Parent-mediated early intervention for young children with autism spectrum disorders (ASD)

A bibliometric analysis of the current state of research on family interventions for ASD

In recent years, family intervention has become a hot research direction in the field of autism spectrum disorder (ASD) treatment. A large amount of research literature shows that family intervention is effective in ASD rehabilitation. Still, the concept of family intervention is vaguely defined, and there is a lack of descriptions of specific intervention programs and treatment pathways and a diversity of intervention programs have been reported. In this study, we conducted an econometric analysis of the literature on family intervention for ASD to clarify the concept of family intervention and to analyze and explore the research hotspots, effective family intervention models for ASD, intervention techniques, and possible future research directions in this field.

Methods

A metrological analysis of the literature related to ASD family interventions on the Web of Science from 1987 to 2024 was conducted using CiteSpace software to map the network of countries/institutions, journals, authors, co-cited literature, and keywords in the field. The results were visualized and analyzed.

Results

A total of 1,891 documents were retrieved. The United States (1,028) led in the number and relevance of publications, followed by Canada (254) and Australia (209). The trend of publications was upward. Baranek was the most published author (19) and the University of California System was the most published university. Developed countries dominate the research. According to the timeline graph, it can be learned that the current research hotspots in this field are mostly focused on early intervention in family-based, psychological stress in parents of children with autism.

Conclusion

This visual analysis identifies the most influential institutions and countries, as well as cited journals and authors in the field of family therapy autism research. The direction of research in family therapy for autism should be to find effective treatments for autism based on the home environment, and currently, the most prominent family therapy for autism is telemedicine and parent-mediated intervention. The future direction of this research area could be taken by artificial intelligence techniques specifically applied to children with autism in a computer context.

Scoping Review: Caregiver Training to Reduce Challenging Behaviors Displayed by Children on the Autism Spectrum

Effective intervention for children on the autism spectrum who engage in challenging behavior is critical. To ensure meaningful behavior change, caregiver training to support intervention implementation in the natural environment is often required. It is fortunate that both behavioral interventions and caregiver training are considered evidence-based for the reduction of challenging behavior. However, behavioral interventions may be comprised of an idiosyncratic combination of behavior-change strategies that require caregivers to accurately implement several strategies simultaneously or sequentially. The complexity of these interventions may affect parents' ability to implement interventions accurately and consistently in the natural environment, which may in turn affect child outcomes. However, no review has synthesized the evidence from single-case design studies that evaluate the effects of caregiver training on a variety of caregiver-mediated interventions for autistic children who engage in challenging behavior. Given the complexity of caregiver training and caregiver-mediated interventions, and their increasing popularity, a greater understanding of the related evidence is warranted. We identified trends in participant demographics, caregiver training approaches implemented, child challenging behavior addressed, and behavioral intervention approaches employed. We propose recommendations for interpreting and applying results in practice, and avenues for future research directions.

Parental Distress and Parenting Behavior in Families of Preschool Children with and Without ASD: Spillover and Buffering

Parents of children with autism spectrum disorder (ASD) report increased distress relative to parents of children with neurotypical development. Parent well-being is generally considered a key determinant of parenting behavior, thus increased distress may spill over into less optimal parenting in families of children with ASD. However, evidence is mixed regarding the degree to which parenting is actually compromised in this population, suggesting the possibility of buffering, wherein the parenting of children with ASD may be robust against spillover from increased parental distress. The current study tested competing spillover and buffering models with regard to relations among child ASD status, parental distress, and parenting behavior. Parents of preschoolers with (n = 73) and without (n = 55) ASD completed self-report measures of parenting stress, depressive symptoms, and emotion dysregulation, as well as of positive and negative parenting behaviors. Families of preschoolers with ASD reported higher distress and negative parenting, and lower positive parenting than did their counterparts. Findings supported the spillover model for negative parenting such that increased parental distress accounted for status-group differences in negative parenting. In contrast, potential buffering was observed for positive parenting in that an inverse association between distress and parenting was observed for parents of children with neurotypical development only. Findings highlight the potential benefit of intervention to reduce parental distress in families of children with ASD, but also suggest some existing ability of these families to buffer certain parenting behaviors from deleterious effects of parent distress.

Parent Perspectives on Parent-Mediated Intervention for Young Children With Down Syndrome

BACKGROUND

Parent-mediated intervention (PMI) is a potentially scalable approach for tailored interventions in neurogenetic conditions like Down syndrome (DS). Because PMIs require ongoing parent engagement, they must be developed in alignment with the needs of intended users. The present study examined caregiver opinions and preferences to inform the development of syndrome-informed interventions for children with DS.

METHOD

Parents of children with DS (n = 34) participated in focus groups discussing PMI. Interviews were transcribed and a thematic analysis was applied to code the data.

RESULTS

Three themes were identified: advantages of PMI, disadvantages of PMI and preferred features of PMI. To align with parent preferences, future PMIs for children with DS should require a brief time commitment, blend intervention activities into daily routines and include family members in activities.

CONCLUSIONS

Findings have implications for developing novel interventions to support early development in children with DS and other neurogenetic conditions.

Using music to assist language learning in autistic children with minimal verbal language: The MAP feasibility RCT

LAY ABSTRACT

Research has shown that autistic individuals often have unusually good musical skills and that combining words and music helps autistic individuals to focus on spoken words. This study tests the idea that music will help with early language learning of preschool autistic children. The results show that when caregivers sing words to autistic children, the children pay more attention to the caregiver than when the words are spoken and that they learn word combinations more easily.

Parent-Mediated Occupational Therapy Interventions for Children with Developmental Disabilities: A Scoping Review

AIM

This scoping review synthesizes literature about occupational therapy parent-mediated interventions (PMIs) that target occupation-based outcomes for children with developmental disabilities (DD).

METHODS

A search of PubMed, Web of Science, and CINAHL from 2010 through 2023 was performed resulting in 471 publications. Studies were included if they involved PMIs for participants with DD aged 3-12 years and were published in English. Studies were excluded if the outcomes were not occupation-based. A thematic analysis was conducted following an iterative review of charted data.

RESULTS

Twelve studies met the inclusion criteria reflecting four themes across occupational therapy PMIs, including variation in terminologies, types of PMIs, key components of PMIs, and the overall impact. While the effects of PMIs are difficult to define due to the variability in the samples, interventions, and outcomes, this review suggests general positive impacts of PMIs.

CONCLUSION

The emerging body of evidence supporting PMIs within the field of occupational therapy suggests they are feasible and have the potential to improve child and parent outcomes when delivered to children with DD. Further research is needed to clarify PMIs' components, unify the identification terminology, and test the efficacy of different types of PMIs for specific populations.

Unraveling the Spectrum: A Comprehensive Review of Autism Spectrum Disorder in India

Autism spectrum disorder (ASD) is a complex neurodevelopmental condition characterized by deficits in social interaction, communication difficulties, and repetitive behaviors that profoundly impact the lives of affected individuals and their families. This article provides a comprehensive overview of ASD, focusing on screening, diagnosis, and intervention strategies. Early signs of ASD can manifest in infancy, but parents may not recognize them until their child falls behind in meeting social milestones. This delay in recognition is often due to a lack of awareness, societal stigma, and limited knowledge about developmental and behavioral disorders. Globally, ASD prevalence is increasing potentially due to broader diagnostic criteria, increased awareness, and improved screening practices. Screening for ASD is crucial for early identification and intervention. Various tools are available such as the Modified Checklist for Autism in Toddlers (M-CHATs), Trivandrum Autism Behavioral Checklist (TABC), and the Social Communication Questionnaire (SCQ). Diagnosing ASD involves using established criteria such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and specific diagnostic tools like the Autism Diagnostic Observation Schedule (ADOS) and the Indian Scale for the Assessment of Autism (ISAA). Interventions for ASD should be multidisciplinary, involving professionals such as developmental pediatricians, psychologists, psychiatrists, special educators, occupational therapists, physiotherapists, speech therapists, and social workers. Applied behavior analysis (ABA), naturalistic developmental behavioral interventions (NDBIs), and parent-mediated treatment are among the evidence-based approaches. Additionally, speech-language therapy, motor therapy, and sensory integration therapy play vital roles in addressing the diverse needs of individuals with ASD. Medical interventions should be used alongside behavioral and environmental strategies. Early screening, accurate diagnosis, and tailored interventions are essential for improving the lives of individuals with ASD. A multidisciplinary approach and increased awareness are crucial in addressing the growing prevalence of ASD worldwide.

Changes in Caregiver Outcomes After Participation in the Engaged Eaters Program: A Caregiver-Mediated Feeding Intervention for Autistic Children and Their Families

IMPORTANCE

Caregivers are essential partners in caregiver-mediated interventions that build on family routines and practices. Research identifying how participation as an intervention partner influences caregivers' outcomes, including stress and self-efficacy, is scarce.

OBJECTIVE

To evaluate caregiver outcomes (stress, self-efficacy, and positive feeding responses and confidence) after participation in the Engaged Eaters Program.

DESIGN

Quasi-experimental pretest-posttest design.

SETTING

In-home via telehealth.

PARTICIPANTS

Fourteen primary caregivers of an autistic child (ages 2-7 yr) with feeding challenges.

INTERVENTION

The Engaged Eaters Program-Telehealth, a caregiver-mediated 6-mo in-home telehealth feeding intervention for autistic children ages 2 to 7 yr that included 24 intervention visits, eight caregiver training modules, and consultation with a dietician.

OUTCOMES AND MEASURES

Relationships between child feeding challenge severity and caregiver outcomes and individual differences in caregivers' intervention responses were evaluated. We assessed caregivers' stress (Parenting Stress Index, Fourth Edition Short Form), self-efficacy (Parent Sense of Competence Scale), Positive Feeding Responses and Confidence (PFRC; composite score of items from other assessments), and individual intervention response using pre- to postintervention change in scores.

RESULTS

Exploration of individual differences revealed that only caregivers with intake PFRC scores below the mean made significant improvements by the end of the intervention. No significant group-level changes were identified for stress, self-efficacy, or PFRC. Feeding challenge severity was not significantly related to caregiver outcomes.

CONCLUSIONS AND RELEVANCE

The results emphasize the importance of considering baseline practices, efficacy, and caregiver confidence when engaging caregivers in intervention. Future research should explore the nuanced relationship between caregiver outcomes and child characteristics. Plain-Language Summary: Caregivers are essential partners with feeding interventions that build on family routines and practices. When working with caregivers, occupational therapists should consider caregivers' readiness for and responses to an intervention because intervention practices may differentially affect caregivers' parenting practices, confidence, and self-efficacy. Caregivers' responses may also affect the overall effectiveness of a caregiver-mediated intervention. Positionality Statement: The term caregiver-mediated in used throughout this article in place of parent-mediated to be inclusive of all types of caregivers.

Maternal obesity and diabetes during pregnancy and early autism screening score at well-child visits in standard clinical practice

LAY ABSTRACT

Early intervention and treatment can help reduce disability in children diagnosed with autism spectrum disorder. Screening for autism spectrum disorder in young children identifies those at increased likelihood of diagnosis who may need further support. Previous research has reported that exposure to maternal obesity and diabetes during pregnancy is associated with higher likelihood of autism spectrum disorder diagnosis in children. However, little is known about whether these maternal conditions are associated with how very young children score on autism spectrum disorder screening tools. This study examined associations between exposure to maternal obesity and diabetes during pregnancy and offspring scores on the Quantitative Checklist for Autism in Toddlers, an autism spectrum disorder screening questionnaire administered between 18-24 months at well-child visits. A higher score on the Quantitative Checklist for Autism in Toddlers suggests a higher likelihood of autism spectrum disorder; children with scores 3 or greater are referred to developmental pediatricians for evaluation. Our study found that children of mothers with obesity or diabetes during pregnancy had higher scores than children whose mothers did not have these conditions. Associations with maternal obesity and gestational diabetes diagnosed at or before 26 weeks of pregnancy were also present in children who did not have later autism spectrum disorder diagnoses, suggesting that exposure to these conditions during early pregnancy may be associated with a broad range of social and behavioral abilities. Identifying associations between maternal health conditions and early Quantitative Checklist for Autism in Toddlers screening scores could influence future screening and provision of support for children of mothers with these conditions.

Comparative effects of mindfulness-based stress reduction and psychoeducational support on parenting stress in families of autistic preschoolers

LAY ABSTRACT

Parents of autistic children often experience high levels of parenting stress, which can have negative mental and physical effects on both the parent and child. This study tested the efficacy of mindfulness-based stress reduction in reducing parenting stress in parents of preschool-aged autistic children compared to a psychoeducation and support intervention. We assessed parenting stress before and after the interventions and at 6- and 12-month follow-up. Both interventions significantly decreased parenting stress, but mindfulness-based stress reduction reduced stress more than did psychoeducation and support, with the strongest effect observed 1 year later. This suggests that the stress-reducing benefits of mindfulness-based stress reduction persist and may increase over time.

Setting Families Up for Success: A Pilot Study of a Toolkit to Enhance the Autism Spectrum Disorder Diagnostic Evaluation Process

Families of children with autism spectrum disorder (ASD) face challenges engaging in services following diagnosis. This study: (1) developed and implemented a toolkit to tailor ASD evaluation feedback to families' needs, and (2) evaluated caregiver and provider perceptions of the toolkit. Focus groups with providers (N = 11) informed toolkit development. Seven providers participated in pilot training and implementation. Provider and caregiver toolkit perceptions were assessed using interviews, surveys, and a fidelity checklist. Toolkit strategies reflect focus group themes. Provider and caregiver ratings suggest the initial feasibility, acceptability, and utility of the toolkit. This toolkit may be feasible to implement in community settings and may increase caregiver satisfaction, though further refinements are needed to support service connection.

Influence of parental education on the intelligence quotient profiles and socially adaptive behavior of school-age children with autism spectrum disorder in eastern China

Intelligence quotient (IQ) and adaptive behavior are the influencing factors of autism spectrum disorder (ASD) in children entering mainstream schools. This study explored the association between parental education level, IQ, and adaptive behavior in ASD groups. A total of 257 school-age ASD children were enrolled in our study from January 2017 to June 2021. Their parents completed a standard demographic form, including age at autism diagnosis, gender, school placement, and parents' educational background. The Chinese version of the Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV) was completed by a certified assessor for each enrolled child. Parents were interviewed on adaptive behavior using the Chinese version of the Adaptive Behavior Assessment System, Second Edition (ABAS-II). The average IQ of school-age ASD children was 76.88 (standard deviation (SD)=22.62) and boys had higher IQ levels than girls. The IQ was positively correlated with age. The General Adaptive Composite (GAC) score was 82.47 (SD=15.86) and adaptive behavior did not increase with age. ASD children who attended mainstream schools had better adaptive behavior profiles than other children. The mother's education level showed a significant correlation with the IQ and adaptive behavior of autistic children, while the father's education level did not. Consequently, better training and support for parents may help autistic children enter mainstream schools, with adaptive training being the most urgently required skill for parents.

Restricted and repetitive behaviors and association with cognition and adaptive functioning in children with autism spectrum disorder in Singapore

Background

One of the core features of autism spectrum disorder (ASD) is restricted, repetitive patterns of behavior, interests and activities (RRBs). RRBs are known to adversely affect cognition and adaptive functioning. We explored the relationship of RRBs with cognition and adaptive functioning in children with ASD in an Asian setting.

Methods

This cross-sectional study was conducted at a tertiary developmental pediatrics center in Singapore from September 2019 to October 2021. Parent-child dyads (parents and their children ≤7 years old diagnosed with ASD) were recruited. Parents completed the Repetitive Behavior Questionnaire-2 (RBQ-2), which reports total score and two subscales - Motor/Sensory Behaviors (RBQ-2 MS) and Rigidity/Routines/Preoccupation with Restricted Interests (RBQ-2 RRPRI). Standardized assessments included Mullen Scales of Early Learning (MSEL) and Vineland Adaptive Behavior Scales (VABS-II). Data analysis utilized descriptive statistics and Pearson's correlation.

Results

Parents of 113 children [75.2% male, mean (SD) age 5.0 (1.2) years] participated. Median (IQR) RBQ-2 score was 29.0 (11.0). Significant negative correlations (adjusted for age, gender and family history of ASD) were observed for total RBQ-2 scores with MSEL ELC scores (r = -0.248, n = 101, p = 0.014) and VABS-II ABC scores (r = -0.281, n = 88, p = 0.009). Specifically, these correlations of fair strength were seen only with the RBQ-2 MS subscale for both ELC (r = -0.321, n = 101, p = 0.001) and ABC (r = -0.3478, n = 88, p = 0.001).

Conclusion

In children with ASD, severity of RRBs correlated with adverse cognition and adaptive functioning measures in our study, consistent with Western literature. While our study does not show causality, it adds to literature serving as a foundation for further research for both clinicians and researchers to target RRBs in improving outcomes with children in ASD.

Examining Treatment Outcomes Across Contexts: How Do Child Baseline Characteristics Impact Measurement of Treatment Response?

The evaluation of the overlap between the ADOS BOSCC and Standard BOSCC as well as the exploration of child characteristics that may predict change are important steps in consolidating data-driven definitions of "improvement". Participants were seen between 2 and 5 times with Standard BOSCC and ADOS BOSCC observations over the course of early intervention trials (Grzadzinski et al. in J Autism Dev Disord 46:2464, 2016; Kim et al. in Autism 23:5, 2019). Results showed consistency between the Standard BOSCC and ADOS BOSCC, highlighting the utility of both as metrics of change and treatment outcome across contexts. Baseline characteristics may play a role in the tailoring of early intervention to maximize treatment outcome and may offer guidance when determining which outcome measures to use.

Optimizing Parent Training to Improve Oral Health Behavior and Outcomes in Underserved Children with Autism Spectrum Disorder

A randomized controlled trial established initial efficacy of a novel parent training (PT) intervention for improving oral hygiene and oral health in underserved children with ASD (Fenning et al., 2022), a population at risk for unmet dental needs. The present study describes our emic approach to PT development alongside treatment outcome data examining feasibility, acceptability, and engagement. Families with Medicaid-eligible children with ASD ages 3 to 13 years (85% male, 62% with intellectual disability) were assigned to receive PT (n = 60) or a psychoeducational toolkit (n = 59). Results indicate strong retention, fidelity, and adherence, with quantitative and qualitative metrics revealing high treatment satisfaction and utilization. Discussion focuses on implications for individualizing treatment to optimize engagement of underrepresented families.

Characterizing Accommodations by Parents of Young Children with Autism: A Mixed Methods Analysis

Symptoms of autism influence families' participation in daily activities, but few studies have broadly explored the types of accommodations caregivers make to their family's routines after their child is diagnosed with autism. The current study used a mixed-methods approach to characterize the rate and types of accommodations made by 171 families and the child and family characteristics that predicted accommodations. Most families (91%) endorsed making accommodations in the past year. Lower income, older child age, marginalized racial/ethnic identity, and higher levels of child problem behavior predicted accommodations in a greater number of domains. Thematic analysis illuminated the types of accommodations caregivers made and their motivation for making these lifestyle adjustments. Findings have important implications for parent-mediated interventions and policy.

Clinician Intentions to use the Components of Parent Coaching Within Community Early Intervention Systems

PURPOSE

Parent coaching is a complex, psychosocial intervention with multiple core components. Clinicians' use of these core components may be influenced by distinct factors; no research has examined whether clinician perceptions of parent coaching vary across core coaching components. This study aimed to examine the extent to which clinicians working with families of young autistic children in publicly funded early intervention intend to use core parent coaching components, and to examine how closely psychological factors relate to providers' intentions to use each component.

METHODS

Using the Theory of Planned Behavior as a framework, this study compared the strength of clinicians' intentions across five core parent coaching components: collaboration with parents, delivering the intervention within daily routines, demonstrating the intervention, providing in-vivo feedback, and reflection and problem solving. We examined the associations between intentions and psychological determinants of intentions (i.e., attitudes, norms, and self-efficacy) for each component.

RESULTS

Clinicians' average intentions varied by core component, with strongest intentions for demonstrating the intervention strategy for a parent. The associations between intentions and psychological determinants also varied by core component. Attitudes, injunctive norms, and self-efficacy, but not descriptive norms, significantly related to clinicians' intentions to use collaboration and daily routines, whereas attitudes and descriptive norms, but not injunctive norms and self-efficacy, significantly related to clinicians' intentions to use feedback and reflection and problem solving.

CONCLUSION

These results suggest that implementation strategies should be tailored to the specific intervention component to be most efficient and effective. The results also provide examples of potentially malleable factors that implementation strategies can strategically target.

Practical Aspects of ASD Management-What Pediatricians Should Know

The increasing prevalence of autism spectrum disorder (ASD) warrants higher levels of clinical attention to optimally manage children with ASD. There is mounting evidence that early intervention programs can help improve developmental functioning, maladaptive behaviors, and core ASD symptoms. The most thoroughly investigated and evidence-based therapies have been developmental, behavioral, and educational interventions mediated by either professionals or parents. Other commonly available interventions include speech and language therapy, occupational therapy, and social skills training. Pharmacological interventions, where needed, are used as an adjunct to treat severe problem behaviors and manage medical and psychiatric comorbidities. Complementary or alternative medicine (CAM) approaches have not proven to be of any benefit, and some of them may be harmful to the child. As the child's first point of contact, the pediatrician is well-positioned to effectively guide the families to therapies that are evidence-based and safe and also collaborate with various specialists to provide seamless, coordinated care for these children so as to improve their developmental outcomes and social functioning.

Non-pharmacological interventions for autistic children: An umbrella review

LAY ABSTRACT

What is already known about the topic?The delivery of evidence-based interventions is an important part of the clinical pathway for many autistic children and their families. However, parents, practitioners, and policymakers face challenges making evidence informed decisions, due to the wide variety of interventions available and the large, and often inconsistent, body of evidence regarding their effectiveness.What this paper adds?This is a comprehensive umbrella review, also known as a 'review of reviews', which examined the range of interventions available, the evidence for their effectiveness, and whether effects were influenced by factors relating to individual children (e.g. chronological age, core autism characteristics, and related skills) or the ways interventions were delivered (by whom and in what setting, format, mode, and amount). There was evidence for positive therapeutic effects for some, but not all, interventions. No single intervention had a positive effect for all child and family outcomes of interest. The influence of child and delivery characteristics on effects was unclear.Implications for practice, research, and policyThe findings provide parents, practitioners, and policymakers with a synthesis of the research evidence to inform decision-making and highlight the importance of individualised approaches in the absence of clear and consistent evidence. The findings also highlight the need to improve consistency and completeness in reporting of research studies, so that the same questions may be answered more comprehensively in the future.

A Longitudinal RCT of P-ESDM With and Without Parental Mindfulness Based Stress Reduction: Impact on Child Outcomes

This randomized controlled trial (NCT03889821) examined Mindfulness Based Stress Reduction (MBSR) in conjunction with the Parent-implemented Early Start Denver Model (P-ESDM). A previous report described improved metrics of parental distress (Weitlauf et al. in Pediatrics 145(Supplement 1):S81-S92, 2020). This manuscript examines child outcomes. 63 children with ASD (< 36 months) and their parents received 12 P-ESDM sessions. Half of parents also received MBSR. Longitudinal examination of whole sample means revealed modest improvements in autism severity, cognitive, and adaptive skills. There was not a significant time × group interaction for children whose parents received MBSR. Future work should examine more proximal markers of child or dyadic change to enhance understanding of the impact of providing direct treatment for parents as part of early intervention initiatives.

Using implementation science frameworks to explore barriers and facilitators for parents' use of therapeutic strategies following a parent-mediated autism intervention

LAY ABSTRACT

Many early autism interventions teach parents therapeutic strategies to help them adjust their communication style with their children. Research has shown that this behaviour change in parents leads to improvements in child communication. It is, therefore, important to learn what factors support or hinder parents in their use of therapeutic strategies learned in such interventions. This study set out to interview parents who had participated in a research trial of the Paediatric Autism Communication Therapy-Generalised intervention. We interviewed 27 caregivers and explored their use of the strategies up to 2 years after the end of the research trial. Qualitative frameworks were used to inform interview questions and data analysis. These frameworks focused on a range of contextual factors, including parents' characteristics, their context and features of the intervention. Parents reported barriers and facilitators to using Paediatric Autism Communication Therapy-Generalised strategies across three themes: Motivating Factors; Opportunity and Support; Parent Characteristics. One of these themes, Motivating Factors, was further divided into the subthemes Compatibility and Buy-In and Alignment of Goals and Outcomes. Almost all parents reported continued use of the Paediatric Autism Communication Therapy-Generalised strategies. Facilitators included parental confidence in using the strategies and barriers included child's behaviour. Consideration of these factors can inform ways to better support parents in future autism interventions.

Efficacy of psychosocial interventions for Autism spectrum disorder: an umbrella review

INTRODUCTION

The wide range of psychosocial interventions designed to assist people with Autism Spectrum Disorder (ASD) makes it challenging to compile and hierarchize the scientific evidence that supports the efficacy of these interventions. Thus, we performed an umbrella review of published meta-analyses of controlled clinical trials that investigated the efficacy of psychosocial interventions on both core and related ASD symptoms.

METHODS

Each meta-analysis that was identified was re-estimated using a random-effects model with a restricted maximum likelihood estimator. The methodological quality of included meta-analyses was critically appraised and the credibility of the evidence was assessed algorithmically according to criteria adapted for the purpose of this study.

RESULTS

We identified a total of 128 meta-analyses derived from 44 reports. More than half of the non-overlapping meta-analyses were nominally statistically significant and/or displayed a moderate-to-large pooled effect size that favored the psychosocial interventions. The assessment of the credibility of evidence pointed out that the efficacy of early intensive behavioral interventions, developmental interventions, naturalistic developmental behavioral interventions, and parent-mediated interventions was supported by suggestive evidence on at least one outcome in preschool children. Possible outcomes included social communication deficits, global cognitive abilities, and adaptive behaviors. Results also revealed highly suggestive indications that parent-mediated interventions improved disruptive behaviors in early school-aged children. The efficacy of social skills groups was supported by suggestive evidence for improving social communication deficits and overall ASD symptoms in school-aged children and adolescents. Only four meta-analyses had a statistically significant pooled effect size in a sensitivity analysis restricted to randomized controlled trials at low risk of detection bias.

DISCUSSION

This umbrella review confirmed that several psychosocial interventions show promise for improving symptoms related to ASD at different stages of life. However, additional well-designed randomized controlled trials are still required to produce a clearer picture of the efficacy of these interventions. To facilitate the dissemination of scientific knowledge about psychosocial interventions for individuals with ASD, we built an open-access and interactive website that shares the information collected and the results generated during this umbrella review.

PRE-REGISTRATION

PROSPERO ID CRD42020212630.

Parental experience of parent-mediated intervention for children with ASD: A systematic review and qualitative evidence synthesis

LAY ABSTRACT

The effectiveness of parent-mediated interventions in the field of autism spectrum disorder is well documented but information on the experience of parents involved in parent-mediated interventions is limited.This study is the first synthesis of evidence concerning the experience of parents involved in parent-mediated interventions. It synthesizes the voice of 345 parents across the world into four general themes: barriers to implementation and logistical issues, feeling overwhelmed and stressed (a need for support), facilitators of implementation, and empowerment in the parent and improvement in the child.The findings of our study provide evidence that parent-mediated interventions should be adapted to the needs of each family. Specific care and support should be offered to parents in addition to parent-mediated interventions. Our study, however, highlights which outcomes are important to parents and should be considered in future studies.

Risk factors for ASD : Risk Factors for Autism Spectrum Disorder in Shanghai, China: A Population-based Case-control Study

Autism spectrum disorder (ASD) is a pervasive neurodevelopmental disorder that brings heavy burdens to families and the society. This case-control study explored risk factors for ASD based on 74,252 children aged 3-12 years who were recruited from general education kindergartens, primary schools, and special education schools in Shanghai, China. One hundred ninety-two children were identified with ASD according to the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition. Male sex, the presence of anoxia or asphyxia at birth, artificial feeding, adverse maternal psychological status, complications during pregnancy and higher paternal education were associated with ASD even after controlling for age, residential district, family history of mental disorders, parental personality, and amount of daily TV viewing.

Pivotal Response Treatment (PRT) parent group training for young children with autism spectrum disorder: a pilot study

Pivotal Response Treatment (PRT) is a promising intervention addressing core symptoms of autism spectrum disorder (ASD), with parent involvement as key component. Parent group-delivered PRT may be an effective treatment model, but currently the evidence is limited. Also, little attention has been paid to therapeutic involvement of multiple important contexts (e.g. home, school, community) of the young child. The current study explores a 14-week protocol of PRT parent group training (PRT-PG), complemented with individual parent–child sessions and involvement of teachers and other childcare providers. Children aged 2–6 years old with ASD and their parents (n = 20) were included. Preliminary results showed a significant increase in spontaneous initiations during a semi-structured therapist-child interaction together with widespread gains in clinical global functioning. No significant improvement on parent-rated general social-communication skills was observed. These findings justify further research on parent group delivered PRT models.

Music therapy for autistic people

BACKGROUND

Social interaction and social communication are among the central areas of difficulty for autistic people. Music therapy uses music experiences and the relationships that develop through them to enable communication and expression, thus attempting to address some of the core problems of autistic people. Music therapy has been applied in autism since the early 1950s, but its availability to autistic individuals varies across countries and settings. The application of music therapy requires specialised academic and clinical training which enables therapists to tailor the intervention to the specific needs of the individual. The present version of this review on music therapy for autistic people is an update of the previous Cochrane review update published in 2014 (following the original Cochrane review published in 2006).

OBJECTIVES

To review the effects of music therapy, or music therapy added to standard care, for autistic people.

SEARCH METHODS

In  August 2021, we searched  CENTRAL, MEDLINE, Embase, eleven other databases and two trials registers. We also ran citation searches, checked reference lists, and contacted study authors to identify additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trials and controlled clinical trials comparing music therapy (or music therapy alongside standard care) to 'placebo' therapy, no treatment, or standard care for people with a diagnosis of autism spectrum disorder were considered for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Four authors independently selected studies and extracted data from all included studies. We synthesised the results of included studies in meta-analyses. Four authors independently assessed risk of bias (RoB) of each included study using the original RoB tool as well as the certainty of evidence using GRADE.   MAIN RESULTS: We included 16 new studies in this update which brought the total number of included studies to 26 (1165 participants). These studies examined the short- and medium-term effect of music therapy (intervention duration: three days to eight months) for autistic people in individual or group settings. More than half of the studies were conducted in North America or Asia. Twenty-one studies included children aged from two to 12 years. Five studies included children and adolescents, and/or young adults. Severity levels, language skills, and cognition were widely variable across studies. Measured immediately post-intervention, music therapy compared with 'placebo' therapy or standard care was more likely to positively effect global improvement (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.06 to 1.40; 8 studies, 583 participants; moderate-certainty evidence; number needed to treat for an additional beneficial outcome (NNTB) = 11 for low-risk population, 95% CI 6 to 39; NNTB = 6 for high-risk population, 95% CI 3 to 21) and to slightly increase quality of life (SMD 0.28, 95% CI 0.06 to 0.49; 3 RCTs, 340 participants; moderate-certainty evidence, small to medium effect size). In addition, music therapy probably results in a large reduction in total autism symptom severity (SMD -0.83, 95% CI -1.41 to -0.24; 9 studies, 575 participants; moderate-certainty evidence). No clear evidence of a difference between music therapy and comparison groups at immediately post-intervention was found for social interaction (SMD 0.26, 95% CI -0.05 to 0.57, 12 studies, 603 participants; low-certainty evidence); non-verbal communication (SMD 0.26, 95% CI -0.03 to 0.55; 7 RCTs, 192 participants; low-certainty evidence); and verbal communication (SMD 0.30, 95% CI -0.18 to 0.78; 8 studies, 276 participants; very low-certainty evidence). Two studies investigated adverse events with one (36 participants) reporting no adverse events; the other study found no differences between music therapy and standard care immediately post-intervention (RR 1.52, 95% CI 0.39 to 5.94; 1 study, 290 participants; moderate-certainty evidence).  AUTHORS' CONCLUSIONS: The findings of this updated review provide evidence that music therapy is probably associated with an increased chance of global improvement for autistic people, likely helps them to improve total autism severity and quality of life, and probably does not increase adverse events immediately after the intervention. The certainty of the evidence was rated as 'moderate' for these four outcomes, meaning that we are moderately confident in the effect estimate. No clear evidence of a difference was found for social interaction, non-verbal communication, and verbal communication measured immediately post-intervention. For these outcomes, the certainty of the evidence was rated as 'low' or 'very low', meaning that the true effect may be substantially different from these results. Compared with earlier versions of this review, the new studies included in this update helped to increase the certainty and applicability of this review's findings through larger sample sizes, extended age groups, longer periods of intervention and inclusion of follow-up assessments, and by predominantly using validated scales measuring generalised behaviour (i.e. behaviour outside of the therapy context). This new evidence is important for autistic individuals and their families as well as for policymakers, service providers and clinicians, to help in decisions around the types and amount of intervention that should be provided and in the planning of resources. The applicability of the findings is still limited to the age groups included in the studies, and no direct conclusions can be drawn about music therapy in autistic individuals above the young adult age. More research using rigorous designs, relevant outcome measures, and longer-term follow-up periods is needed to corroborate these findings and to examine whether the effects of music therapy are enduring.

Research-Based Intervention (RBI) for Autism Spectrum Disorder: Looking beyond Traditional Models and Outcome Measures for Clinical Trials

The rising prevalence of Autism Spectrum Disorders (ASD) has led to a quickly increasing need for effective interventions. Several criteria and measures have been developed to critically assess these interventions with particular focus on the evaluation of the efficacy. Given the huge diversity of ASD symptoms and the different levels of severity across individuals, identifying a one size fits all intervention approach is challenging, and the question What works and for whom? Remains still unanswered. Why do we seem to be dragging our feet on this fundamental issue? The main aim of this paper is to answer this question through four non-alternative points. First, there are a scarce number of studies with a solid methodology. Secondly, most trials on intervention efficacy for ASD are designed exclusively in terms of behavioral outcomes. Thirdly, there is a reduced use of biologically oriented outcome measures. Fourthly, in most clinical trials, appropriate practices emerging from research evidence are not systematically applied. A strong effort to improve the methodology of clinical trials is mandatory for the future of autism research. The development of a research-based intervention (RBI) perspective aimed at better integrating: (a) evidence-based approaches; (b) more sensitive behavioral outcome measures; and (c) biomarkers, with the aim of increasing a more detailed clustering of phenotypes, may strongly improve our approach to a precision medicine.

A Review of Parent-Implemented Early Start Denver Model for Children with Autism Spectrum Disorder

The purpose of this review is to provide an overview of findings from selected research published between 2012 and 2022 in English-language peer-reviewed journals to evaluate the effectiveness of the parent-implemented Early Start Denver Model (P-ESDM). Thirteen studies used quantitative methods to examine the relationship between variables. We considered four categories of variables in the analysis: child characteristics, intervention intensity and duration, child outcome measures, and parent-related outcome measures and parental fidelity. The findings revealed positive child-parent-related outcomes. In addition, the quality of implementation, relating to parent fidelity, should be considered when evaluating the efficacy of the intervention. However, only half the studies revealed that the standard benchmark for acceptable fidelity was being achieved. Implications for future research and practice are discussed.

Pivotal Response Treatment (PRT) - Parent Group Training for Young Children with Autism Spectrum Disorder: A Qualitative Study on Perspectives of Parents

Pivotal Response Treatment (PRT) is considered to be an empirically supported parent-mediated treatment for children with autism spectrum disorder (ASD), but research on parental experiences is lacking. This qualitative study examined the perspectives of parents of young children with ASD who participated in a 14-week PRT with parent group training (PRT-PG). Semi-structured interviews (n = 12) were carried out, based on Grounded Theory principles. Results indicated that facilitators and barriers were related to timing and expectations, training setting and characteristics, and participant characteristics. Perceived effects were related to improved child’s social-communication skills and well-being, parental insights into their child’s needs and own habitual patterns in communication and behavior, and positive changes in family cohesion. The findings indicate that in general parents value PRT-PG as feasible and effective.

User testing of a Scottish Intercollegiate Guideline Network public guideline for the parents of children with autism

Background

The Scottish Intercollegiate Guidelines Network (SIGN) is the leading national clinical guideline producer in Scotland. Improved design and dissemination of guidelines produced for the public can empower people to take an active role in self-management and shared decision-making. The public version of the guideline examined covered getting assessed and diagnosed with autism, and approaches that can help. The aim of this study was to test a public version of a guideline for the parents of children and young people with autism, implement improvements, and identify what works in making it usable and accessible.

Methods

We recruited mothers from across Scotland. User testing involved formal ‘think aloud’ semi-structured interviews that guided users through the booklet. Interviews took place individually and were recorded and transcribed. Key findings were identified and themed using the honeycomb user experience model.

Results

Fourteen user-testing interviews were conducted. Facilitators for usability and desirability of the guideline included the chunking of text, consistent use of colour and boxes to highlight important information. Simple language, written in a tone of partnership, helped to engage mothers. Value arose from the guidelines ability to explain the process of diagnosis and make mothers feel empowered in their relationships with healthcare professionals. There was a lack of consensus on the usefulness of rating the strength of evidence and recommendations.

Conclusion

There was a marked similarity between what was important to the mothers and what has been found to be important to other groups. The involvement of service users and carers in the guidelines development was key to its credibility. One size does not fit all in presenting evidence-based recommendations to the public and it is a challenge to provide sufficient information while avoiding information overload. Recommendations and evidence levels are suitable for use in public versions, but these should be kept as simple as possible.

Quickstart for toddlers with autism spectrum disorder: A preliminary report of an adapted community-based early intervention program

Background and Aims

Early intervention (EI) for young children with autism spectrum disorder (ASD) must be resource-efficient while remaining effective; thus, clinicians are challenged to create and implement useful methods. Clinical evidence from community-based interventions that include reliable diagnoses, individual EI programs, along with comprehensive descriptions of participants, procedures, and participant outcomes can inform practice, translational research, and local policy. Parent-mediated EI for toddlers with ASD can promote positive developmental outcomes and lifelong well-being, but evidence of successful community uptake of research-based EIs is somewhat limited. The community-based, parent-mediated, evidence-informed QuickStart EI program aims to encourage toddlers' early social communication, social interactions, and relationship-building, in a community clinic setting.We aim to (1) describe our adaptations to the evidence-based Parent-Delivered Early Start Denver Model and (2) present promising findings for toddlers with or at risk for ASD and their families who received QuickStart. We also intend to motivate a similar study of EI in real-world situations to advance evidence-based practice and create relevant dialogue and questions for research.

Methods

Complete data were identified and analyzed for up to 89 toddlers diagnosed with, or at risk of, ASD. Pre- and post-intervention parent- or self-report data were analyzed using descriptive statistics and paired-sample t-tests, as appropriate. Pre-intervention measures included demographic information (n = 89) and the Early Screening of Autism and Communication (ESAC; n = 89). Measures taken pre- and post-intervention included the Adaptive Behavior Assessment System-II (n = 60), MacArthur-Bates Communication Development Inventories (n = 58), and the parental sense of competence scale (n = 62). The Measure of Processes of Care (n = 60) was taken post-intervention. On enrollment, parents signed standard clinical agreements that included statements allowing their anonymous data to be analyzed for research.

Results

Using standardized parent/self-report measures, toddler gains were noted for social interaction, language, communication skills, and ASD symptoms, but not for parents' feelings of competence. Parents identified QuickStart procedures as family centered (Measure of Processes of Care).

Conclusions

The QuickStart EI program, provided to toddlers and their families over 20 weeks in a community clinic, resulted in promising positive behavior and communication changes, as indicated on the parent-response measures, for a moderately large sample of toddlers.

Implications

This study adds to the literature by describing a new EI program with clear procedures by which clinicians can create, provide, and evaluate a readily accessible, community-based EI for toddlers with or at risk of ASD. Methodological limitations inherent to our study design that precluded a control group and necessitated a reliance on available parent-report data are carefully critiqued and discussed.

Current practices, supports, and challenges in speech-language pathology service provision for autistic preschoolers

Background

Speech-language pathology services are among the most frequently accessed services for young autistic children. Therefore, understanding the nature of these services, what challenges these clinicians face, and what supports they value is critical for developing appropriate policies and practices that can maximize positive outcomes for children and families. This study had two primary aims. The first was to examine the self-reported assessment and intervention practices of community-based Speech Language Pathologists (SLPs) and communicative disorders assistants (CDAs; who provide services under the supervision of a SLP) in supporting preschool children with suspected and diagnosed autism. The second aim was to identify barriers and supports (facilitators) to providing services in the community using the Consolidated Framework for Implementation Research (CFIR) as a framework.

Methods

A cross-sectional online survey was used to collect qualitative and quantitative data from clinicians in Ontario Canada who were providing speech and language services to preschool children with suspected or diagnosed autism. Quantitative data were used to describe clinicians" practices, and qualitative data captured their perspectives on barriers and supports to providing services.

Results

A total of 258 clinicians participated in the survey. On average, clinicians reported almost half of the preschoolers on their caseload had either diagnosed or suspected autism. There was consistency across the skill development areas assessed by SLPs, and targeted during therapy sessions, with the top four areas targeted being: foundational social communication, language, play and pragmatics. However, there was wide variation in speech and language assessment and intervention practices reported by this sample of clinicians (i.e., service delivery models, tools or programs used, length and duration of therapy services, level of collaboration with other professionals). Clinicians identified several barriers to providing services: limited funding and time, lack of inter-professional collaboration, difficulty accessing services, community messaging about autism services, family readiness and clinician knowledge. Supports (facilitators) included: access to autism-focused professional development, inter- and intra-professional collaboration, and access to additional supports in the community.

Early years autism and bilingualism: An interpretative phenomenological analysis of parent perceptions during lockdown

AIM

This study explores how bilingual parents of autistic children made language decisions for their families, how the event of the SARS-CoV-2 pandemic and subsequent lockdown impacted the communication environment of their households, and whether these experiences affected their language habits.

METHOD

Semi-structured interviews were conducted with five bilingual parents of autistic children who lived through lockdown in France. Data were analysed using interpretative phenomenological analysis. Demographic and background information was collected using an adapted version of the Questionnaire for Parents of Bilingual Children.

RESULTS

Participants reported conflicting advice given by a range of practitioners. Parents expressed differing beliefs about the impact of language choices on their children. Parents described active engagement with their children's home-learning as generally positive. Parents identified an increase in children's exposure to their first language during the lockdown. Parents reported an increase in children's overall communication abilities.

CONCLUSION

Parents believed that their children's positive communication development during lockdown was related to increased exposure to their first language(s), and direct involvement in their children's learning programs.

Maternal Immune Activation and Interleukin 17A in the Pathogenesis of Autistic Spectrum Disorder and Why It Matters in the COVID-19 Era

Autism spectrum disorder (ASD) is the commonest neurodevelopmental disability. It is a highly complex disorder with an increasing prevalence and an unclear etiology. Consensus indicates that ASD arises as a genetically modulated, and environmentally influenced condition. Although pathogenic rare genetic variants are detected in around 20% of cases of ASD, no single factor is responsible for the vast majority of ASD cases or that explains their characteristic clinical heterogeneity. However, a growing body of evidence suggests that ASD susceptibility involves an interplay between genetic factors and environmental exposures. One such environmental exposure which has received significant attention in this regard is maternal immune activation (MIA) resulting from bacterial or viral infection during pregnancy. Reproducible rodent models of ASD are well-established whereby induction of MIA in pregnant dams, leads to offspring displaying neuroanatomical, functional, and behavioral changes analogous to those seen in ASD. Blockade of specific inflammatory cytokines such as interleukin-17A during gestation remediates many of these observed behavioral effects, suggesting a causative or contributory role. Here, we review the growing body of animal and human-based evidence indicating that interleukin-17A may mediate the observed effects of MIA on neurodevelopmental outcomes in the offspring. This is particularly important given the current corona virus disease-2019 (COVID-19) pandemic as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy is a potent stimulator of the maternal immune response, however the long-term effects of maternal SARS-CoV-2 infection on neurodevelopmental outcomes is unclear. This underscores the importance of monitoring neurodevelopmental outcomes in children exposed to SARS-CoV-2-induced MIA during gestation.

Effectiveness of Online-Delivered Project ImPACT for Children With ASD and Their Parents: A Pilot Study During the COVID-19 Pandemic

OBJECTIVE

During the COVID-19 pandemic, face-to-face intervention services for families of children with autism spectrum disorder (ASD) were limited. This study aimed to evaluate the effectiveness of an 8-week, online-delivered Project ImPACT program for children with ASD and their parents in China during the COVID-19 pandemic.

METHODS

A pilot non-randomized study with a waitlist control group was conducted in 68 children with ASD and their parents in the Department of Developmental and Behavioral Pediatrics between April 15, 2020 and March 19, 2021. Participants were allocated to either the intervention (IG) or the waitlist group (WLG) according to their order of recruitment. Parents in the IG immediately received 8 weeks of the online-delivered Project ImPACT program, and the WLG received the same program with a delay when the IG had completed all sessions. Participants in both groups received treatment as usual during the research period.

RESULTS

The online-delivered Project ImPACT program significantly improved the parent-reported social communication skills of children with ASD. Furthermore, parent's involvement in the training program produced a collateral reduction in parenting stress and an increase in perceived competence in the parental role. Parents rated the program acceptable in terms of curriculum schedule, session content, homework assignments, and therapist feedback.

CONCLUSIONS

The 8-week, online-delivered Project ImPACT program is a feasible and effective social skill training program for families of children with ASD in China during the COVID-19 pandemic. Due to the methodological limitations, randomized controlled studies with larger sample sizes are suggested to provide more solid evidence.

Benefits of Parent Training in the Rehabilitation of Deaf or Hard of Hearing Children of Hearing Parents: A Systematic Review

The present study is a systematic review on the effectiveness of Parent Training (PT) and coaching in deaf and hard of hearing (DHH) rehabilitation programs which reviews and synthesizes the existing body of evidence to assess the benefits of these programs in enhancing parents' sensitivity, responsivity and promoting language development in DHH children during the first years after HA fitting or CI activation. Five published studies met the Population, Intervention, Comparison and Outcomes (PICO) inclusion criteria and were eligible to be included, but heterogeneity in terms of the study design, interventions and outcomes did not allow for performing a meta-analysis. All included studies shared the view that a parent's learning is a circular (rather than frontal) process, and the results appear promising in terms of enhancing parents' responsiveness and promoting DHH child language development. Nevertheless, the available evidence was judged to not be robust enough due to limitations in the studies' designs. Further high-quality evidence is needed to evaluate the true degree of clinical value and the cost effectiveness of PT programs aimed at increasing parents' responsiveness to their DHH children.

Effectiveness of Responsivity Intervention Strategies on Prelinguistic and Language Outcomes for Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis of Group and Single Case Studies

We conducted a systematic review to identify randomized controlled trials (RCTs) and single case research design (SCRD) studies of children with autism spectrum disorder that evaluate the effectiveness of responsivity intervention techniques for improving prelinguistic and/or language outcomes. Mean effect sizes were moderate and large for RCTs (33 studies; g = 0.36, 95% CI [0.21, 0.51]) and SCRD (34 studies; between-case standardized mean difference = 1.20, 95% CI [0.87, 1.54]) studies, respectively. Visual analysis (37 studies) revealed strong evidence of a functional relation for 45% of the opportunities and no evidence for 53%. Analyses of moderator effects and study quality are presented. Findings provide support for responsivity intervention strategies with more robust support for context-bound outcomes than more generalized outcomes.

Pre-symptomatic intervention for autism spectrum disorder (ASD): defining a research agenda

Autism spectrum disorder (ASD) impacts an individual's ability to socialize, communicate, and interact with, and adapt to, the environment. Over the last two decades, research has focused on early identification of ASD with significant progress being made in understanding the early behavioral and biological markers that precede a diagnosis, providing a catalyst for pre-symptomatic identification and intervention. Evidence from preclinical trials suggest that intervention prior to the onset of ASD symptoms may yield more improved developmental outcomes, and clinical studies suggest that the earlier intervention is administered, the better the outcomes. This article brings together a multidisciplinary group of experts to develop a conceptual framework for behavioral intervention, during the pre-symptomatic period prior to the consolidation of symptoms into diagnosis, in infants at very-high-likelihood for developing ASD (VHL-ASD). The overarching goals of this paper are to promote the development of new intervention approaches, empirical research, and policy efforts aimed at VHL-ASD infants during the pre-symptomatic period (i.e., prior to the consolidation of the defining features of ASD).

A randomised controlled feasibility trial of music-assisted language telehealth intervention for minimally verbal autistic children-the MAP study protocol

BACKGROUND

About 30% of children with autism spectrum disorder (ASD) do not develop functional speech and remain non-verbal or minimally verbal even after years of speech, language and educational interventions. A wide range of interventions have been developed for improving communication in ASD, but none have proved effective in eliciting functional language in ASD children. Research has found that people with ASD are more likely to have perfect pitch and prefer music to language. Further, it seems that language delay tends to co-occur with better musical skills. Brain imaging research has found that music alongside words increases the attention that people with ASD pay to spoken words.

METHODS

In this protocol, we describe our music-assisted programmes (MAP) that will use music to attract the attention of people with ASD to speech. MAP may open the brain pathways to language and therefore help improve communication skills for people with ASD more than standard communication protocols. In particular, we aim to develop and test whether individualised, easily used MAP would increase spoken language in 24-60-month-old, nonverbal or minimally verbal children with ASD. We will develop a structured training method, delivered through naturalistic, interactive activities (e.g. songs) to teach language to ASD children. We will test this by comparing two groups: one undertaking music-assisted programmes, and the other receiving speech and language therapy in the way that is recommended in NHS clinics. Participants will be allocated to groups randomly. The feasibility of MAP will be assessed through estimations of recruitment and retention rates, the sensitivity and reliability of the outcome measures, the intensity and frequency of the trial, the usability of the MAP app (beta version), and the burden of the assessments for the children and parents.

DISCUSSION

This feasibility randomised controlled trial will establish the acceptability and estimate the power of the MAP intervention to improve early word learning in children with ASD. In the longer term, this research will help us develop an app for parents or carers of children with ASD to design their own songs and implement their own individualised MAP.

TRIAL REGISTRATION

ISRCTN, ISRCTN12536062 . Registered on 26 June 2019.

Assessing Parent Behaviours in Parent-Child Interactions with Deaf and Hard of Hearing Infants Aged 0-3 Years: A Systematic Review

Background: Despite early identification and advancements in cochlear implant and hearing aid technology, delays in language skills in deaf children continue to exist. Good-quality parent–child interaction (PCI) is a key predictor for the successful development of deaf children’s signed and/or spoken language. Though professionals have standard assessments to monitor child language, a clinical tool to observe the quality of parental interaction is yet to be developed. Aims and methods: This systematic review with narrative synthesis aims to uncover which parent behaviours are assessed in PCI studies with deaf infants aged 0–3 years, how these behaviours are assessed, and which are correlated with higher scores in child language. Results: Sixty-one papers were included, spanning 40 years of research. Research included in the review assessed parents’ skills in gaining attention, joint engagement, emotional sensitivity, and language input. PCI was mostly assessed using coding systems and frame-by-frame video analysis. Some of the parent behaviours mentioned previously are associated with more words produced by deaf children. Conclusion: The results of the review provide the evidence base required to develop the content of a future clinical assessment tool for parent–child interaction in deafness.

Dohsa-hou intervention for reciprocal interpersonal interaction for a girl with Kabuki syndrome and autism spectrum disorder

Although available evidence for psychosocial treatment for patients with Kabuki syndrome is limited, Dohsa-hou, a psychomotor therapy, could be a treatment option for autism spectrum disorder associated with the disorder.

A Refined Model of Stress-Diathesis Relationships in Mothers With Significant Depressive Symptom Severity

BACKGROUND: Mothers' depressive symptoms affect their children's growth as well as physical and mental well-being. Moreover, mothers of young children with developmental delay or disability (DD) tend to have higher depressive symptoms. AIMS: The purpose of this study was to examine associations between maternal depressive symptoms and number of children with DD among mothers with significant levels of depressive symptoms, while accounting for maternal diathesis factors and family stress factors. METHODS: This study was a secondary analysis of pooled baseline data collected from 2004 to 2012 in the northeastern and southeastern United States from three intervention studies to reduce depressive symptoms of mothers with young children (n = 364). Multiple regression analyses were conducted to examine associations between maternal depressive symptoms and number of children with DD, followed by the post hoc pairwise comparison. RESULTS: In the model including family stress factors, we found a significant test for linear trend in the mean for maternal depressive symptoms across the number of children with DD (F[1] = 4.3, p = .0388). CONCLUSIONS: Mothers who have multiple children with DD tend to experience higher depressive symptoms; thus, interventions are needed to help prevent these mothers from experiencing higher depressive symptoms or to reduce their current depressive symptoms. Both theory-based and strength-based interventions can target conflict management at the family level, reducing maternal depressive symptoms while improving mothers' self-efficacy, which would help mothers care for their own health, manage family conflict, and seek appropriate support to manage the children's medical and developmental needs.

Preliminary Evaluation of the FETASS Training for Parents of Children With Autism Spectrum Disorder: A Pilot Study

While several recent evaluation studies have shown the efficacy of parent training programs for children with neurodevelopmental disorders, manual-based training in German is still scarce. To address this gap, we developed a specific modularized training program for parents of children from preschool to pre-adolescent age with Autism Spectrum Disorder (FETASS). The overarching purpose of the FETASS intervention is to enhance social communication behavior and quality of life of the child by coaching parents. As a proximal target, the FETASS training aims to provide families with behavior management and communication strategies. The development of the training was influenced by published behavioral parent trainings and autism-specific interventions. The training comprises eight weekly sessions and targets families whose children have a diagnosis of Autism Spectrum Disorder (ASD) without intellectual and language impairments. As a preliminary pilot study, the purpose was to evaluate the acceptability of the training. Furthermore, the study aimed at initially evaluating social communication behavior, quality of life of the child, parental stress level, and parenting after training in comparison to a treatment as usual (TAU) group. Exploratively, long-term effects were investigated after 6 months of training as well. In total, 57 families participated (n[TAU] = 29, n[FETASS] = 28). Questionnaires about social communication behavior and quality of life of the child, parental stress, and parenting were administered at three time points (t1: baseline TAU/FETASS, t2: post TAU/FETASS; and t3: 6-month follow-up after FETASS). Primary outcome measures were the social communication behavior of the child and the parent's proxy report on quality of life of the child. Secondary outcome measures were changes in parental stress and parenting behavior. Acceptability of the training was very high and we had almost no dropouts during training. Results for the primary outcome measure of social communication behavior, overall quality of life of the child, and long-term effects on social communication behavior were not significant. While long-term findings for parent stress reduction and for the quality of life of the child are promising, further research has to be done in a future randomized controlled trial.

Using qualitative content analysis to understand the active ingredients of a parent-mediated naturalistic developmental behavioral intervention

LAY ABSTRACT

Although naturalistic developmental behavioral interventions are supported by research for supporting the development of children on the autism spectrum, how they work is not well understood. This study reviewed parent reflection comments in a systematic way to better how one such treatment worked, when delivered by caregivers. Caregivers completed weekly written reflection responses as they learned how to use the treatment techniques. We studied these responses to understand caregiver perspectives on how their children responded to the techniques. The responses were then compared to a theory of how the treatment works. Many responses were consistent with the treatment theory; however, others were not. We found that individual techniques were associated with different child responses, suggesting that general measures of social communication may not measure these specific short-term changes. Our findings point to specific behaviors that may be useful to measure in future research, or useful as indicators of treatment response in clinical practice settings. Overall, qualitative methods may be useful for understanding complex treatment processes.

A SWOT analysis of parent-mediated intervention for children with autism spectrum disorder: Oman as a Regional Model

The prevalence of autism in the Arabian Gulf region is on the rise leading to overstretching of the pre-existing intervention services. The World Health Organization Caregiver Skills Training Program is a novel renovation being studied around the globe to overcome the scarcity of resources, improve autistic children's outcome and empower parents with comparable results to therapist-based models. Recently, Oman achieved great success in advocating for autism and initiated the first screening program for autism in the region. This review aims to use a Strength, Weakness, Opportunities and Threats (SWOT) analysis matrix to investigate the potential for using a parent-mediated intervention program as a supplementary approach to the currently used therapist-based intervention model in the country as an example for Gulf region.

Implementation of Video Feedback Within a Community Based Naturalistic Developmental Behavioral Intervention Program for Toddlers With ASD: Pilot Study

Video feedback (VF) is an intervention delivery technique that complements naturalistic developmental behavioral interventions (NDBI) and parent-mediated interventions (PMI) by using caregiver-child interaction videos reviewed with a clinician to facilitate behavioral change in caregivers. Although VF has been implemented in PMI with young children with ASD, examinations of feasibility and acceptability, as well as the potential effectiveness of VF in community settings, have been limited. In this pilot randomized control trial (NCT03397719; https://clinicaltrials.gov/ct2/show/NCT03397719), families were randomized into a state-funded Early Intervention (EI) NDBI program or the NDBI program augmented with VF. Results demonstrated high levels of implementation and acceptability of VF augmenting the community-based EI program in caregivers and clinicians. Both groups showed significant improvements after 6 months in social communication symptoms and some areas of developmental and adaptive skills. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT03397719, identifier: NCT03397719.

Cognitive, Language, and Behavioral Outcomes in Children With Autism Spectrum Disorders Exposed to Early Comprehensive Treatment Models: A Meta-Analysis and Meta-Regression

Background: Early comprehensive treatment models (CTMs) have been developed as effective treatments for children with autism spectrum disorder (ASD). Numerous studies have suggested that CTMs can improve short-term outcomes, but little is known about precise outcome information in childhood. The current meta-analysis reviewed studies reporting broader outcomes in children with ASD who had ever participated in a CTM and examined the predictors of developmental gains. Methods: We searched eight databases up to June 13, 2019, for relevant trials and natural experiments. Longitudinal studies were selected if they investigated the outcomes of CTMs. Two meta-analyses were undertaken to provide a summary estimate of change in treatment outcomes and to evaluate the effect of CTMs; one used the standardized mean change between the pretest and posttest, and the other was a classical meta-analysis. Stratified and random-effects meta-regression analyses were performed to search for outcome differences among studies. Results: Eighteen intervention studies (involving 495 children with ASD) met all the inclusion criteria: 12 used early intensive behavioral intervention (EIBI), and two used the Early Start Denver Model (ESDM). Outcomes were categorized into three parts: cognitive, language and behavioral (e.g., adaptive functioning and symptomatology). Overall, most children with ASD who had ever participated in an early CTM made gains in many areas of functioning, especially in terms of symptom- and language-related outcomes. Stratified analyses indicated that the ESDM displayed the largest effect on IQ improvement (ES = 1.37, 95% CI: 0.95 to 1.80), while EIBI was more effective for symptom reduction (ES = -1.27, 95% CI: -1.96 to -0.58). Further, meta-regression suggested that interventions with parent involvement, higher intensity, and longer treatment hours yielded greater improvements in IQ and social adaptive functioning, respectively. Conclusion: The results demonstrate a positive association between CTMs and better prognosis in childhood, especially regarding symptoms, and language. However, most extant research involves small, non-randomized studies, preventing definitive conclusions from being drawn. Clearly, the outcomes of children with ASD are still far from normal, especially with respect to adaptive functioning, and the four mediating variables pertaining to treatment elements can affect their gains, including approach, implementer, intensity, and total treatment hours. Systematic Review Registration: [www.crd.york.ac.uk/PROSPERO], identifier [CRD42019146859].

Parent-Mediated Interventions for Children and Adolescents With Autism Spectrum Disorders: A Systematic Review and Meta-Analysis

There has been increasing interest in parent-mediated interventions (PMIs) for children with autism spectrum disorders (ASDs). The objective of this systematic review and meta-analysis was to examine the effect of PMIs compared to no PMI for children with ASD aged 2-17 years. The primary outcome was adaptive functioning rated by a parent or clinician. The secondary outcomes were long-term adaptive functioning rated by the parents, adverse events, core symptoms of ASD, disruptive behavior, parental well-being, quality of life of the child rated by the parents and anxiety. The MEDLINE, PsycInfo, Embase, and CINAHL databases were searched in March 2020. The Cochrane Risk of Bias Tool was used to rate the individual studies, and the certainty in the evidence was evaluated using GRADE. We identified 30 relevant randomized controlled trials (RCTs), including 1,934 participants. A clinically relevant effect of PMIs on parent-rated adaptive functioning was found with a low certainty of evidence [Standard mean difference (SMD): 0.28 (95% CI: -0.01, 0.57)] on Vineland Adaptive Behavior Scales (VABS), whereas no clinically relevant effect was seen for clinician-rated functional level, with a very low certainty of evidence [SMD on Clinical Global Impressions (CGI)-severity scale: SMD -0.45 [95% CI: -0.87, -0.03)]. PMIs may slightly improve clinician-rated autism core symptoms [SMD: -0.35 (95% CI: -0.71, 0.02)]. Additionally, no effect of PMIs on parent-rated core symptoms of ASD, parental well-being or adverse effects was identified, all with a low certainty of evidence. There was a moderate certainty of evidence for a clinically relevant effect on disruptive behavior [SMD: 0.55 (95% Cl: 0.36, 0.74)]. The certainty in the evidence was downgraded due to serious risk of bias, lack of blinding, and serious risk of imprecision due to few participants included in meta-analyses. The present findings suggest that clinicians may consider introducing PMIs to children with ASD, but more high-quality RCTs are needed because the effects are not well-established, and the results are likely to change with future studies. The protocol for the systematic review is registered at the Danish Health Authority website (www.sst.dk).