Brief Report: Mindfulness Training for Chinese Adolescents with Autism Spectrum Disorder and Their Parents in Hong Kong

Comparison of effects of interventions to promote the mental health of parents of children with autism: A systematic review and network meta-analysis

Individuals diagnosed with autism spectrum disorders often face persistent challenges in social interaction and engage in repetitive and stereotyped behaviors. Parenting a child with autism can profoundly affect parents both physically and psychologically, potentially leading to negative impacts on their mental health. This study employs a network meta-analysis methodology to evaluate the comparative effectiveness of mental health interventions specifically designed for parents of autistic children. A total of 69 empirical intervention studies involving 4213 parents of autistic children were included in the analysis. Employing the frequency framework model and utilizing Stata 16.0 software, we quantitatively analyzed the impact of various interventions on anxiety, depression, parenting stress, and parenting self-efficacy. Our findings indicate that mindfulness-based interventions demonstrate the highest efficacy in reducing parenting stress, while cognitive behavioral therapy is effective in alleviating anxiety and depression in parents of children with autism. Psychoeducational interventions have shown significant benefits in mitigating parental anxiety, depression, and parenting stress, and acceptance and commitment (ACT) displays promising outcomes in reducing depression. We also elaborate on the underlying mechanisms that contribute to the effectiveness of these interventions. This network meta-analysis presents valuable insights for the development of targeted interventions to provide support to parents of children with autism.

Mindfulness-Based Interventions for People with Autism Spectrum Disorder: A Systematic Literature Review

BACKGROUND/OBJECTIVES

Mindfulness-based interventions (MBIs) have emerged in recent years as a strong candidate for the treatment of a range of difficulties faced by individuals with autism spectrum disorder (ASD), including cognitive, emotional, and social aspects. Therefore, we aimed to conduct a review that systematically examined the efficacy of MBIs for individuals with ASD and their caregivers.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our literature search was conducted within the MEDLINE database. We included in the review only longitudinal or intervention studies focusing mainly on mindfulness principles, while we excluded mixed intervention studies. We only included studies that explicitly utilized quantitative methodologies for evaluating the outcomes of the interventions, including mental health indices (e.g., stress, anxiety, depression) and assessments of cognitive and social skills (e.g., attention, prosociality). We conducted also a risk of bias assessment through the method of the Cochrane risk of bias tool for intervention studies ROBINS-I.

RESULTS

Thirty-seven studies were included in the review, and we grouped the studies by the targets of the interventions, i.e., adults (n = 12), children and adolescents (n = 9), caregivers and medical staff (n = 13), and combined intervention for both children/adolescents and their parents/caregivers (n = 5). The reviewed papers seem to support the feasibility and utility of mindfulness interventions for persons with ASD and their caregivers, but any recommendations based on this body of evidence should be made with caution due to the overall low quality of the studies conducted so far.

CONCLUSIONS

The review reveals a positive outcome, including the alleviation of psychological distress, reduced behavioral problems, and enhanced cognitive and social skills in individuals with ASD. Despite such promising results, the review notes a limitation in the scarcity of MBIs for young patients, emphasizing caution in universally endorsing the existing literature. Moreover, the results underline the urgency of the exploration of tailored interventions for different ASD subgroups, considering varying levels of autism, and expanding support to teachers in educational settings.

Cognitive-Based Interventions for Improving Psychological Health and Well-Being for Parents of Children with Developmental Disabilities: A Systematic Review and Meta-analysis

This review aims to systematically summarize existing evidence to determine the effectiveness of cognitive-based interventions (CBIs) on psychological health and well-being among parents of children with developmental disabilities (DD). Six databases were searched to identify eligible randomized controlled trials (RCTs) from their inception to April 2023. The revised Cochrane Risk of Bias tool for RCTs was applied to assess the risk of bias and the certainty of evidence was evaluated using the Grading of Recommendation, Assessment, Development and Evaluation. Meta-analyses were conducted using a random-effects model. Twenty-five RCTs involving 1915 participants were identified. The results indicated that CBIs reduced parental stress levels (Hedges' g = - 0.69), depressive symptoms (g = - 0.95), anxiety levels (g = - 0.78), and parental distress (g = - 0.29), and improved parental well-being (g = 0.62) and parent‒child relationships (g = 0.43) postintervention compared with the active/inactive control groups. Subgroup analysis of the effectiveness of interventions using mindfulness-based interventions and cognitive behavioural therapy showed positive effects. The favourable intervention duration and participant targets were also identified in this review. Furthermore, the effects of CBIs were impacted by the different types of DD among the children. This review highlighted the positive effects of CBIs on parental stress levels, depressive symptoms, anxiety levels, parental distress levels, parental well-being levels, and parent‒child relationships. Future well-designed RCTs are needed to further investigate the effects of MBIs and CBT interventions on children with DD and their parents, as well as the factors and mechanisms of action affecting the efficacy of these interventions.

Reducing parenting stress in Chinese parents of children with learning disabilities with a mindful parenting program: A randomized controlled trial

BACKGROUND

Parents raising children with Learning Disabilities (LDs) often face multiple challenges and high levels of parenting stress, especially in societies with intense academic competitions. Mindful parenting (MP) is an emerging approach that brings mindful awareness to parent-child interactions and is found effective in reducing parenting stress in various parent populations.

AIMS

This study examined the effectivenesss of an 8-week online MP program on Chinese parents of children with LDs.

METHODS AND PROCEDURES

A MP program was adapted and implemented in an online format with 69 parents of children with LDs. A randomized controlled trial design was used to examine the efficacy of the mindful parenting group compared with a wait-list control group. Parenting stress, mindful parenting and self-compassion were assessed pre- and post-intervention.

OUTCOMES AND RESULTS

Compared with the wait-list control group, the MP group participants showed decreased parenting stress (d = 0.62, p < 0.05), improved mindful parenting (d = 0.63, p < 0.05), and increased self-compassion (d = 0.61, p < 0.05).

CONCLUSIONS AND IMPLICATIONS

These findings support the effectiveness of an online MP intervention in reducing parenting stress and increasing mindful parenting and self-compassion among Chinese parents of children with LDs. The behavioral and intrapersonal aspects of MP are more amenable to improvement, whereas the attitudinal and interpersonal aspects, particularly non-judgmental acceptance and compassion towards the child, are resistant to change. Future studies should explore strategies to enhance these attitudinal aspects and interpersonal processes of MP.

The effect of mindfulness-based interventions on mental health outcomes and wellbeing of informal caregivers of people with mental illness: A systematic review and meta-analysis

The increasing prevalence of mental illness has resulted in a growing burden on informal caregivers. Mindfulness-based interventions, as a form of psychotherapy, have shown efficacy in alleviating psychological stress and enhancing emotional and physical well-being. However, the utilisation of mindfulness-based interventions for informal caregivers of individuals with mental illness remains limited. The aim of the meta-analysis is to evaluate the impact of mindfulness-based interventions on the mental health and well-being among informal caregivers of people with mental illness. A comprehensive literature search was conducted across seven electronic databases (PubMed, Scopus, Web of Science, Cochrane Library, Embase, APA PsycINFO and CINAHL Ultimate) from the inception of these databases until 20 July 2023. Two authors independently screened the studies and extracted the relevant data. The meta-analysis was performed by using Stata 12.0 software, and the effect sizes were calculated utilising standardised mean difference (SMD) along with their corresponding 95% confidence intervals (CI). The meta-analysis included 13 studies with 1007 participants, and the results demonstrated that mindfulness-based interventions were efficacious in reducing stress (SMD = -0.80, 95% CI [-1.33, -0.28], p = 0.003), depression (SMD = -0.43, 95% CI [-0.62, -0.24], p < 0.001) and caregiver burden (SMD = -0.21, 95% CI [-0.40, -0.01], p = 0.038), and enhancing the mindfulness level (SMD = 0.37, 95% CI [0.09, 0.65], P = 0.010) and quality of life (SMD = 0.22, 95% CI [0.04, 0.39], p = 0.015) among informal caregivers of people with mental illness, but not on anxiety reduction (SMD = -0.19, 95% CI [-0.49, 0.10], p = 0.198). Furthermore, future research should aim to employ more rigorous methodologies to confirm the effectiveness.

Mindfulness-enhanced parenting programmes for improving the psychosocial outcomes of children (0 to 18 years) and their parents

BACKGROUND

Emotional and behavioural difficulties (EBD) in children are common, characterised by externalising or internalising behaviours that can be highly stable over time. EBD are an important cause of functional disability in childhood, and predictive of poorer psychosocial, academic, and occupational functioning into adolescence and adulthood. The prevalence, stability, and long-term consequences of EBD highlight the importance of intervening in childhood when behavioural patterns are more easily modified. Multiple factors contribute to the aetiology of EBD in children, and parenting plays an important role. The relationship between parenting and EBD has been described as bidirectional, with parents and children shaping one another's behaviour. One consequence of bidirectionality is that parents with insufficient parenting skills may become involved in increasingly negative behaviours when dealing with non-compliance in children. This can have a cyclical effect, exacerbating child behavioural difficulties and further increasing parental distress. Behavioural or skills-based parenting training can be highly effective in addressing EBD in children. However, emotional dysregulation may intercept some parents' ability to implement parenting skills, and there is recognition that skills-based interventions may benefit from adjunct components that better target parental emotional responses. Mindful parenting interventions have demonstrated some efficacy in improving child outcomes via improvements in parental emotion regulation, and there is potential for mindfulness training to enhance the effectiveness of standard parent training programmes.

OBJECTIVES

To assess the effectiveness of mindfulness-enhanced parent training programmes on the psychosocial functioning of children (aged 0 to 18 years) and their parents.

SEARCH METHODS

We searched the following databases up to April 2023: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, PsycINFO, Sociological Abstracts, Social Sciences Citation Index, Conference Proceedings Citation Index - Social Science & Humanities, AMED, ERIC, ProQuest Dissertations & Theses, Cochrane Database of Systematic Reviews, Campbell Collaboration Library of Systematic Reviews, as well as the following trials registers: ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also contacted organisations/experts in the field.

SELECTION CRITERIA

We included randomised and quasi-randomised trials. Participants were parents or caregivers of children under the age of 18. The intervention was mindfulness-enhanced parent training programmes compared with a no-intervention, waitlist, or attentional control, or a parent training programme with no mindfulness component. The intervention must have combined mindfulness parent training with behavioural or skills-based parent training. We defined parent training programmes in terms of the delivery of a standardised and manualised intervention over a specified and limited period, on a one-to-one or group-basis, with a well-defined mindfulness component. The mindfulness component must have included mindfulness training (breath, visualisation, listening, or other sensory focus) and an explicit focus on present-focused attention and non-judgemental acceptance.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane procedures.

MAIN RESULTS

Eleven studies met our inclusion criteria, including one ongoing study. The studies compared a mindfulness-enhanced parent training programme with a no-treatment, waitlist, or attentional control (2 studies); a parent training programme with no mindfulness component (5 studies); both a no-treatment, waitlist, or attentional control and a parent training programme with no mindfulness component (4 studies). We assessed all studies as being at an unclear or high risk of bias across multiple domains. We pooled child and parent outcome data from 2118 participants to produce effect estimates. No study explicitly reported on self-compassion, and no adverse effects were reported in any of the studies. Mindfulness-enhanced parent training programmes compared to a no-treatment, waitlist, or attentional control Very low certainty evidence suggests there may be a small to moderate postintervention improvement in child emotional and behavioural adjustment (standardised mean difference (SMD) -0.46, 95% confidence interval (CI) -0.96 to 0.03; P = 0.06, I2 = 62%; 3 studies, 270 participants); a small improvement in parenting skills (SMD 0.22, 95% CI 0.06 to 0.39; P = 0.008, I2 = 0%; 3 studies, 587 participants); and a moderate decrease in parental depression or anxiety (SMD -0.50, 95% CI -0.96 to -0.04; P = 0.03; 1 study, 75 participants). There may also be a moderate to large decrease in parenting stress (SMD -0.79, 95% CI -1.80 to 0.23; P = 0.13, I2 = 82%; 2 studies, 112 participants) and a small improvement in parent mindfulness (SMD 0.21, 95% CI -0.14 to 0.56; P = 0.24, I2 = 69%; 3 studies, 515 participants), but we were not able to exclude little to no effect for these outcomes. Mindfulness-enhanced parent training programmes compared to parent training with no mindfulness component Very low certainty evidence suggests there may be little to no difference postintervention in child emotional and behavioural adjustment (SMD -0.09, 95% CI -0.58 to 0.40; P = 0.71, I2 = 64%; 5 studies, 203 participants); parenting skills (SMD 0.13, 95% CI -0.16 to 0.42; P = 0.37, I2 = 16%; 3 studies, 319 participants); and parent mindfulness (SMD 0.11, 95% CI -0.19 to 0.41; P = 0.48, I2 = 44%; 4 studies, 412 participants). There may be a slight decrease in parental depression or anxiety (SMD -0.24, 95% CI -0.83 to 0.34; P = 0.41; 1 study, 45 participants; very low certainty evidence), though we cannot exclude little to no effect, and a moderate decrease in parenting stress (SMD -0.51, 95% CI -0.84 to -0.18; P = 0.002, I2 = 2%; 3 studies, 150 participants; low certainty evidence).

AUTHORS' CONCLUSIONS

Mindfulness-enhanced parenting training may improve some parent and child outcomes, with no studies reporting adverse effects. Evidence for the added value of mindfulness training to skills-based parenting training programmes is suggestive at present, with moderate reductions in parenting stress. Given the very low to low certainty evidence reviewed here, these estimates will likely change as more high-quality studies are produced.

The efficacy of mindfulness-based therapy for anxiety, social skills, and aggressive behaviors in children and young people with Autism Spectrum Disorder: A systematic review

Introduction

The purpose of this systematic review was to examine the efficacy of mindfulness-based interventions for improving anxiety, social skills, and aggressive behaviors in children and young people (CYP) with Autism Spectrum Disorder (ASD); summarize the results across clinic, home, and school contexts; and evaluate the quality of these interventions for clinical practice.

Methods

A search of the PsycINFO, Medline (Ovid), Web of Science, and Scopus databases was conducted in June 2021, and no date restrictions were applied. Inclusion criteria were quantitative or qualitative research implementing a mindfulness-based intervention for CYP aged 6–25 years with a diagnosis of ASD, Pervasive Development Disorder, or Asperger’s Syndrome.

Results

We identified 23 articles for inclusion including within subject pre- and post-testing, multiple baselines, and randomized control trials, among other research designs. Of these, a quality analysis conducted using an ASD research-specific risk of bias tool found over half (14) were of weak methodological quality, whereas only four and five were found to be of strong and adequate quality, respectively.

Discussion

While the results of this systematic review suggest promising evidence for the use of mindfulness-based interventions to improve anxiety, social skills, and aggressive behaviors in CYP with ASD, results should be interpreted with caution due to the limitations resulting from the overall weak quality of the studies.

The review protocol was pre-registered on PROSPERO (CRD42021259125) and can be viewed at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=259125

Cost-effectiveness of immune checkpoint inhibition and targeted treatment in combination as adjuvant treatment of patient with BRAF-mutant advanced melanoma

BACKGROUND

Immune checkpoint inhibitors (ICIs) and targeted treatments have improved the health outcomes of patients with advanced melanoma. However, due to the high cost of novel therapies, it is crucial to evaluate their value by considering both effectiveness and cost. To compare the cost-effectiveness of these novel agents (atezolizumab-vemurafenib-cobimetinib, vemurafenib-plus-cobimetinib, dabrafenib-plus-trametinib, and encorafenib-plus-binimetinib) for first-line treatment of metastatic melanoma with the BRAF^V600 mutation.

METHODS

A patient-level model was developed to project the health outcomes of 4 strategies for patients with advanced melanoma. We estimated transition probabilities from the IMspire150 (ClinicalTrials.gov, NCT02908672), COMBI-AD (NCT01682083), and COLUMBUS (NCT01909453) trials using a parametric survival model. All health outcomes, including direct cost, quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratio (ICER), were estimated from the US payer perspective. Lifetime cost, QALYs, life-years (LYs), and ICERs were calculated. Univariable and probabilistic sensitivity analyses were performed to test model robustness, along with multiple scenario analyses.

RESULTS

Of the 4 competing strategies, atezolizumab-vemurafenib-cobimetinib produced the best health outcomes, and the vemurafenib-cobimetinib strategy was the least expensive option. Atezolizumab-vemurafenib-cobimetinib, dabrafenib-plus-trametinib, and vemurafenib-cobimetinib formed the cost-effective frontier, indicating that the ordered ICERs were $325,113/QALYs for dabrafenib-plus-trametinib vs. vemurafenib-cobimetinib strategies and $2,247,500/QALYs for atezolizumab-vemurafenib-cobimetinib vs. dabrafenib-plus-trametinib strategies. Encorafenib-plus-binimetinib was dominated by the other 3 competing strategies. The drug price and first-line utility significantly influenced the model utcomes.

CONCLUSIONS

For BRAF-mutant advanced melanoma, the vemurafenib-cobimetinib strategy could be considered the most cost-effective treatment at the willingness-to-pay threshold of $150,000.

Stress and Anxiety Among Parents of Transition-Aged Children with Autism Spectrum Disorder: a Systematic Review of Interventions and Scales

The period between adolescence to young adulthood can be stressful for parents of transition-aged children (14 to 22 years old) with autism spectrum disorder. A systematic review was undertaken to examine if existing interventions address the unique parental stressors of this phase and if the scales used to measure parental stress and anxiety are suitable for this group. Of the 9813 studies screened, only 13 studies met the inclusion criteria. Findings indicated that interventions focused on mindfulness, social functioning, or multiple components, of which only two addressed the transition period and only three specifically targeted parents of this age group. Moreover, of the six scales which assessed stress or anxiety, none were designed for these parents. Findings highlight the urgent need for more suitable scales and targeted interventions.

Longitudinal impact of public stigma and courtesy stigma on parents of children with autism spectrum disorder: The moderating role of trait mindfulness

BACKGROUND

Although the public and courtesy stigma of autism spectrum disorder (ASD) are prevalent, there are very few studies examining their adverse psychological effects on parents of children with ASD or exploring plausible factors that can alleviate these adverse effects. The present study addressed these literature gaps by investigating the longitudinal linkages of public and courtesy stigma to detrimental cognitive (i.e., self-stigma content and process) and affective (i.e., perceived stress and symptoms of depression and anxiety) consequences for parents of children with ASD and testing if these linkages would be moderated by trait mindfulness.

METHODS

At two time points separated by 12 months, 372 Hong Kong parents of children with ASD provided questionnaire data on public and courtesy stigma, mindfulness, self-stigma content and process, perceived stress, and symptoms of depression and anxiety.

RESULTS

Hierarchical regressions showed that public and courtesy stigma interacted significantly with mindfulness at baseline in predicting self-stigma content and process, perceived stress, and symptoms of depression and anxiety at follow-up. Moreover, simple slope analyses showed that the linkages of public and courtesy stigma to the five detrimental psychological consequences were weaker in parents with high mindfulness than in those with low mindfulness.

CONCLUSIONS

Our findings highlight the longitudinal linkages of public and courtesy stigma to detrimental cognitive and affective consequences for parents of children with ASD, and reveal the plausible protective effects of mindfulness against such linkages. These findings suggest the potential utility of increasing mindfulness in parents of children with ASD in coping with community stigma and improving mental health.

Protocol of a randomized controlled trial to investigate the efficacy and neural correlates of mindfulness-based habit reversal training in children with Tourette syndrome

BACKGROUND

Tourette syndrome (TS) is a developmental neuropsychiatric disorder. Behavior therapy, especially habit reversal training (HRT), has gradually become regarded as one of the core therapies for TS. Mindfulness approaches can improve psychological adjustment and reduce stress and anxiety, suggesting potential benefits when incorporated into behavior therapy. To improve the efficacy of HRT, we combined it with mindfulness, an approach named mindfulness-based habitual reversal training (MHRT). The aim of this protocol is to investigate the efficacy and neural mechanisms of MHRT for TS.

METHODS/DESIGN

We will perform a randomized control trial (RCT) to evaluate the efficacy and neural mechanisms of MHRT. The sample will include 160 participants (including 120 patients with TS and 40 healthy controls). The patient sample will be randomly divided into three groups exposed to three different types of training: MHRT, HRT, and psychoeducation and supportive therapy (PST). Participants will be assessed and undergo resting-state fMRI scans at baseline and at the end of the 12-week training. The Yale Global Tic Severity Scale (YGTSS) and Premonitory Urge for Tic Scale (PUTS) will be used to assess the severity of tic symptoms and premonitory urges. The primary outcomes are change scores on the YGTSS and other assessments from baseline and the end of the training. The secondary outcomes are the neural correlates of these trainings among these groups based on graph theory, which is used to characterize brain functional connectivity networks. The default mode network (DMN) and the salience network (SN) will be assessed (which have been associated with mindfulness as well as the generation of tic symptoms) by network parameters, including clustering coefficients and shortest path lengths. Changes in these network parameters will be regarded as the neural correlates of the behavioral training.

DISCUSSION

MHRT was newly developed for the treatment of TS. MHRT may lead to greater reductions in tic severity than traditional HRT. Changes in the network parameters of the DMN and SN may show associations with the efficacy of MHRT.

CLINICAL TRIAL REGISTRATION

http://www.chictr.org.cn, ChiCTR2100053077, China.

Investigating the structure of trait rumination in autistic adults: A network analysis

LAY ABSTRACT

Autistic adults are substantially more likely to develop depression than individuals in the general population, and recent research has indicated that certain differences in thinking styles associated with autism may play a role in this association. Rumination, the act of thinking about the same thing over and over without a functional outcome, is a significant risk factor for depression in both autistic and non-autistic adults. However, little is known about how different kinds of rumination relate to each other and to depressive symptoms in the autistic population specifically. To fill this gap in knowledge, we recruited a large online sample of autistic adults, who completed questionnaire measures of both the tendency to ruminate and symptoms of depression. By examining the interacting network of rumination and depression symptoms, this study was able to identify particular aspects of rumination-such as thinking repetitively about one's guilty feelings or criticizing oneself-that may be particularly important in maintaining these harmful thought patterns in autistic adults. Although further study is needed, it is possible that the symptoms identified as most "influential" in the network may be particularly good targets for future interventions for mood and anxiety disorders in the autistic population.