Assistive devices for mobility and communication in autism spectrum disorder: A retrospective cross-sectional cohort study on disability management

Abstract

BACKGROUND

Assistive devices are crucial for supporting communication and mobility for individuals with autism spectrum disorder (ASD).

AIM

To investigate the provision of assistive devices for children and adolescents with ASD in a metropolitan area of Southern Italy, with specific focus on communication and mobility aids.

METHODS

The study analysed specialist prescriptions to evaluate age distribution and device allocation in different healthcare districts, the specialty of the prescribing physicians, and integration with rehabilitation services.

RESULTS

A total of 120 prescriptions were analysed, and the peak prescription rates occurred at the ages 7 years and 10 years. Child neurologists predominantly prescribed communication aids (P = 0.009), while physical medicine and rehabilitation specialists managed most mobility-related devices (P = 0.29). Device allocation was guided by functional needs rather than age (P = 0.73 for communication aids, P = 0.45 for wheelchairs, and P = 0.37 for gait aids, such as orthosis or insoles. Rehabilitation services, including home care and residential programs, were frequently integrated with device provision.

CONCLUSION

This study provides one of the few evaluations of assistive device prescription patterns for children and adolescents with ASD, which are important for both holistic care and healthcare resource management. Further studies are warranted to establish standardized prescribing protocols and whether expanding prescriber training or implementing interdisciplinary pathways could improve equitable access without compromising quality.

Key Words: Autism spectrum disorder; Assistive devices; Mobility aids; Communication aids; Disability; Rehabilitation; Management

Core Tip: Access to assistive technologies and rehabilitation services for children with autism spectrum disorder (ASD) remains poorly documented in real-world healthcare systems. In this cross-sectional study conducted in a large metropolitan area, prescription patterns for communication and mobility aids were analyzed together with access to rehabilitation services. About one third of children with ASD receiving assistive devices were enrolled in rehabilitation centres, mostly in outpatient or community-based programs. Child neurologists mainly prescribed communication aids, while Physical Medicine and Rehabilitation specialists managed mobility devices. These findings highlight the importance of integrated clinical and rehabilitation pathways and may inform service planning in other healthcare systems facing similar organizational challenges.

INTRODUCTION

Autism spectrum disorder (ASD) is a neurodevelopmental condition that is characterized by persistent challenges in social communication and interaction, as well as restricted and repetitive patterns of behaviour, interests, and activities[1]. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) introduced the term ASD to consolidate previously separate categories into a single diagnosis, including autistic disorder, Asperger’s syndrome, childhood disintegrative disorder, pervasive developmental disorder – not otherwise specified, and other related conditions[2]. Symptoms typically emerge in early childhood, vary widely in severity, and have heterogeneous clinical presentation. Early recognition and timely intervention are crucial for mitigating functional challenges, improving developmental outcomes, and enhancing the quality of life of individuals with ASD[1]. Current global data indicate a median prevalence of approximately 65 per 10000 individuals[3], and more recent estimates in Italy report a rate of about 1 in 77 children aged 7-9 years[4]. Communication difficulties and motor impairments, including toe walking, are common among individuals with ASD[5,6]. Roughly 25%-30% of children with ASD fail to acquire functional speech or remain minimally verbal and, use fewer than 30 words[5]. Approximately 9% are diagnosed with toe walking, whereas with less than 0.5% of children without an ASD diagnosis. Among toe-walkers with ASD, physical therapy is the most common intervention, which is provided to 59.3% of individuals but only 38.1% of typically developing children[7]. Casting is also more frequent among children with ASD than children without ASD (7.4% vs 3.6%). Persistent toe walking is present in 0.47% of the ASD population[7]. Individuals with ASD have varying levels of support needs and diverse co-occurring medical conditions[4], which necessitate a holistic approach to care. The provision of targeted assistive devices, such as mobility aids or communication supports, can be instrumental in fostering autonomy, participation, and functional independence. In Italy, these devices are available through the essential levels of care (LEA), which guarantees specific health services and assistive technologies to all citizens with disabilities through the National Health Service[8]. The aim of this study was to characterize the provision of assistive devices among children and adolescents with ASD in a metropolitan area of Southern Italy. The analysis focused on mobility supports (wheelchairs and gait aids, such as orthotic insoles, footwear and casting) and communication devices, and their distribution was evaluated according to age groups and medical specialties of the prescribing physicians. The study also examined the geographic distribution of recipients in different healthcare districts and their participation in rehabilitation services, including multidisciplinary programs provided in accredited rehabilitation centres under Italian Law Article 26/1978 (CdR)[9].

MATERIALS AND METHODS

This retrospective cross-sectional study adhered to the ethical standards outlined in the Declaration of Helsinki and was approved from the local ethics committee (protocol No. 92/CEL). The project is part of the digit-aid research group, which aims to advance digitalization processes and foster knowledge-sharing frameworks that were essential to the development of this research. The Data Protection Officer of the Local Health Authority verified that all study procedures complied with the applicable data protection regulations -regulation (EU) 2016/679 of General Data Protection Regulation (GDPR)- (protocol 56540/2026). The analysis included only children with ASD who received at least one assistive device prescription during the study period. ASD diagnoses were made by specialized Child Neuropsychiatry Units within Local Health Authorities, accredited specialist centres, and hospitals. The level of disability was assessed according to the severity levels defined in the DSM-5[2]. The status of very severe disability was identified according to the Italian Ministerial Decree of September 26, 2016. For ASD, this classification includes individuals with behavioural disabilities corresponding to DSM-5 severity level 3 (“requiring very substantial support”). Level 3 is characterized by severe deficits in verbal and nonverbal social communication, minimal social initiative and response, and highly restricted, repetitive behaviours or fixed rituals that markedly interfere with functioning across all settings, with extreme distress and great difficulty redirecting attention when routines are interrupted. For comparison, level 2 indicates marked deficits requiring substantial support, while level 1 reflects milder impairments requiring support. The study included all assistive devices prescribed to individuals with ASD within a metropolitan area of 1071813 inhabitants[10,11]. The area is administratively organized into nine healthcare districts, which are defined by the regional healthcare authority to facilitate local service delivery (Table 1). Devices addressing motor or communication impairments were analysed. All prescriptions were issued within a formal individual rehabilitation plan. Prescription records for children and adolescents with ASD (0-18 years) from January 2024 to July 2025 were extracted (Table 2). Data were reviewed and classified according to the following variables: (1) Type of assistive device (distinguishing between mobility aids -such as wheelchairs and gait aids-, and communication devices); (2) Sex and age group of the recipients; (3) Specialty of the prescribing physician; (4) Healthcare district of residence (which enabled territorial epidemiological assessment of demand); (5) Participation in CdR rehabilitation programs, offering multidisciplinary care to individuals with disabilities; (6) Presence of “severe disability” status, as defined by the Italian Ministerial Decree of 09/26/2016[12,13]; and (7) International Organization for Standardization (ISO) codes, based on their classification system for assistive products. This system categorizes devices according to their function and intended use within the Italian national nomenclature and reimbursement framework. Data were collected from assistive device prescriptions issued by medical specialists in all healthcare districts. The data were exported to Microsoft Excel for initial organization and then analysed using R Statistical Software. Continuous variables are reported as the mean and standard deviation. Categorical variables were analysed using frequency distributions and cross-tabulations. Associations between categorical variables were assessed using the χ² test. The contingency coefficient was calculated to evaluate the strength of these associations. Statistical significance was set at P < 0.05.

Table 1 District-level demographic and prescription indicators.

Districts	Paediatric population, %	% of ASD cases	Mean prescriptions per child with ASD	% of total prescriptions
D1	18	10.9	2.0	8.3
D2	22	15.2	2.3	13.3
D3	18	2.2	1.0	0.8
D4	18	13.0	1.3	6.7
D5	20	15.2	1.3	7.5
D6	17	0	–	0
D7	20	13.0	5.2	25.8
D8	20	21.7	4.1	34.2
D9	21	8.7	1.0	3.3

ASD: Autism spectrum disorder.

Table 2 Assistive device prescriptions by medical specialty.

Type of assistive devices	% of total prescriptions	Prescribing medical speciality
		Physical medicine and rehabilitation, %	Child neurology, %
Communication devices (n = 47)	39.2	9.2	30.0
Mobility: Wheelchairs (n = 39)	32.5	31.6	0.8
Mobility: Lower-limb aids (n = 34)	28.3	23.3	5.0

RESULTS

Several aspects of assistive device provision to children and adolescents with ASD were evaluated, including the age and district distribution of prescriptions, the influence of medical specialty on device selection, and access to rehabilitation services. In the metropolitan area investigated in this study, approximately 0.022% of minors with ASD received at least one assistive device prescription. This proportion reflects only children and adolescents (< 18 years) with ASD who received assistive devices that were prescribed within structured rehabilitation pathways and provided free of charge under the LEA framework. A total of 120 prescriptions were issued to 46 children aged 3-16 years with ASD. The peaks numbers of prescriptions occurred at the ages 7 (18.3%) and 10 years (15.0%) (Figure 1). There were 31 the recipients (67.4%) who had severe disabilities. About 32.6% of the cohort was enrolled in rehabilitation centres, and 73.3% of them had severe disabilities. Among those attending rehabilitation services, 86.7% received outpatient or community-based (extramural) care, while the remaining cases were in semi-residential or inpatient settings. Of the 120 prescriptions, 39.2% were for communication aids, while 60.8% were related to mobility and gait disorders (Table 2). The average was 2.6 prescriptions per child (range 1-13). Most children received one or two prescriptions, while a small number of individuals accounted for a higher volume, which was mainly due to multi-component devices such as customized wheelchairs or orthoses. The age distribution across healthcare districts was analysed separately according to device category. No significant association was observed for communication aids (P = 0.105), whereas significant differences emerged for wheelchairs and gait aids (both P < 0.0001) (Table 3). Regarding communication disorders, the most frequent devices were dynamic communicators (36.2%), 100-cell symbolic communicators (34.0%), and vocal synthesizers (8.5%), which were prescribed to mainly children aged 8 years to 12 years (14.9%). Wheelchair prescriptions were more evenly distributed across ages, with higher frequencies at 10 years (33.3%) and 7 (28.2%) years. No significant associations emerged between the type of prescribed device age (communicators P = 0.73; wheelchairs P = 0.45; gait aids P = 0.37), indicating that device selection was not dependent on this factor. Nevertheless, the contingency coefficients revealed considerable dispersion, reflecting heterogeneity in prescriptions across age groups (Table 3). Clinically, the predominance of certain devices (e.g., insoles, footbeds and linings) suggests their versatility across a wide range of functional profiles, whereas the scattered use of other codes underscores the need for highly customized interventions. Assistive devices were classified according to the ISO system, which assigns specific codes to each category of technical aid. To reduce data sparsity, the ISO codes were aggregated into broader functional categories (communication devices, wheelchairs, and lower-limb aids), and analyses were performed separately for each group. Only communication aids showed a statistically significant association between healthcare districts and ISO code distribution (P = 0.025), while no significant associations were found for wheelchairs (P = 0.12) or lower-limb aids (P = 0.23). These findings suggest that geographical variability in prescribing patterns is more pronounced for communication aids, which may potentially reflect differences in specialist expertise, service organization, or access to augmentative and alternative communication (AAC) resources in different districts. In contrast, prescriptions for mobility-related devices were more standardized and less influenced by local factors. Regarding demographics, no significant associations emerged between device categories and age groups for communication aids (P = 0.73), wheelchairs (P = 0.45), or gait aids (P = 0.37), suggesting that device allocation is primarily guided by individual functional needs rather than age. Medical specialty significantly influenced device choice. Child neurologists prescribed the majority of communication aids (76.6%) (P = 0.009), particularly dynamic and 100-cell symbolic communicators, whereas physical medicine and rehabilitation (PM&R) specialists prescribed most gait aids (82.4%) and all wheelchairs (100%). Despite this predominance, the statistical analysis showed no significant association between the PM&R specialty and the specific type of wheelchair (P = 0.12) or gait aid (P = 0.29) prescribed (Figure 2). These findings should be interpreted cautiously, however, as the limited sample size may have limited the ability to detect whether device selection is driven by clinical judgment, specific prescription patterns, or prescriber preference.

Figure 1 Age distribution of recipients with autism spectrum disorder receiving prescribed assistive devices. ISO: International Organization for Standardization.

Figure 2 Distribution of aids related to the specialty of prescribing physicians. ISO: International Organization for Standardization; NP: Child Neurologists; PM&R: Physical Medicine and Rehabilitation Specialists.

Table 3 Statistical associations between International Organization for Standardization codes and clinical and demographic variables.

Distribution analysis of ISO codes	Statistical parameter	Communication aids	Wheelchairs	Gait aids
Healthcare districts	χ2	53.11	39	70.92
	DF	35	30	63
	Significance level	0.025a	0.12	0.23
Age	χ2	52.67	90.81	151.84
	DF	60	90	147
	Significance level	0.73	0.45	0.37
Prescribing physicians	χ2	15.20	39.0	23.90
	DF	5	30	21
	Significance level	0.009a	0.12	0.29
Distribution analysis of age in the districts	χ2	100.49	39.0	102.0
	DF	84	3	21
	Significance level	0.105	< 0.0001a	< 0.0001a

^aP < 0.05.

ISO: International Organization for Standardization; DF: Degrees of freedom.

DISCUSSION

The present study sheds light on the clinical and organizational dynamics underlying assistive device provision for individuals with ASD in a metropolitan area of Southern Italy. The findings provide three key messages. First, only a small proportion of the paediatric population with ASD received assistive devices (0.022% of minors), which highlights the targeted access to these technologies. Second, the prescription patterns showed peaks at patient ages of 7 years and 10 years and differed according to medical specialty, with child neurologists mainly prescribing communication aids and PM&R specialists managing mobility-related devices. Third, assistive device provision was frequently integrated into rehabilitation pathways, and about one-third of the children were enrolled in rehabilitation services (predominantly in outpatient or community-based programs). There was a clear predominance of child neurologists in prescriptions of communication aids and PM&R specialists in prescriptions of mobility-related supports, which has implications that may extend to healthcare planning in similar settings. Allocation was driven by functional requirements rather than chronological age, although prescription peaks coincided with developmental transitions, which likely reflect increased environmental and educational demands. The variability in prescription volume between healthcare districts, likely reflects differences in the distribution of users with more complex needs. The use of rehabilitation services underscores how assistive devices are embedded within broader, multidisciplinary care pathways. In Italy, communication and mobility aids and AAC technologies are included in the LEA framework, which ensure comprehensive publicly supported care for individuals with disabilities[8]. AAC tools significantly benefit individuals with ASD who may struggle with verbal communication, particularly under stress[1]. Furthermore, such individuals frequently present gait abnormalities, including reduced step length, altered upper-limb angles[14], variable rhythm[15], and toe walking[6]. Clinicians should monitor gait closely and consider targeted interventions[6]. Effective options include insole inserts in shoes[16], serial casting and ankle-foot orthoses[17]. The central role of child neurologists in prescribing communication aids reflects their expertise in evaluating complex speech and language impairments, which is consistent with their primary responsibility in ASD care[18]. Physicians can support autistic individuals by understanding communication differences and guiding colleagues to foster mutual understanding[19]. The predominance of PM&R specialists in prescribing mobility aids highlights their essential role in achieving personal, social, and vocational goals and selecting appropriate physical stimulation equipment[20,21]. The findings highlight that a multidisciplinary approach is crucial for accurate diagnosis, effective treatment, and improved long-term outcomes in ASD[22]. Interdisciplinary collaboration in the prescription of assistive devices for children with ASD is essential[23]. While child neurologists and PM&R specialists currently play complementary roles, more integrated care models could enhance appropriateness and continuity of interventions. Structured multidisciplinary assessment pathways, including joint evaluations and shared clinical decision-making, could facilitate a more comprehensive approach to device allocation. In this context, individualized rehabilitation plans serve as a key framework to coordinate different specialist contributions and ensure that both communicative and motor-functional domains are addressed cohesively[24]. Improving adaptability to diverse rehabilitation strategies, such as communication styles and learning abilities, can foster independence and participation in daily life[25]. This principle supports the individualized functional assessment approach adopted for prescribing assistive devices in ASD and ensures that both motor and cognitive needs are adequately addressed. The study showed limited geographic variability in prescribing patterns, and significant differences emerged only for communication aids, while prescriptions for mobility-related devices appeared more homogeneous across districts. The lack of age-specific trends supports the principle that assistive devices should be allocated primarily based on individual functional needs rather than developmental benchmarks. However, the observed prescription peaks at school transition ages suggest that environmental demands, such as increased communication requirements or mobility challenges in educational settings, may influence the timing of prescriptions. For students with ASD, these supports should always be integrated into individualized education programs, which typically include accommodations such as assistive technology, telemedicine, preferential seating, and interventions like speech-language therapy and visual supports[26,27]. This underscores the need for coordinated care among healthcare providers, families, and educational services to optimize resources and enhance social, physical, and mental health outcomes for ASD individuals[28,29]. Families especially require reliable guidance to manage co-occurring conditions and life transitions, yet many healthcare professionals struggle to provide adequate resources for the complex psychosocial and healthcare needs of ASD individuals and their families[30]. Another key finding is that geographical variability in prescription volume likely reflects differences in patient distribution or local prescribing practices. This finding is reassuring in terms of equity but also underscores the necessity of maintaining standardized protocols across healthcare districts to minimize unwarranted variability. Despite the contributions of this study, it has certain limitations. The relatively small sample size may have reduced the statistical power, particularly in the subgroup analysis. In addition, the study was based on prescription data from a single metropolitan area, which limits the availability of detailed clinical information such as ASD severity, functional profiles, and comorbidities. The analysis relied on prescription data and did not include direct clinical findings on actual device use, adherence, or long-term functional outcomes, which prevented assessment of their real-world implementation and functional impact. Potential variability in individual prescriber decisions and prescriptions’ appropriateness could not be fully captured. Nevertheless, although the generalizability may be limited, the data from this metropolitan area provide useful insights into clinical practice and healthcare management.

CONCLUSION

This study provides one of the few evaluations of assistive device prescription patterns for children and adolescents with ASD, which are essential for both holistic care and healthcare resource management. Specific functional assessment scores were not available in the administrative database, the lack of correlation with demographic and anthropometric data suggests that prescriptions are likely driven by individual functional needs. Child neurologists and PM&R specialists play distinct but complementary roles in providing communication and mobility supports. Understanding these patterns is essential to optimize individual interventions, and guide healthcare planning and resource allocation, given the substantial economic impact of high-cost devices. The data may provide useful insights for improving the clinical and organizational management of ASD, as well as a framework that could be adapted and applied to other healthcare settings. Future research should investigate whether expanding prescriber training or implementing interdisciplinary pathways could improve equitable access while maintaining the quality of care.