Multidisciplinary parent education for caregivers of children with autism spectrum disorders

A Systematic Review of Family Functioning in Families of Children on the Autism Spectrum

This article aims to review the literature on family functioning in the field of autism. The search was conducted in August 2021 in PubMed, PsycINFO, and PubPsy and sixty-two articles were included. Studies were published in English between 1980 and 2021 and provided quantitative data from validated measures of family functioning in families with an official diagnosis of autism. Results showed that family functioning appeared more problematic for families of autistic children than non-autistic ones. Difficulties were correlated with more caregiver demand and less resources. Interventional results varied. The findings highlight the importance of considering family functioning when providing care for autistic children and their families. Limitations and implications for future research are discussed.Prospero registration number: CRD42022297696.

Parental Quality of Life and Impact of Multidisciplinary Intervention for Children with Autism Spectrum Disorders: A Qualitative Study

The presence of a child with Autism Spectrum Disorder (ASD) in the family can have a negative impact on parental Quality of Life (QoL), but evidence on how treatments for children with ASD can affect parental QoL is currently limited. In this qualitative study, we develop a semi-structured interview in order to investigate the impact of ASD on the QoL of mothers and fathers from a subjective perspective, as well as the effect of the intervention on their QoL and adjustment process. The sample consisted of 31 parents of children with ASD severity 2 or 3, aged 5 to 11 years, undergoing a multidisciplinary intervention. In order to identify emerging themes from the interview transcripts, a Thematic Analysis was conducted using a bottom-up approach. We identified three main themes relating to parental QoL (ASD impact on QoL, useful external resources, QoL improvement-related factors) and five themes relating to parents' views on the intervention (positive impact on parent, dissatisfaction with previous interventions, parental involvement, useful features, critical issues). The results provide indications of the process of parental adaptation and the components of interventions that foster an improvement in their QoL. In conclusion, living with a child with ASD can have a significant influence on a parents' QoL, not just physically and emotionally, but also in terms of general goals, family structure, and social interactions.

The interplay of supports and barriers during the transition to adulthood for youth on the autism spectrum

PURPOSE

Transition to adulthood is a complex process that involves important life domains such as education, work, independent living, community, health, and social relationships. Autistic youth face the transition with greater challenges than their peers, and there continues to have significant gaps in the services as they approach young adulthood. The study was conducted to understand the complex interplay between supports and barriers to participation in the transition process.

METHOD

Data was collected through six focus groups with 24 participants (7 parents, 11 practitioners, 6 autistic youth), digitally audio-recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Four themes were reported: Inadequacy of Services, Ambivalence about Formal Services and Support, Understanding Good Partnership, and Evolving Parental Involvement. While parents and practitioners see the fragmented services and lack of comprehensive support as the most prominent challenge, autistic youth feel ambivalent about the type of services they need. Practitioners address the importance of establishing an appropriate level of engagement with parents in the transition process. Autistic youth expect their parents to set a boundary that affirms their independence.

CONCLUSIONS

Our study highlights the need to elicit input across different stakeholders to make transition services centralized, easily accessible, and individualized.Implications for RehabilitationIt is important to have a systematic road map, early preparation of families and autistic youth about the array of adult transition services, and a centralized hub of information to be disseminated.Disability service agencies should develop and implement plans for enhancing outreach and services to transition youth on the autism spectrum and their families.Practitioners need to identify locally available resources and channels for outreach and make available service more visible by producing transition-related materials with examples of current legislative information, problem solving, and best practices.Practitioners should consider how autistic youth identify their needs and wants may be different than how service providers and parents conceptualize them.It is critical to capitalize appropriate levels of caregivers/family support and engagement by provision of education about policies and guidelines for communication and collaboration.

Effectiveness of Parent-to-Parent Support Group in Reduction of Anxiety and Stress Among Parents of Children With Autism and Attention Deficit Hyperactivity Disorder

BACKGROUND

Parental interventions are efficacious and robust in managing children's behavioral problems. Yet, research addressing their role in parental stress and anxiety is sparse. Our first aim was to assess the extent of anxiety and stress among parents of children with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). The second was to assess the effectiveness of a parent-to-parent support group for addressing the stress and anxiety among those parents.

METHODS

We selected a single group pretest posttest design. We recruited 24 parents from the two in-patient facilities of child and adolescent psychiatry. The intervention consisted of a parent-to-parent support group. We assessed parental stress and anxiety before and after the intervention.

RESULTS

The differences in anxiety and stress scores prior to and after the intervention were statistically significant (P < 0.001). Before the intervention, low level of parents' education and lower family income had a statistically significant relationship with higher parental stress. Also, parents who were employed had lesser anxiety.

CONCLUSION

The parent-to-parent support group effectively reduced stress and anxiety among parents of children with ASD and ADHD. These are preliminary findings. The lack of a control group is a major limitation.

A scoping review of education and training interventions in Autism Spectrum Disorder

OBJECTIVE

Autism Spectrum Disorder (ASD) is a chronic neurodevelopmental disorder. Living with ASD requires that individuals and parents develop skills in order to cope with daily life. Education interventions are recommended to support them. This study aims to get an overview of education and training interventions in ASD.

METHODS

A scoping review of international literature was conducted.

RESULTS

43 articles were analyzed. Four main types of intervention stand out: support groups, parental training; psychoeducation; therapeutic patient education. However, the majority of publications is focused on the parents rather than on individuals living with ASD, and the needs assessments identified focused on general needs rather than educational needs.

CONCLUSION

While educational interventions for parents and individuals with ASD are now encouraged, considerable heterogeneity is observed. But this variety is not based on a reasoned approach to matching supply and needs. Future studies could focus more on the educational needs of individuals with ASD.

PRACTICE IMPLICATIONS

Overview of education and training interventions in ASD help health care providers to better understand the strengths and limitations of their interventions.

Parenting Programs That Address Physical Abuse in Childhood for Families of Children With Developmental Disabilities in Mainland China: Systematic Review and Meta-Regression

Millions of children in China are diagnosed with developmental disabilities (DD), many of whom are subject to physical abuse. While a significant body of research suggests that parenting interventions can reduce the incidence and risk of such abuse, there is currently limited evidence of their effectiveness for this population or from non-English-speaking countries. This review involved searches in both English and Chinese databases to identify randomized controlled trials and quasi-experimental studies of parenting interventions for families of children with DD in mainland China. Multilevel meta-analyses were undertaken to examine the effectiveness of parenting programs. Subgroup analyses and meta-regression were conducted to investigate heterogeneity and identify potential moderators with a focus on intervention and delivery components. Risk of bias was assessed for each study. Thirty-one studies were included. The results showed that parenting interventions could reduce child emotional and behavioral problems (CEBP) and improve the parent-child relationship, although only one study directly measured the actual incidence of abuse. Programs for autism and epilepsy had stronger treatment effects. Teaching knowledge about CEBP, skills to improve parental mental health, and techniques to cultivate empathy were associated with program success; however, positive reinforcement was associated with more problems. The results also supported the delivery of programs with longer duration, a combination of group and individual sessions, efforts to build rapport, ongoing communication outside the programs, and delivery in hospitals or service agencies. Further research is needed, however, in addition to improvements in the quality of research and reporting.

Impact in the quality of life of parents of children with chronic diseases using psychoeducational interventions - A systematic review with meta-analysis

OBJECTIVE

This study aimed to identify psychoeducational interventions applied to parents of children with chronic diseases and evaluate their impact on their quality of life (QoL).

METHODS

It was conducted in six databases, complemented by references from the included studies and other reviews, manual search, and contact with experts. We included primary studies on parents of children with chronic diseases that studied psychoeducational interventions versus standard care.

RESULTS

We screened 6604 titles and abstracts, reviewed the full text of 60 records, and included 37 primary studies. Half of the studies were on Asthma. We found three intervention formats: one-to-one (43%), groups (49%), and combined approach with individual and group settings (8%). More than 60% of the included studies found statistically significant differences between the intervention and the control group (p < 0.05).

CONCLUSION

Several interventions have shown efficacy in improving parental QoL. Despite that, there is insufficient evidence of interventions' implementation.

PRACTICE IMPLICATIONS

A holistic approach encompassing the patient and the family's biopsychosocial dimensions is fundamental in successfully managing chronic disease in children. It is vital to design and implement interventions accommodating the common issues experienced by children, parents, and families that deal with chronic childhood conditions. Systematic review registration number PROSPERO 2018 CRD42018092135.

The effect of mental health interventions on psychological distress for informal caregivers of people with mental illness: A systematic review and meta-analysis

INTRODUCTION

Informal caregivers of people with a mental illness are at increased risk of developing depression, anxiety, and stress, so preventive interventions are needed.

METHOD

The review was reported in PROSPERO (ID: CRD42018094454). The PsycINFO, PubMed, and Scopus databases were searched in June 2019. The Cochrane Risk of Bias and Jadad scale scores were used to assess study quality. Inclusion criteria were: RCTs of informal caregiver interventions regardless of the care receiver's mental illness and intervention modality. Interventions should be compared to a waitlist, treatment as usual or active control, taught in real-time by a mental health professional, include an outcome measure on psychological distress, and published in a peer-reviewed journal article in English. RCTs were excluded if the intervention was given in dyads (caregiver + care receiver), limited to the provision of respite care where the patient sample included a mix of both physical and psychological illnesses, unpublished, not peer-reviewed, study protocols, or dissertations.

RESULTS

A total of 2,148 studies were identified; of these, 44 RCT studies met the inclusion criteria, and 31 had sufficient data to conduct a meta-analysis including subgroup analysis (N = 1,899). The systematic review showed that thirty-one out of the 44 RCTs had an effect of the intervention on decreasing psychological distress. The results of the meta-analysis, which included informal caregiver interventions, compared to waitlist, treatment as usual, or active control, regardless of care-receiver mental illness or intervention modality showed a small effect of -0.32 (95% CI -0.53 to -0.11). The heterogeneity of the included studies was high (I ² = 78). The subgroup analysis included manualized interventions lasting at least 8 weeks and the subgroup analysis that included an active control showed a small effect and low heterogeneity. Lack of active control and long-term follow-up is a limitation of most of the studies.

CONCLUSION

The evidence supports that several interventions improve the mental health of caregivers. Manualized interventions ≥ 8 weeks with active participation are most effective. Future RCTs should improve methodology, and research should investigate which intervention modality is most effective for what kind of caregiver. Future research should clearly specify what the included intervention components are, use longer follow-up times, and conduct mediational analyses to better understand what mechanisms create the effect of an intervention.

SYSTEMATIC REVIEW REGISTRATION

Identifier: CRD42018094454.

Peer support interventions for parents and carers of children with complex needs

BACKGROUND

Parents and family carers of children with complex needs experience a high level of pressure to meet children's needs while maintaining family functioning and, as a consequence, often experience reduced well-being and elevated psychological distress. Peer support interventions are intended to improve parent and carer well-being by enhancing the social support available to them. Support may be delivered via peer mentoring or through support groups (peer or facilitator led). Peer support interventions are widely available, but the potential benefits and risks of such interventions are not well established.

OBJECTIVES

To assess the effects of peer support interventions (compared to usual care or alternate interventions) on psychological and psychosocial outcomes, including adverse outcomes, for parents and other family carers of children with complex needs in any setting.

SEARCH METHODS

We searched the following resources. • Cochrane Central Register of Controlled Trials (CENTRAL; latest issue: April 2014), in the Cochrane Library. • MEDLINE (OvidSP) (1966 to 19 March 2014). • Embase (OvidSP) (1974 to 18 March 2014). • Journals@OVID (22 April 2014). • PsycINFO (OvidSP) (1887 to 19 March 2014). • BiblioMap (EPPI-Centre, Health Promotion Research database) (22 April 2014). • ProQuest Dissertations and Theses (26 May 2014). • metaRegister of Controlled Trials (13 May 2014). We conducted a search update of the following databases. • MEDLINE (OvidSP) (2013 to 20 February 2018) (search overlapped to 2013). • PsycINFO (ProQuest) (2013 to 20 February 2018). • Embase (Elsevier) (2013 to 21 February 2018). We handsearched the reference lists of included studies and four key journals (European Child and Adolescent Psychiatry: 31 March 2015; Journal of Autism and Developmental Disorders: 30 March 2015; Diabetes Educator: 7 April 2015; Journal of Intellectual Disability Research: 13 April 2015). We contacted key investigators and consulted key advocacy groups for advice on identifying unpublished data. We ran updated searches on 14 August 2019 and on 25 May 2021. Studies identified in these searches as eligible for full-text review are listed as "Studies awaiting classification" and will be assessed in a future update.

SELECTION CRITERIA

Randomised and cluster randomised controlled trials (RCTs and cluster RCTs) and quasi-RCTs were eligible for inclusion. Controlled before-and-after and interrupted time series studies were eligible for inclusion if they met criteria set by the Cochrane Effective Practice and Organisation of Care Review Group. The comparator could be usual care or an alternative intervention. The population eligible for inclusion consisted of parents and other family carers of children with any complex needs. We applied no restriction on setting.

DATA COLLECTION AND ANALYSIS

Inclusion decisions were made independently by two  authors, with differences resolved by a third  author. Extraction to data extraction templates was conducted independently by two authors and cross-checked. Risk of bias assessments were made independently by two authors and were reported according to Cochrane guidelines. All measures of treatment effect were continuous and were analysed in Review Manager version 5.3. GRADE assessments were undertaken independently by two review authors, with differences resolved by discussion.

MAIN RESULTS

We included 22 studies (21 RCTs, 1 quasi-RCT) of 2404 participants. Sixteen studies compared peer support to usual care; three studies compared peer support to an alternative intervention and to usual care but only data from the usual care arm contributed to results; and three studies compared peer support to an alternative intervention only. We judged risk of bias as moderate to high across all studies, particularly for selection, performance, and detection bias. Included studies contributed data to seven effect estimates compared to usual care: psychological distress (standardised mean difference (SMD) -0.10, 95% confidence interval (CI) -0.32 to 0.11; 8 studies, 864 participants), confidence and self-efficacy (SMD 0.04, 95% CI -0.14 to 0.21; 8 studies, 542 participants), perception of coping (SMD -0.08, 95% CI -0.38 to 0.21; 3 studies, 293 participants), quality of life and life satisfaction (SMD 0.03, 95% CI -0.32 to 0.38; 2 studies, 143 participants), family functioning (SMD 0.15, 95% CI -0.09 to 0.38; 4 studies, 272 participants), perceived social support (SMD 0.31, 95% CI -0.15 to 0.77; 4 studies, 191 participants), and confidence and skill in navigating medical services (SMD 0.05, 95% CI -0.17 to 0.28; 4 studies, 304 participants). In comparisons to alternative interventions, one pooled effect estimate was possible: psychological distress (SMD 0.2, 95% CI -0.38 to 0.79; 2 studies, 95 participants). No studies reported on adverse outcomes. All narratively synthesised data for psychological distress (compared to usual care - 2 studies), family functioning (compared to usual care - 1 study; compared to an alternative intervention - 1 study), perceived social support (compared to usual care - 2 studies), and self-efficacy (compared to alternative interventions - 1 study) were equivocal. Comparisons with usual care showed no difference between intervention and control groups (perceived social support), some effect over time for both groups but more effect for intervention (distress), or mixed effects for intervention (family function). Comparisons with alternative interventions showed no difference between the intervention of interest and the alternative. This may indicate similar effects to the intervention of interest or lack of effect of both, and we are  uncertain which option is likely. We found no clear evidence of effects of peer support interventions on any parent outcome, for any comparator; however, the certainty of evidence for each outcome was low to very low, and true effects may differ substantially from those reported here. We found no evidence of adverse events such as mood contagion,  negative group interactions, or worsened psychological health. Qualitative data suggest that parents and carers value peer support interventions and appreciate emotional support.

AUTHORS' CONCLUSIONS

Parents and carers of children with complex needs perceive peer support interventions as valuable, but this review found no evidence of either benefit or harm. Currently, there is uncertainty about the effects of peer support interventions for parents and carers of children with complex needs. However, given the overall low to very low certainty of available evidence, our estimates showing no effects of interventions may very well change with further research of higher quality.

The Caregiver Burden Inventory as a Sleep Disturbance Screening Tool for Parents of Children with Autism Spectrum Disorder

PURPOSE

The study was conducted to explore the degree to which caregiver burden is associated with sleep quality in parents of children with autism spectrum disorder, and to determine a statistically valid cutoff score for the Caregiver Burden Inventory (CBI) in order to identify parents of risk of poor sleep quality.

DESIGN AND METHODS

We conducted a cross-sectional analysis. We assessed caregiver burden with the CBI, sleep quality with the Pittsburgh Sleep Quality Index, emotional status with the Hospital Anxiety and Depression Scale, and impact on family with the Impact on Family Scale. Caregiver burden was evaluated with a logistic regression analysis. The best fit model was used in a receiver operating characteristic analysis. Likelihood ratios and post-test probabilities were calculated.

RESULTS

A total of 116 parents were included in this study. Higher caregiver burden was associated with a reduction in sleep quality in the logistic regression analysis (p < 0.001). The area under the curve for the univariate burden test model (best fit) was 76.70 (p < 0.001). The cutoff score for poor sleep quality was caregiver burden ≥26.50. The post-test probability of poor sleep quality increased to 82.02% from a pre-test probability of 76.72%.

CONCLUSIONS

Our findings suggest that caregiver burden is associated with sleep quality among parents of children with autism spectrum disorder. The findings suggest that a CBI cutoff score of 26.50 may help to detect risk of poor sleep quality in parents of children with autism spectrum disorder.

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

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

The Role of Acceptance in the Transition to Adulthood: A Multi-Informant Comparison of Practitioners, Families, and Youth with Autism

This study investigated the role of acceptance during the transition process among autistic young adults, parents, and practitioners. Six focus groups were run and thematic analysis was used to identify four themes: Youth on the autism spectrum discussed transition as a time where Self-Advocacy and Self-Acceptance were salient. Both youth and parents discussed the Lack of Understanding and Acceptance they experience. Particularly, youth highlighted the lack of understanding of sensory needs and parents underscored the lack of understanding by medical professionals. In contrast, practitioners highlighted the presence of Community Openness. Both practitioners and parents discussed Finding Personal Support through Acceptance. Self-acceptance and acceptance of autism are imperative for autistic young adults and families to achieve well-being.

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

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

While quarantined: An online parent education and training model for families of children with autism in China

PURPOSE

In the wake of the COVID-19 outbreak, already limited services and resources for families of children with autism spectrum disorder (ASD) in China became even more scarce. This qualitative case study highlights one online parent education and training (PET) program developed during the pandemic to offer home-intervention strategies to parents of children with ASD in mainland China. This exploratory study sought to examine the emic perspectives of the trainers and parents who participated in the 12-week intensive training program while considering the cultural context in China and the transnational, remote nature of the program.

METHODS

The primary data focused on the experiences of the trainers and parents within PET program's structure and strategies, which were adapted from the Training of Trainers model, and were collected from semi-structured, in-depth individual and focus group interviews conducted virtually with trainers (n = 4). Supplemental data sources included training session materials and feedback forms collected from parents (n = 294) at the midpoint and end of the program. After the collected data were sorted and condensed, a thematic analysis was performed using the data analysis spiral to further organize and code the data, and the codes were finally collapsed into themes.

FINDINGS

Three overarching themes were identified: (1) training as modeling with resources, (2) dilemmas in cultural contexts and expectations, and (3) cultivating parent support networks.

CONCLUSION

The online PET program became a hub of support networks and learning spaces for parents of children with ASD in different regions in China during the pandemic. Through the interactive virtual training sessions, parents were supported by continuous feedback on their home intervention and coached to cultivate support networks among themselves despite tensions arising from cultural differences and to implement effective intervention strategies that were individualized and authenticated to their specific familial needs.

Clinical Psychological Figures in Healthcare Professionals: Resilience and Maladjustment as the "Cost of Care"

Background: The health professionals are involved in the paths of care for patients with different medical conditions. Their life is frequently characterized by psychopathological outcomes so that it is possible to identify consistent burdens. Besides the possibility to develop pathological outcomes, some protective factors such as resilience play a fundamental role in facilitating the adaptation process and the management of maladaptive patterns. Personal characteristics and specific indexes such as burdens and resilience are essential variables useful to study in-depth ongoing conditions and possible interventions. The study was aimed at highlighting the presence and the relations among factors as personal variables, burdens, and resilience, to understand health professionals' specific structure and functions.

Methods: The observation group was composed of 210 participants, 55 males (26.2%), and 155 females (73.8%), aged from 18 to 30 years old with a mean age of 25.92 years old (SD = 3.33). The study considered personal characteristics of the subjects, such as age, gender, years of study, days of work per week, hours of work per week, and years of work. Our study had been conducted with the use of measures related to burdens (Caregivers Burden Inventory) and resilience (Resilience Scale for Adults).

Results: The performed analyses consisted of descriptive statistics, correlations, and regressions among the considered variables. Several significant correlations emerged among personal characteristics, CBI, and RSA variables. Specifically, age and work commitment indexes appeared to be significantly related to the development of burdens, differently from the years of study. Significant correlations emerged among personal and RSA variables, indicating precise directions for both domains. Age and gender were identified as predictors to perform multivariate regression analyses concerning CBI factors. Significant dependence relations emerged with reference to all CBI variables.

Conclusion: Pathological outcomes and resilience factors represent two sides of the health professionals' experiences, also known as “invisible patients.” Greater knowledge about present conditions and future possibilities is a well-known need in literature so that the current analyses considered fundamental factors. In line with state of the art, future studies are needed in order to deepen elusive phenomena underlying maladjustment.

A systematic review and meta-analysis of parent-mediated intervention for children and adolescents with autism spectrum disorder in mainland China, Hong Kong, and Taiwan

LAY ABSTRACT

The ideal dosage for early intensive interventions for autism spectrum disorder has been suggested to be at least 25-hour per week to reach optimal effects. However, insufficient service use and unmet needs among families with children with autism spectrum disorder are frequently reported worldwide. Helping parents to develop strategies for interaction and management of behavior through parent training has been demonstrated to be a prominent way to supplementing service insufficiency for autism spectrum disorder, which is particularly crucial in less-resourced areas. This review included 21 parent-mediated intervention programs conducted in China, the most populated developing country. Among them, we were able to combine outcome information from 12 randomized controlled trials to increase confidence in the results. We also rated the quality of methodology and evidence for all included studies, which was taken into account in making conclusions. The included programs varied in the content, length, and delivery method of trainings. Although targeting different training outcomes, the majority of the studies aimed to help parents be more competent and responsive during interactions with their child in order to decrease symptom severity. Overall, results showed sufficient evidence that parent training did improve child outcomes as intended. However, the quality of more than half (14/21) of the included studies were below satisfactory. Identified programs lack the capacity to be further transported in the Chinese societies due to the lack of solid theoretical foundations, implementation manuals, and appropriate cultural adaptations. This review reinforces the need for promotion and improvement of parent-mediated interventions in low-resource context.

Interventions based on early intensive applied behaviour analysis for autistic children: a systematic review and cost-effectiveness analysis

BACKGROUND

Early intensive applied behaviour analysis-based interventions are intensive interventions for autistic children that are often delivered on a one-to-one basis for 20-50 hours per week.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of early intensive applied behaviour analysis-based interventions for autistic children, based on current evidence.

METHODS

A systematic review and individual participant data meta-analysis were conducted to evaluate the clinical effectiveness of an early intensive applied behaviour analysis-based intervention for autistic children. An economic analysis included a review of existing analyses and the development of a new model.

RESULTS

Twenty studies were included in the clinical review. Individual participant data were retrieved from 15 of these studies. Results favoured the interventions when assessing adaptive behaviour after 2 years compared with treatment as usual/eclectic interventions (mean difference 7.00, 95% confidence interval 1.95 to 12.06). In analyses of cognitive ability (intelligence quotient), results favoured the interventions by approximately 10 points after 1 year (mean difference 9.16, 95% confidence interval 4.38 to 13.93) and 2 years (mean difference 14.13, 95% confidence interval 9.16 to 19.10). Evidence for other outcomes was limited and meta-analyses were generally inconclusive. There was no evidence that the effect of the interventions varied with characteristics of the children, but data were limited. Adopting a £30,000 per quality-adjusted life-year threshold, the results of the cost-effectiveness analysis indicate that early intensive applied behaviour analysis-based interventions would need to generate larger benefits or cost savings to be cost-effective. Adopting a public sector perspective and making pessimistic assumptions about long-term effects, the incremental cost-effectiveness ratio for early intensive applied behaviour analysis-based therapy compared with treatment as usual is £189,122 per quality-adjusted life-year. When optimistic assumptions are made, the incremental cost-effectiveness ratio is £46,768 per quality-adjusted life-year. Scenario analyses indicated that these interventions can potentially be cost-effective if long-term improvements persist into adulthood, or if they have significant impact on educational placement. Care should be taken when interpreting these scenarios owing to the limited data.

LIMITATIONS

All included studies were at risk of bias, there was substantial heterogeneity and effects varied considerably across studies. The effect of intervention on autism symptom severity, language development and school placement remains uncertain because of the limited data. The long-term effects are unclear owing to a lack of follow-up data.

CONCLUSIONS

This review found limited evidence that early intensive applied behaviour analysis-based interventions may improve cognitive ability and adaptive behaviour, but the long-term impact of the interventions remains unknown. The economic analysis is constrained by the limited effectiveness evidence, but suggests that these interventions are unlikely to be cost-effective unless clear long-term benefits, or a substantial change in which schools children attend, can be identified.

FUTURE WORK

Further studies into the effectiveness of early intensive applied behaviour analysis-based interventions may be warranted if they include well-defined, alternative interventions as comparators and collect relevant outcomes. Consideration should be given to future studies that not only address whether or not early intensive applied behaviour analysis-based interventions are clinically effective, but also aim to identify which components of early intensive applied behaviour analysis-based interventions might drive effectiveness.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068303.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 35. See the NIHR Journals Library website for further project information.

Effects of Caregiver-Focused Programs on Psychosocial Outcomes in Caregivers of Individuals with ASD: A Meta-analysis

The current meta-analysis comprehensively reviewed group-design studies of interventions designed to improve ASD caregiver psychosocial outcomes and explored potential moderators of effectiveness. Forty-one unique studies targeting 1771 caregivers met inclusion criteria. Overall, the interventions had a small positive effect in improving psychosocial outcomes in caregivers of individuals with ASD (within-subjects: Hedges' g = .44; between-subjects: Hedges' g = .28). Most intervention approaches demonstrated some evidence of effectiveness. Acceptance and commitment therapy, mindfulness-based interventions, and cognitive behavioral treatments demonstrated the strongest impact in improving caregiver psychosocial outcomes in pre-post comparisons. Although the results provide preliminary support for the effectiveness of caregiver-focused interventions, more studies with larger sample sizes, rigorous research designs, and long-term follow-up assessments are needed.

Parent Education and Training for autism spectrum disorders: Scoping the evidence

Empowering families of children with autism spectrum disorder through education and training is best practice. A wide range of Parent Education and Training programmes are delivered around the globe, but there is limited knowledge about the characteristics of these programmes, or about the research methods and outcomes used to evaluate them, particularly in countries outside the United States. We, therefore, performed a scoping review of all peer-reviewed Parent Education and Training publications outside the United States. A search was conducted between March and May 2017. Four reviewers extracted data and performed a mixed-methods quality appraisal of publications. Thirty-seven publications representing 32 unique programmes were identified. Publications described a highly diverse range of Parent Education and Training programmes across 20 countries and all continents except South America. The majority were group-based, but varied significantly in goals, modalities and duration. The majority of studies (86.4%) reported positive outcomes in relation to the core study objectives and only two studies reported some negative findings. Quality appraisal rated only 27% of studies to have met all the methodological quality criteria. Implementation factors such as manualisation, fidelity and cost were commented on infrequently. In spite of the clear need for Parent Education and Training programmes, our findings show that the research evidence-base in autism spectrum disorder outside the United States is relatively small, non-representative and in need of methodological quality improvements.

Neuropsychiatric Symptoms, Parenting Stress and Social Support in Chinese Mothers of Children with Autism Spectrum Disorder

Although little is known about the current situation regarding autism spectrum disorder (ASD) in mainland China, psychiatric disorders are common among Chinese mothers of preschool children with ASD. Previous studies showed ASD child's behavioral symptoms, maternal anxiety, and maternal depressive symptoms were associated with overall parenting stress in northern China. In the present study, we retrospectively analyzed medical records at the hospital related to neuropsychiatric symptoms, parenting stress and social support in mothers of children with ASD from southern China. A total of 80 mothers of children with ASD were screened. Among them, 34 mothers were in low-functioning ASD group (L-ASD group) and 46 mothers were in high-functioning ASD group (H-ASD group). Identification of the ASD cases was confirmed with a Revised Autism Diagnostic Inventory. Neuropsychiatric symptoms, parenting stress and social support were measured by neuropsychiatric inventory (NPI), parenting stress index short form (PSI-SF), and multi-dimensional scale of perceived social support (MSPSS). Total mean score of the NPI in the L-ASD group was significantly higher than that in the H-ASD group (P<0.01). The subscale scores of NPI, including depression, anxiety, apathy, irritability, agitation, night time behavior disturbances and change in appetite were significantly higher in the L-ASD group than those in the H-ASD group (P<0.01 or P<0.05). Meanwhile, the total PSI-SF scores and the scores of parental distress (PD), parental-child dysfunctional interaction (PCDI) and difficult child (DC) in the L-ASD group were significantly higher than those in the H-ASD group (P<0.01 or P<0.05). The total score of MSPSS was also higher in the L-ASD group than in the H-ASD group (P<0.01). This study goes further to show the neuropsychiatric symptoms and parenting stress are significantly higher in mothers of children with ASD, and more social supports are needed for mothers of children with ASD from southern China, especially for mothers of children with low-functioning ASD.

Mental Health Interventions for Parent Carers of Children with Autistic Spectrum Disorder: Practice Guidelines from a Critical Interpretive Synthesis (CIS) Systematic Review

Parent carers of children with Autism Spectrum Disorder (ASD) often report increased levels of stress, depression, and anxiety. Unmet parent carer mental health needs pose a significant risk to the psychological, physical, and social well-being of the parents of the child affected by ASD and jeopardize the adaptive functioning of the family as well as the potential of the child affected by ASD. This systematic review identifies key qualities of interventions supporting the mental health of parent carers and proposes practitioner-parent carer support guidelines. A search of four databases (Medline, PubMed, PsycINFO, and Social Science Data) was conducted to identify studies that met the following criteria: (1) an intervention was delivered to parent carers of a child with ASD under the age of 18 years; (2) the research design allowed for a comparison on outcomes across groups; and (3) outcome measures of the parent carers’ mental health were used. A total of 23 studies met the inclusion criteria. A critical interpretive synthesis approach was used to produce an integrated conceptualization of the evidence. Findings suggest practitioner guidelines to support the mental health and wellbeing of parent carers should include addressing the parent’s self-perspective taking and skill for real time problem-solving.

Contribution of Benson's Relaxation Technique and Brief Psycho-Educational Intervention on Quality of Life of Primary Caregivers of Iranian Children with Chronic Diseases

BACKGROUND

Chronic diseases leave a significant effect on not only the afflicted children but also their parents. Chronic diseases in children may also influence their parents' or primary caregivers' quality of life (QoL).

OBJECTIVE

To determine the effectiveness of a Brief Psycho-educational Intervention (BPI) and Benson's Relaxation Technique (BRT) on the QoL of primary caregivers of children with chronic diseases.

METHODS

The present quasi-experimental pre-test post-test design was conducted on 100 parents with children who had one chronic disease (50 in each of the control and intervention groups) and were admitted to two state-run pediatric hospitals in Tehran, Iran in 2014. The primary caregivers' QoL was assessed using the SF-36 questionnaire before (T1) and four weeks after the intervention (T2). The training was done in four 60-70minute sessions over one week with a 4-week follow-up. Paired t-test, independent t-test, chi-square and Fisher's exact tests were used to analyze the data.

RESULTS

On average, large effect sizes (ES≥0.80) were observed after interventions in SF-36 subscales that measured the effect of emotional roles. Small (0.20-0.49) to moderate (0.50-0.79) ESs were found in subscales measuring physical functioning, physical-role, bodily pain, vitality, social functioning and mental health. General health scores remained relatively unchanged at T2.

CONCLUSION

These results suggested that BPI and BRT were effective strategies to improve the QoL of primary caregivers. Furthermore, interventions with low cost, and good safety and outcome could improve the QoL of primary caregivers of children with chronic diseases.

Effect of a multidisciplinary supportive program for family caregivers of patients with heart failure on caregiver burden, quality of life, and depression: A randomized controlled study

BACKGROUND

Caregivers of patients with heart failure experience burden and negative health outcomes. Adequate support for family caregivers improves their well-being and the quality of care provided to the patients. However, little is known about the benefits of interventions for caregivers of patients with heart failure in China.

OBJECTIVES

To test the effects of a multidisciplinary supportive program for family caregivers on caregiver burden, quality of life, and depression.

DESIGN

A randomized controlled design with repeated measures was used in this study.

METHODS

A total of 118 participants were randomized into experimental (n=59) and control groups (n=59) from May to December 2014 in one hospital in Chengdu, People's Republic of China. Participants in the experimental group received a 3-month multidisciplinary supportive program, consisting of three 60-min sessions of group classes, three 30-min peer support groups, and regular telephone follow-ups and consultations, while participants in the control group received usual care only. Outcomes were caregiver burden, quality of life, and depression. Data were collected at baseline, post-test (3 months after discharge), and 3 months after post-test (6 months after discharge). The repeated measures analysis of variance was used to examine the effects of groups, changes over time, and time-group interaction on outcome variables.

RESULTS

There were significant improvements in caregiver burden, mental health, and depression after post-test and 3 months after post-test in the experimental group. However, there was no significant improvement in caregivers' physical health at either 3 or 6 months following discharge.

CONCLUSIONS

A multidisciplinary supportive program for caregivers of heart failure patients had positive effects and provides a unique perspective of an intervention considering Chinese culture and customs.