Stigma among parents of children with autism: A literature review

Are a Child's Autistic Traits, Behavioural Difficulties, Prosocial Behaviour and Temperament Predictors of Parental Self-Efficacy and Satisfaction? A Study on Parents of Autistic and Neurotypical Children Aged 7-11 Years

The aim of the study was to evaluate the significance of the severity of autistic traits, behavioural difficulties, prosocial behaviour and temperamental characteristics in children for parental self-efficacy and parental satisfaction in two groups of parents: parents of autistic children, and parents of neurotypical children. Data come from 145 parents of autistic children and 239 parents of neurotypical children. Using hierarchical multiple regression analyses, the analysis explored the role of child characteristics in prediction of parental self-efficacy and parental satisfaction. The regression model tested explained 21% variation in parental self-efficacy and 27% variation in parental satisfaction in parents of autistic children and 3% of variation of results with respect to parental self-efficacy and 17% variation in parental satisfaction in parents of neurotypical children. In both groups, parental self-efficacy and parental satisfaction were negatively correlated with such child characteristics as severity of behavioural difficulties, severity of autistic traits and emotionality as also positively related to the child's prosocial behaviour. These findings may suggest that particularly useful mental health prevention programs for parents should combine two elements: developing parents' abilities of effectively coping with children's behavioural difficulties and working on attribution processes and negative convictions about parenthood.

Made to feel different: Families perspectives on external responses to autism and the impacts on family well-being and relationships

LAY ABSTRACT

The influence of the environment on different groups of people with disabilities has rarely been studied in the context of neurodevelopmental disabilities, such as autism, in adolescence. This study explored how external responses to autism affect the experiences, outcomes and family relationships of autistic adolescents and their family members, including siblings and parents. This study adds to the knowledge of factors that contribute to the social disadvantage and exclusion autistic adolescents and their families face in their communities. Interviews with 30 participants from families with an autistic adolescent show that external factors greatly impact the well-being of autistic adolescents and their families. The school environment, including sensory overload, bullying and negative interactions with teachers, was found to be a key factor that negatively influenced mental health and family relationships. The study also revealed that isolation and stigma are major concerns for families, indicating the importance of public awareness campaigns to increase understanding of autism. In addition, the lack of adequate support and services presented significant challenges for families. The study emphasises the importance of person-centred approaches to providing services, which involve including autistic individuals and their families in designing and delivering support.

Revealing the Most Vulnerable Groups: Courtesy Stigma in Caregivers of Autistic Persons in Quebec

Introduction

Caregivers of autistic persons often face "courtesy stigma," a phenomenon by which caregivers experience stigma because of their association with a person whose disability may be stigmatized. Understanding the repercussions of this stigma is crucial not only for caregivers' mental health but also for the quality of care provided to their dependent. This study aimed to explore courtesy stigma among caregivers of autistic persons in Quebec, examining its prevalence and impact in order to identify groups that are particularly susceptible to negative outcomes.

Methods

This study used a cross-sectional online survey methodology employing quota sampling to collect responses from 194 participants. Data were collected using a computer-assisted web interview (CAWI) platform. The impact of courtesy stigma was measured in terms of care burden, mental health, and overall well-being of caregivers.

Results

The findings revealed that caregivers frequently experience rejection, isolation, and work-related challenges. Notably, caregivers' health was below average with the lowest reported health outcomes in Quebec. The caregivers who are the most vulnerable to negative outcomes included female caregivers, those aged 45 or older, financially strained households, caregivers of children requiring elevated levels of support, caregivers who isolated due to their autistic dependents, and those who experienced stigmatization directed at themselves or their children in the form of rejection.Interestingly, 60% of respondents reported that the caregiving burden was "not at all" to "somewhat" difficult, raising questions about factors that may mitigate caregiving challenges over time.

Conclusion

Negative outcomes from courtesy stigma vary depending on certain risk factors and individual characteristic. This study underscores the need for targeted public policies and interventions, particularly for those at a higher risk of experiencing the negative effects of courtesy stigma on the burden of care, overall health, and mental health. By tailoring resources and support for these priority groups, we can better address the challenges faced by families of autistic persons.

Depression and parental distress among caregivers of autistic children: a serial mediator analysis in caregivers of autistic children

BACKGROUND

This study aimed to investigate the relationship between the severity of autism, emotional and behavioral problems of autistic children, internalized stigma, depressive symptoms, and primary caregiver parental stress. Specifically, we explored the mediating role of internal stigmatization and total difficulties of individuals with autism on parenting stress and depressive symptoms of the primary caregiver.

METHOD

Mothers of 93 children with autism were included in the study. The mothers were given the Beck Depression Inventory (BDI), The Internalized Stigma of Mental Illness Scale (ISMI), the Autism Behavior Checklist, the Parenting Stress Index-Short Form, Strength, and Difficulties Questionnaire -Parent Form (SDQ-P).

RESULTS

As a result of our study, the emotional and behavioral problems of the child and the internalized stigmatization felt by the parent played a mediator role in the relationship between the child's autism severity and the parent's stress and depressive symptoms.

CONCLUSIONS

Our findings highlight that internalized stigmatization and behavioral characteristics of individuals with autism are among the most critical problems for their primary caregivers. These results have important implications for the development of interventions aimed at reducing the internalized stigma experienced by primary caregivers of individuals with autism and for improving their mental health outcomes.

The Well-being and Support Needs of Australian Caregivers of Neurodiverse Children

Caregivers of children with neurodiverse needs are known to experience challenges and hardship due to the increased needs of the child and the lack of support available. This study aimed to explore the support needs and well-being of caregivers of children with neurodiverse needs in Australia. Sixty-six caregivers participated in an online survey asking questions about support needs. The results highlighted five main themes that caregivers commonly experienced including: barriers to community engagement, impact on close relationships, negative impact on mental health and identity, financial hardship, and identified support needs. Findings identified multiple unmet needs existing amongst caregivers and further emphasises the importance of addressing these needs to improve the quality of life of caregivers of children with neurodiverse needs.

Participation Strategies of Parents of Children with Neurodevelopmental Disorders: An Exploratory Study

Strategies are critical to promote child participation in important life activities. This study analyzed the participation strategies of the parents of children with neurodevelopmental disorders. Ninety-two Japanese elementary children with neurodevelopmental disorders and their parents were recruited. The parents completed the Participation and Environment Measure for Children and Youth (PEM-CY) questionnaire. Strategy text data obtained from the PEM-CY were analyzed with the co-occurrence network and correspondence analyses. The co-occurrence network analysis showed that the commonality of strategies to enable participation at home, school, and community settings was able to explain the child's characteristics when involved in each setting. The correspondence analysis also suggested the need for specific strategies in each setting. The importance of strategies to improve the attitudinal environment and promote the participation of children with neurodevelopmental disorders was evident. Reducing stigma is important in all environments, especially in the public sphere. In addition, specific strategies are needed in each setting, suggesting the importance of context-specific approaches.

A Review of the Literature on the Multiple Forms of Stigmatization of Caregivers of Children with Autism Among Ethnic Minority Groups

Multiple forms of stigmatization are experienced by caregivers of children with autism among ethnic minority (EM) groups in various countries. Such forms of stigmatization can lead to delayed assessment and services for mental health among children and caregivers. This review identified the research literature on the types of stigmatization experienced by caregivers of children with autism with an EM background. A total of 19 studies published after 2010 (i.e., 12 from the USA, 2 from the UK, 1 from Canada, and 1 from New Zealand) of caregivers of 20 ethnicities were identified and reviewed, and their reporting qualities systematically also assessed. Four main themes: (1) self-stigma, (2) social stigma, (3) stigma towards EM parents of children on the autism spectrum, and (4) service utilization stigma, and nine sub-themes were identified. The discrimination experienced by caregivers were extracted, synthesized, and further discussed. While the reporting quality of the studies included is good, the depth of the understanding of this under-researched yet important phenomenon is very limited. The multiple forms of stigmatization experiences are complex, and it may be difficult to disentangle whether the causes of stigmatization were autism and/or EM related, and the types of stigmatization can vary enormously among different ethnic groups in different societies. More quantitative studies are needed to quantify the impacts of multiple forms of stigmatization on families of children with autism in EM groups so that more socially inclusive support for caregivers with an EM background in host countries can be developed.

"They Were Saying That I Was a Typical Chinese Mum" : Chinese Parents' Experiences of Parent-Teacher Partnerships for Their Autistic Children

Effective parent-teacher partnerships improve outcomes for autistic students. Yet, we know little about what effective partnerships look like for parents of autistic children from different backgrounds. We conducted interviews with 17 Chinese parents of autistic children attending Australian kindergartens/schools to understand their experiences. Parents appreciated the acceptance, opportunities and supports they received in Australia. They had high expectations of children; expectations not often shared by educators. Parents were respectful of teachers' expertise and polite and undemanding in interactions. Nevertheless, parents were frustrated by inconsistent teaching quality and inadequate communication. Navigating systems was also challenging and parents faced discrimination from teachers and their community. Recommendations include fostering open home-school communication, proactively seeking parents' expertise about children and explicitly scaffolding parents' self-advocacy.

Courtesy stigma among primary caregivers of children with autism spectrum disorder in eastern China

Introduction

The experience and perception of stigma is a common problem among primary caregivers of children with autism spectrum disorder (ASD), and has a profound adverse impact on primary caregivers and children with ASD; however, few studies have explored courtesy stigma among primary caregivers of children with ASD in the Chinese context. The aim of this study was to explore the status of courtesy stigma among primary caregivers of children with ASD in Lianyungang, Jiangsu Province, Eastern China, and to conduct in-depth analysis of its predictors from multiple perspectives.

Methods

An institution-based multi-center cross-sectional survey was conducted in the rehabilitation department of a large specialized hospital and 10 rehabilitation centers for children with special needs in Lianyungang, Jiangsu Province, Eastern China, from October 2022 to February 2023. A structured questionnaire to assess child-related factors, primary caregiver-related factors, courtesy stigma, general self-efficacy, and social support, was used to collect data. Predictors of courtesy stigma among primary caregivers of children with ASD were identified by linear regression.

Results

A total of 428 primary caregivers of children with ASD were recruited. The mean ± standard deviation (SD) score for courtesy stigma was 7.49 ± 4.13. Multiple linear regression analysis revealed that primary caregivers of children with ASD who were not too satisfied with their current marital status (β = 1.21, 95% CI: 0.34-2.08, p < 0.05) were more likely to have a high courtesy stigma; however, significantly lower courtesy stigma was observed in primary caregivers of children with ASD who were not picky eaters (β = -1.33, 95% CI: -2.08 - -0.58, p < 0.05), and who reported low level challenge in caring for children with ASD (β = -1.16, 95% CI: -2.20 - -0.12, p < 0.05), good general self-efficacy (β = -0.16, 95% CI: -0.25 - -0.06, p < 0.05), and good social support (β = -0.04, 95% CI: -0.08 - -0.01, p < 0.05).

Conclusion

There is a high level of courtesy stigma among primary caregivers of children with ASD in eastern China, and it is affected by numerous factors. More resources should be directed to groups that are more likely to experience stigma.

Anxiety, Depression, Quality of Life, and Family Support Among Family Caregivers of Children with Disabilities

Purpose

To investigate the family support, anxiety, depression, health-related quality of life (HRQoL), and their associations among parents and grandparents of children with disabilities.

Methods

This is a cross-sectional study and a total of 327 family caregivers were included. Chi-square test, Mann-Whitney U-test, and two independent t-test were used to identify the intergenerational differences in sociodemographic characteristics, received family support, anxiety, depression, and HRQoL. Eight generalized linear models were developed to examine the associations in both generations.

Results

Parents and grandparents were most in need of rehabilitation and financial support, but both populations received the least amount of financial support. 33.6% and 36.1% of family caregivers had the risk of anxiety and depression and found no significant intergenerational differences. As for HRQoL, intergenerational differences were found in the physical component score, but not found in the mental component score. Among parents, childcare support of respite care and household tasks assistance was negatively associated with their depression (p<0.05), professional support of appropriate surgery for children (p<0.05) and psychological support from professional psychologists (p<0.01) were negatively associated with their anxiety and depression, psychological support from relatives and friends was negatively associated with their depression (p<0.05) whereas was positively associated with their mental HRQoL (p<0.01). As for grandparents, financial support for daily living expenses was negatively associated with depression (p<0.05), and psychological support from families was negatively associated with depression (p<0.05) whereas was positively associated with mental HRQoL (p<0.05). However, no relationship was found between family support and anxiety among grandparents. Notably, no association was found between family support and physical HRQoL among both populations.

Conclusion

Both parents and grandparents had high risks of anxiety, depression and low levels of mental HRQoL. To efficiently improve psychological health, care providers and policymakers may consider intergenerational differences and provide targeted family support.

Self-compassion mitigates the cognitive, affective, and social impact of courtesy stigma on parents of autistic children

PURPOSE

Due to the courtesy stigma of autism spectrum disorder, many parents of autistic children are devaluated and discriminated against by the public. Despite the high prevalence of this courtesy stigma, very few studies have examined its negative effects on parents of autistic children and explored the factors that may protect the parents from these negative effects. The present study utilized a 2-year, two-wave prospective longitudinal design to examine the associations of courtesy stigma with adverse cognitive (self-stigma), affective (depressive and anxiety symptoms), and social (parent-child and inter-parental conflicts) consequences for parents of autistic children and to test whether these associations would be moderated and mitigated by self-compassion.

METHODS

A total of 381 parents of autistic children completed questionnaires about courtesy stigma, self-compassion, self-stigma, depressive and anxiety symptoms, and parent-child and inter-parental conflicts at time 1 (T1) and time 2 (T2).

RESULTS

Courtesy stigma interacted with self-compassion at T1 in predicting self-stigma, depressive and anxiety symptoms, and parent-child and inter-parental conflicts at T2. Specifically, the associations of courtesy stigma with the adverse psychological consequences were weaker for parents with high self-compassion than for those with low self-compassion.

CONCLUSION

Our results demonstrate the prospective associations of courtesy stigma with adverse cognitive, affective, and social consequences for parents of autistic children, as well as the protective effects of self-compassion against such associations. These results highlight the importance of increasing parents' self-compassion to help them cope with courtesy stigma and improve their psychological well-being.

Public concerns and attitudes towards autism on Chinese social media based on K-means algorithm

To investigate the hot topics and attitudes of autism in the larger community. In this study, we analyzed and summarized experimental texts from the social media platform Zhihu using the TF-IDF algorithm and K-means clustering approach. Based on the analysis of the 1,740,826-word experimental text, we found that the popularity of autism has steadily risen over recent years. Sufferers and their parents primarily discuss autism. The K-means clustering algorithm revealed that the most popular topics are divided into four categories: self-experience of individuals with autism, external views of individuals with autism, caring and stressful behaviors of caregivers, and information about autism. This study concluded that people with autism face more incredible negative emotions, external cognitive evaluations of the autistic group reflect stereotypes, the caregiver's family suffers high financial and psychological stress, and disorders caused by disease in autistic individuals.

Oral Healthcare Practices and Awareness among the Parents of Autism Spectrum Disorder Children: A Multi-Center Study

This study aimed to evaluate the knowledge and attitudes of the parents of autistic children toward oral health and the practice of oral hygiene habits. A questionnaire was constructed, validated, and distributed to the parents of autistic children at different autistic centers. The questionnaire was divided into three parts: demographic information on the parents of autistic children, the knowledge and attitudes of parents toward oral health, and the practice of oral hygiene habits in the current population. A total of 206 responses were collected. Irrespective of the parents' educational and employment statuses, most second children were diagnosed with autism, and most of the parents have four or more children. In terms of knowledge and attitudes toward oral health, a total of 90.30% of the patients were aware of the oral healthcare of their child, and 55.80% of parents take them to the dentist for checkups. Moreover, the response to the practice of oral hygiene habits from the parents was positive, and most of the parents assist in the oral hygiene practices of their autistic children. This study showed that most of the parents appeared to have satisfactory knowledge about oral health practices for autistic children. However, additional studies should also be conducted.

Longitudinal impact of parents' discrimination experiences on children's internalizing and externalizing symptoms: A 2-year study of families of autistic children

LAY ABSTRACT

Although many parents of autistic children are routinely discriminated against, the potential impact of this discrimination on their parenting processes and child-rearing outcomes has seldom been investigated. The present study addressed this gap in the literature by examining the longitudinal associations of parents' discrimination experiences with children's internalizing and externalizing symptoms among families of autistic children and testing whether these associations would be mediated by parental depression, harsh parenting, and coparenting conflict. On three occasions across 2 years (i.e. T1, T2, and T3), 441 parents of autistic children from Hong Kong, China, provided questionnaire data. Path analyses showed that parents' discrimination experiences at T1 had significant direct effects on parental depression, harsh parenting, and coparenting conflict at T2, which, in turn, had significant direct effects on children's internalizing and externalizing symptoms at T3. Bootstrap analyses further demonstrated that parents' discrimination experiences at T1 had significant indirect effects on children's internalizing and externalizing symptoms at T3 via parental depression, harsh parenting, and coparenting conflict at T2. Our findings have important theoretical contributions and significant practical implications. Theoretically, our findings elucidate how parents' discrimination experiences may longitudinally heighten children's internalizing and externalizing symptoms by adversely affecting parental well-being and parent-child and inter-parental relationships. Practically, our findings highlight the importance of designing and implementing community-based stigma reduction programs and family-based stigma coping interventions to reduce parents' discrimination experiences and associated adverse outcomes on well-being, parenting, marriage, and child development.

The impact of educational rewards on the diagnosis of autism spectrum disorder

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder that affects social interactions and communication. The prevalence of ASD has risen dramatically in recent years, but the underlying factors leading to this rise are not clear. In this paper, we test whether changes in state-level educational policy that impact school-level resources are associated with the rise in ASD diagnostic prevalence. Early identification of ASD can improve an array of outcomes for children, and school systems play an important role with identification of the condition. It is plausible that children attending schools with better resources from state governments are more likely to receive an ASD diagnosis and presumably appropriate services. We focus on one educational policy in particular, state-level rewards, which consist of a monetary transfer from state governments to school districts. To test the impact of educational rewards on ASD diagnosis, we rely on policy variation across states and time and estimate both two-way fixed effects (TWFE) models alongside recently advanced methods in the difference-in-differences (DiD) literature. Under a baseline TWFE specification we estimate that rewards policies are associated with a 18.46% increase in ASD diagnosis. Further, using DiD methods that account for bias in settings of differential policy timing, we find that the magnitude of the effect increases to 24.8%. We believe these findings to be suggestive evidence that educational rewards policies improved the likelihood of detection and diagnosis of ASD.

'We've come a very, very, long way' Overcoming stigma of autism: An interpretative phenomenological analysis within the UK Jewish community

LAY ABSTRACT

Autistic people contend with high levels of stigma in a wide array of cultures worldwide. There is a scarcity of literature on stigma in relation to autism in faith communities, with some limited research on this issue in Christian, Muslim and Hindu populations. There is virtually no research focussing on this topic in Jewish communities and to our knowledge, none at all within UK Jewish contexts. In this study, we aimed to explore experiences of stigma towards autism and sought views on what steps have and can be taken to reduce such stigma. Using an interpretative phenomenological analysis approach, we conducted semi-structured interviews with 10 participants within the UK Jewish community, including parents, rabbis, SENDCos, teachers, and headmasters of autistic children in both mainstream and specialist autistic schools. Interviews were conducted over 2 months in 2020. During analysis, 5 superordinate (central) themes and 13 subordinate themes were abstracted from the data. Superordinate themes included 'Stigma not specific to the Jewish community'; 'Considerable strides made'; 'More a lack of knowledge or denial than stigma'; 'Fear of stigma is a real concern but not widely prevalent'; and 'Potent factors that reduce stigma in the Jewish community'. We recommend workshops for greater awareness and training for teachers and parents on autism and autistic children's experiences. We also recommend the formation of specialist autism schools in other communities and promotion of positive narratives concerning autistic people, as this successfully reduced stigma within the Jewish community.

Clinical and demographic differences by sex in autistic Venezuelan children: A cross-sectional study

BACKGROUND

Sex differences in symptom severity and adaptive function in children with ASD have been historically inconsistent and studies are predominantly from American- and European-residing populations. Alike, there is limited information on the complex interplay between sex, intelligence, adaptive function, and autism symptom severity; this is crucial to identify given their predictive value for health outcomes in autism AIM: This study aimed to identify sex differences in autism symptom severity and adaptive function in a sample of Venezuelan children.

METHOD

One-hundred-and-three Venezuelan children ages 3-7 completed a comprehensive assessment for symptom severity, adaptive functioning, and intelligence.

RESULTS

Sex differences were not present in any autism diagnostic domain or adaptive function.Symptom severity was not a significant predictor for adaptive function, which contrasts with studies sampling American children.

CONCLUSION

This study corroborates other findings based on non-American children, where symptom severity was not a function of adaptive function. Awareness of the interplay of culture, sex-related standards, and autism symptomatology will result in better identification and diagnosis of autism regardless of sex or cultural background. What this paper adds? This paper aids the current literature on sex difference on both autism symptom severity and adaptive function. It also provides a snapshot of the relationship between symptom severity, adaptive function, and other psychological variables that influence the outcome of children with ASD.

Autistic children's age difference in affiliate stigma and resilience of their parents in China: A cross-sectional study

BACKGROUND

Parents of children with Autism Spectrum Disorders (ASD) experience high levels of stigma, especially in China where the culture is shame socialized. Resilience can help overcome stigma; while parent characteristics predict resilience, other factors may also be significant such as the child's age.

OBJECTIVE

The study sought to identify the differences in affiliate stigma and resilience among Chinese parents of children with ASD according to the child's age, and to determine whether the levels of resilience and experience of stigma are related.

METHODS

A cross-sectional survey of 184 parents of children with ASD was conducted. Affiliate stigma and resilience were measured using the Chinese version of the 22-item Affiliate Stigma Scale and the Chinese version of the Connor-Davidson Resilience Scale. Differences were examined by using regression and correlation analysis.

RESULTS

Parents of school-age children experienced more affiliate stigma than parents of preschoolers, but there was no difference in resilience when other factors were controlled.

CONCLUSIONS

Considering the child's age is important to understand affiliate stigma and resilience, particularly where resilience is protective and could inform the design of support strategies for preschooler parents.

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.

Analysis of Spanish Parents’ Knowledge about ASD and Their Attitudes towards Inclusive Education

To make possible the inclusion of children with autism spectrum disorder (ASD) in mainstream settings, parental knowledge and attitudes towards the disorder play a key role between the home and the school setting. However, prior literature has not carried out an in-depth analysis of parents’ knowledge about ASD and their attitudes toward the inclusion of children with this diagnosis. This study examined the parental attitudes towards inclusion and knowledge about ASD. Participants were parents of children with ASD (n = 75), parents of children without ASD whose children had prior or current contact with peers with ASD (n = 44), and parents of children with no previous interactions with a peer with ASD (n = 51). The Attitudes of Regular Educators Towards Inclusion for Students with Autism Survey and the Autism Knowledge Questionnaire were filled out. Nonparametric statistical tests were used. Results showed that parents of children with ASD have better knowledge about this disorder and hold more favorable attitudes towards the inclusion of children with ASD than the other parents. These findings suggest that the benefits of inclusive schooling are limited to the school setting and do not appear to affect families of children without ASD.

Longitudinal impact of self-stigma content and process on parental warmth and hostility among parents of children with autism spectrum disorder

This study examined whether self-stigma content and process would prospectively influence parental warmth and hostility through increasing parenting stress among parents of children with autism spectrum disorder (ASD). On three occasions across two years, 441 Hong Kong parents of children with ASD provided questionnaire data. Path analyses showed that self-stigma content and process were associated with greater parenting stress, which was, in turn, associated with reduced parental warmth and increased parental hostility. Our findings reveal the longitudinal influences of self-stigma on parenting practices and demonstrate how these influences can be explained by parenting stress. Our findings also suggest the importance of supporting parents of children with ASD to mitigate self-stigma and associated parenting stress in improving their parenting practices.

Understanding Stigma in Autism: A Narrative Review and Theoretical Model

The experience of stigma by autistic people is relatively understudied, despite contributing to a range of poor outcomes and having an overarching impact on well-being. The current review of the literature synthesizes research to determine what is currently known and presents a theoretical model of autism stigma. Autism stigma is primarily influenced by a public and professional understanding of autism in combination with interpretation of visible autistic traits. Moderating factors include the quality and quantity of contact with autistic people, cultural factors, sex and gender, individual differences, and diagnostic disclosure. Stigma can reduce well-being as well as increase the presence of camouflaging behaviors, which mask autistic traits. Caregivers of autistic people can experience stigma by association, that is, affiliate stigma, which can impact their own well-being. A variety of interventions and approaches to reduce stigma are discussed, including "autism friendly" spaces, positive media representation, educational and psychosocial training for the public and professionals, as well as cultural and systemic shifts that foster inclusivity and recognize neurodiversity.

Impact of Antipsychotic Use on Readmission Rates in Children and Adolescents With Autism Spectrum Disorder and Irritability

Background

Risperidone and aripiprazole have been established as standard pharmacological treatments for irritability and associated aggressive behaviors in individuals with autism spectrum disorder (ASD), and are the only drugs approved by the United States Food and Drug Administration for those purposes. However, the rates of readmission with the use of these drugs in the pediatric population have not been studied, leaving a gap in the knowledge of antipsychotic effects. Readmission rates are a valuable metric of treatment efficacy that also reflect the financial burden, morbidity, and medical complications associated with multiple hospitalizations.

Methodology

A retrospective study was conducted in 65 Hospital Corporation of America Healthcare hospitals within the United States from 2016 to 2019. Patients aged 6-17 years with a diagnosis of ASD with irritability were included. The primary outcome was 30-, 60-, and 90-day readmission rates. Chi-square tests of independence and post-hoc analyses were used to assess the relatedness between readmission rate and antipsychotic use, as well as the type of antipsychotic medication if used. A binary regression analysis was used to analyze the relationship between demographic characteristics and readmission rate in this population. Patients on antidepressants, anxiolytics, or medications primarily used as mood stabilizers were excluded from the study to reduce confounding effects of such medications.

Results

A total of 2,375 patients aged 6-17 years were admitted for irritability and a diagnosis of ASD. In total 323 (13.8%) patients were readmitted from this group within 30 days of discharge. After controlling for age, sex, and gender, the use of antipsychotic medication was found to decrease 30- and 90-day readmission rates with an odds ratio of 1.2 to 1.4 times compared to no antipsychotic use (p < 0.04). In patients with autism not on antipsychotics, regression analysis revealed that older age (p = 0.0471) and White race (p = 0.0471) were associated with 30-day readmission (a = 0.05). For these patients, race was also significantly associated with 60-day (p = 0.0494) and 90-day (p = 0.0416) readmission rates. In patients with autism on either risperidone or aripiprazole, age (p = 0.0393) and race (p = 0.0316) were significantly associated with 30-day readmission rate.

Conclusions

Antipsychotic use reduced readmission rates within 30 days and 90 days in patients with irritability and ASD. Additionally, oral aripiprazole and oral risperidone were found to be equally effective in reducing the 30-day readmission rate, and neither was superior in comparison to the other in 30-, 60-, or 90-day readmission rates. The reduced 30- and 90-day readmission rates seen in our study with the use of antipsychotic medications emphasize the importance of antipsychotic use for individuals with ASD and irritability, even if the antipsychotic is not risperidone or aripiprazole. Groups who can particularly benefit from antipsychotic use include individuals who are refractory to first- and second-line therapies, such as behavioral interventions, or for those who present with persistent and serious risk of harm to themselves or others. Additionally, the use of antipsychotic medications in this scenario may reduce hospitalizations within 30 days of discharge, allowing reduction of the financial and emotional strain associated with these readmissions.

The possible relation between stigma, parent psychiatric symptoms, quality of life and the disease burden in families of children with autism spectrum disorder in Egypt: a multicentre study

Background

Most autism spectrum disorder (ASD) interventions evaluated child outcomes and ignoring the role of parent and family factors on both the immediate- and long-term effects of therapy. The purpose of this study was to determine the relationship between stigma, parent mental health problems, and quality of life and burden in families of children with ASD in Egypt and its risk factors. Seventy parents of ASD children were recruited from two child intervention centers. Participants were divided into two groups based on burden scale: caregivers of moderate burden (n = 27) and caregivers of severe burden (n = 43). All parents were evaluated for demographic data, zarit Burden Interview, socioeconomic scale, symptom checklist–90 (SCL90), Explanatory Model Interview Catalogue Community Stigma Scale (EMIC-CSS), and the World Health Organization Quality of Life–BREF (WHOQOL-BREF).

Results

Half of the parents reported significant stigma, particularly caregivers with a severe burden. Caregivers with severe burden had more depression and about twice the frequency of sensitivity and somatization problems, lower QoL (20%) as compared with caregivers with moderate burden. Parents with ASD had many associate factors such as work, male autistic children and their caregiver, age of children and parents, the severity of the condition, and disease duration with burden, stigma, QoL, and mental health problems.

Conclusions

This study linked the interrelationships between increased burden and stigma, impaired quality of life, and parental mental health problems; the presence of one of these variables was found to increase the risk of other variables.

A systematic review on autistic people's experiences of stigma and coping strategies

Autism can be understood as a concealable stigmatized identity. This is the first systematic review to synthesize the literature on autistic people's experiences of stigma and coping strategies. 2877 studies were screened and 27 were included in this review. The reviewed literature demonstrates that autistic individuals are acutely aware of being stereotyped, judged, and discriminated by others. Autistic people also show signs of internalizing stigma, rendering them more vulnerable to low self-worth and poorer mental health. To manage the impact of stigma, the included studies suggest that autistic individuals may use these strategies: concealment and camouflaging, selective disclosure and self-advocacy, as well as positive reframing and reconstructing identity. However, the evidence is limited and mixed in terms of how helpful and effective these strategies are. Future studies should include autistic populations with a wider range of intellectual abilities and explore interventions that can support autistic people in managing stigma to supplement interventions that seek to reduce stigma towards autistic people. The power of language in perpetuating and challenging stigma also has important implications for research and practice, underscoring the need for researchers and practitioners to reflect carefully on the messages they are communicating about autism.

Internalization of stigma among parents of children with autism spectrum disorder in Nigeria: a mixed method study

Background

Autism Spectrum disorder (ASD) has uniquely stigmatizing aspects because children with ASD have no physical markers of their condition. Parents are usually blamed and judgment from others is often internalized (felt stigma).

Aim

This study was conducted to determine knowledge about ASD, negative experiences (enacted stigma), internalization of stigma (felt or self stigma) and its correlates among parents of children with ASD in Lagos, Nigeria.

Methods

This was a cross-sectional study of 230 parents in Lagos, Nigeria employing mixed-method data collection methods. Quantitative data were collected using a structured interviewer-administered questionnaire and analyzed with Epi- Info™ version 7.0 statistical package. Data were summarized with proportions, mean and standard deviation. Chi square and Spearman’s correlation tests were done, and the level of significance was pre-determined at 5% (p < 0.05). In-depth interviews were also conducted among six parents to further explore the topic. The interviews were analyzed narratively.

Results

The proportion of mothers and fathers were 175 (76.1%) and 55 (23.9%) respectively. The mean age of respondents was 42 ± 8.5 years. Overall knowledge of ASD was very poor as only 3(1.3%) had good knowledge. Overall, 122(53%) usually had negative experience of parenting a child with ASD (enacted stigma), mothers (17.1%) more than fathers (9.1%). Majority 192(83.5%) internalized stigma. There was a low–moderate correlation between ‘enacted’ stigma and ‘internalized’ stigma (ρ- 0.400, p < 0.001). From in-depth interviews, many parents revealed that their child’s condition had negative effects on the family. Many also recounted negative experience of stigma.

Conclusion

Overall, parents of children with ASD had poor knowledge of the condition. Majority internalized stigma and this increases with negative treatment from others. Parents should be properly educated about ASD. Community-based education to increase awareness about ASD in addition to encouraging people to show empathy and reduce stigmatizing behaviour towards parents of children with ASD are recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00687-3.

Social Support and Subjective Well-Being in Chinese Parents of Children With Autism Spectrum Disorder: The Mediating Role of Perceived Discrimination

The present research was done to examine whether social support was related to subjective well-being on Chinese parents of children with autism spectrum disorder (ASD) and how perceived discrimination affected this relationship. Two hundred four parents with ASD children were investigated by Inventory of Social Support Behavior, Perceived Discrimination Scale for Parents of Children With ASD, Subjective Well-being Scale. The results showed that perceived discrimination was negatively associated with social support and subjective well-being, and social support was positively related to subjective well-being. Furthermore, perceived discrimination played a partial mediating role between social support and subjective well-being. All the findings suggest that social support can directly influence subjective well-being of parents of ASD children and indirectly influence subjective well-being through perceived discrimination.

Clarification of stigma concepts in research with families of individuals with neurodevelopmental disabilities

Stigma concepts among families of individuals with neurodevelopmental disabilities have received increased attention from researchers in the past decade. With a growing number of studies published, there are also notable discrepancies in conceptualizations and uses of stigma terms among scholars. These variations may result in inadequate comparisons of findings across studies and a failure to generalize the results. Therefore, I have compared various stigma concepts and offered key features of each term as well as suggested methodology for facilitating stigma research.

The influence of race on parental beliefs and concerns during an autism diagnosis: A mixed-method analysis

LAY ABSTRACT

The goal of this study was to examine if there were differences between races in parental concern and belief about autism spectrum disorder (ASD) and the perspectives of clinicians. We studied 489 children with ASD who were having their first evaluation at an ASD clinic. Parents of White children most often believed that their child had ASD. However, White children whose parents believed the child had ASD were less severe in their symptoms. Parents of Black/African American or Hispanic children were more likely to have concerns about communication than parents of White children. In Hispanic families, parental concern about social communication was related to more severe symptoms in children. We discuss the implications of our findings for diagnosis.

Overcoming the Double Empathy Problem Within Pairs of Autistic and Non-autistic Adults Through the Contemplation of Serious Literature

Recent research based on the needs of the autistic community has explored the frequent social misunderstandings that arise between autistic and non-autistic people, known as the double empathy problem. Double empathy understandings require both groups to respect neurodiversity by focussing on individuality across groups. This study aimed to explore how literature, through its ability to uncover nuanced emotional response differences between readers, could facilitate double empathy understandings within pairs of autistic and non-autistic adults. A longitudinal, qualitative design was used, with 4 gender-matched pairs. Participants read Of Mice and Men for 1 week, whilst completing a structured, reflective diary. This was followed by 4 one-hour paired reading sessions, where pairs discussed the book and their reflections in depth. Participants were then invited to a final one-on-one interview to discuss their thoughts and experiences of the paired reading sessions. Thematic and literary analysis of the session and interview data revealed four themes (1) The Book as Social Oil; (2) From a World of Difference to a World of Affinity; (3) Emotional Intelligence: From Thinking About to Feeling with; and (4) From Overwhelming to Overcoming. All participants reported having achieved an individualised view of one another to explore their nuanced differences. The non-autistic group reported a more sensitive understanding of what it means to be autistic, while the autistic group overcame concerns about non-autistic people stereotyping autism, and instead reported feeling valued and accommodated by their non-autistic partners.

Information needs and services for autism in China: is there any gap between them?

Purpose

This study aims to explore the gap between information needs and services for autism in China.

Design/methodology/approach

The gap is revealed by investigating the status quo of autism information needs and services. The authors extracted categories and subcategories of information needs through content analysis of academic documents and then supplemented the subcategories through text mining of an online forum. Meanwhile, categories and subcategories of information services were extracted through content analysis of autism websites. Finally, the authors matched the two to explore the gap and designed a quantitative index to measure it.

Findings

A total of eight and ten categories of information needs and services are extracted, respectively. In total, six categories of information needs can be partly matched, but nearly half of the subcategories failed. Huge gaps in economic support, sociality and policy mechanisms categories are observed through the quantitative index and medium gaps in social resource services and employment categories while almost no gaps in psychological/emotional counseling, rehabilitation skills training and professional knowledge/information categories.

Originality/value

This study takes a deep insight into the gap between autism information needs and services in China, providing evidences and suggestions for information providers to improve their services. Academic documents and online forum data are adopted to avoid the impact of stigmatization, which provides a multi-source data analysis approach for the information needs of special groups.

A qualitative study of autism services and supports in Singapore: Perspectives of service providers, autistic adults and caregivers

LAY ABSTRACT

Because autism is a lifelong and complex condition, autistic people may need a range of supports cutting across different sectors (e.g. health, education and social care) at different stages of their lives. Studies in some countries have shown that autistic people and their families face difficulties accessing the services they need, but no research has been done on this topic in Singapore. To start addressing this gap, we interviewed 21 service providers, autistic adults and caregivers/parents of autistic children to find out their perceptions and experiences of autism services and supports in Singapore. Our participants told us that beyond improving access to autism-specific services, they also hoped to see more flexible supports in an inclusive environment and a broader change in societal attitudes. This study highlights that autism service provision should be informed by autistic voices and not only focus on impairment but also recognise the strengths of autistic people alongside their very real needs. The whole of society - including policymakers, professionals, employers, educators, families and autistic people themselves - needs to work together to fight autism stigma and discrimination.

Annual Research Review: Achieving universal health coverage for young children with autism spectrum disorder in low- and middle-income countries: a review of reviews

BACKGROUND

Autism presents with similar prevalence and core impairments in diverse populations. We conducted a scoping review of reviews to determine key barriers and innovative strategies which can contribute to attaining universal health coverage (UHC), from early detection to effective interventions for autism in low- and middle-income countries (LAMIC).

METHODS

A systematic literature search of review articles was conducted. Reviews relevant to the study research question were included if they incorporated papers from LAMIC and focused on children (<eight years old) with autism or their caregivers. The database search was supplemented with bibliographic search of included articles and key informant suggestions. Data were extracted and mapped onto a Theory of Change model toward achieving UHC for autism in LAMIC.

RESULTS

We identified 31 articles which reviewed data from over fifty countries across Africa, Latin America, Middle East, and Asia and addressed barriers across one or more of four inter-related domains: (a) the social context and family experience for a child with autism; (b) barriers to detection and diagnosis; (c) access to appropriate evidence-based intervention; and (d) social policy and legislation. Key barriers identified included: lack of appropriate tools for detection and diagnosis; low awareness and experienced stigma impacting demand for autism care; and the prevalence of specialist models for diagnosis and treatment which are not scalable in LAMIC.

CONCLUSIONS

We present a Theory of Change model which describe the strategies and resources needed to realize UHC for children with autism in LAMIC. We highlight the importance of harnessing existing evidence to best effect, using task sharing and adapted intervention strategies, community participation, and technology innovation. Scaling up these innovations will require open access to appropriate detection and intervention tools, systematic approaches to building and sustaining skills in frontline providers to support detection and deliver interventions embedded within a stepped care architecture, and community awareness of child development milestones.

Linking Child Autism to Parental Depression and Anxiety: The Mediating Roles of Enacted and Felt Stigma

This study examined whether child autistic symptoms would heighten parental affective symptoms through evoking enacted stigma from the community (i.e., public and courtesy stigma) and felt stigma within the parents (i.e., vicarious and self-stigma). Cross-sectional questionnaire data were collected from 441 parents of children with autism spectrum disorder. Path analyses showed that social communication and interaction deficits and restricted and repetitive behaviors in child autism were positively associated with public and courtesy stigma. While public stigma was positively associated with parental vicarious stigma, courtesy stigma was positively associated with parental self-stigma. Both vicarious and self-stigma were positively associated with depressive and anxiety symptoms among parents. Findings revealed how child autism could compromise parental well-being through exacerbating the family's stigmatizing experiences.

Perceived Stigma Among Serbian Parents of Children with Autism Spectrum Disorder and Children with Physical Disabilities: Validation of a New Instrument

Limited research has been done to explore parental perception of stigma. The present study developed the Parental Perceptions of Public Attitudes Scale to examine perceived stigma among Serbian parents of children with autism spectrum disorder (ASD) and children with physical disabilities (PD). The convenience sample consisted of 82 participants. A confirmatory factor analysis was done to validate the scale and a 9-item solution clustered into two factors proved to be the best model. Overall, the parents reported a low-to-moderate level of perceived stigma. Parents of children with ASD reported higher degree of perceived stigma compared to the parents of children with PD. The scale was useful in measuring parental perceived stigma and could be used in other Eastern European countries.

Improving multicultural parenting program for children with emotional and behavioral problems: An integrated review

Children with emotional and behavioral problems are often managed using medications or behavioral therapy, but in some countries, there is no structured parenting intervention to equip parents from different cultural backgrounds with adequate parenting skills to help these children. This paper aims to synthesize key findings from previous research on multicultural parenting programs and produce a comprehensive integrated view by looking into three separate themes: effective multicultural parenting programs, ethnocultural groups and cultural adaptation process. Literature search through Scopus and Google Scholar from 1999 to 2019 was conducted using the terms "effective parenting program", "effective parenting intervention", "effective multicultural parenting program", "effective multicultural parenting intervention", "multicultural parenting program", "multicultural parenting intervention", "parenting program and ethnic groups", "parenting intervention and ethnic groups", "adapted parenting program", "adapted parenting intervention", "cultural adaptation of parenting program'' and "cultural adaptation of parenting intervention". By applying the "Literature Review Synthesis Process", authors conducted cross-analysis, integrated possibilities, and prioritized the synthesized information gearing towards highly probable solutions for improving multicultural parenting programs to manage emotional and behavioral problems in children better. Development of a culturally fit parenting intervention and its implications on existing parenting programs are also discussed. The findings highlight the need 1) to engage with ethnocultural groups of parents during development of a new multicultural parenting program, and 2) to incorporate specific measures for engaging with parents during multicultural parenting program implementation. This paper contributes in acknowledging cultural components in future parenting intervention programs. Finally, recommendations are made for future directions of research.

Caregiving burden among informal caregivers of people with disability

OBJECTIVE

Chinese informal caregivers experience burden due to their caregiving responsibilities that violate their belief of reciprocal parent-child relationship, but little is known about this burden and coping processes among Chinese. It is believed that internal coping (i.e., self-reliance) and external coping (i.e., seeking help from others) better captured cultural characteristics of coping styles observed among Chinese. Thus, the aim of this study was to estimate the prevalence of mental ill health, identify correlates, investigate the impact of caregiving burden on mental health, and explore the potentially moderating role of two coping strategies.

DESIGN

A purposive sample of 234 informal caregivers of family with intellectual or mental disability in Macao (SAR), China, from August to September 2018 was investigated.

METHODS

DASS-21, Caregiving Burden Inventory (CBI), Perceived Difficulty Scale (PD), and a modified Chinese Coping Scale were used. Multiple regression analyses were conducted.

RESULTS

CBI and PD were associated with depression, anxiety, and stress. Whereas internal coping buffered the effect of PD on depression and anxiety, external coping exacerbated the effect of PD on anxiety and the effect of CBI on depression and anxiety.

CONCLUSION

Poor mental health among caregivers is associated with greater caregiving challenges and burdens. Internal coping helped to buffer but external coping worsened the effect of burdens on mental health outcomes. Interventions that improve internal coping and mental health might be helpful for ageing informal caregivers.

Perceptions and experiences of stigma among parents of children with developmental disorders in Ethiopia: A qualitative study

Although stigma related to developmental disorders (DD) has been associated with poor mental health among caregivers, an in-depth understanding of factors that influence internalisation of stigma by caregivers is missing. The aim of our study was to explore perceptions and experiences of stigma among parents of children with DD in Ethiopia and examine the contributing and protective factors for internalised stigma based on the perspectives of the parents themselves. We conducted in-depth interviews with eighteen parents (fourteen mothers, four fathers) in Addis Ababa (between December 25, 2017 and January 8, 2018) and the rural town of Butajira (between August 08, 2018 and August 16, 2018). We analysed the data using thematic analysis. Parents perceived and experienced different forms of stigma that were directed towards their child (public stigma) and themselves (courtesy stigma). Some parents also described how they isolated themselves and their child from social life (affiliate stigma). Parents perceived the negative consequence of stigma on the lives of their child with DD, siblings and themselves. Most parents also described examples of positive reactions and support from their own family and the community. Participants' accounts suggested supportive contributions and positive responses from the general public came primarily from those who had better awareness of DD. Not all parents in our study internalised the stigma that was directed at them. Whilst perceived family support and acceptance and increased awareness about DD appeared to help some parents not to internalise stigma, the perceived lack of social support and acceptance made some parents vulnerable to internalised stigma. These findings can inform anti-stigma intervention priorities. Awareness-raising activities targeting the community as a whole as well as interventions targeting parents themselves are likely to be beneficial. Interventions should consider the wellbeing of the whole family unit rather than focus on individuals alone.

Assessment of caregiver needs in parents of children suffering from neurodevelopmental disorders in an Indian population

Parents of children with neurodevelopmental disorders have significant unmet needs in various domains, particularly in a Low-Middle Income Country setting such as India. This study assessed parental needs using a Hindi version of the Caregiver Needs Scale (CNS) and found that 65.7% of the respondents expressed a definite need for help in all the items of the scale. The total score on CNS showed a significant negative correlation with the age of the child. Age of parent showed a significant negative correlation with scores for community and support needs.

Association of breastfeeding status with risk of autism spectrum disorder: A systematic review, dose-response analysis and meta-analysis

Current evidence indicates that nutritional status in newborns, especially the duration of breastfeeding, plays a key role in the pathogenesis of autism spectrum disorder. We aimed to systematically review and meta-analyze relevant studies with findings of an association between autism spectrum disorder and breastfeeding patterns, and undertook an extensive dose-response analysis to interpret the results more accurately. Ten electronic databases and manual search of reference lists were used to identify relevant studies in September 2018. Dose-response and conventional meta-analysis were conducted by the random-effects model. The study protocol was registered in PROSPERO with CRD42016043128. Seven case-control studies were found in which the association between ever breastfeeding and risk of autism spectrum disorder was investigated. We found a 58 % decrease in the risk of autism spectrum disorder with ever breastfeeding and a 76 % decrease in the risk with exclusive breastfeeding. According to our dose-response meta-analysis, breastfeeding for 6 months was associated with a 54 % reduction in the risk. In the conventional meta-analysis, breastfeeding for 12-24 months was associated with the most significant reduction in the risk of autism spectrum disorder. Our results highlight the importance of breastfeeding to decrease the risk of autism spectrum disorder.

A pilot study of family-based management of behavioral excesses in young Iranian children with autism spectrum disorder

OBJECTIVE

Parent-mediated early behavioral interventions are considered as effective approaches in the treatment of children with Autism Spectrum Disorder (ASD). The majority of these interventions focus on social-communication deficits rather than behavioral excesses which severely irrupt child and family social life as well as the child's appearance behavior and learning processes. The study examines the effectiveness and feasibility of Family-based Management of Behavioral Excesses of Autism Program (FMBEAP) on Iranian families.

METHOD

This pre-post and follow-up intervention study involved 17 parents of children with DSM-5 diagnosis of ASD recruited from Tehran Autism Center. All parents conducted FMBEAP on their children while receiving 10-weekly group supervision on top of everyday on-line individual coaching. The study's measures were Repetitive Behavior Scale-R, video-monitoring of child-parent Interaction, Clinical Global Impression-Improvement Scale, Parental Self-Efficacy and Parenting Stress Index-short form. The measures were applied to the sample three times: pre and post-intervention and at one-month follow-up.

RESULTS

The Results showed high and low order behavioral excesses significantly decreased at post-intervention and the follow-up. 15 out of 17 children reached to recovered or highly recovered at post-test. Parents showed significant improvements in self-efficacy and parenting stress scales. The intervention was highly accepted by them.

CONCLUSION

FMBEAP is shown to be a feasible, acceptable and effective intervention to improve autistic behavioral. The parents should also benefit from the program in terms of self-efficacy and parenting stress. FMBEAP is highly recommended for overcoming behavioral excesses along with those interventions focus on behavioral deficits in ASD.