Parenting a child with autism in India: narratives before and after a parent-child intervention program

Transporting and implementing a caregiver-mediated intervention for toddlers with autism in Goa, India: evidence from the social ABCs

Introduction

Autism is a global health priority with an urgent need for evidence-based, resource-efficient, scalable supports that are feasible for implementation in low- and middle-income countries (LMICs). Initiating supports in the toddler years has potential to significantly impact child and family outcomes. The current paper describes the feasibility and outcomes associated with a Canadian-developed caregiver-mediated intervention for toddlers (the Social ABCs), delivered through a clinical service in Goa, India.

Methods

Clinical staff at the Sethu Centre for Child Development and Family Guidance in Goa, India, were trained by the Canadian program development team and delivered the program to families seen through their clinic. Using a retrospective chart review, we gathered information about participating families and used a pre-post design to examine change over time.

Results

Sixty-four families were enrolled (toddler mean age = 28.5 months; range: 19-35), of whom 55 (85.94%) completed the program. Video-coded data revealed that parents learned the strategies (implementation fidelity increased from M = 45.42% to 76.77%, p < .001, with over 90% of caregivers attaining at least 70% fidelity). Toddler responsivity to their caregivers (M = 7.00% vs. 46.58%) and initiations per minute (M = 1.16 vs. 3.49) increased significantly, p's < .001. Parents also reported significant improvements in child behaviour/skills (p < .001), and a non-significant trend toward reduced parenting stress (p = .056).

Discussion

Findings corroborate the emerging evidence supporting the use of caregiver-mediated models in LMICs, adding evidence that such supports can be provided in the very early years (i.e., under three years of age) when learning may be optimized.

Coherence of Parental Representations Following Therapy for Autistic Children

Autistic children experience high rates of mental health challenges, and links have been found between child mental health and the parent-child relationship. As parents of autistic children are often actively involved in their child's treatment, it is important to consider aspects of the parent-child relationship within this context. The present study investigated changes in a component of the parent-child relationship, the coherence of parental representations, following participation in a 10-week cognitive behavioural therapy intervention designed to address autistic children's mental health challenges. Relationships were examined between coherence and child characteristics (i.e., autism symptoms, mental health), and associations with child treatment outcomes (i.e., mental health). Participants included 81 children (89% boys) aged 8 to 13 years and their parents (85% mothers) aged 35 to 54 years. Baseline levels of coherence were related to children's mental health symptoms but not autism symptoms. Although there were no significant changes in overall coherence across therapy, subscale-level improvements (i.e., concern, acceptance) emerged. Changes in coherence across therapy were linked with children's post-intervention behavioural symptoms and were approaching significance for internalizing problems, but were not associated with externalizing problems. It is critical to investigate factors that shape the coherence of parents' representations of their children, as this may provide insight into potential targets for intervention. Ascertaining whether participation in therapy improves parental coherence, and consequently child treatment outcomes, can advocate for parent-involved therapy, which will ultimately benefit the well-being of autistic children.

Spring is not yet here: raising a child with ASD in rural southwest China

PURPOSE

This study aims to reveal the parenting experiences of parents of children with autism spectrum disorder (ASD) in rural southwest China under the framework of ecological systems theory.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 21 parents of children with ASD from rural southwest China and the interview data were analyzed using the three coding steps of the grounded theory method, namely open, axial, and selective coding.

RESULTS

The results showed four themes: challenges from within the family; relationships between parents, the school, and the community; scarcity and low accessibility of available resources and services; the culture of discriminating against people with disabilities and the loss of eligibility for welfare. The mismatch between the needs of families of children with ASD and the resources available in social-environmental systems is the major issue faced by parents.

CONCLUSIONS

Raising a child with ASD in rural southwest China is affected by the interactions between the families and the internal structures in different environmental systems. The culture of discriminating against people with disabilities formed in the macrosystem could be the essential factor that affects the smoothness of the parenting process of children with ASD.

A randomised controlled trial of clinical and cost-effectiveness of the PASS Plus intervention for young children with autism spectrum disorder in New Delhi, India: study protocol for the COMPASS trial

BACKGROUND

Autism Spectrum Disorder (ASD) is a neurodevelopmental disability affecting at least 5 million children in South Asia. Majority of these children are without access to evidence-based care. The UK Pre-school Autism Communication Therapy (PACT) is the only intervention to have shown sustained impact on autism symptoms. It was systematically adapted for non-specialist community delivery in South Asia, as the 'Parent-mediated Autism Social Communication Intervention for non-Specialists (PASS)' and extended 'PASS Plus' interventions. RCTs of both showed feasibility, acceptability and positive effect on parent and child dyadic outcomes.

METHODS

The Communication-centred Parent-mediated treatment for Autism Spectrum Disorder in South Asia (COMPASS) trial is now a scale-up two-centre, two-arm single (rater) blinded random allocation parallel group study of the PASS Plus intervention in addition to treatment as usual (TAU) compared to TAU alone, plus health economic evaluation embedded in the India health system. Two hundred forty children (approximately 120 intervention/120 TAU) with ASD aged 2-9 years will be recruited from two tertiary care government hospitals in New Delhi, India. Accredited Social Health Activists will be one of the intervention delivery agents. Families will undertake up to 12 communication sessions over 8 months and will be offered the Plus modules which address coexisting problems. The trial's primary endpoint is at 9 months from randomisation, with follow-up at 15 months. The primary outcome is autism symptom severity; secondary outcomes include parent-child communication, child adaptation, quality of life and parental wellbeing. Primary analysis will follow intention-to-treat principles using linear mixed model regressions with group allocation and repeated measures as random effects. The cost-effectiveness analysis will use a societal perspective over the 15-month period of intervention and follow-up.

DISCUSSION

If clinically and cost-effective, this programme will fill an important gap of scalable interventions delivered by non-specialist health workers within the current care pathways for autistic children and their families in low-resource contexts. The programme has been implemented through the COVID-19 pandemic when restrictions were in place; intervention delivery and evaluation processes have been adapted to address these conditions.

TRIAL REGISTRATION

ISRCTN; ISRCTN21454676 ; Registered 22 June 2018.

Narrative analysis of parents' experiences with participating in the intervention of children on the autism spectrum in mainland China

PURPOSE

Although the challenges encountered by parents of children on the autism spectrum during the intervention process have garnered scholarly attention, how parents subjectively review those challenges and construct meanings of their experiences remained underexamined. By applying the narrative analysis framework, we investigated the lived experiences of parents of children on the autism spectrum regarding challenges they faced in the intervention process, along with the meanings of those experiences that they constructed in the sociocultural context of mainland China.

METHODS

We purposively sampled 16 parents to narrate their experiences following semistructured interviews. Each participant had one child who had participated in autism intervention for more than two years.

RESULT

The narrative analysis revealed that parents experienced a series of challenges imposed by structural barriers in the intervention process, which resulted in psychological distress and negative perceptions of their parental identities. Albeit susceptible to those adversities, the parents actively constructed new meanings of parenthood and their children's situations through reflexive dialogues.

CONCLUSION

Our results indicate the essential role of meaning-oriented coping in helping parents with children on the autism spectrum to mitigate the negative influence of challenges on their parental identity, strengthen their parent-child relationships, and readjust their priorities for intervention.IMPLICATIONS FOR REHABILITATIONThe role of encouraging new meanings through reflexive dialogues was found to be particularly important among parents with children on the autism spectrum to cope with the challenges they faced in the intervention process.New meanings assigned can mitigate the negative impact of challenges on parents' parental identity, strengthening their parent-child relationships, and readjusting their priorities for intervention within the Chinese socio-cultural context.It is crucial for social workers and other practitioners to support parents in mainland China by facilitating them to assign new meanings to the challenging situations.It is important for social workers and other practitioners to encourage parents to cultivate inner strengths and self-value to support their children on the autism spectrum.

Towards a "New Mothering" Practice? The Life Experiences of Mothers Raising a Child with Autism in Urban Ethiopia

Autism spectrum disorder (ASD) is a complex neurological and developmental disorder that has seen an increase in prevalence over the past two decades, particularly in low and middle-income countries. The purpose of the current paper is to examine the experiences of mothers in Ethiopia raising a child with ASD through employing a qualitative research design involving semi-structured interviews with twenty mothers. The experiences of mothers in this study fell into three thematic areas: (1) grieving and experiencing other emotions arising from the diagnosis of their child; (2) developing, understanding and defining autism; and (3) accepting the diagnosis and developing coping strategies for raising their child. The findings revealed that raising a child with autism introduced a new lifelong experience to mothers' everyday lives, profoundly changing their parenting role and transforming their view of mothering. Recognition of the experience of "new mothering" and mothers' meaning-making process, stress, coping mechanisms and resilience is critical to informing policies, programs, counseling and other therapeutic efforts to assist children with autism and their families for social workers in Ethiopia and those working with the Ethiopian diaspora in other regions of the world.

Parents planning for the long-term future of adults with ASD in India: "But that's a maybe. It's still a maybe"

Research on long-term planning for adults with Autism Spectrum Disorder (ASD) in India is non-existent. The mixed-methods study examined caregiver's expectations around the future planning of an adult with ASD and the barriers and facilitators to the future planning. The purposive sample included 139 caregivers to adults and adolescents with ASD who were part of the survey and 25 caregivers who participated in in-depth interviews. 40% of caregivers hadn't started planning for the future.The family was considered the ideal place to age, but perceived and objective barriers impacted caregivers' ability to plan for the future. The most common barrier that impacted all domains of long-term care was the fear of the unknown or the fear that none of the plans would fall in place. The study also identified resources and strategies used by parents to plan. Findings from the study can potentially impact policy, advocacy, and practice.

World Health Organisation-Caregiver Skills Training (WHO-CST) Program: Feasibility of Delivery by Non-Specialist Providers in Real-world Urban Settings in India

The World Health Organization-Caregiver Skills Training Program, a parent-mediated early intervention facilitated by non-specialist providers piloted in urban India was evaluated using mixed-methods for feasibility and effects on child and caregiver outcomes. Caregivers (n = 22) of children (2-9 years) with social-communication delays participated in a single-group pre-post study. High rates of caregiver attendance, improved caregiver fidelity, and facilitator competency suggested program feasibility. Caregivers voiced acceptability of various intervention-components. The intervention was associated with improved caregiver-reported skills and knowledge (p < 0.00), reduction in stress (p = 0.03), improved child developmental outcomes on communication and social interaction (p < 0.00), and adaptive behaviors (p < 0.00). Challenges about logistics and availability of time were highlighted. Implications of results in resource-poor settings and recommendations for future feasibility trials are discussed.

Parent mediated intervention programmes for children and adolescents with neurodevelopmental disorders in South Asia: A systematic review

OBJECTIVE

Parent-mediated programmes have been found to be cost effective for addressing the needs of the children and adolescents with Neurodevelopmental Disorders (NDD) in high-income countries. We explored the impact of parent-mediated intervention programmes in South Asia, where the burden of NDD is high.

METHODS

A systematic review was conducted using the following databases; PUBMED, MEDLINE, PsycINFO, Google Scholar and Web of Science. Predefined MeSH terms were used, and articles were included if published prior to January 2020. Two independent researchers screened the articles and reviewed data.

OUTCOMES MEASURES

The review included studies that targeted children and adolescents between 1 and 18 years of age diagnosed with any of four specific NDDs that are commonly reported in South Asia; Autism Spectrum Disorder (ASD), Intellectual Disability (ID), Attention Deficit Hyperactivity Disorder (ADHD) and Cerebral Palsy (CP). Studies that reported on parent or child outcomes, parent-child interaction, parent knowledge of NDDs, or child activities of daily living were included for full text review.

RESULTS

A total of 1585 research articles were retrieved and 23 studies met inclusion criteria, including 9 Randomized Controlled Trials and 14 pre-post intervention studies. Of these, seventeen studies reported effectiveness, and six studies reported feasibility and acceptability of the parent-mediated interventions. Three studies demonstrated improved parent-child interaction, three studies demonstrated improved child communication initiations, five studies reported improved social and communication skills in children, four studies demonstrated improved parental knowledge about how to teach their children, and four studies reported improved motor and cognitive skills, social skills, language development, learning ability, or academic performance in children.

CONCLUSION

This systematic review of 23 studies demonstrated improvements in parent and child skills following parent-mediated intervention in South Asia. Additional evaluations of locally customized parent-mediated programmes are needed to support development of feasible interventions for South Asian countries.

Autism spectrum disorder in India: a scoping review

Autism is a grand challenge in global mental health to be dealt with on a priority basis. Phenotypic knowledge, biological understanding, and evidence-based intervention studies are all from western countries. We know very little about autism in the low- and middle-income countries (LMIC). Lack of infrastructure and difficulties in operationalizing research has widened the knowledge gap. We performed a comprehensive scoping review of research in Autism Spectrum Disorder in India to have an overall impression, identify gaps, and formulate evidence-based recommendations for further study. We searched PubMed, SCOPUS, and Cochrane Library to identify relevant Indian studies. A hundred and fifty-nine publications met the inclusion criteria. Most of the research contribution in autism is from few tertiary care medical centres, technological institutes, and not-for-profit organizations. We identified various themes of research like clinical profile, interventions, biomarkers, psychological, social, epidemiological, and risk factors. Evidence-based intervention studies, translation and adaptation of standard diagnostic instruments, and qualitative research on the experience of autism appeared to be state of the art. However, epidemiological studies, biomarkers identification, risk assessment studies were of low quality. There is a need for nationwide studies with representative sampling on epidemiology, biomarkers, and risk factors for a complete evaluation of the actual burden and biology of autism in India. Also, there is a need to design implementation research to evaluate the effectiveness of evidence-based interventions in routine healthcare settings. We recommend that future research should fill these gaps in understanding autism and improving its outcome in India.

The Impact of Autism Spectrum Disorder in Comparison with Other Neuro-Developmental Disorders in Children on the Family: Single Centre Experience

BACKGROUND

Neurodevelopmental disorders (NDD), especially autism spectrum disorder (ASD), have a substantial impact on the family, with a consequent decrease in the quality of life. The current study was undertaken to understand if having ASD contributed to a higher impact on families compared to other NDD and to understand additional factors impacting families of children with either disorder in a low-middle income country (LMIC) setting.

METHODS

Impact of ASD and other NDD along with sociodemographic factors was examined, by a retrospective analysis, among 540 children in a tertiary care center in South India.

RESULTS

Both ASD and NDD had high, but comparable, impact on the family. Being a girl child, having seizures, and having sleep problems predicted a higher impact.

CONCLUSIONS

In children with NDD, managing co-morbidities such as achieving better seizure control and addressing sleep-related problems may improve the impact of NDD on the family. Gender disparity in disability needs to be studied within the local cultural context.

A qualitative study on perspective of parents of children with autism on the nature of parent-professional relationship in Kerala, India

LAY ABSTRACT

This study explored the nature of relationship between parents of children with autism and professionals who provide therapy-based services for autism in Kerala, India. Given the shortage of professionally qualified therapists and educators (particularly in the case of autism) in low- and medium-income countries, parent-mediated interventions where professionals and parents work as partners are recommended as an effective means to meet the demand. However, for parent-mediated interventions to be effective, we first need to understand the customary nature of parent-professional relationship and develop the intervention accordingly. It is within this context that parents of 21 children with autism whose age ranged between 5.8 and 17.3 years were interviewed in order to understand the customary nature of parent-professional relationship. There was a dearth of scheduled, in-depth, and personalized one-on-one interaction between the parent and the professional. Though parents were involved hands on in their child's training under professional direction, they remained mere information providers in decision making. The parent-professional relationship did not nurture parent's self efficacy. This led to parents feeling inadequate to provide for their child's developmental needs and being apprehensive about adulthood. The customary nature of parent-professional relationship observed may be a reflection of the collectivist culture in India. The findings suggest that parent-mediated interventions will need to focus on enabling parents to break cultural barriers that might be holding them back from partnering with professionals as equals.

Teaching students with autism spectrum disorders in South Asia: a scoping study and recommendations for future

Objectives: Our paper reviews current teaching practices used to support students with autism spectrum disorder (ASD) in the South Asian region, and to what extent these teaching practices reflect key research based effective practices. We have focused our attention on teaching practices at a time when we are witnessing a greater thrust towards achieving inclusive education at both, regional and global levels. Methods: We have used an eclectic approach for the study by employing a scoping review methodology to identify peer reviewed journal articles from South Asian countries. Having identified 10 articles and three dissertations in total from India, Pakistan, and Sri Lanka, we have used a matrix method to present our data against nine best teaching practices for students with ASD. Results: Results from the review indicate three practices (of the nine best teaching practices) were most frequently used. These are assessments, alternative, and augmentative communication systems, and parent-implemented instruction/program. The other six teaching practices were not widely reported. Conclusions: We identify significant implications for practitioners, educators, and teacher education programs within the Asian region and beyond. The use of an eclectic approach in making choices regarding teaching strategies, incorporating varied research based effective teaching practices, and following a systematic and informed approach of assessments - teaching interventions - ongoing evaluation are key to supporting students with ASD.

Influence of Community-Level Cultural Beliefs about Autism on Families' and Professionals' Care for Children

This qualitative study aimed to understand how community-level cultural beliefs affect families' and professionals' care for children with autism and developmental delays in immigrant communities, as a first step towards promoting early identification and access to early intervention services. The study was part of the larger New York City (NYC) Korean Community Autism Project, which was designed to identify strategies to increase awareness of autism and reduce delays in treatment seeking within the NYC Korean-American community. Our study elicited early childcare workers' and church leaders' beliefs about autism and developmental disorders and, in particular, early intervention. We also elicited responses to newly developed outreach materials targeting this community. An inductive approach was used to identify concepts and categories associated with autism. Our study confirmed that discomfort, stigma and discrimination are the prevailing community attitudes toward autism and developmental disorders in the Korean-American community. Families' and professionals' understanding of autism and their care for children are affected by these community beliefs. Approaching immigrant communities with general information about child development and education rather than directly talking about autism and developmental disorders is likely to engage more families and professionals in need for diagnostic evaluation and early intervention for autism.

'How deep are your pockets?' Autoethnographic reflections on the cost of raising a child with autism

Background

In this article, we reflected on our experience of the cost of parenting a child with autism, including our ongoing search for educational and therapeutic intervention.

Objectives

We aimed to give an academic insight into the state of autism education and care in South Africa as seen by us, with special attention to its cost and sustainability.

Methods

Using evocative autoethnography as storied scholarship together with critical autism studies, we reflected on stories of the past 5 years since our son’s diagnosis.

Results

Our experiences agree with international studies that establish autism as the most expensive disability. In addition to the high costs of diagnosis, existing intervention and support approaches are unaffordable for the majority of South Africans. We recommend that teachers should be trained to participate in early screening and diagnosis, as well as co-therapists, to strengthen the implementation of inclusive education.

Conclusion

The kind of autism intervention currently offered in South Africa is financially and socially unsustainable. Instead of positioning autism as an individual or family dilemma, it should be addressed as an educational and societal issue. Future research should explore cost-effective options for a developing country context, while promoting best practice within inclusive settings.

Psychological Distress in Jordanian Parents of Children With Autism Spectrum Disorder: The Role of Trait Mindfulness

AIM

This study examines the role of mindfulness in predicting psychological distress in Arab parents of children with autism spectrum disorder (ASD).

METHOD

In this descriptive study, parents of 104 children with ASD completed measures of psychological distress and mindfulness. The severity of autism in children was measured using the DSM-V criteria.

RESULTS

After controlling for parental age and gender and the severity level of ASD, mindfulness was significantly associated with the levels of anxiety, stress, and depression in parents (anxiety: β = 0.49, p < .001; stress: β = 0.55, p < .001; depression: β = 0.53, p < .001).

CONCLUSION

Mindfulness-based intervention may help to reduce psychological distress in Arab parents of children with ASD.

Lessons learned while developing, adapting and implementing a pilot parent-mediated behavioural intervention for children with autism spectrum disorder in rural Bangladesh

Low- and middle-income countries often have limited resources, underdeveloped health systems and scarce knowledge of autism spectrum disorder. The objectives of this preliminary study were to develop and adapt intervention materials and to train a native clinician to implement a community-based parent-mediated behavioural intervention in rural Gaibandha, Bangladesh. Intervention materials to support parents' use of behavioural strategies were developed and refined by US behavioural intervention experts and Bangladesh field experts. Study investigators trained a native child psychologist in developmental milestones and behavioural intervention techniques. The native clinician delivered a 1-day group education session attended by 10 families of children aged 7-9 years with autism spectrum disorder, followed by two one-on-one training sessions with each family to train and practice individualized strategies for targeted challenging behaviours. Preliminary qualitative results indicate the importance of materials that are culturally appropriate and at an adequate literacy level. All families expressed strong desires to have learned the behavioural strategies when their child was younger and vocalized their need for further support and tools to help their children. This study is a preliminary step to creating sustainable and low-cost autism spectrum disorder interventions in rural Bangladesh, and possibly for families in regions with similar cultural and socioeconomic status backgrounds.

Asperger's Syndrome, Subjectivity and the Senses

Situated at the intersection of anthropological work on illness narratives and research on the anthropology of autism, this paper is a close reading of an autobiographical narrative recounted by Peter, a young man diagnosed with Asperger's Syndrome, a type of autism spectrum disorder (ASD). Responding to Solomon's (2010a:252) call for phenomenologically grounded accounts of "the subjective, sensory, and perceptual experiences of autism … based on personal narratives and practices of being and self-awareness," this paper calls into question key assumptions in the clinical and popular literature about ASD relating to theory of mind, empathy, capacity for metaphorical thinking, and ASD as a life-long condition.

Understanding parents’ and professionals’ knowledge and awareness of autism in Nepal

Autism is a global phenomenon. Yet, there is a dearth of knowledge of how it is understood and its impact in low-income countries. We examined parents’ and professionals’ understanding of autism in one low-income country, Nepal. We conducted focus groups and semi-structured interviews with parents of autistic and non-autistic children and education and health professionals from urban and rural settings ( n = 106), asking questions about typical and atypical development and presenting vignettes of children to prompt discussion. Overall, parents of typically developing children and professionals had little explicit awareness of autism. They did, however, use some distinctive terms to describe children with autism from children with other developmental conditions. Furthermore, most participants felt that environmental factors, including in-utero stressors and birth complications, parenting style and home or school environment were key causes of atypical child development and further called for greater efforts to raise awareness and build community capacity to address autism. This is the first study to show the striking lack of awareness of autism by parents and professionals alike. These results have important implications for future work in Nepal aiming both to estimate the prevalence of autism and to enhance support available for autistic children and their families.

Custodial Homes, Therapeutic Homes, and Parental Acceptance: Parental Experiences of Autism in Kerala, India and Atlanta, GA USA

The home is a critical place to learn about cultural values of childhood disability, including autism and intellectual disabilities. The current article describes how the introduction of autism into a home and the availability of intervention options change the structure and meaning of a home and reflect parental acceptance of a child's autistic traits. Using ethnographic data from Kerala, India and Atlanta, GA USA, a description of two types of homes are developed: the custodial home, which is primarily focused on caring for basic needs, and the therapeutic home, which is focused on changing a child's autistic traits. The type of home environment is respondent to cultural practices of child rearing in the home and influences daily activities, management, and care in the home. Further, these homes differ in parental acceptance of their autistic children's disabilities, which is critical to understand when engaging in international work related to autism and intellectual disability. It is proposed that parental acceptance can be fostered through the use of neurodiverse notions that encourage autism acceptance.