Video-feedback Intervention to promote Positive Parenting adapted to Autism (VIPP-AUTI): A randomized controlled trial

Annual Research Review: Early intervention for infants and young children with, or at-risk of, autism spectrum disorder: a systematic review

BACKGROUND

There has been increased interest in early screening and intervention for young children with, or at risk of, autism spectrum disorder (ASD). This has generated a debate about the potential harms versus benefits of early identification and treatment. This review aims to identify the evidence base for early intervention in ASD.

METHODS

A systematic review searching for randomised controlled trials (RCTs) of interventions for children up to 6 years of age with, or at risk of, ASD was undertaken. Characteristics and outcomes of included studies were collated and described in tabular format, and all included studies were rated according to the Cochrane Risk of Bias Tool.

RESULTS

Forty-eight RCTs were identified, of which 40 were published since 2010. Most studies (n = 34) were undertaken in the United States. Included RCTs evaluated 32 different models of intervention. If blinding of participants and relevant personnel is overlooked as a source of bias, only six studies met criteria for low risk of bias across all domains of the Cochrane Risk of Bias Tool. The majority of studies had a relatively small sample size with only seven studies having a sample size >100.

CONCLUSIONS

There has been a substantial increase in the number of RCTs evaluating early interventions in ASD. However, few studies, only 12.5% of the total, were rated as being at low risk of bias. Small sample size, unclear concealment of allocation and lack of clarity in the identification of the active ingredients in a diverse range of differently named treatment models were identified as challenges to the design, conduct and interpretation of studies. Improved co-ordination and design of studies is, therefore, required if future research in the field is to more clearly investigate the effects of early intervention for ASD.

Efficacy of early interventions for infants and young children with, and at risk for, autism spectrum disorders

With advances in the field's ability to identify autism spectrum disorders (ASD) at younger ages, the need for information about the evidence-base for early intervention continues to rise. This review of the ASD early intervention (EI) literature focuses on efficacy studies published within the past 15 years. The neurodevelopmental context for early intervention, timing of initiating intervention, primary intervention approaches, and predictors of treatment outcomes are discussed. The evidence indicates that young children with ASD benefit from EI, and their parents learn to implement child-responsive engagement strategies when a parent-coaching intervention is provided. Evidence supports combining parent-mediated and direct clinician-implemented intervention to maximize child developmental gains. Clinical practice recommendations are presented, based on the literature reviewed.

The efficacy of VIPP-V parenting training for parents of young children with a visual or visual-and-intellectual disability: a randomized controlled trial

Video-feedback Intervention to promote positive parenting-visual (VIPP-V) or visual-and-intellectual disability is an attachment-based intervention aimed at enhancing sensitive parenting and promoting positive parent-child relationships. A randomized controlled trial was conducted to assess the efficacy of VIPP-V for parents of children aged 1-5 with visual or visual-and-intellectual disabilities. A total of 37 dyads received only care-as-usual (CAU) and 40 received VIPP-V besides CAU. The parents receiving VIPP-V did not show increased parental sensitivity or parent-child interaction quality, however, their parenting self-efficacy increased. Moreover, the increase in parental self-efficacy predicted the increase in parent-child interaction. In conclusion, VIPP-V does not appear to directly improve the quality of contact between parent and child, but does contribute to the self-efficacy of parents to support and to comfort their child. Moreover, as parents experience their parenting as more positive, this may eventually lead to higher sensitive responsiveness and more positive parent-child interactions.

Randomised trial of a parent-mediated intervention for infants at high risk for autism: longitudinal outcomes to age 3 years

BACKGROUND

There has been increasing interest in the potential for pre-emptive interventions in the prodrome of autism, but little investigation as to their effect.

METHODS

A two-site, two-arm assessor-blinded randomised controlled trial (RCT) of a 12-session parent-mediated social communication intervention delivered between 9 and 14 months of age (Intervention in the British Autism Study of Infant Siblings-Video Interaction for Promoting Positive Parenting), against no intervention. Fifty-four infants (28 intervention, 26 nonintervention) at familial risk of autism but not otherwise selected for developmental atypicality were assessed at 9-month baseline, 15-month treatment endpoint, and 27- and 39-month follow-up.

PRIMARY OUTCOME

severity of autism prodromal symptoms, blind-rated on Autism Observation Schedule for Infants or Autism Diagnostic Observation Schedule 2nd Edition across the four assessment points.

SECONDARY OUTCOMES

blind-rated parent-child interaction and child language; nonblind parent-rated communication and socialisation. Prespecified intention-to-treat analysis combined estimates from repeated measures within correlated regressions to estimate the overall effect of the infancy intervention over time.

RESULTS

Effect estimates in favour of intervention on autism prodromal symptoms, maximal at 27 months, had confidence intervals (CIs) at each separate time point including the null, but showed a significant overall effect over the course of the intervention and follow-up period (effect size [ES] = 0.32; 95% CI 0.04, 0.60; p = .026). Effects on proximal intervention targets of parent nondirectiveness/synchrony (ES = 0.33; CI 0.04, 0.63; p = .013) and child attentiveness/communication initiation (ES = 0.36; 95% CI 0.04, 0.68; p = .015) showed similar results. There was no effect on categorical diagnostic outcome or formal language measures.

CONCLUSIONS

Follow-up to 3 years of the first RCT of a very early social communication intervention for infants at familial risk of developing autism has shown a treatment effect, extending 24 months after intervention end, to reduce the overall severity of autism prodromal symptoms and enhance parent-child dyadic social communication over this period. We highlight the value of extended follow-up and repeat assessment for early intervention trials.

Preventing enduring behavioural problems in young children through early psychological intervention (Healthy Start, Happy Start): study protocol for a randomized controlled trial

BACKGROUND

Behavioural problems are common in early childhood, and can result in enduring costs to the individual and society, including an increased risk of mental and physical illness, criminality, educational failure and drug and alcohol misuse. Most previous research has examined the impact of interventions targeting older children when difficulties are more established and harder to change, and have rarely included fathers. We are conducting a trial of a psychological intervention delivered to families with very young children, engaging both parents where possible.

METHODS

This study is a two-arm, parallel group, researcher-blind, randomized controlled trial, to test the clinical effectiveness and cost-effectiveness of a parenting intervention, Video Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD) for parents of young children (12-36 months) at risk of behavioural difficulties. VIPP-SD is an evidence-based parenting intervention developed at Leiden University in the Netherlands which uses a video-feedback approach to support parents, particularly by enhancing parental sensitivity and sensitive discipline in caring for children. The trial will involve 300 families, who will be randomly allocated into either an intervention group, who will receive the video-feedback intervention (n = 150), or a control group, who will receive treatment as usual (n = 150). The trial will evaluate whether VIPP-SD, compared to treatment as usual, leads to lower levels of behavioural problems in young children who are at high risk of developing these difficulties. Assessments will be conducted at baseline, and 5 and 24 months post-randomization. The primary outcome measure is a modified version of the Preschool Parental Account of Child Symptoms (Pre-PACS), a structured clinical interview of behavioural symptoms. Secondary outcomes include caregiver-reported behavioural difficulties, parenting behaviours, parental sensitivity, parental mood and anxiety and parental relationship adjustment. An economic evaluation will also be carried out to assess the cost-effectiveness of the intervention compared to treatment as usual.

DISCUSSION

If shown to be effective, the intervention could be delivered widely to parents and caregivers of young children at risk of behavioural problems as part of community based services.

TRIAL REGISTRATION

ISRCTN Registry: ISRCTN58327365 . Registered 19 March 2015.

Feasibility and efficacy of an attachment-based intervention in a maltreatment sample in residential care: A pilot study

The effects of the Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline on improving maternal sensitivity and sensitive discipline were investigated using a randomized control design in a pilot sample of mothers at high risk of maltreatment. The study included 12 mothers and their 10- to 36-month-old children placed in parental residential care, due to a guardianship order issued by the Youth Court. Both at pretest and post-test, maternal sensitivity and sensitive discipline were assessed during mother-child interaction via observational measures. Mothers who received the intervention showed a significant reduction in dysfunctional strategies of maternal discipline. Results highlight the usefulness and feasibility of a brief residential care-based intervention in such a risk sample, with promising implications for the prevention of child maltreatment.

Systemic-attachment formulation for families of children with autism

Purpose

Case formulation has gained increasing prominence as a guide to intervention across a range of clinical problems. It offers a contrasting orientation to diagnosis and its value is considered in the context of clinical work with autistic spectrum disorders (ASD). The purpose of this paper is to argue that case formulation integrating attachment, systemic and narrative perspectives offers a valuable way forward in assisting people with the diagnosis and their families.

Design/methodology/approach

The literature on ASD and related conditions is reviewed to examine levels of co-morbidity, consider the role of parental mental health difficulties and explore the issues inherent with current approaches to diagnosis.

Findings

ASD is found to have a high level of co-morbidity with other difficulties, such as anxiety and insecure attachment. Research findings, alongside the authors own clinical experience, are developed to suggest that formulation can allow the possibility of early intervention based on a holistic appraisal of the array of difficulties present prior to a diagnosis.

Originality/value

It is argued that the use of this systemic-attachment formulation approach could offset the exacerbation in ASD and related conditions, and deterioration in families’ mental health, whilst they face long waiting times for a diagnosis.

Alleviating Parenting Stress in Parents with Intellectual Disabilities: A Randomized Controlled Trial of a Video-feedback Intervention to Promote Positive Parenting

BACKGROUND

Adapted parenting support may alleviate the high levels of parenting stress experienced by many parents with intellectual disabilities.

METHODS

Parents with mild intellectual disabilities or borderline intellectual functioning were randomized to experimental (n = 43) and control (n = 42) conditions. Parents in both groups received care-as-usual. The experimental group also received an adapted version of video-feedback intervention for positive parenting and learning difficulties (VIPP-LD). Measures of parenting stress were obtained pre-test, post-test and 3-month follow-up.

RESULTS

Randomization to the experimental group led to a steeper decline in parenting stress related to the child compared to the control group (d = 0.46). No statistically significant effect on stress related to the parent's own functioning or situation was found.

CONCLUSIONS

The results of the study suggest the feasibility of reducing parenting stress in parents with mild intellectual disability (MID) through parenting support, to the possible benefit of their children.

Meta-analysis of parent-mediated interventions for young children with autism spectrum disorder

A number of studies of parent-mediated interventions in autism spectrum disorder have been published in the last 15 years. We reviewed 19 randomized clinical trials of parent-mediated interventions for children with autism spectrum disorder between the ages of 1 and 6 years and conducted a meta-analysis on their efficacy. Meta-analysis outcomes were autism spectrum disorder symptom severity, socialization, communication-language, and cognition. Quality of evidence was rated as moderate for autism spectrum disorder symptom severity, communication-language, and cognition, and very low for socialization. Weighted Hedges' g varied from 0.18 (communication-language) to 0.27 (socialization) and averaged 0.23 across domains. We also examined the relationship between outcome and dose of parent training, type of control group, and type of informant (parent and clinician). Outcomes were not significantly different based on dose of treatment. Comparing parent training to treatment-as-usual did not result in significantly different treatment effects than when parent training was compared to an active comparison group. Based on parent report only, treatment effects were significant for communication-language and non-significant for socialization, yet the opposite was found based on clinician-rated tools. This meta-analysis suggests that while most outcome domains of parent-delivered intervention are associated with small effects, the quality of research is improving.

Autism, attachment, and social learning: Three challenges and a way forward

We explore three challenges that Autism Spectrum Disorder (ASD) poses to our understanding of the processes underlying early attachment. First, while caregiver-infant attachment and later social-affiliative behavior share common biobehavioral mechanisms, individuals with ASD are able to form secure attachment relationships, despite reduced social-emotional reciprocity and motivation for social interaction. Therefore, disruptions in social affiliation mechanisms can co-exist with secure caregiver-infant bonding. Second, while early attachment quality is associated with later social outcomes in typical development, interventions targeting caregiver-child interaction in ASD often show positive effects on parental responsivity and attachment quality, but not on child social behavior. Therefore, improvements in parent-child bonding do not necessarily result in improvements in social functioning in ASD. Third, individuals with ASD show normative brain activity and selective social affiliative behaviors in response to people that they know but not to unfamiliar people. We propose a conceptual framework to reformulate and address these three theoretical impasses posed by ASD, arguing that the dissociable pathways of child-parent bonding and social development in ASD are shaped by (1) a dissociation between externally-driven and internally-driven attachment responses and (2) atypical learning dynamics occurring during child-caregiver bonding episodes, which are governed by and influence social-affiliation motives and other operant contingencies.

Discrepancies between direct and indirect measures of interpersonal and neurocognitive skills in autism spectrum disorder children

BACKGROUND

Subjects with autistic spectrum disorders (ASD) show persistent deficits in social interaction. In order to explore the scope of their deficits, it is of great interest to compare the different interpersonal skills and executive functions of ASD subjects to those of children with typical development. Assessing these skills usually involves a large variety of informants (parents, teachers, other family members) and of measures, with frequent discrepancies between direct performance measures and indirect measures (third-party report). Different explanations of this mismatch between measures have been addressed in previous studies.

OBJECTIVES

We wish to analyze whether there are differences between children with ASD and children with typical development on several direct performance measures of interpersonal and neurocognitive skills and one third-party report on real-life performance of interpersonal skills; we also want to look at whether discrepancies appear between the two types of measurements in the two groups of participants.

METHOD

A total of 68 Spanish children between the ages of 7 and 12 years participated; 34 were children with ASD, and 34 showed typical development. All participants were tested for recognition of emotions, solving interpersonal conflicts, and executive function.

RESULTS

Significant differences between the two groups were not found on most of the direct performance measures, but they did appear in the report by third parties, in favor of the group with typical development. There was also a significant association between neurocognitive and social variables in the latter group.

CONCLUSIONS

There were intergroup differences and discrepancies between the direct performance and indirect measures in children with ASD, and these must be explained. For this reason, future studies could seek to explain the cause of these discrepancies with a greater number of measures for each of the skills.

Video feedback compared to treatment as usual in families with parent-child interactions problems: a randomized controlled trial

BACKGROUND

For the first time to our knowledge, short- and long-term effects of a multi-site randomized-controlled trial (RCT) of video feedback of infant-parent interaction (VIPI) intervention in naturalistic settings are published. The intervention targets families with children younger than 2 years old and parent-child interactions problems. Outcome variables were 1) observed parent-child interactions and 2) parent-reported child social and emotional development. Between-group differences of the moderating effects of parental symptoms of depression, personality disorders traits, and demographic variables were investigated.

METHOD

The study had a parallel-group, consecutively randomized, single-blinded design; participants were recruited by health- and social workers. Seventy-five families received VIPI, and 57 families received treatment as usual (TAU). Videotapes of each parent-child interactions were obtained before treatment, right after treatment, and at a 6-month follow-up and coded according to Biringen's Emotional Availability Scales. Parental symptoms of depression and personality disorder traits were included as possible moderators.

RESULTS

Evidence of a short-term effect of VIPI treatment on parent-child interactions was established, especially among depressed parents and parents with problematic interactions-and, to some extent, among parents with dependent and paranoid personality disorder traits. A long-term positive effect of VIPI compared with TAU on child social/emotional development was also evident. In a secondary analysis, VIPI had a direct positive effect on the depressive symptoms of parents compared with TAU.

CONCLUSION

The findings of the study support the use of VIPI as an intervention in families with interaction difficulties.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN99793905.

Parent-mediated intervention versus no intervention for infants at high risk of autism: a parallel, single-blind, randomised trial

BACKGROUND

Risk markers for later autism identified in the first year of life present plausible intervention targets during early development. We aimed to assess the effect of a parent-mediated intervention for infants at high risk of autism on these markers.

METHODS

We did a two-site, two-arm assessor-blinded randomised controlled trial of families with an infant at familial high risk of autism aged 7-10 months, testing the adapted Video Interaction to Promote Positive Parenting (iBASIS-VIPP) versus no intervention. Families were randomly assigned to intervention or no intervention groups using a permuted block approach stratified by centre. Assessors, but not families or therapists, were masked to group assignment. The primary outcome was infant attentiveness to parent. Regression analysis was done on an intention-to-treat basis. This trial is registered with ISCRTN Registry, number ISRCTN87373263.

FINDINGS

We randomly assigned 54 families between April 11, 2011, and Dec 4, 2012 (28 to intervention, 26 to no intervention). Although CIs sometimes include the null, point estimates suggest that the intervention increased the primary outcome of infant attentiveness to parent (effect size 0.29, 95% CI -0.26 to 0.86, thus including possibilities ranging from a small negative treatment effect to a strongly positive treatment effect). For secondary outcomes, the intervention reduced autism-risk behaviours (0.50, CI -0.15 to 1.08), increased parental non-directiveness (0.81, 0.28 to 1.52), improved attention disengagement (0.48, -0.01 to 1.02), and improved parent-rated infant adaptive function (χ(2)[2] 15.39, p=0.0005). There was a possibility of nil or negative effect in language and responsivity to vowel change (P1: ES-0.62, CI -2.42 to 0.31; P2: -0.29, -1.55 to 0.71).

INTERPRETATION

With the exception of the response to vowel change, our study showed positive estimates across a wide range of behavioural and brain function risk-markers and developmental outcomes that are consistent with a moderate intervention effect to reduce the risk for later autism. However, the estimates have wide CIs that include possible nil or small negative effects. The results are encouraging for development and prevention science, but need larger-scale replication to improve precision.

FUNDING

Autistica, Waterloo Foundation, Autism Speaks, and the UK Medical Research Council.