Authors Reply to the Comments – Migration Status and Severity of Autism Spectrum Disorder: A Retrospective Study at two Specialist Centers in Northern Italy

To the Editor, We are pleased that our article, recently published in the Archives of Medicine and Health Sciences, elicited the interest of the journal’s readers.[1] We presented the results of an epidemiological study on the relationship between migration status and severity of autism spectrum disorder (ASD) at two specialist centers in Northern Italy. By retrospectively reviewing the geographical area of origin of 184 children with ASD (75.0% of males), of whom 99 classed as immigrants (74.7% of males), we found that the immigrant group had significantly higher ASD severity than the nonimmigrant group. More specifically, we found that ASD severity was significantly higher in immigrant patients from Asia and Africa, while there were no differences in ASD severity between nonimmigrants and immigrant patients from South America or from Eastern Europe. Our findings from the Italian region with the highest rate of immigration confirmed previous reports that immigrant patients have an increased risk of developing more severe ASD compared to nonimmigrants. Among the possible explanations, we cited a few environmental factors, including the role of migration-related maternal stress. Among the protective factors, we focused on the possible role played by shared linguistic roots and/or sociocultural proximity for Hispanic immigrants from South America and Eastern European White immigrants, compared to immigrants of Asian and African origins. By adopting an occupational perspective, a more fine-grained picture of the real-life impact and implications of the mentioned environmental factors can be achieved. Diagnostic and Statistical Manual for mental disorders (DSM)-informed conceptualizations of ASD severity are rooted in the evaluation of core symptoms, but functional outcomes also depend heavily on adaptive behavior, participation in daily occupations, and lived experience. Recent evidence highlights the role of occupational therapy domains - including play, social engagement, communication, and self-care - in moderating the real-world impact of ASD symptoms and shaping severity as experienced by both individuals and families. Occupational therapy frameworks emphasize occupations as both the target and vehicle of intervention. Play, as a foundational occupation in early childhood, promotes social attunement, joint attention, symbolic communication, and flexible thinking-all areas salient to autism symptom expression. Structured play-based strategies, including imitation and modeling, can improve play skills and promote social reciprocity in children with ASD, which may subsequently influence the developmental trajectory of core symptoms and functional engagement.[2] Play-based interventions that aim to scaffold social interaction and communication have been widely studied. Play can act as a naturalistic context for enhancing language and social communication outcomes, with implications for symptom severity as reflected in improved social engagement and interaction ratings.[3] The implementation of occupational therapy strategies has been shown to improve social participation through joint attention training, parent-mediated approaches, and social skills groups, although evidence for play and leisure domains is more heterogeneous.[4] These domains are critical because deficits in play and peer engagement are inherent to the ASD diagnostic criteria. Communication and social interaction are deeply intertwined with adaptive behavior, the real-world skills needed for independent living. Lower adaptive scores are consistently documented in subjects with ASD and are associated with greater functional impairment beyond core diagnostic severity. For instance, adaptive behavior variability correlates with the severity of socialization deficits, and adaptive behavior scores add meaningful information about an individual’s strengths and needs above symptom severity alone.[5] Beyond specific domains, it is ultimately the individual’s lived experience, including family context, environmental supports, and opportunities for meaningful engagement, which modulates the functional impact of ASD severity. Children with comparable diagnostic severity may demonstrate different adaptive capacities depending on early intervention, occupational therapy input, and social participation opportunities. It is important to appreciate that adaptive behavior is not static: longitudinal studies indicate that adaptive skills in socialization and daily living may not improve solely with age and are predictive of independence and adult outcomes.[6] Although specific experimental studies in immigrant samples are limited, qualitatively it has been shown that barriers to early service access for immigrant families – including language challenges, cultural beliefs about child development, and limited navigation of health systems – can impede timely intervention in social and communication domains, potentially affecting how severity manifests and evolves in functional domains.[7] Moreover, lived experiences of navigating ASD services within a different cultural milieu influence both family adaptation and child outcomes. Immigrant parents often interpret ASD symptoms through culturally informed frameworks, which can affect engagement with diagnostic and therapeutic processes, including occupational therapy-targeted domain support. These culturally mediated perceptions of communication difficulties, social interaction challenges, and everyday behavior may delay participation in play and self-care interventions, contributing to sustained severity in adaptive behavior profiles.[8] Finally, we recently documented age differences in accessing specialist assessments for ASD between children of immigrant families and nonimmigrant families.[9] Specifically, our data led to the suggestion that the lower prevalence of high-functioning ASD in immigrants, likely related to environmental and cultural factors, could be responsible for their earlier age at first medical appointment. In summary, there is growing evidence that interventions targeting participation, adaptive behavior, and meaningful occupations can attenuate functional impairments and support better real-world outcomes in patients with ASD. We agree with the proposal of adopting an occupational framework that promotes a view of migration as not merely a biological or environmental risk factor, but as a contextual modifier of occupational engagement. The implementation of the occupational framework deepens the interpretation of our findings and provides valuable insights into the future directions of ASD research for the benefit of migrant families. This also provides a good illustration of the complex interplay between clinical symptoms and lived adaptive functioning or, in the broadest sense, between nature and nurture.[10] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.