Impact of one-to-one instruction on activity participation, playfulness, and enjoyment in children with Autism Spectrum Disorder in Rwanda: A quasi-experimental study

Background: Children with autism spectrum disorder often have limited engagement in daily activities, particularly in low‑resource settings. This study aimed to evaluate whether individualised therapist-led intervention increases activity participation, enjoyment, and playfulness among children with autism compared with standard group-based care. Methods: A quasi-experimental study was conducted at two centres involving 86 children with autism spectrum disorder (n=86), aged 3–12 years. Participants were assigned to either the intervention group (n = 43) which received 9 months’ one-to-one instruction or a comparison group (n = 43) which received standard care. The Children's Assessment of Participation and Enjoyment, Children's Preferences for Activities, and the Test of Playfulness were used to evaluate the children both before and after the intervention. Results: Significant, statistically robust improvements were observed with one-on-one instruction in some activities. Participation increased across domains with the largest effects for quiet recreation and hobbies (Cohen’s d ≈1.0–1.2; p<0.001) while enjoyment (p = 0.046, d = 0.45, ηp² = 0.21) and a marked improvement of playfulness (p<0.001). Preference shifts occurred within the intervention group but were not significantly different from controls after covariate adjustment. Conclusion: Individualised one‑to‑one instruction yielded meaningful participation gains and is promising for low‑resource settings. Future research should include fidelity measurement, longer follow‑up, and a larger sample to confirm effectiveness.   Implications for Practice ·       One-to-one instruction should be considered as an effective option in clinical and school settings to increase participation and playfulness for children with autism spectrum disorder ·       Routine use of validated tools and fidelity audits is recommended to monitor outcomes, detect preference shifts, and guide individualised goal setting. ·       Interventions should target playfulness (extent, intensity, and skilfulness) alongside participation frequency because improvements in play quality drive meaningful engagement. ·      Pilot one-to-one instructional programmes in district centres, funding staff, training, and monitoring to broaden access in low-resource settings.