay. Whatever. As long as you're listening, I'm good.”

Despite the adaptations that the teachers made toward more accepting and flexible behavioral expectations when outside, styles of instruction that would align more closely with NBL or FS, the lessons remained fairly “traditional” in that they were teacher-centered and lesson-centered. Each lesson focused on a particular skill that was addressed; these skills aligned with expectations of what a social skills group should cover and included, during the time of the study, constructs such as emotion regulation, teamwork, problem solving, and conversational turn-taking. A further shift toward an embrace of NBL or FS would result in lessons being more child-centered, child-led, and inquiry-based. These adaptations were not observed during the study.

Affordances

During our observations, we tracked the frequency of certain behaviors exhibited by three of the students, Jacob, Tracy, and Curtis; the target behaviors were selected based upon the students’ IEP goals. Jacob’s goal involved “being able to communicate basic wants and needs and … asking and answering questions.” Tracy’s IEP goal was to utilize self-regulation skills to identify and remove himself from situations that made him over-stimulated, and Curtis’ goal was to ask questions to elicit more information, rather than staying silent, which can then lead to frustration. We wanted to see if being outside might help these students meet the goals in their IEPs.

In tracking Curtis’ goal, we found that his question asking increased more indoors compared to outdoors. Those indoor questions, however, pertained to going outside. For instance, during one session, Curtis asked about a specific material that was being brought outside and if he could help carry it. In another, he asked if he could wear his sunglasses outside. While outdoors, Curtis noticed a helicopter leaf on the ground. After he asked what it was, Ms. Smith helped him to pick it up and throw it in the air to watch how it floated to the ground. The number of times Curtis asked questions certainly increased overall, and it appeared that his interest or enjoyment in going outside prompted those questions.

During the study, Tracy did not utilize any self-regulation techniques. We did not observe him reach a point of being over-stimulated during any of the outdoor or indoor sessions that we observed. This suggests that, despite some fears from the teachers, the outdoor environments did not overwhelm or worsen any feelings for Tracy. To the contrary, we noticed that Tracy enjoyed being outside and looked forward to learning in the outdoor environments. In fact, several situations occurred while outdoors that reasonably could have led to conflict or feeling overwhelmed but did not. For instance, during the lesson where the class read a book about diffusing anger, one of his peers seemed to become annoyed with Tracy’s movements (stomping on the ground) and yelled, “Stop!” In response, Tracy stopped what he was doing and further conflict was avoided. In several other instances, Tracy was directed to pay attention or stop a certain behavior; in each case, Tracy effectively followed the teacher or peer’s directions and re-engaged with the activity. This was in contrast to the indoor lessons, where his behavior was observed to be more chaotic and unsettled. During one indoor lesson, Tracy interrupted the lesson by whispering, “Tornado!” unprompted. He then pretended to play the drums on his legs and moved his body and mouth throughout the rest of instruction. In another indoor lesson that required the students to sit on the carpet and watch a video, Tracy repeatedly spoke aloud during the video.

Perhaps most strikingly, Jacob’s goal of increasing his utterances as well as his responses to questions was clearly and certainly addressed while outside. Jacob spoke and responded to prompts more frequently while outside compared to inside; it also seemed that teachers and peers prompted Jacob to speak more frequently while outside as well. Reflecting on this, Ms. Smith said, “[Jacob] speaks up more. He speaks up more to his classmates, I would say, outside. Like, I think, ‘cause … he feels like there’s more space between him and the teacher … but he does initiate more conversation to his peers outside than he does inside.” Mrs. Barrett attributed this to the outdoor environment, noting, “[Ms. Smith] told me that he talked, had a conversation with another student in front of her, and he asked a question, point blank, to her … Very unusual. That’s where we see him, like, even after school, when they're outside playing, that's when we see him really interacting, is outside. That's when he … That’s his forte, I guess.” This was evident from the first outdoor lesson, when Ms. Smith noted that Jacob was speaking to his peers as she’d never observed before, through to one of the last sessions that we observed when Jacob and his peers found a spider on its web. When asked if he preferred the classroom or being outdoors, Jacob replied, “Outdoors.”

Separate from the frequency tracking of specific IEP goals, the group also experienced additional affordances from spending time outside. Ms. Smith observed “a higher energy level outside, just in more of an eagerness to participate because it's almost like it’s a surprise, what we're gonna, like, what are we gonna do now? And the kids really do look forward to it every time they come in.” The unpredictability of the use of outdoor environments excited and interested the students.

Both teachers repeatedly mentioned that all of their students were more focused while outside and exhibited clearer signs of listening during activities. Additionally, several students who were more prone to shouting out or interrupting other speakers inside were noticeably calmer and shouted out far less while outside. This was particularly true for Mark; according to Ms. Smith, “(Mark) doesn't call out as much outside. He listens more. I don't know why, but he does. I don't know if it's the environment or he knows we're doing something new so he has to pay attention more.” One of Mark’s daily behavioral goals was to reduce instances of blurting out in class; thus, these observations were particularly significant to the teachers.

Finally, the students seemed to benefit from the fresh air, the ability to more freely move around, and the ability to fidget or move when necessary while still listening without disrupting their peers’ learning. Additionally, while instances of the students struggling with behavior outside were very infrequent, Mrs. Barrett did note that the class “did have one incident out there where (a student) shut down, but after the … incident, like, he refused to move. So, we just calmly had everyone come back in because it was at the end. I let him sit there … He got up. Because usually before in the classroom, he would throw chairs, desks, things.” Thus, students potentially had more space to safely work through the process of regulating their emotions when outside. Most importantly, perhaps, in assuaging any fears that teachers may have about taking their autistic students into a new environment is Ms. Smith’s view that “no one’s (behavior has) gotten worse outside.”

The students were not the only participants who experienced clear positive effects from spending time outside. Both teachers repeatedly noted ways that they benefited from the experience as well. The teachers felt that the outdoor environments required them to be more creative in lesson planning. While this may have been challenging at times, they also noted that it made them “more thoughtful about the space we use and how we use it.” Additionally, the teachers seemed to harness the feelings of being challenged by their mission to use the outdoor environments in a productive way, sharing that while it was sometimes intimidating, they found the experience exciting as well. The other main impact that the teachers experienced was increasing feelings of peacefulness and calm while taking the students outside. Ms. Smith said that she doesn’t “feel quite as drained after being outside. I think it’s more refreshing because it's a break from the usual.

Nature can serve as an accommodation to support autistic students in meeting IEP goals, particularly due to the positive impact time outside has on stress reduction ( Ulrich et al., 1991 ). Our observations suggest that the outdoor environments did not hinder progress in meeting IEP goals and, in some cases, may have facilitated opportunities to work toward those goals due to lower stress levels.

Jacob, for instance, did not speak unprompted in the social skills class for the first half of the year when the class was inside, likely due to selective mutism. Selective mutism is reported as being connected to stressful life experiences, including those occurring at school ( Muris and Ollendick, 2015 ), though some autistic individuals with selective mutism are reported as not speaking due to a lack of interest in the social context rather than shyness or anxiety ( Steffenburg et al., 2018 ). It is possible that this was a factor for Jacob as well. During the first trip outside and in many subsequent sessions, Jacob participated verbally. There could be a number of reasons that Jacob felt more able to speak while outside; these include having physical distance from the teachers, feeling more relaxed and enjoying class more, or the different style of activities used in some instances outside (e.g., incorporating more physical movement). Additionally, the stress reduction that occurs in nature might have allowed Jacob to feel comfortable enough to speak. Whatever the reason, it was evident from tracking Jacob’s utterances, both prompted and unprompted, that being outside led to an increase in utterances, moving him closer to that specific IEP goal.

In the case of Tracy, the outdoor environments did not cause him to feel overstimulated to the point of having difficulty regulating his feelings or behavior. While we are not able to conclude whether this was from being in an outdoor space or if another alternative education space that was indoors would have had a similar effect on him, it is possible that the stress reduction from being outdoors minimized feelings of overstimulation. Regardless, the impact of the outdoor environments on Tracy was not a negative one. Both Jacob and Tracy’s suspected experiences of lower stress levels outdoors are supported by prior research (e.g., Wells and Evans, 2003 ; Chawla, 2015 ).

Finally, the outdoors seemed to provide a topic of conversation for Curtis, as he asked several questions regarding the details of his class going outside. In the case of all three students, being outside did not hinder their progress toward addressing their IEP goals; rather, our data suggest that outdoor environments moved them closer to reaching those goals. Given the well documented negative effects that poorly designed indoor classrooms can have on autistic children ( McAllister and Maguire, 2012 ), accessing an educational space that does not have those same detrimental impacts could have additional beneficial effects and should be considered as a relatively accessible support or accommodation. Despite the aforementioned benefits, it is important to avoid romanticizing the positive impacts of time outdoors for autistic children. It is unreasonable to expect that all people, including all autistic children, will enjoy being outdoors all of the time or respond positively; in some cases, time in or near nature may increase anxiety ( Larson et al., 2018 ).

While this began as a study focused on how outdoor environments might affect autistic students, the picture that emerged following five months of data collection placed the teachers’ experiences front and center as well. The two special educators demonstrated a growth mindset; they began the study with no outdoor learning experience, confronted the barriers that they came across throughout the process, and appreciated the benefits that outdoor learning offered to themselves and their students. This growth mindset was likely supported by the impacts to teachers that we did not expect. There are many legitimate reasons why teachers may be hesitant to take their students outside; these include time constraints, safety concerns, lack of confidence, or rigidity in developing lessons to adhere to standards ( Rickinson et al., 2004 ; Dyment, 2005 ). Several of these barriers were factors for the teachers in the study, particularly the lack of confidence and feelings of having insufficient time. Despite the presence of these challenges, Ms. Smith and Mrs. Barrett persisted and continued to take their students outside. Thus began what seemed to be a feedback loop: the more the teachers took their students outside, the more the students looked forward and expected to go outside. Furthermore, as the teachers gained more experience taking their social skills group outside, their confidence increased to the point that, unprompted, they began taking their other classes outside as well.

Additionally, teachers are undoubtedly under a tremendous amount of stress, which can lead to burnout and negative impacts to wellbeing ( Richards et al., 2018 ). While we initially expected Ulrich et al.'s (1991) SRT to be a factor influencing how autistic students responded in the outdoor environment due to reported stressful school experiences, it is possible that the teachers equally benefited from stress reduction while outside, evidenced by continued mention of feelings of calm, enjoying the peace of the outdoors, and feeling less drained. It would seem that in the midst of a chaotic school day, spending time outside offered a reprieve for the teachers that outweighed the difficulties of identifying and planning lessons to execute outside. Feelings of lowered stress and increased relaxation are among the most commonly noted positive effects of exposure to nature for adults ( Maller et al., 2006 ; Morita et al., 2007 ; Cole and Hall, 2010 ).

In particular, Mrs. Barrett seemed to undergo a stark transformation. When approached about the research, we received a more reluctant acceptance from Mrs. Barrett; it seemed that Ms. Smith naturally took the lead, likely due to a higher comfort level with the topic or more motivation to tackle the opportunity. Whatever the reason, it is due to this initial hesitance that Mrs. Barrett’s experience taking her students outside is more striking. When interviewing her at the end of the study, she reported having opted to take her other special education classes outdoors as well, citing the positive feelings that she got from the experience as a driving factor. She made at least three references to feeling peaceful and calm while outdoors in her second interview. Mrs. Barrett also seemed to evolve in her expectations of her students while outside, mentioning that as long as she knew her students were listening, she did not mind them moving around or choosing to stand or lay down while she taught outside. This contrasted with her teaching style inside, which was far more structured and emphasized traditional listening cues such as sitting upright, being quiet, and maintaining eye contact.

Future Research

Despite our initial focus on the development of the students, the teachers in our study, Ms. Smith and Mrs. Barrett, became crucially important to the overall case. The evolution and impacts that they experienced suggest that future research should explore the wellbeing effects for teachers who take their students outside as well as the implications this may have for job satisfaction, teacher retention, and reducing burnout.

In our observations of a social skills class consisting of five autistic students and their two special education teachers who incorporated outdoor learning into their day for five months, we saw a range of affordances available to teachers and students alike and ample evidence of their enjoying these affordances. Harnessing such benefits in an educational context requires teachers who are willing and capable of supporting students in engaging with the outdoors. Ms. Smith and Mrs. Barrett, neither of whom had any previous experience or training with taking autistic children outside to learn, were able to adapt their existing knowledge and skills to support their students in learning in the new environment. Additionally, there was no evidence of students experiencing negative outcomes or feeling worse while outside. Coupled with the progress that students such as Jacob showed during the outdoor lessons, this suggests that nature should be considered as an option to meet the needs of autistic children during the school day. This case study serves to demonstrate that, even for teachers with no prior experience taking children into nature, outdoor learning is possible and beneficial to everyone involved.

Data Availability Statement

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

Ethics Statement

The studies involving human participants were reviewed and approved by Elon University Institutional Review Board. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.

Author Contributions

SF and SM contributed to conception, design, and recruitment for the study. SF collected data. Both SF and SM contributed to analysis. SF wrote the first draft of the manuscript, and both SF and SM revised and approved the manuscript.

Conflict of Interest

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

Acknowledgments

The authors would like to thank Jessica Wery and Maddie Craft for their assistance on this study.

1 Following Kenny et al.’s (2016) study of preferred terminology in the autism community, we are using identity-first language throughout.

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Keywords: outdoor learning, nature-based learning, special education, case study, autism

Citation: Friedman S and Morrison SA (2021) “I just want to stay out there all day”: A Case Study of Two Special Educators and Five Autistic Children Learning Outside at School. Front. Educ. 6:668991. doi: 10.3389/feduc.2021.668991

Received: 17 February 2021; Accepted: 30 April 2021; Published: 20 May 2021.

Reviewed by:

Copyright © 2021 Friedman and Morrison. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Samantha Friedman, [email protected]

Case Studies

Case study 1.

• Special school

Child’s name & age: AB, 12

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

Case study 2

• Mainstream primary

Child’s name & age: CD, 5

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

Case study 3

• Mainstream post-primary

Child’s name & age: EF, 13

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

Case study 4

Child’s name & age: GH, 9

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

Case study 5

Child’s name & age: IJ, 16

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

Case study 6

Child’s name & age: KL, 13

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

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The Full Report and Practitioner Guide presents eight principles of good autism practice. These summarise the ethos, values and practice that should inform inclusive education for all children and young people whilst specifying the distinctive knowledge, teaching approaches required. Eight principles are identified which are linked to the new Ofsted Framework, the SEND Code of Practice and the Teacher Standards. The Guide is designed to support staff in Early Years settings, Schools and Post-16 provision to develop effective practice. The case studies serve to illustrate the eight principles.

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Autism Spectrum Disorder in a Child Case Study

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Medical History and Background Information

Developmental domains, works cited.

M. is a seven years old boy diagnosed with autism spectrum disorder at the age of two. He lives in Orlando, Florida with his mother and father and two other younger siblings. Patient’s physical development is within the norm; he is 43’’in tall and weighs 60 lbs. M. was born prematurely at 36 weeks through an uncomplicated vaginal delivery. Around the age of two, his parents became increasingly concerned about his lack of response to other people (Masi et al. 186).

Moreover, M. was not eager to maintain eye contact with anyone nor he shifted his gaze towards objects shown to him (Masi et al. 186). M. started primary at the age of seven and has been receiving special early childhood education. Other than ASD, M. does not suffer from any diseases or disorders safe for occasional seasonal colds and flu.

Generally, cognitive skills in children with autism vary greatly on the case to case basis (Soorya et al. 211). M. was medically recognized as a high-functioning individual on the autism spectrum; he is verbal even though he has certain struggles with language use and acquisition. At school, his education success depends on the level of engagement with the subject matter. So far, M. has discovered his inclination to numbers and simple calculations and showed the ability to retain information in his field of interest.

Communication

M.’s parents made sure that their son was involved in normal situations and never felt excluded because he was different (Gargiulo and Kilgo 160). Studies show that familial love and support help children with ASD handle their symptoms better (Woodman et al. 122). At the moment, M. is more verbal with his parents and siblings and reacts adequately to them, especially in repeated day-to-day situations. However, when put in an unfamiliar setting, M. tends to shut down and become unresponsive.

Social-emotional

Children with autism might express emotions differently as compared to their neurotypical peers (Kret and Ploeger 160). M. is handling his feelings relatively well, especially in social situations. However, his parents report cases of him having meltdowns with tears more characteristic of younger kids. The most challenging event in the social-emotional developmental domain was M.’s enrollment to primary education. When confronted with new situations, patient used to have fight-or-flight response – he became aggressive or escaped the setting altogether. As of now, parents state that his emotional health has improved.

Physical and Adaptive Development

M.’s physical development was assessed as normal – he has appropriate height and weight for his age. However, patient displays slight delays in coordination and fine motoric skills, for instance, when it comes to writing or drawing. For all the challenges, the prognosis is rather positive: the parents report improvements due to his adaptation to the school setting. In class, M. recognizes his peers, responds when talked to, and initiates contact on rare occasions. Moreover, he is less emotional about changes in daily routines even though it still takes time for him to process such information.

Gargiulo, Richard, and Jennifer L. Kilgo. An Introduction to Young Children with Special Needs: Birth through Age Eight . Nelson Education, 2010.

Kret, Mariska E., and Annemie Ploeger. “Emotion Processing Deficits: A Liability Spectrum Providing Insight into Comorbidity of Mental Disorders.” Neuroscience & Biobehavioral Reviews, vol. 52, 2015, pp. 153-171.

Masi, Anne, et al. “An Overview of Autism Spectrum Disorder, Heterogeneity and Treatment Options.” Neuroscience Bulletin, vol. 33, no. 2, 2017, pp. 183-193.

Soorya, Latha V., et al. “Randomized Comparative Trial of a Social Cognitive Skills Group for Children with Autism Spectrum Disorder.” Journal of the American Academy of Child & Adolescent Psychiatry, vol. 54, no. 3, 2015, pp. 208-216.

Woodman, Ashley C., et al. “Change in Autism Symptoms and Maladaptive Behaviors in Adolescence and Adulthood: The Role of Positive Family Processes.” Journal of Autism and Developmental Disorders , vol. 45, no. 1, 2015, pp. 111-126.

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IvyPanda. (2021, June 9). Autism Spectrum Disorder in a Child. https://ivypanda.com/essays/a-child-with-autism-spectrum-disorder-case-study/

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Effectiveness of interventions for children and adolescents with autism spectrum disorder in high-income vs. lower middle-income countries: An overview of systematic reviews and research papers from LMIC

Maleka pervin.

1 Institute of Psychology, Georg August University of Goettingen, Göttingen, Germany

2 Department of Psychology, University of Dhaka, Dhaka, Bangladesh

Helal Uddin Ahmed

3 Department of Child Adolescent and Family Psychiatry, National Institute of Mental Health, Dhaka, Bangladesh

York Hagmayer

Associated data.

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

There is a multitude of systematic reviews of interventions for children and adolescents with autism spectrum disorder (ASD). However, most reviews seem to be based on research conducted in High-Income Countries (HIC). Thus, summary findings may not directly apply to Lower Middle-Income Countries (LMIC). Therefore, we conducted a Meta-Review analyzing systematic reviews on the effectiveness of interventions for target outcomes in children and adolescents with ASD to find out whether there are differences in effectiveness between HIC and LMIC and which interventions can be considered evidence-based in LMIC.

Electronic databases (PsycINFO, PubMed, Cochrane database of systematic reviews) were searched for reviews on interventions for ASD in children and adolescents from January 2011 through December 2021, which included studies not coming from HIC. Systematic reviews with qualitative and quantitative syntheses of findings were included. Two investigators independently assessed studies against predetermined inclusion/exclusion criteria and extracted relevant data including quality and evidence assessments. Evidence for different types of interventions in HIC vs. LMIC was planned to be compared, but none of the reviews assessed potential differences. Therefore, a narrative review of the studies from LMIC was conducted including an assessment of quality and evidence.

Thirty-five reviews fulfilled the inclusion criteria. Eleven considered findings from HIC and LMIC. Sixty-nine percent included studies with various research designs; 63% provided a qualitative synthesis of findings; 77% percent assessed the quality of studies; 43% systematically assessed the level of evidence across studies. No review compared evidence from HIC and LMIC. A review of the studies from LMIC found some promising results, but the evidence was not sufficient due to a small number of studies, sometimes poor quality, and small sample sizes.

Systematic reviews on interventions for children and adolescents with ASD did not look for potential differences in the effectiveness of interventions in HIC and LMIC. Overall, there is very little evidence from LMIC. None of the interventions can be considered evidence-based in LMIC. Hence, additional research and mutually agreed methodological standards are needed to provide a more secure basis for evidence-based treatments in LMIC trying to establish evidence-based practices.

Introduction

Autism Spectrum Disorder (ASD) is characterized by persistent deficits in social communication and social interaction across multiple contexts, including deficits in social reciprocity, in non-verbal communicative behaviors, and in skills required for developing, maintaining, and understanding relationships. In addition, restricted, repetitive patterns of behavior, interests, or activities have to be present for a diagnosis ( 1 ). Symptoms emerge during the first 3 years of life ( 2 , 3 ). The symptoms of ASD vary in severity and may present differently in children with a mixture of cognitive abilities ( 4 ). The extreme variability of behavioral and communicative problems and coexisting conditions make it difficult for mental health professionals and non-specialists to identify ASD as early as possible ( 5 , 6 ), although respective diagnostic tools exist for children as young as 18 months. The American Academy of Pediatrics (AAP), for example, recommends standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance in primary care.

Worldwide, there is an increasing number of children, who meet the diagnostic criteria for ASD ( 7 , 8 ). The estimated number of cases is 52 million worldwide, which means that 1–2% of children are affected ( 9 – 12 ). The prevalence rate for children was one in 44 in the U.S, based on a sample of 8-year-old children ( 13 ) and one in 100 in the UK ( 14 ). In Europe (Germany, Poland, France, Belgium, Denmark, Iceland, Sweden, Ireland), China, and North America the reported prevalence of ASD is close to 1.5%, but varies considerably between regions and populations ( 11 , 15 – 22 ). The majority of the epidemiological studies were conducted in HIC. According to the World Bank ( 23 ), HIC are defined as countries with an average income of more than 12,353 U.S. dollars per year, upper middle-income countries (UMIC) by an average income between 4,046 and 12,535 dollars, and LMIC by an average income between 1,036 and 4,045 dollars per year. The prevalence rate in LMIC is rather uncertain due to a lack of research ( 24 ). A systematic review on the prevalence of ASD in Asia revealed that it was around 1.9/10,000 before 1980 and 14.8/10,000 from 1980 to 2008 ( 25 ). For South Asia, a systematic review estimated the prevalence as 0.09% in India, 1.07% in Sri Lanka, and 3% in Bangladesh ( 26 ).

ASD is considered an emerging public health issue by the World Health Organization ( 27 ). Still, research, public awareness, and mental health services are mostly concentrated in HIC. In these countries, large efforts have been made to bridge the gap between evidence and practice. By contrast, a large gap exists in LMIC due to a lack of public awareness, professional knowledge, and well-conducted scientific studies ( 28 ). International studies found that 75–85% of individuals with mental disorders including autism do not receive particular treatment services in LMIC ( 29 ), which prevents children from realizing a healthy life ( 30 ). Major barriers to increasing services for childhood mental disorders in these countries include financial constraints, absence of government initiatives, inadequately trained healthcare professionals, and an overcentralized health system ( 31 – 37 ). In addition, there might be limited knowledge about effective evidence-based treatments and a lack of competencies required for their implementation ( 38 ).

Many different types of treatments for children and adolescents with ASD have been developed and investigated [cf. ( 39 )]. With respect to cognitive and/or behavioral interventions, it is important to delineate comprehensive treatment models and focused interventions. Comprehensive treatment models (CTM) are conceptually organized sets of practices, which address the core deficits of ASD over a lengthy period of time (e.g., 1–2 years). Multiple developmental domains (e.g., social communication, daily living skills, and repetitive behaviors) are targeted by using multiple interventions (e.g., The UCLA Young Autism Program by Lovaas ( 40 ), the TEACCH program developed by Lord and Schopler ( 41 ), the LEAP model, the Early Start Denver model). Many comprehensive programs aim at young children, which underlines the importance of an early diagnosis. By contrast, focused interventions are a set of individual instructional strategies that are designed to address a specific behavioral or developmental problem, for instance, joint attention or repetitive behaviors. Further examples are social skills training or visual support in academic instruction.

A special sub-group of treatments is psychosocial interventions delivered by non-specialists (parents or caregivers, peers, and teachers). In many LMIC, interventions for children and adolescents with ASD have to be delivered by these non-specialists due to a lack of other resources. Therefore, we considered these treatments separately, although the interventions themselves overlap with focussed interventions. In community settings, these interventions have been found to produce benefits in development, social-communication skills, daily living skills, comprehension or academic performance, behavior, or family outcomes ( 42 , 43 ).

In recent years, technological devices have been used more often to deliver treatments, train, and support health care professionals as well as parents. Technology-based interventions make use of a broad range of devices such as speech-generating devices or robots, and software applications like computer-assisted instructional programs, or mobile- and tablet-based applications ( 44 – 47 ). Educational computer games (e.g., EmotionTrainer, FaceMaze, FaceSay, Squizzy, TeachTown) were designed for enhancing a broader set of skills, including social, emotional, as well as cognitive, and academic skills ( 48 – 53 ). As technological devices and software programs require substantial financial resources to acquire and maintain them, we decided to treat respective treatments as a separate sub-group to provide respective information for readers coming from LMIC.

In addition to cognitive and behaviorally oriented treatments, medical and alternative treatments have been developed and tested ( 47 , 54 ). The use of medical treatments to address behavioral problems in children and youth with ASD has increased significantly since the publication of the AAP's clinical report in 2007 [cf. ( 55 , 56 )]. The U.S. Food and Drug Administration (FDA) has approved the use of some antipsychotic drugs, such as aripiprazole and risperidone, for the treatment of irritability/ aggression and repetitive behaviors in children and youth with ASD.

Complementary and alternative medicine (CAM) treatments refer to a broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system ( 57 ). These encompass diets (e.g., gluten-free diet, ketogenic diet), nutritional supplements (e.g., omega 3 fatty acids, vitamins, melatonin), traditional alternative medicine (e.g., acupuncture), exercise (e.g., yoga), body therapies (e.g., massage, touch therapy). CAM treatments are frequently used to treat behavioral problems (e.g., aggression, irritability, hyperactivity). Some interventions classified as CAM were found to be ineffective, some potentially harmful ( 58 , 59 ).

The research on the effectiveness of the different types of treatments looked at various outcomes, including language development, interpersonal skills, behavior, and academic achievement. Systematic reviews often summarize the findings for a specific type of treatment and/or for a specific type of outcome. Very few try to collate the evidence across all types of treatments [see ( 47 , 54 , 60 ), for exceptions]. Based on the findings, some treatments have been identified as evidence-based practices, that is, as treatments for which sufficient evidence is available that they are beneficial for the outcome under investigation. The latest review of the National Standards Project (NSP) and the National Professional Development Center (NPDC) identified 27 evidence-based practices ( 61 , 62 ).

Research has shown that clinical features of ASD present the same in HIC and LMIC ( 63 – 65 ). However, the significant contextual differences between HIC and LMIC may result in very different consequences ( 66 ). HIC provide treatment facilities and comprehensive care for children and adolescents with ASD. A rather large number of mental health professionals with a specific focus on developmental disorders (psychiatrists as well as clinical psychologists) are available. The awareness of ASD is generally high. The situation in LMIC is rather different. In many aspects, it is quite the opposite. In most LMIC, there are very few trained professionals, who have expertise with respect to ASD-related interventions. In addition to insufficient training, there are financial constraints and limited resources within health care systems, which are much less elaborated than in HIC ( 33 , 36 , 37 ). Finally, there are substantial cultural differences and medical traditions in LMIC than in the mostly Western HIC. Therefore, interventions designed and tested in HIC may turn out to be less applicable and less effective in LMIC ( 43 , 67 – 71 ). Hence, it is important to look for potential differences.

In the past two decades, many reviews (systematic and unsystematic) on treatments for children and adolescents with ASD and other developmental disorders have been published. Most of these come from researchers in HIC, although ~95% of individuals with ASD do not live in these countries ( 64 , 72 , 73 ). There are very few reviews that come from and focus on evidence from LMIC, although some studies have been conducted (see Table 2 for on overview). Hence, there is a need for conducting a systematic review of reviews to summarize and compare the results from HIC and/or LMIC. This is the aim of the present meta-review. It provides an overview of the existing systematic reviews published from the beginning of 2011 up to the end of 2021, analyzes potential differences in findings from HIC and LMIC, summarizes the effectiveness of the different types of interventions, and describes the quality and findings of the studies coming from LMIC.

The following research questions were addressed:

• Do systematic reviews of treatments for children and adolescents with ASD consider research findings from LMIC?
• Are there differences in the effectiveness of interventions in HIC and LMIC?
• Which types of treatments can be considered evidence-based in LMIC?

Search strategy

A systematic review of reviews was carried out in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines [PRISMA, ( 74 )]. Eligible review articles were obtained by searching three electronic databases: PsycINFO, PubMed and Cochrane Database of Systematic Reviews. The research team developed a series of search terms appropriate for each database using medical subject headings (MeSH). These terms included “Review” OR “Review as literature” AND “Autism” OR “Autism spectrum disorders” AND “Evidence based practice” OR “Evidence based treatment” OR “Treatment program” OR “Interventions” AND “High- income countries” OR “Lower middle-income countries.” A manual search of the reference lists of all included reviews was conducted to identify additional reviews.

Eligibility criteria

Criteria for inclusion were defined in advance. To be included, the review had to be systematic (i.e., a clear objective and research questions had to be specified and the methodology including a search and data extraction strategy had to be described in enough detail to be replicable). Reviews had to be published between January 2011 and December 2021 in English. The population had to be children and adolescents (up to 18 years of age) diagnosed with ASD. There were no restrictions with respect to treatment, treatment setting, or outcome. Reviews had to include studies coming not only from HIC. Following the classification of countries from the World Bank, this includes studies from LMIC and UMIC, although we were interested in LMIC. Note that we decided to be overinclusive at this point to provide a good overview on how research not coming from HIC is taken into account in systematic reviews. Reviews with a qualitative and/or quantitative synthesis of findings were included. Reviews not meeting these inclusion criteria were excluded.

Study selection

The first author screened all review papers, initially on the basis of title and abstract to identify potentially eligible reviews. All titles and abstracts were screened independently by the third author. Following this, full articles were assessed independently by the first author and third author with respect to the inclusion criterion. Initial agreement was 92%. Disagreements were resolved through discussion. Reviews not meeting the inclusion criteria were excluded. The flow of studies is presented in the respective PRISMA diagram shown in Figure 1 .

PRISMA flow diagram [modified from Moher et al. ( 74 )].

Data extraction and management

Data were extracted from all eligible reviews and tabulated by the first reviewer using a set of data extraction forms, which were developed for the present meta-review. The following information were collected: name of the first author, year of publication, age group, countries of included studies [HIC, LMIC, or UMIC, as defined by the ( 23 )], number of included studies, study designs, data synthesis method, quality assessment method for individual studies, method for evidence rating across studies, types of treatments, types of outcomes, evidence for each type of treatment according to the authors of the review. Treatments and outcomes were classified following the categories proposed by the National Autism Center ( 61 , 62 , 75 ). To provide a better overview, we organized treatments into the seven major groups outlined in the introduction: Comprehensive treatment programs (e.g., Early Start Denver Model, UCLA/Lovaas-based interventions), Focused interventions (e.g., social skill training), Treatments delivered by non-specialists (e.g., parent-mediated interventions), Technology-assisted interventions (e.g., video modeling), Medical treatments (e.g., risperidone), Complementary and Alternative Medicine (e.g., acupuncture), and Other (e.g., weighted vests). We selected these groups of treatments, as they might be most informative for LMIC. With respect to outcomes, we differentiated between communication and language skills, social behavior, joint attention, play, cognitive/intellectual functioning, academic performance/comprehension skills, restricted/repetitive/stereotyped behavior, challenging/problematic behaviors/irritability, hyperactivity, adaptive behavior, emotion regulation, ASD symptoms, daily living skills, sensory-motor skills, and others, respectively. Adverse effects were reported for medical as well as CAM treatments.

Narrative summary of individual studies from LMIC

It turned out that none of the reviews addressed potential differences between HIC and LMIC even when studies from both classes of countries were considered. Therefore, we further analyzed the studies coming from LMIC, which were included in the reviews to find out which types of interventions are effective in LMIC and can be considered evidence-based. All empirical studies investigating outcomes of children and adolescents were analyzed in detail. Information on study design, number of participants, interventions investigated, and major findings were extracted. Findings were summarized in a qualitative way because research designs varied widely. In addition, the quality of the studies and evidence across studies was assessed. We used the What Works Clearinghouse standards (version 4.1, https://ies.ed.gov/ncee/wwc/Resources/ResourcesForReviewers ) ( 76 ), as they are applicable to group-based and single-subject designs. Data extraction and rating of studies were performed by the first and last author independently. Initial agreement was 93 and 92%, respectively (see Table 2 ).

Review selection

Electronic database search identified a total of 1,117 review papers. Fourteen additional reviews were found by manually searching reference lists. From a total of 1,131 review papers, 15 duplicate reviews were removed. One thousand one hundred sixteen review papers were assessed for eligibility, 973 of which were excluded based on abstract and title. The full text of the remaining 143 reviews was examined against the inclusion criteria. One hundred seven reviews were excluded because they failed to meet inclusion criteria, 46 reviews because they considered only studies from HIC. One review was not considered, because it could not be obtained ( 77 ). Finally, 35 reviews were included in the current meta-review (see Figure 1 ).

Description of reviews

An overview of included reviews can be found in Table 1 . Eight out of 35 reviews considered findings from HIC, UMIC, and LMIC, 21 from HIC and UMIC, three from HIC and LMIC, and three only from LMIC. Considering also the 46 reviews, which only included studies from HIC but met all other inclusion criteria (see Online Appendix for full list), this means that 32 of 81 reviews (40%) included research from HIC and other countries.

Overview of systematic reviews including studies from high-income countries (HIC), lower middle-income countries (LMIC), and upper middle-income countries (UMIC).

Reviews included between 6 and 85 different studies (M = 21.3, SD = 14.1). Reviews included either none or only very few studies from LMIC. Across all reviews, only 29 studies from LMIC investigating children's and adolescents' outcomes could be identified (see Table 2 ).

Studies from LMIC included in systematic reviews from 2011 to 2021 investigating the effectiveness of treatments.

*Only abstract could be obtained .

Only randomized control trials (RCTs) were considered in 10 reviews, one considered only single case studies, the remaining included studies with various research designs. To integrate the findings, 22 (63%) provided only a qualitative synthesis, 5 (14%) only a quantitative synthesis, and 8 (23%) reported both. None of the reviews analyzed potential differences in the effectiveness of treatments for different classes of countries. This is also true for the eleven reviews, which included studies from HIC and LMIC.

Twenty-seven reviews (77%) assessed the quality or evidence provided by each individual study using a specific methodology. These methodologies varied considerably between studies. Most often Cochrane's risk of bias tool ( 79 , 164 ) and the criteria proposed by Reichow et al. ( 81 ) were used. Fifteen (43%) assessed the evidence for types of treatments across studies using a specific methodology. Again, methodologies varied substantially. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system ( 95 , 112 ) and the criteria by Reichow et al. ( 81 ) were most frequently utilized.

Evidence for different types of treatment

Although most of the thirty-five reviews focused on a particular topic [e.g., parent-mediated early interventions, ( 117 ), see Table 1 ], many of the thirty-five reviews addressed more than one type of treatment according to our classification [e.g., comprehensive treatment programs, focused interventions, and parent-mediated interventions in the case of ( 117 )]. Six reviews including 36 studies (two from LMIC) addressed comprehensive treatment programs; 14 reviews including 191 studies (five from LMIC) addressed various focused interventions; 15 reviews including 203 studies (eight from LMIC) addressed non-specialist mediated interventions; 15 reviews including 171 studies (five from LMIC) technology-assisted interventions, four reviews including 65 studies (two from LMIC) medical interventions, and 11 reviews including 67 studies (seven from LMIC) complementary and alternative medicine interventions. Hence the percentage of studies from LMIC ranged from 2.6% for focused interventions to 10% for complementary and alternative medicine. In the individual reviews only very few studies came from LMIC (0–4). This was true even for the three reviews that focused on research from LMIC ( 67 , 97 , 119 ). Many of the cited studies in these reviews did not investigate the ASD-related outcomes for children or adolescents.

The following sections first briefly describe which types of treatments are judged evidence-based in systematic reviews which only consider research from HIC (see Online Appendix for more detailed information on these reviews and their findings). Second, the results of the individual studies from LMIC for the respective type of treatment are summarized and their quality as well as the quality of the evidence is evaluated. Details on the studies can be found in Table 2 .

Comprehensive treatment programs

As described above, comprehensive treatment programs integrate various types of interventions (i.e., applied behavior analysis, early intensive behavioral interventions, the UCLA young autism program by Lovaas and colleagues, ESDM, ToM, LEAP, TEACCH as well) over a prolonged period and are usually designed for preschoolers. The specific interventions differ between programs ( 60 , 165 ).

There was consensus across reviews from HIC that comprehensive Applied Behavior Analysis (ABA) programs are evidence-based ( 126 , 166 , 167 ) as are Lovaas-based programs [UCLA Early Autism Project; ( 167 , 168 )].

With respect to LMIC, one single case study from India was cited in the reviews ( 136 ). It reported a positive effect of a comprehensive program on ASD symptoms and theory of mind. Another study investigated DEALL (Developmental Eclectic Approach to Language Learning), an indigenous early intervention program for children with autism, using an uncontrolled pre-post group design ( 137 ). Significant improvements in social-communication skills, motor skills, adaptive behaviors, language, and reduced behavioral problems were found.

The quality of the studies was low. The single case study did not meet the standards due to the absence of an experimental manipulation of the independent variable ( 136 ). The other study ( 137 ) did not meet the standards for group designs due to missing controls (see Table 2 ).

Focused interventions

Overall, focused interventions addressing social behavior (e.g., social skill training, play-based interventions, social stories) were considered established evidence-based treatments [( 80 , 91 , 111 , 169 , 170 ); see also ( 171 – 173 )]. The same was true for educational interventions aiming to improve academic performance by discrete skills teaching, response prompting strategies, and self-determination instructions ( 80 , 169 , 174 ). In addition, reviews judged joint attention-based interventions as evidence-based ( 80 , 111 , 167 , 175 ).

Regarding LMIC, two reviews ( 67 , 119 ) summarized studies from India on various focused interventions. One uncontrolled study investigated a vocabulary language program and reported significant improvement in language and social-communication skills at posttest ( 139 ). One single case study reported a positive effect of PECS on communication and repetitive behaviors while another single case study found that social stories reduced problematic behavior ( 141 , 142 ). One RCT ( 140 ) found that a Developmental, Individual-Difference, Relationship-Based (DIR)/Floortime™ intervention improved social behavior. A second controlled study ( 138 ) reported a positive effect of play therapy in addition to the regular treatment (see Table 2 for details).

According to the WWC Procedures and Standards Handbook, one RCT met all basic design standards ( 140 ). The other controlled trial could not be evaluated because only the abstract could be obtained ( 138 ). The uncontrolled trial failed to meet standards ( 139 ) as did the two single case studies [( 141 , 142 ); see Table 2 for details].

Non-specialist mediated interventions

Most reviews focused on parent-mediated interventions, rather few considered peer-mediated interventions or teacher-mediated interventions (cf. Table 1 ). Several reviews judged parent training or parent-mediated interventions as evidence-based [( 43 , 117 , 126 , 167 , 175 , 176 ); see also ( 173 )]. There was a consensus among two reviews on peer-mediated interventions ( 80 , 111 ) that these interventions are effective and can be considered evidence-based. There is also some evidence for the effectiveness of teacher-implemented interventions ( 43 , 126 ).

Regarding LMIC, four recent reviews looked into parent-mediated interventions for children with ASD ( 84 , 97 , 101 , 119 ). However, most of the cited studies did not investigate the outcomes for children but looked into outcomes for parents (e.g., gain in knowledge, perceived helpfulness of intervention). Eight studies did assess ASD-related outcomes in children. Three uncontrolled studies from India ( 145 , 146 , 149 ) found that parent-mediated interventions improved ASD symptoms as well as social and language skills, sensory-motor and adaptive skills. One RCT from India and Pakistan ( 71 ) investigated the effectiveness of the Parent-mediated intervention for Autism Spectrum Disorder in South Asia (PASS), which is a program adapted from a program developed in the UK. They found that adding the program to a treatment as usual resulted in better parent-child interaction, but no further improvement in other outcomes. A second RCT from India by Manohar et al. ( 148 ) reported significant improvements in child-related measures such as autism severity, joint attention, social-communication skills, and adaptive behavior after a parent-mediated intervention. A third Indian RCT by Divan et al. ( 144 ) found positive effects of a community health worker-mediated communication intervention on autism severity scores and dyadic social communication skills. Louis and Kumar ( 147 ) found a positive effect of an intensive training for fathers added to a home-based program on social-communication skills, adaptive behaviors, and repetitive behaviors. One uncontrolled trial from Nigeria reported a significant effect of a parent-mediated behavioral intervention on challenging behaviors ( 143 ).

By WWC criteria, three RCTs were of good quality because they fulfilled the standards without reservations ( 71 , 144 , 148 ). One RCT ( 147 ) fulfilled the standards with reservations due to missing information on the randomization procedure and attrition. Four uncontrolled studies (pre-post design) did not meet the standards due to a lack of a control group ( 143 , 145 , 146 , 149 ). According to the WWC standards at least two studies meeting standards without reservations are required for an intervention to be eligible for being considered evidence-based. There were three well-conducted RCTs. However, only one of the two studies investigating parent-mediated interventions ( 71 , 148 ) reported positive effects on ASD symptoms. The third study ( 144 ) concerned community-health worker mediated interventions. In addition, <50% of the evidence comes from studies meeting standards without reservations. Hence there is not sufficient evidence.

Technology-assisted interventions

In line with previous research, we considered technology-assisted interventions to be interventions in which technology is the central feature supporting the acquisition of a goal of the learner such as social or academic skills, challenging behaviors, or daily living activities ( 44 – 47 ). Interventions include computer-based interventions, video-modeling music therapy, visual strategies training, video modeling, neurofeedback, Ayres Sensory Integration, and Augmented Auditory Integration. Overall, there was no consensus among reviews that technology-based interventions can be considered evidence-based, although promising results have been reported in quite a number of studies [see the reviews by ( 106 , 120 , 130 , 177 ); for more information].

Regarding LMIC, one single case experimental study from Georgia investigating the effect of distance coaching of therapists found some effects of the intervention on the language skills of three children ( 150 ). A single case experimental study from India ( 154 ) found that sung instructions, as compared to spoken directives, were more effective in improving socio-communicative responsiveness in children. A non-experimental single case study from India on virtual reality-based interventions reported positive effects on social-communication skills [( 151 ); see Table 2 ]. One controlled trial from India reported a significant effect of technology-based visual strategy training on communication skills ( 152 ). One RCT from India on home-based sensory interventions reported significant improvement in sensory abnormalities as well as overall wellbeing and health-related quality of life ( 153 ).

According to WWC Procedures and Standard Handbook, the two studies with single-case experimental designs met the standards ( 150 , 154 ), while the other single case study did not ( 151 ). One RCT met all basic design standards ( 153 ). Unfortunately, the quality of one controlled trial could not be assessed as the full article could not be acquired ( 152 ).

Medical treatments

Overall, quite a number of reviews based on research from HIC considered aripiprazole and risperidone as evidence-based treatments for irritability, hyperactivity, repetitive behaviors, and inappropriate speech. However, significant side effects including marked weight gain and sedation were found for these medications ( 78 , 108 , 125 , 178 – 180 ). Two Cochrane reviews pointed out lacking evidence for a long-term use of aripiprazole and risperidone ( 178 , 180 ). The cited reviews also addressed other pharmacological treatments (including SSRIs, stimulants, sympatholytic agents, and chelating agents), none of which were considered evidence-based.

No evidence from LMIC was mentioned in the reviews until 2019. A more recent review ( 119 ), cites one RCT from India, which found risperidone to be effective in reducing behavioral problems (aggressiveness, hyperactivity, and irritability) and in improving social responsiveness and non-verbal communication skills ( 155 ). The same review also considers a non-randomized trial from India, which compared the efficacy and safety of risperidone and fluoxetine ( 156 ). A significant positive effect of risperidone on irritability and hyperactivity was found, while fluoxetine reduced speech deviance, social withdrawal, and stereotypic behavior. While the RCT met the standards of the WWC without reservations, the non-randomized trial did not. In addition, sample sizes were rather small.

Complementary and alternative medicine

In general, none of the treatments in this category have been considered evidence-based [see ( 78 , 83 , 111 , 123 , 124 , 131 )].

Regarding LMIC, one RCT from Indonesia found inconclusive results with respect to gluten and casein supplementation ( 160 ). One RCT from Egypt ( 162 ) investigated the effect of digestive enzymes and found significant improvement in emotional response and autistic behaviors. Another RCT from Egypt ( 158 ) showed an effect of L-Carnitine therapy in improving autistic behaviors. An RCT on acupuncture from Egypt ( 157 ) found that acupuncture in conjunction with language therapy may have an additional positive effect on some aspects of communication and language [see Cochrane review from ( 83 ), for more findings on acupuncture mostly coming from China a UMIC). A recent review from India ( 119 ) cited two studies on yoga. A controlled trial found that structured yoga improved gastrointestinal symptoms, sleep problems, and behavioral problems ( 159 ). A small uncontrolled study reported that integrated yoga therapy (IAYT) increased imitation skills ( 161 ). Another recent review by Tan et al. ( 131 ) cited one study from Egypt on probiotics and reported significant improvements in the severity of ASD and gastrointestinal symptoms ( 163 ). The four RCTs met the WWC standards without reservations, while the three other studies did not meet the standards (see Table 2 for more details).

Summary of evidence

Comprehensive treatment programs are well-investigated in HIC and some are considered evidence-based [see ( 47 )]. Evidence from LMIC is lacking apart from two low-quality studies from India ( 136 , 137 ), which entails that none of these programs can be considered evidence-based for LMIC.

Research on focused interventions also comes mostly from HIC [( 61 , 62 ); see ( 173 ), for a recent summary]. There are a few isolated studies on different types of focused interventions from LMIC, not providing sufficient evidence to consider them evidence-based. There were, however, two controlled studies looking into interventions addressing social-communication skills (a DIR/Floortime intervention and a play-based intervention) with reported positive findings ( 138 , 140 ).

Non-specialist mediated interventions are particularly interesting for LMIC, as they require less resources and may be used to provide care for a larger number of children and adolescents. Reviews judged parent training or parent-mediated interventions as effective with good evidence, especially for preschoolers in HIC [( 42 , 43 , 176 ); see also ( 173 )]. In LMIC, however, the evidence is still insufficient to judged parent-mediated interventions as evidence-based. Two reviews from India and one review from Bangladesh judged parent-mediated interventions as effective ( 67 , 97 , 119 ). It is important to note, however, that in the review by Dababnah et al. ( 67 ) the total number of studies with respect to ASD was low. Two recent reviews by Patra and Kar ( 119 ) and Koly et al. ( 97 ) reported only three RCTs with good quality, while the other studies were mostly low-quality. Three other reviews also looked into parent-mediated interventions and/or parent training citing studies from LMIC ( 69 , 84 , 101 ). However, most of these studies did not look into children's outcomes in LMIC.

Many technology-based interventions have been tried for children and adolescents in HIC. For most interventions, high-quality evidence is still lacking. Recently, Steinbrenner et al. ( 173 ) judged video modeling and technology-aided instruction and intervention as evidence-based. Concerning LMIC, there is a lack of studies exploring the effect of technology-based interventions.

With respect to medical interventions, most studies were conducted in HIC focusing on the effect of pharmacological agents on behavioral problems. A new review from India [LMIC, ( 119 )] included two studies on risperidone and found this medical agent to be effective for reducing behavioral problems ( 155 , 156 ). These findings on antipsychotic medication conform to the findings in HIC.

Research on complementary and alternative medical treatments comes from HIC, UMIC, and LMIC. The existing evidence base is still too limited for the various types of CAM treatments. Again, evidence from LMIC is scarce and scattered across different treatments. Hence, none can be considered evidence-based.

In line with the significant increase in the prevalence of ASD in children and adolescents over the past two decades worldwide, a lot of research on different types of treatments for many different types of outcomes has been completed. Many systematic reviews have been published summarizing the respective research and more are published every year. We conducted a meta-review analyzing systematic reviews on the effectiveness of treatments and interventions in children and adolescents with ASD from 2011 until the end of 2021, which also considered research not coming from HIC. Our aims were to find out whether there are differences in the effectiveness of treatments in HIC vs . LMIC and which types of treatments can be considered evidence-based in LMIC.

Summary of key findings

In this systematic review of reviews, we identified 35 systematic reviews that included research from LMIC and/or UMIC. Thirty-one of these considered also research from HIC. In the same time span (2011–2021) another 46 reviews on interventions for children and adolescents with ASD were published only including studies from HIC. There are many potential reasons why research studies from LMIC (and UMIC) may not be included in a systematic review. One is that these studies may be difficult to find and/or obtain. Another is that many of the studies were not RCTs and many not of high quality. Thus, these studies may have been excluded due to the inclusion criteria of the respective review.

Although eleven of the identified reviews included research from HIC and LMIC, none of the reviews looked for potential differences in effectiveness for a particular type of intervention. One obvious reason was the low number of studies from LMIC, which precluded any meaningful statistical comparison. Another seems to be lack of awareness that there may be relevant differences.

When we went back to the original studies from LMIC, which were cited in the reviews, we found studies with many different research questions, various research designs, and often a rather low quality. Nevertheless, we analyzed these studies and provided a narrative synthesis. Because of their heterogeneity, it did not make sense to integrate their findings statistically and compare them to the average findings from HIC. Thus, we were unable to determine, whether there are differences in the effectiveness of treatments in HIC and LMIC.

Finally, we evaluated the studies from LMIC for quality and evidence. Due to the low number of high-quality studies, no type of treatment fulfilled the criteria for being evidence-based according to the What Works Clearinghouse standards (version 4.1, https://ies.ed.gov/ncee/wwc/Resources/ResourcesForReviewers ). One reason, why research from LMIC is still scarce, is probably the limited amount of funding available [cf. ( 33 , 36 , 37 )]. Another reason may be that the awareness of the importance of research and knowledge about respective research methodologies is still moderate in some LMICs. A final reason might be that international publication fees are often prohibitively expensive, despite the price reductions for researchers from LMIC. This may reduce the international visibility of existing research.

Limitations

Because of the many choices that have to be made when conducting a review of reviews with many methodological differences, some limitations exist. First, we decided to include only reviews that were published in English. Despite English being the common language of science, some reviews especially from LMIC might have been published in other languages. Therefore, some reviews and the findings summarized in them may be missing.

Second, we decided to include reviews being published between 2011 and the end of 2021 that consider research from HIC and LMIC and/or UMIC by searching only three electronic databases (PsycINFO, PubMed, Cochrane Database of Systematic Reviews). An updated version of this meta-review in the future should use more databases including databases collating research papers published in the languages of LMIC.

The third important decision, which limits our findings, was to consider only reviews that systematically reviewed the literature on interventions. While assessing the full texts we found some interesting unsystematic reviews of research from LMIC [e.g., ( 181 )]. Following our inclusion criteria, we excluded these reviews. If the results from these unsystematic collections of research studies had been included, more research from LMIC might have been taken in account.

Fourth, we used the classification scheme of high-income, upper middle-income, and lower middle-income countries provided by the World Bank, which is the commonly used standard (e.g., by the WHO). This classification scheme is based on average income. As it does not specifically consider the health care system, some researchers have criticized using this classification scheme for making comparisons between countries [e.g., ( 101 )]. They suggest to compare low-resource settings in health care to high resource settings instead.

Implications for practice and future research

Although we were able to identify 35 systematic reviews summarizing the results from many empirical studies, there was very little evidence from LMIC. The eleven reviews including research from LMIC ran no analyses comparing results from HIC and LMIC. This finding has two important implications. First, more research needs to be conducted in LMIC on the effectiveness of different treatments and interventions for children and adolescents with ASD. The research should be of high quality no matter whether single case experimental designs or randomized group-based designs are used. Second, findings for HIC and LMIC need to be compared systematically. HIC and LMIC countries differ in many respects, including differences in health care systems but also in cultural and medical traditions. Hence, findings from HIC on specific treatments cannot be easily transferred to LMIC. There is no alternative to conducting the respective studies and to comparing the findings.

Nevertheless, there are some tentative implications for practice in LMIC. Many of the treatments that have been established as evidence-based by previous research, have to be considered as evidence-based only for HIC (see https://mn.gov/mnddc/asd-employment/pdf/09-NSR-NAC.pdf and https://www.nationalautismcenter.org/national-standards-project/phase-2/ for a good overview of these treatments). As shown in the present meta-review, there is currently not sufficient evidence for these interventions and treatments in LMIC to consider them evidence-based. There seems to be one notable exception: parent-mediated interventions. The reviews by Dababnah et al. ( 67 ), Koly et al. ( 97 ), Lee and Meadan ( 101 ), and Patra and Kar ( 119 ) concluded that these interventions are effective in LMIC. The evidence, however, was mostly indirect showing that parents acquire more knowledge and skills through these interventions. As shown here, direct evidence with respect to children's outcomes is still limited and studies were often of low quality. The review by Reichow et al. ( 43 ), however, supports the conclusion of the four reviews by showing that educating parents to deliver behavioral interventions is effective to address developmental disorders in LMIC. Thus, parent-mediated interventions can be considered at least promising and probably effective.

Another interesting option for LMIC might be the delivery of interventions by paraprofessionals, e.g., nurses, teaching assistants, social workers [cf. ( 182 )]. At present respective research is almost completely lacking, but it might be interesting to explore this option in the future [see ( 144 ) for a first trial]. It also important to note that other evidence-based treatments and interventions from HIC might be promising for LMIC when being adapted to the respective context. Given the biological basis of ASD and the similar presentation of ASD in LMIC and HIC, treatments could work in both contexts.

Treatments for children and adolescents with ASD, which are considered evidence-based in HIC, are still rarely investigated in LMIC. The findings presented here may still support mental health researchers, government organizations, and NGOs that seek to improve an uptake of effective treatments for children with autism in LMIC by summarizing the present state of research and pointing out, what evidence is still missing. It also shows that parent-mediated interventions at present have the best evidence for being effective, although the evidence is not sufficient when high standards are applied. We hope that the overview of reviews considering studies from LMIC and/or UMIC provides an easy access to mental health professionals (both specialists and non-specialists) in LMIC to the respective research. We recommended mental healthcare providers, clinicians, and other caregivers to look into these reviews and maybe even individual studies for more details on the specific treatments and interventions. This information along with their personal experience may allow them to engage in evidence-based practice when delivering treatments to children and adolescents with ASD.

Data availability statement

Author contributions.

MP, HA, and YH contributed to the conception and design of the meta-review. MP organized the database, wrote the first draft of the manuscript, and extracted the data. MP and YH made the bibliographic search and selected papers for the meta-review. HA contributed with comments to the draft, especially the introduction and the LMIC context. All authors contributed to the revision of the first draft, read, and approved the submitted version of the manuscript.

This work was supported by a grant from the University of Goettingen, Germany and Ministry of Science and Technology, Government of Bangladesh.

Conflict of interest

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

Publisher's note

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

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.834783/full#supplementary-material