The Autism Family Experience Questionnaire (AFEQ): An Ecologically-Valid, Parent-Nominated Measure of Family Experience, Quality of Life and Prioritised Outcomes for Early Intervention

Predictors of Change in Wellbeing and Mental Health of Parents of Autistic Pre-Schoolers

Parenting is a rewarding experience but is not without its challenges. Parents of Autistic children face additional challenges, and as a result can experience lower levels of wellbeing and more mental health problems (i.e., depression, anxiety, stress). Previous studies have identified concurrent correlates of wellbeing and mental health. However, few have investigated predictors of subsequent wellbeing and mental health, or of change over time, among parents of pre-school aged autistic children. We examined child-, parent-, and family/sociodemographic factors associated with change in parents' mental health and wellbeing across three timepoints (spanning approximately one year) among 53 parents of Autistic pre-schoolers (M = 35.48, SD = 6.36 months. At each timepoint, parents reported lower wellbeing and greater mental health difficulties compared to normative data. There was no significant group-level change over time in parent outcomes. However, individual variability in short-term (~ 5 months) wellbeing and mental health change was predicted by a combination of child- and parent-related factors, while variability in medium-term (~ 10 months) change was predicted by parent factors alone. Parents' description of their child and their relationship predicted change in both wellbeing and mental health. Furthermore, participating in a parent-mediated intervention (available to a subgroup) was a significant predictor of change in wellbeing. Our findings highlight potentially modifiable factors (e.g., learning healthier coping strategies) that may positively impact both short- and medium-term change in parental outcomes.

Psychometric Properties of the Portuguese Version of the Quality of Life in Autism Questionnaire (QoLA)

The aim of this study was to cross-culturally adapt and validate of the Brazilian Portuguese version of the Quality of Life in Autism Questionnaire (QoLA) among parents of children ASD. The translated version was administered to 91 parents (Male: 4, Female: 85, other: 2) of individuals diagnosed with ASD. Among these, 22 completed the questionnaire twice, providing data for the assessment of test-retest reliability (ICC). The B-QoLA score ranged from 41 to 122, with a mean (SD) of 74.3 ± 18.5 in Part A and ranged from 22 to 94, with a mean (SD) of 61.6 ± 16.4, in Part B. Cronbach's alpha coefficient was 0.94 for Part A, 0.92 for Part B and 0.94 for total B-QoLA, indicating excellent internal consistency. Test-retest reliability was assessed using the intraclass correlation coefficient, which was 0.96 for the total scale, 0.94 for Part A, and 0.95 for Part B. Part A-X2 (df) = 297, (167), X2/2 = 1.7, CFI = 0.85, TLI = 0.84, GFI = 0.78, AGFI = 0.75, and RMSEA (95%CI) = 0.09 (0.07-0.11); Part B-X2 (df) = 297, (167), X2/2 = 1.7, CFI = 0.85, TLI = 0.84, GFI = 0.78, AGFI = 0.75, and RMSEA (95%CI) = 0.09 (0.07-0.11), thus indicating moderate fit of the model. The Brazilian version of the QoLA shows encouraging psychometric properties on each of the two subscales, showing strong internal consistency and good construct validity.

Characterising Insistence on Sameness and Circumscribed Interests: A Qualitative Study of Parent Perspectives

Manifestations of insistence on sameness (IS) and circumscribed interests (CI) are complex, with individuals varying considerably, not only in the types of behaviours they express, but also in terms of a behaviour's frequency, intensity, trajectory, adaptive benefits, and impacts. However, current quantitative RRB instruments capture only certain aspects of these behaviours (e.g., mostly frequency or general "severity"). Thus, the current study utilised a semi-structured caregiver interview to provide an in-depth, qualitative characterization of different aspects of IS and CI presentation. Caregivers of 27 autistic children and adolescents displaying IS and/or CI behaviours (3-16 years; 18 males; 9 females) participated in a semi-structured interview. Responses were analysed using thematic framework analysis. Framework analysis identified nine different aspects of IS and CI presentation: (1) intensity, (2) frequency, (3) emergence of behaviour, (4) changes over time, (5) day-to-day fluctuations, (6) purpose/adaptive benefit, (7) experiences of distress, (8) challenges for the individual, their family, and their socialisation, and (9) management strategies and their effectiveness. Autistic children and adolescents were reported to vary greatly on each of these dimensions. Findings demonstrate the complexity of IS and CI presentations and highlight the need for more comprehensive quantitative assessments that independently assess the frequency, intensity, and impact of behaviours. Further, findings reported here emphasize the need for ecologically valid measures that assess the contexts in which these behaviours occur and how their presentations can change within and across days.

Economic Evaluation of Early Interventions for Autistic Children: A Scoping Review

Many autistic children access some form of early intervention, but little is known about the value for money of different programs. We completed a scoping review of full economic evaluations of early interventions for autistic children and/or their families. We identified nine studies and reviewed their methods and quality. Most studies involved behavioral interventions. Two were trial-based, and the others used various modelling methods. Clinical measures were often used to infer dependency levels and quality-adjusted life-years. No family-based or negative outcomes were included. Authors acknowledged uncertain treatment effects. We conclude that economic evaluations in this field are sparse, methods vary, and quality is sometimes poor. Economic research is needed alongside longer-term clinical trials, and outcome measurement in this population requires further exploration.

The Pediatric Autism Research Cohort (PARC) Study: protocol for a patient-oriented prospective study examining trajectories of functioning in children with autism

INTRODUCTION

The developmentally variable nature of autism poses challenges in providing timely services tailored to a child's needs. Despite a recent focus on longitudinal research, priority-setting initiatives with stakeholders highlighted the importance of studying a child's day-to-day functioning and social determinants of health to inform clinical care. To address this, we are conducting a pragmatic multi-site, patient-oriented longitudinal investigation: the Pediatric Autism Research Cohort (PARC) Study. In young children (<7 years of age) newly diagnosed with autism, we will: (1) examine variability in trajectories of adaptive functioning from the point of diagnosis into transition to school; and (2) identify factors associated with trajectories of adaptive functioning.

METHODS AND ANALYSIS

We aim to recruit 1300 children under 7 years of age with a recent (within 12 months) diagnosis of autism from seven sites: six in Canada; one in Israel. Participants will be followed prospectively from diagnosis to age 8 years, with assessments at 6-month intervals. Parents/caregivers will complete questionnaires administered via a customized online research portal. Following each assessment timepoint, families will receive a research summary report describing their child's progress on adaptive functioning and related domains. Analysis of the longitudinal data will map trajectories and examine child, family and service characteristics associated with chronogeneity (interindividual and intraindividual heterogeneity over time) and possible trajectory turning points around sensitive periods like the transition to school.

ETHICS AND DISSEMINATION

Ethics approvals have been received by all sites. All parents/respondents will provide informed consent when enrolling in the study. Using an integrated knowledge translation approach, where stakeholders are directly engaged in the research process, the PARC Study will identify factors associated with trajectories of functioning in children with autism. Resulting evidence will be shared with government policy makers to inform provincial and national programs. Findings will be disseminated at conferences and published in peer-reviewed journals.

'Turning up and tuning in'. Factors associated with parental non-attendance and non-adherence in intervention for young children with speech, language communication needs

BACKGROUND

When parents bring their child to appointments and then adhere to agreed speech and language therapy (SLT) recommendations, there is the potential to increase the intensity of the intervention, support generalization and improve outcomes. In SLT, however, little is known about factors that may promote attendance or adherence. Studies in other clinical areas such in medicine, psychology and physiotherapy have identified risk factors for non-attendance or non-adherence that are multifactorial and variable dependent on, for example, population and intervention.

AIMS

To identify rates of non-attendance and non-adherence, and to identify parent or child factors associated with parent involvement in intervention for children under 5 years of age receiving SLT.

METHODS

Parents completed questionnaires at two time points assessing the domains of parents' beliefs (problem perceptions, self-efficacy), personal circumstances (socio-demographics, family functioning), treatment experience and child factors. Predictors of parent attendance and adherence were identified through multiple regression analyses. Non-attendance rates were identified via local health records and non-adherence ascertained using a specific parent-reported measure within the treatment experience domain.

RESULTS

Participants (N = 199) were predominantly mothers, and were ethnically and socio-economically diverse, speaking a wide range of languages. Their children presented with a range of speech, language communication needs (SLCN). The rate of non-attendance was 25% and the main predictors of non-attendance were maternal age, education level and two factors within the parent beliefs domain. This model explained 40% of the variance in attendance. The rate of non-adherence in this cohort was 26% with parental rating of the importance of a recommendation and self-efficacy beliefs predicting adherence; this explained 56% of the variance in adherence to SLT recommendations at home.

CONCLUSIONS & IMPLICATIONS

Our research has provided preliminary evidence of the influence of parents' beliefs, personal circumstances and treatment experiences on their involvement in their child's therapy. Speech and language therapists should consider factors impacting attendance and adherence to treatment and explore parental perceptions of their child's SLCN before embarking on an intervention, a foundation for collaborative practice. A possible limitation of this study is that the levels of attrition in our sample led to generally high measured rates of participation, which should be considered in future studies. Future research should explore adherence in treatments with varying doses, with different types of SLCN or interventions and in different settings.

WHAT THIS PAPER ADDS

What is already known on the subject It is acknowledged that parent involvement in their child's therapy, such as attending and adhering to recommendations, is important but little is known about the rates of involvement and what factors may be associated with attendance and adherence in SLT. Qualitative research has explored parental involvement suggesting that beliefs about an intervention may be pertinent. Extensive research in other clinical areas suggest multiple and varied factors are influential and further exploration of particular populations and interventions is necessary. What this paper adds to the existing knowledge This study identified rates of parental non-attendance and non-adherence in a cohort of predominantly mothers of children under the age of 5 years. It is the first study to measure parent adherence in SLT and identify factors that are associated parental adherence to SLT recommendations. It adds to the small body of SLT specific research in understanding risk factors for non-attendance. What are the potential or actual clinical implications of this work? This study highlights the need for a speech and language therapist to consider and explore parents' perspectives of their child's SLCN as a part of achieving collaboration with a parent in order to achieve the best outcomes. It provides a foundation for further systematic research into parent involvement with the ultimate aim of enhancing outcomes for children with SLCN.

Do Naturalistic Developmental Behavioral Interventions improve family quality of life? A systematic review and meta-analysis

LAY ABSTRACT

Naturalistic Developmental Behavioral Interventions have been described as culturally responsive and family-friendly interventions, with research demonstrating improvements in children's development following the receipt of these interventions. Given the child-directed nature of Naturalistic Developmental Behavioral Interventions and the intervention's integration within families' daily routines, many studies have examined the impact of Naturalistic Developmental Behavioral Interventions on family and family member quality of life. We conducted a systematic review and meta-analysis to explore the relationship between Naturalistic Developmental Behavioral Interventions and family quality of life. Results suggest that the provision of a Naturalistic Developmental Behavioral Intervention neither improved nor worsened family or family member quality of life. For those involved in delivering Naturalistic Developmental Behavioral Intervention services, there is an immediate need to convey to families that children's improvements will likely not translate into improvements in family quality of life.

Acceptability and feasibility of a parent-mediated social-communication therapy for young autistic children in Brazil: A qualitative implementation study of Paediatric Autism Communication Therapy

LAY ABSTRACT

Parents of autistic children and health professionals who work with autistic children in Brazil had positive views about introducing Paediatric Autism Communication Therapy as a therapy for autistic children in Brazil. The parents and clinicians also mentioned some difficulties about using Paediatric Autism Communication Therapy in Brazil. We made adaptations to Paediatric Autism Communication Therapy to address these difficulties. Paediatric Autism Communication Therapy is a therapy to support the development of social and communication skills for autistic children aged 2-10 years. The therapy is conducted with the autistic child's parent. Paediatric Autism Communication Therapy has not been used in Brazil before. There are few therapy options available for autistic children in Brazil and we believed that Paediatric Autism Communication Therapy may be useful. We asked three groups of people in Brazil about their views of Paediatric Autism Communication Therapy, after explaining how the therapy works. Group 1 included 18 parents of autistic children aged 2-10 years. Group 2 included 20 health professionals such as psychologists who work with autistic children. Group 3 included 15 parents of autistic children aged 2-7 years who received the Paediatric Autism Communication Therapy. We learned that parents and clinicians felt that Paediatric Autism Communication Therapy would be a beneficial therapy for autistic children in Brazil. We also found out about the challenges of using Paediatric Autism Communication Therapy in Brazil. We used these findings to make small cultural adaptations to Paediatric Autism Communication Therapy to make it more suitable for Brazil.

Economic analysis of early intervention for autistic children: findings from four case studies in England, Ireland, Italy, and Spain

BACKGROUND

Many autistic children experience difficulties in their communication and language skills development, with consequences for social development into adulthood, often resulting in challenges over the life-course and high economic impacts for individuals, families, and society. The Preschool Autism Communication Trial (PACT) intervention is effective in terms of improved social communication and some secondary outcomes. A previously published within-trial economic analysis found that results at 13 months did not support its cost-effectiveness. We modeled cost-effectiveness over 6 years and across four European countries.

METHODS

Using simulation modeling, we built on economic analyses in the original trial, exploring longer-term cost-effectiveness at 6 years (in England). We adapted our model to undertake an economic analysis of PACT in Ireland, Italy, and Spain. Data on resource use were taken from the original trial and a more recent Irish observational study.

RESULTS

PACT is cost-saving over time from a societal perspective, even though we confirmed that, at 13 months post-delivery, PACT is more expensive than usual treatment (across all countries) when given to preschool autistic children. After 6 years, we found that PACT has lower costs than usual treatment in terms of unpaid care provided by parents (in all countries). Also, if we consider only out-of-pocket expenses from an Irish study, PACT costs less than usual treatment.

DISCUSSION

PACT may be recommended as a cost-saving early intervention for families with an autistic child.

Participants' Bias in Disability Research on Family Quality of Life during the 0-6 Years Stage

BACKGROUND

Over the past two decades, various research teams have designed and applied instruments to measure the quality of life of families with a member who has a disability. A recent systematic review on the state of the Family Quality of Life in early care identified that many of these studies collected data only from the mothers. The present study aimed to investigate whether there is a bias in participant selection in these types of studies.

METHOD

A systematic review of the scientific literature was conducted in three databases-Scopus, Web of Science, Eric-from 2000 to 2022. A total of 72 empirical studies were identified.

RESULTS

The findings indicate that most studies examining the Family Quality of Life were based on the information of a single informant per family unit. The profiles of participants according to the research objective are quite similar. In one-third of studies, the authors reported that family members who participate cannot be represented by only mothers or one participant per household.

CONCLUSIONS

Given the dynamic and collective nature of the construct, the application of a systemic approach is necessary.

Piloting a Home Visual Support Intervention with Families of Autistic Children and Children with Related Needs Aged 0-12

Visual supports are an important intervention for autistic individuals and others with neurodevelopmental differences. However, families often report limited access to visual supports and lack of information and confidence in their use at home. This pilot study aimed to evaluate the feasibility and effectiveness of a home-based visual supports intervention.

METHODS

29 families with children (n = 20 males; mean age 6.59 years [Range 3.64-12.21 years SD 2.57]) receiving support for autism or related needs participated in the study. Parents engaged in an individualised assessment and intervention process through home visits, completing pre- and post-measures. Qualitative methods were used to explore the parents' experiences of the intervention.

RESULTS

The intervention led to a statistically significant improvement in parent-reported quality of life (t28 = 3.09, p = 0.005) and parent-reported perception of autism-specific difficulties (t28 = 2.99, p = 0.006). Parents also reported improved access to resources and relevant information and increased confidence in using visual supports at home. The home visit model was strongly supported by the parents.

CONCLUSION

The results provide initial evidence of the acceptability, practicality, and utility of the home-based visual supports intervention. These findings suggest that outreach into the family home may be a beneficial mechanism for delivering interventions related to visual supports. This study highlights the potential of home-based interventions to improve access to resources and information for families and the importance of visual supports in the home setting.

Brief Report: Above and Beyond Safety: Psychosocial and Biobehavioral Impact of Autism-Assistance Dogs on Autistic Children and their Families

Autism-Assistance Dogs (AADs) are highly-skilled service animals trained primarily to ensure the safety of an autistic child by preventing elopement and mitigating 'meltdowns'. Although anecdotal accounts and case-studies have indicated that AADs confer benefits above and beyond safety, empirical support anchored in validated clinical, behavioral, and physiological measures is lacking. To address this gap, we studied children and their families before and after receiving a well-trained AAD using a within-subject, repeated-measures design. Notably, this study is the first to assess change in a biomarker for chronic stress in both autistic children and their parents. Final analyses included pre-/post-AAD data from 11 triads (parent/handler-dog-child) demonstrating significantly positive psychosocial and biobehavioral effects of AADs.

Emotional availability in the mother-child relationship for families of young children with autism spectrum disorder in Australia: A cross-sectional survey

BACKGROUND

In families of children with autism spectrum disorder (ASD) the mother-child relationship can be affected by many factors; however, the impacts of maternal broad autism phenotype (BAP) and attachment styles are unknown. This study investigated predictors of emotional availability in the mother-child relationship in families of children with ASD.

METHODS

Mothers (N = 231) of children with ASD living in Australia completed questionnaires assessing emotional availability in the parent-child relationship (mutual attunement, child involvement, affect quality) and mothers' BAP, mental health, adult attachment style and parenting experiences. Hierarchical multiple regressions and a mediation analysis were conducted.

RESULTS

Parent-reported positive parenting experiences was the greatest predictor of mutual attunement, child involvement and affect quality in the parent-child relationship. Maternal stress and anxiety predicted poorer mutual attunement, stress and depressive symptoms predicted less child involvement and anxiety predicted worse affect quality. Negative parenting experiences, maternal anxiety and stress mediated the relationship between BAP and mutual attunement.

CONCLUSION

Interventions combining mental health and parenting support for mothers of children with ASD to bolster emotional availability within the mother-child relationship may be warranted.

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.

REACH-ASD: a UK randomised controlled trial of a new post-diagnostic psycho-education and acceptance and commitment therapy programme against treatment-as-usual for improving the mental health and adjustment of caregivers of children recently diagnosed with autism spectrum disorder

BACKGROUND

Autism is a neurodevelopmental disability affecting over 1% of UK children. The period following a child's autism diagnosis can present real challenges in adaptation for families. Twenty to 50% of caregivers show clinically significant levels of mental health need within the post-diagnostic period and on an ongoing basis. Best practice guidelines recommend timely post-diagnostic family support. Current provision is patchy, largely unevidenced, and a source of dissatisfaction for both families and professionals. There is a pressing need for an evidenced programme of post-diagnostic support focusing on caregiver mental health and adjustment, alongside autism psycho-education. This trial tests the clinical and cost-effectiveness of a new brief manualised psychosocial intervention designed to address this gap.

METHODS

This is a multi-centre two-parallel-group single (researcher)-blinded randomised controlled trial of the Empower-Autism programme plus treatment-as-usual versus usual local post-diagnostic offer plus treatment-as-usual. Caregivers of children aged 2-15 years with a recent autism diagnosis will be recruited from North West England NHS or local authority centres. Randomisation is individually by child, with one "index" caregiver per child, stratified by centre, using 2:1 randomisation ratio to assist recruitment and timely intervention. Empower-Autism is a group-based, manualised, post-diagnostic programme that combines autism psycho-education and psychotherapeutic components based on Acceptance and Commitment Therapy to support caregiver mental health, stress management and adjustment to their child's diagnosis. The comparator is any usual local group-based post-diagnostic psycho-education offer. Receipt of services will be specified through health economic data.

PRIMARY OUTCOME

caregiver mental health (General Health Questionnaire-30) at 52-week follow-up.

SECONDARY OUTCOMES

key caregiver measures (wellbeing, self-efficacy, adjustment, autism knowledge) at 12-, 26- and 52-week follow-up and family and child outcomes (wellbeing and functioning) at 52-week endpoint.

SAMPLE

N=380 (approximately 253 intervention/127 treatment-as-usual). Primary analysis will follow intention-to-treat principles using linear mixed models with random intercepts for group membership and repeated measures. Cost-effectiveness acceptability analyses will be over 52 weeks, with decision modelling to extrapolate to longer time periods.

DISCUSSION

If effective, this new approach will fill a key gap in the provision of evidence-based care pathways for autistic children and their families.

TRIAL REGISTRATION

ISRCTN 45412843 . Prospectively registered on 11 September 2019.

An integrated early care pathway for autism

In this Viewpoint, we argue for the need to reconceptualise an integrated early-care provision for autistic children in the light of their enduring support needs and relevant new findings from developmental and intervention research. This model goes beyond short-term reactive care to outline an early proactive, evidenced, developmentally phased, and scalable programme of support for autistic children and their families from the earliest opportunity, with timely access to later step-up care when needed. We also integrate this model with emerging opportunities from data science and digital health technologies as a potential facilitator of such a pathway. Building on this work, we argue that the best current autism intervention evidence can be integrated with concepts and evidence gained in the management of other enduring health conditions to support an autistic child and their family through their early development. The aim is to improve those children's social communication abilities, expand their range and flexibility of interests, and mitigate any negative impacts of sensory difficulties and restricted, repetitive behaviours on the child and their family wellbeing. The pathway solutions described could also be adapted for older adolescents and adults and could be used within the health systems of different countries, including within low-income and middle-income contexts.

The effect of different service models on quality of care in the assessment of autism spectrum disorder in children: study protocol for a multi-centre randomised controlled trial

Background

There is significant variability in clinical pathways available in the diagnostic assessment of ASD, including the order and timing of allied health assessments in relation to paediatrician consultations. Allied health professionals in first-contact models are increasingly used to improve the timeliness of healthcare access, whilst complementing medical specialty workforce shortages. Anecdotally, the implementation of allied health first-contact models in paediatrics has improved waitlists and timely access to healthcare. However, no rigorous studies have been conducted to evaluate the outcomes of these models. This study aims to determine the impacts of an allied health first-contact model on health service use and costs and patient quality of life and satisfaction.

Methods

An open, semi-blinded, multi-centre randomised controlled trial in paediatric outpatient clinics at two Australian metropolitan public hospitals. 56 children (0–16 years) fulfilling the inclusion criteria will be randomised to one of two clinical pathways for assessment of ASD: (1) allied health first-contact or (2) medical first-contact model. Cost outcomes will be collected from both health service and family perspectives. Caregiver-reported outcome measures include: Pediatric Quality of Life Inventory (PedsQL), the EuroQOL Five Dimension Youth Version (EQ-5D-Y), the Autism Family Experience Questionnaire (AFEQ) and Measure of Processes of Care.

Discussion

Evidence of improvements in service and consumer centric outcomes will help inform the development and implementation of high-value, evidenced based models of care for the assessment of ASD in children. The findings from this study are expected to contribute to the evidence base around the costs and consequences of allied health first contact models for the assessment of children with ASD in the Australian setting. Findings of this study may help to inform the allocation of health care resources while maintaining, or potentially improving, patient and family quality of life and experience of care. These findings may be useful in informing the wider adoption of these models in Australia and internationally, particularly in healthcare settings where medical specialist shortages exist.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR) ACTRN12621001433897. Registered: 25^th October, 2021.

Combined social communication therapy at home and in education for young autistic children in England (PACT-G): a parallel, single-blind, randomised controlled trial

BACKGROUND

Autistic children can have difficulty generalising treatment effects beyond the immediate treatment context. Paediatric Autism Communication Therapy (PACT) has been successful when delivered in the clinic. Here we tested the Paediatric Autism Communication Therapy-Generalised (PACT-G) intervention combined between home and education settings for its overall effect and mechanistic transmission of effect across contexts.

METHODS

In this parallel, single-blind, randomised, controlled trial, we recruited autistic children aged 2-11 years in urban or semi-urban areas in Manchester, Newcastle, and London, England. Children needed to meet core autism criteria on Autism Diagnostic Observation Schedule-second edition (ADOS-2) and parent-rated Social Communication Questionnaire (SCQ-lifetime), and children older than 5 years were included if they had intentional communication but expressive language equivalent of age 4 years or younger. Eligible children were randomly assigned (1:1), using block randomisation (random block sizes of 2 and 4) and stratified for site, age (2-4 years vs 5-11 years), and gender, to either PACT-G plus treatment as usual or treatment as usual alone. Research assessors were masked to treatment allocation. The PACT-G intervention was delivered by a therapist in parallel to the child's parents at home and to learning-support assistants (LSA) at their place of education, using both in-person and remote sessions over a 6 month period, to optimise adult-child social interaction. Treatment as usual included any health support or intervention from education or local community services. The primary outcome was autism symptom severity using the ADOS-2, as measured by researchers, at 12 months versus baseline. Secondary outcomes were Brief Observation of Social Communication Change (BOSCC) and dyadic social interaction between child and adult across contexts, both at 12 months. Other secondary outcome measures were assessed using the following composites: language, anxiety, repetitive behaviour, adaptive behaviour, parental wellbeing, child health-related quality of life, and disruptive behaviour. Assessments were done at baseline, 7 months, and 12 months. We used an intention-to-treat (ITT) analysis of covariance for the efficacy outcome measures. Adverse events were assessed by researchers for all trial families at each contact and by therapists in the PACT-G group at each visit. This study is registered with the ISRCTN Registry, ISRCTN 25378536.

FINDINGS

Between Jan 18, 2017, and April 19, 2018, 555 children were referred and 249 were eligible, agreed to participate, and were randomly assigned to either PACT-G (n=122) or treatment as usual (n=127). One child in the PACT-G group withdrew and requested their data be removed from the study, giving an ITT population of 248 children. 51 (21%) of 248 children were female, 197 (79%) were male, 149 (60%) were White, and the mean age was 4·0 years (SD 0·6). The groups were well balanced for demographic and clinical characteristics. In the PACT-G group, parents of children received a median of 10 (IQR 8-12) home sessions and LSAs received a median of 8 (IQR 5-10) education sessions over 6 months. We found no treatment effect on the ADOS-2 primary outcome compared with treatment as usual (effect size 0·04 [95% CI -0·19 to 0·26]; p=0·74), or researcher-assessed BOSCC (0·03 [-0·25 to 0·31]), language composite (-0·03 [-0·15 to 0·10]), repetitive behaviour composite (0·00 [-0·35 to 0·35]), adaptive behaviour composite (0·01 [-0·15 to 0·18]), or child wellbeing (0·09 [-0·15 to 0·34]). PACT-G treatment improved synchronous response in both parent (0·50 [0·36 to 0·65]) and LSA (0·33 [0·16 to 0·50]), mediating increased child communication with parent (0·26 [0·12 to 0·40]) and LSA (0·20 [0·06 to 0·34]). Child dyadic communication change mediated outcome symptom alteration on BOSCC at home (indirect effect -0·78 [SE 0·34; 95% CI -1·44 to -0·11]; p=0·022) although not in education (indirect effect -0·67 [SE 0·37; 95% CI -1·40 to 0·06]; p=0·073); such an effect was not seen on ADOS-2. Treatment with PACT-G also improved the parental wellbeing composite (0·44 [0·08 to 0·79]) and the child disruptive behaviour composite in home and education (0·29 [0·01 to 0·57]). Adverse events on child behaviour and wellbeing were recorded in 13 (10%) of 127 children in the treatment as usual group (of whom four [31%] were girls) and 11 (9%) of 122 in the PACT-G group (of whom three [33%] were girls). One serious adverse event on parental mental health was recorded in the PACT-G group and was possibly study related.

INTERPRETATION

Although we found no effect on the primary outcome compared with treatment as usual, adaptation of the 12-month PACT intervention into briefer multicomponent delivery across home and education preserved the positive proximal outcomes, although smaller in effect size, and the original pattern of treatment mediation seen in clinic-delivered therapy, as well as improving parental wellbeing and child disruptive behaviours across home and school. Reasons for this reduced efficacy might be the reduced dose of each component, the effect of remote delivery, and the challenges of the delivery contexts. Caution is needed in assuming that changing delivery methods and context will preserve an original intervention efficacy for autistic children.

FUNDING

National Institute for Health Research and Medical Research Council Efficacy and Mechanism Evaluation Award.

Autism as emergent and transactional

The current epistemology of autism as a phenotype derives from the consistency of historical accounts and decades of work within the tradition of descriptive epidemiology, culminating in current categorical descriptions within DSM and ICD nosologies and the concept of "prototypical autism." The demonstrated high heritability of this phenotype has led to an essentialist theory of autism as a biological entity and the concerted search within the developmental brain and genetic science for discrete biological markers. This search has not revealed simple markers explaining autistic outcomes and has led to moves towards a more dimensional account. This article proposes an alternative transactional approach. It proposes to understand autistic states as an emergent property within a complex developmental system; as the neurodivergent brain, and mind and body, encounter their social and physical environment within early development. Key evidence in support of this approach comes from random allocation intervention trials based on such transactional development theory, both in the infancy pre-diagnostic prodrome and the early post-diagnostic period. In replicated evidence, these intervention trials show that a targeted alteration in the quality of social transactional environment available for the child leads to significant, predictable, and sustained alterations in the outcome dimensional autistic phenotype over time; and further, in one prodromal trial, to a significant reduction in later categorical classification status. The inference from this evidence is that the prototypical autistic phenotype is to a degree malleable with a changed experienced social environment and that it is emergent from its constituent traits. Such a transactional approach enlarges our notion of the phenotype and brings the study of autism within mainstream individual difference developmental science. It challenges essentialist views, for instance as to intrinsic autistic "social avoidance" or theory of mind empathy deficits, integrates dimensional and categorical perspectives, and is consistent with the lived experience of autistic people and their advocacy for improved understanding within a social model.

Investigating the Associations Between Child Autistic Symptoms, Socioeconomic Context, and Family Life: A Pilot Study

Objective: The day-to-day experience of families with an Autistic child may be shaped by both, child characteristics and available resources, which often are influenced by the socioeconomic context of the family. Using a socioecological approach, this study explored the quantitative associations between child autistic symptoms, family socioeconomic status, and family life.

Methods: Data came from the Pediatric Autism Research Cohort—PARC Study (pilot). Parents of children with a recent diagnosis of autism completed a set of assessments, including the Autism Family Experience Questionnaire, Autism Impact Measure, and a Sociodemographic Questionnaire. A series of multiple, iterative linear regression models were constructed to ascertain quantitative associations between child autistic symptoms, socioeconomic context, and family life.

Results: A total of 50 children (mean age: 76 months; SD: 9.5 months; and 84% male) with data on the variables of interest were included in the analysis. The frequency of child autistic symptoms was associated with family life outcomes (p = 0.02 and R² = 24%). Once autistic symptom frequency, symptom impact, and sociodemographic variables were considered, parents of higher educational attainment reported worse family life outcomes compared to their lesser-educated counterparts. This cumulative regression model had considerable explanatory capability (p = 0.01, R² = 40%).

Conclusion: This study demonstrates the utility of using a socioecological approach to examine the dynamic interplay between child characteristics and family circumstances. Our findings suggest that family life for parents (of an autistic child) who have obtained higher education is reported (by the parents themselves) as less satisfactory compared to that of parents without higher education, once adjusted for the autistic symptom frequency of child, symptom impact, and income. These findings can inform the design and delivery of more family-centered care pathways during the years following a diagnosis of autism.

Outcomes of assistance dog placement in the home for individuals with autism spectrum disorder and their families: A pilot study

INTRODUCTION

Evidence indicates that assistance dogs placed in the home are effective in supporting individuals with Autism Spectrum Disorder (ASD) by increasing social and community participation and promoting quality of life. This study aimed to examine the outcomes of assistance dog placement on quality of life, independence, and participation of families including individuals with ASD placed with an assistance dog compared to families on the waiting list for an autism assistance dog and to evaluate the feasibility of the design for future studies.

METHODS

A cross-sectional comparative study was conducted. The Adaptive Behaviour Analysis System, Social Responsiveness Scale, Autism Treatment Evaluation Checklist, Canadian Occupational Performance Measure, and Autism Family Experience Questionnaire were used to evaluate adaptive skills, behaviour, social difficulties, daily functioning, and family quality of life.

RESULTS

Six families who had an autism assistance dog placed with them, and 12 families who were on the waiting list were recruited using purposeful sampling. The pilot data found no significant differences between the two groups. However, trends were observed which suggested that assistance dogs can increase desired social behaviours, decrease ASD severity, and improve family wellbeing. For families with an assistance dog, more positive outcomes were observed for families who were partnered with an assistance dog for longer. Parents (and sometimes individuals with ASD) were able to complete and return the outcome measures via mail to collect the outcome data for the study.

CONCLUSION

These study findings add to the developing evidence about the use of assistance dogs with this population. A larger sample size may have allowed for significant associations to be detected. The methods used were feasible to be applied in a larger study. These results may assist health professionals advocate for funding for assistance dog placement to individuals with ASD and their families.

Parental Quality of Life and Involvement in Intervention for Children or Adolescents with Autism Spectrum Disorders: A Systematic Review

Previous research has examined several parental, child-related, and contextual factors associated with parental quality of life (QoL) among parents with a child or an adolescent with autism spectrum disorders (ASD); however, no systematic review has examined the relationship between parental QoL and parental involvement in intervention. To fill this gap, a systematic review was conducted using four electronic databases and checked reference lists of retrieved studies. Records were included in the systematic review if they presented original data, assessed parental QoL, and involvement in intervention for children or adolescents with ASD, were published in peer-reviewed journals between 2000 and 2020, and were written in English. Among the 96 screened full-texts, 17 articles met the eligibility criteria. The selected studies included over 2000 parents of children or adolescents with ASD. Three categories of parental involvement (i.e., none, indirect, direct) were identified, which varied across studies, although most had direct parental involvement. The results from this review show that increased parental involvement in the intervention for children or adolescents with ASD may be one way to promote their QoL. However, further research specifically focused on parental involvement during the intervention for children and adolescents with ASD is warranted.

Drug development for Autism Spectrum Disorder (ASD): Progress, challenges, and future directions

In 2017, facing lack of progress and failures encountered in targeted drug development for Autism Spectrum Disorder (ASD) and related neurodevelopmental disorders, the ISCTM with the ECNP created the ASD Working Group charged to identify barriers to progress and recommending research strategies for the field to gain traction. Working Group international academic, regulatory and industry representatives held multiple in-person meetings, teleconferences, and subgroup communications to gather a wide range of perspectives on lessons learned from extant studies, current challenges, and paths for fundamental advances in ASD therapeutics. This overview delineates the barriers identified, and outlines major goals for next generation biomedical intervention development in ASD. Current challenges for ASD research are many: heterogeneity, lack of validated biomarkers, need for improved endpoints, prioritizing molecular targets, comorbidities, and more. The Working Group emphasized cautious but unwavering optimism for therapeutic progress for ASD core features given advances in the basic neuroscience of ASD and related disorders. Leveraging genetic data, intermediate phenotypes, digital phenotyping, big database discovery, refined endpoints, and earlier intervention, the prospects for breakthrough treatments are substantial. Recommendations include new priorities for expanded research funding to overcome challenges in translational clinical ASD therapeutic research.

Autistic Self-Advocacy and the Neurodiversity Movement: Implications for Autism Early Intervention Research and Practice

The growth of autistic self-advocacy and the neurodiversity movement has brought about new ethical, theoretical and ideological debates within autism theory, research and practice. These debates have had genuine impact within some areas of autism research but their influence is less evident within early intervention research. In this paper, we argue that all autism intervention stakeholders need to understand and actively engage with the views of autistic people and with neurodiversity as a concept and movement. In so doing, intervention researchers and practitioners are required to move away from a normative agenda and pay diligence to environmental goodness-of-fit, autistic developmental trajectories, internal drivers and experiences, and autistic prioritized intervention targets. Autism intervention researchers must respond to these debates by reframing effectiveness, developing tools to measure autistic prioritized outcomes, and forming partnerships with autistic people. There is a pressing need for increased reflection and articulation around how intervention practices align with a neurodiversity framework and greater emphasis within intervention programmes on natural developmental processes, coping strategies, autonomy, and well-being.

Efficacy of parent-mediated communication-focused treatment in toddlers with autism (PACT) delivered via videoconferencing: a randomised controlled trial study protocol

INTRODUCTION

Intervention in the preschool period is currently recommended for autism spectrum disorder. Therapies delivered by parents are particularly suitable for young children. Preschool Autism Communication Trial (PACT) is a parent-mediated therapy that has shown a significant and sustained impact on autism symptom reduction. However, access to such evidence-based therapies for families is limited due to autism centres located in large urban areas. Using videoconferencing to deliver PACT training to parents may improve accessibility for families living in underserved areas.

METHODS AND ANALYSIS

This single-blind randomised controlled trial, involving six sites in France, will investigate the efficacy of a telehealth, videoconferencing-based, parent-mediated PACT therapy on autism symptoms, over a 12-month period. It will compare PACT plus treatment as usual (TAU) against TAU only in a cohort of 238 toddlers (119 per group) aged 18-36 months at inclusion and living with their families more than 40 min away from the specialist centres for autism. Primary outcome will include change of overall autism score on the Autism Diagnostic Observation Scale (ADOS) at 12 months. Secondary outcomes will measure change in child skills, child functioning, impact on parents (stress, health, priorities) and implementation characteristics. Repeated measures analyses will be used to test the effect of PACT intervention on the overall ADOS module 1 score over the 12-month study period. Linear mixed models will be used with time, treatment allocation and the interaction between treatment and time as fixed effects and individual variation as random effect.

ETHICS AND DISSEMINATION

This protocol (V.5, date: 25 October 2019) is approved by the French National Review Board (reference no 2018-A02516-49). The results will be disseminated via peer-reviewed journals TRIAL REGISTRATION NUMBER: NCT04244721.

A clinical and cost-effectiveness trial of a parent group intervention to manage challenging restricted and repetitive behaviours in young children with autism spectrum disorder: study protocol for a randomised controlled trial

BACKGROUND

Restricted and repetitive behaviours vary greatly across the autism spectrum, and although not all are problematic some can cause distress and interfere with learning and social opportunities. We have, alongside parents, developed a parent group based intervention for families of young children with autism, which aims to offer support to parents and carers; helping them to recognise, understand and learn how to respond to their child's challenging restricted repetitive behaviours.

METHODS

The study is a clinical and cost-effectiveness, multi-site randomised controlled trial of the Managing Repetitive Behaviours (MRB) parent group intervention versus a psychoeducation parent group Learning About Autism (LAA) (n = 250; 125 intervention/125 psychoeducation; ~ 83/site) for parents of young children aged 3-9 years 11 months with a diagnosis of autism. All analyses will be done under intention-to-treat principle. The primary outcome at 24 weeks will use generalised estimating equation (GEE) to compare proportion of children with improved RRB between the MRB group and the LAA group. The GEE model will account for the clustering of children by parent groups using exchangeable working correlation. All secondary outcomes will be analysed in a similar way using appropriate distribution and link function. The economic evaluation will be conducted from the perspective of both NHS costs and family access to local community services. A 'within trial' cost-effectiveness analysis with results reported as the incremental cost per additional child achieving at least the target improvement in CGI-I scale at 24 weeks.

DISCUSSION

This is an efficacy trial to investigate the clinical and cost-effectiveness of a parent group based intervention designed to help parents understand and manage their child's challenging RRB. If found to be effective, this intervention has the potential to improve the well-being of children and their families, reduce parental stress, greatly enhance community participation and potential for learning, and improve longer-term outcomes.

TRIAL REGISTRATION

Trial ID: ISRCTN15550611 Date registered: 07/08/2018. Sponsor and Monitor: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust R&D Manager Lyndsey Dixon, Address: St Nicholas Hospital, Jubliee Road, Gosforth, Newcastle upon Tyne NE3 3XT, lyndsey.dixon@cntw.nhs.uk , Tel: 0191 246 7222.

Quality of Life Among Malaysian Parents with Autism Spectrum Disorder Child: The Double ABCX Model Approach

This paper reported the quality of life (QoL) of 260 Malaysian parents with autism spectrum disorder (ASD) and factors which influencing it. About half of these parents reported to having good QoL. The factors identified in the double ABCX model showed that perceived social support and sense of coherence (SOC) were mediated by coping strategies and had a positive direct and indirect effect on parents' QoL. These finding reiterate the importance of social support, coping skills, and strong SOC reflection skills in influencing the QoL of parents with ASD child. We therefore suggest parents to utilize the widely available social and organization supports to gain good QoL, which is also important for the wellbeing of their child.

Play-based interventions to support social and communication development in autistic children aged 2-8 years: A scoping review

BACKGROUND AND AIMS

Play is used by practitioners from across disciplinary backgrounds as a natural and enjoyable context for providing intervention and support in early childhood. In the case of autism interventions, many therapies are based on the association between social play and the development of social skills, language development, and communication skills, as these are often particular areas of challenge for autistic children. However, play is a wide-ranging concept and the extant literature on play-based interventions is large and heterogeneous. This means it is challenging for practitioners and families to navigate the evidence base and make choices about differing intervention strategies. This review aims to provide a comprehensive map of the research on this topic and to develop a conceptual framework to inform clinical decision-making.

METHODS

An initial stakeholder consultation confirmed the relevance of the topic to practitioners and autistic people. A scoping review methodology (preregistered) was used to identify relevant literature. We systematically searched seven databases to find peer-reviewed primary intervention studies of play-based approaches targeting language, social and communication outcomes for autistic children aged 2-8 years. We then summarised the literature using narrative synthesis and Evidence Gap Maps (EGMs). The literature was summarised according to a range of characteristics, including study design, population characteristics, agent of intervention and outcomes measured, among others. These summaries were then used to develop a framework for some key considerations for practitioners appraising play-based approaches.

RESULTS

388 studies met inclusion criteria. Approximately 21% of studies were RCTs, and over 50% had ≤10 participants. Over 45% of studies reported multiple relevant outcomes, with social play skills being the most common single intervention target. Girls and minority background groups are under-represented. A range of intervention types were identified, and some high-level categorisations are proposed.Main contribution: On the basis of the evidence synthesis we suggest important dimensions for appraisal of play-based interventions, including the role of play within an intervention (as a context, a key developmental mechanism, or a component of a larger approach), the underpinning philosophy (e.g. behaviourist or developmental), and the role of the practitioner (providing parent feedback, 1:1 intervention, group facilitation).

CONCLUSIONS

The wide range of approaches uncovered by this review is a testament to the wonderful diversity inherent to both play and autism. However, research could usefully focus on consolidating the evidence base for existing approaches, rather than aiming for further diversification. Implications: The conceptual framework proposed in this review can help practitioners appraise the literature and aid their advice to families when making shared intervention decisions.

State of the Art of Family Quality of Life in Early Care and Disability: A Systematic Review

Background: In recent years, there has been a growing international interest in family quality of life The objective of this systematic review is to understand and analyze the conceptualization of the quality of life of families with children with disabilities between 0 and 6 years of age, the instruments for their measurement and the most relevant research results. Method: A bibliographic search was conducted in the Web of Science, Scopus and Eric databases of studies published in English and Spanish from 2000 to July 2019 focused on "family quality of life" or "quality of family life" in the disability field. A total of 63 studies were selected from a total of 1119 and analyzed for their theoretical and applied contributions to the field of early care. Results: The functional conceptualization of family quality of life predominates in this area, and a nascent and enriching holistic conceptualization is appreciated. There are three instruments that measure family quality of life in early care, although none of them is based on unified theory of FQoL; none of them focus exclusively on the age range 0-6 nor do they cover all disabilities. Conclusions: The need to deepen the dynamic interaction of family relationships and to understand the ethical requirement that the methods used to approach family quality of life respect the holistic nature of the research is noted.

A Brief Measure of Parental Wellbeing for Use in Evaluations of Family-Centred Interventions for Children with Developmental Disabilities

Increasing emphasis is placed on the provision of family-centred interventions when children have developmental disabilities with the aim of supporting parents as well as fostering the child’s development. Although various instruments have been developed to assess parental health, stress and quality of life, these are rarely used by practitioners because of the burden they place on informants. A brief measure, rooted in the concept of subjective wellbeing, was developed and tested with over 400 parents of children with ASD participating in a home-based intervention. Consisting of eight items and using a 10-point rating scale, the measure was readily understood and accepted by parents. The items contributed to one main factor that confirmed the measure’s construct validity. The internal reliability of the scale was reasonable, and there was promising evidence of test–retest reliability. There is evidence too for criterion validity through a significant relationship with a measure of parental mental health. The summary score derived from the measure was sensitive to the predicted differences on wellbeing scores by parent characteristics as well as to features of their engagement with the intervention. This brief assessment tool could help practitioners to evidence the impact of their family-centred interventions.

Listening to parents to understand their priorities for autism research

Involving the autism community in research increases the real-world translation and impact of findings. The current study explored the research priorities of parents of school-aged children on the autism spectrum across the home, school, and community settings. A combination of content analysis of an online questionnaire (n = 134) and Q-sort methodology (n = 9) was used. The most commonly identified research priorities in the online questionnaire were child health and well-being (home setting), socialisation and social support (school), and community awareness and understanding of autism (community). The Q-sort method highlighted different top priorities, with understanding the parent, sibling, child and family impact and stress the highest ranked priority for home, teacher/staff education and support for the school, and recognizing and supporting anxiety for the community. The implications of the findings are discussed in relation to shifting the framework of autism research to align research agendas with parental priorities.

Parent perceptions of participation in a parent-mediated communication-focussed intervention with their young child with autism spectrum disorder

Paediatric Autism Communication Therapy is a parent-mediated, video-aided, communication-focussed intervention for young children with autism spectrum disorder. It has been shown in a UK randomised controlled trial to lead to improvements in parent–child communication and family quality of life, together with a sustained reduction in child autism symptom severity. This qualitative study examined parental perceptions of their participation in Paediatric Autism Communication Therapy within the context of the randomised controlled trial. Semi-structured interviews were carried out with 18 parents within 12 months of completion of the therapy. The thematic analysis provides insights into parents’ hopes, expectations, and learning processes when working with Paediatric Autism Communication Therapy therapists and carrying out daily practice in the home. Parents reported positive changes in their interaction and relationship with their child and improvements to their child’s communication and interaction. Some also highlighted poignant realisations and emotional challenges associated with taking part in this post-diagnostic therapy. Practical difficulties were also emphasised. Implications for the clinical practice of parent-mediated interventions with young children with autism spectrum disorder are discussed.

The Scientific Study of Parents and Caregivers of Children with ASD: A Flourishing Field but Still Work to be Done

There is a long history of research on parents and caregivers of individuals within autism. Parents and other primary caregivers typically play the most important part in the lives of persons with ASD although the need for support as the child becomes of age varies widely. This special issue includes 30 articles on central areas related to parenting and caregiving for people with ASD. Some of the key themes include intervention and training, mental health issues related to parent and family stress, measurement and assessment, and parent-child transactional processes. Other articles in this issue consider different but equally important topics such as sibling as potential future caregivers and parent support of preschool peer relationships.

The Association Between Child and Family Characteristics and the Mental Health and Wellbeing of Caregivers of Children with Autism in Mid-Childhood

We examined predictors of mental health difficulties and wellbeing in caregivers of children with autism in the Pre-school Autism Communication Trial cohort in middle childhood (N = 104). Child’s intellectual disability, daily living skills impairment, elevated emotional and behavioural difficulties, high educational level of caregiver and household income below the median significantly predicted caregivers’ mental health difficulties, but autism severity, child communication skills and family circumstances did not. Lower caregiver mental wellbeing was predicted by elevated child emotional and behavioural difficulties. The need to support the mental health and wellbeing of caregivers of children with autism is discussed in light of the results.