Autism in China: Progress and challenges in addressing the needs of children and families

Adaptation and Feasibility of the Mandarin Version of PEERS® for Autistic Adolescents

PURPOSE

The Program for the Education and Enrichment of Relational Skills (PEERS®) is a group-based social skills training program for adolescents on the autism spectrum. Although the program has been shown to be effective in improving social skills in autistic adolescents, evidence of its effectiveness from the Mandarin-speaking Chinese population is sparse. The present study used a non-randomized, pre- and post-intervention research design to investigate the feasibility and cultural validity of the program, as well as examine the moderators of intervention outcomes.

METHODS

Thirty-three autistic adolescents with intelligence quotient above 70 (Mage = 13.57, SDage = 1.43; Male: Female 25:8) and their parents received 14 concurrent 90-minute sessions. Adolescents' autistic traits, challenging behaviors, emotional functioning, socio-cognitive process, social environment factors (school support), and caregivers' well-being were evaluated.

RESULTS

The findings suggest that with minor adjustments, the Mandarin version of PEERS® was generally acceptable and feasible for autistic adolescents and their parents. PEERS® may improve the social skills knowledge, reciprocal communication abilities, and emotional well-being of autistic adolescents. Also, participants with a higher level of school support, and parents with lower perceived subjective well-being at baseline may gain more benefits from PEERS®. The cultural adaptation and acceptability of the Mandarin Version of PEERS® were discussed.

CONCLUSION

This feasibility study (Chinese Clinical Trial Registry: ChiCTR2200061417, 2022-06-23, retrospectively registered) provides a basis for further randomized control trials of the Mandarin version of PEERS®.

Early identification of autism spectrum disorder based on machine learning with eye-tracking data

BACKGROUND

Early identification of autism spectrum disorder (ASD) improves long-term outcomes, yet significant diagnostic delays persist.

METHODS

A retrospective cohort of 449 children (ASD: 246, typically developing [TD]: 203) was used for model development. Eye-movement data were collected from the participants watching videos that featured eye-tracking paradigms for assessing social and non-social cognition. Five machine learning algorithms, namely random forest, support vector machine, logistic regression, artificial neural network, and extreme gradient boosting, were trained to classify children with ASD and TD. The best-performing algorithm was selected to build the final model which was further evaluated in a prospective cohort of 80 children. The Shapley values interpreted important eye-tracking features.

RESULTS

Random forest outperformed other algorithms during model development and achieved an area under the curve of 0.849 (< 3 years: 0.832, ≥ 3 years: 0.868) on the external validation set. Of the ten most important eye-tracking features, three measured social cognition, and the rest were related to non-social cognition. A deterioration in model performance was observed using only the social or non-social cognition-related eye-tracking features.

LIMITATIONS

The sample size of this study, although larger than that of existing studies of ASD based on eye-tracking data, was still relatively small compared to the number of features.

CONCLUSIONS

Machine learning models based on eye-tracking data have the potential to be cost- and time-efficient digital tools for the early identification of ASD. Eye-tracking phenotypes related to social and non-social cognition play an important role in distinguishing children with ASD from TD children.

Autistic adults in China and the Netherlands: Proxy-reported community integration and life satisfaction

LAY ABSTRACT

Even though there are about 10 million Chinese autistic individuals, we know little about autistic adults in China. This study examined how well young autistic adults in China integrate into their communities (such as having a job, living independently and having friends) and how satisfied they are with their lives as reported by their caregivers. We compared them to autistic adults with similar characteristics (such as high support needs) from the Netherlands. We included 99 autistic adults in China and 109 in the Netherlands (18-30 years). In both countries, autistic adults were reported to have a hard time fitting into their communities. They often had no work, did not live on their own and had few close friends. Also, in both countries, caregivers reported that autistic adults felt low satisfaction with their life. Chinese adults were less satisfied with their life than Dutch adults, as indicated by their caregivers. This could be because of a lack of support for autistic adults in China, higher parental stress in Chinese caregivers, or general cross-country differences in happiness. Only in the Dutch group, younger compared with older adults fitted better into their communities, and adults without additional psychiatric conditions were reported to have higher life satisfaction. Country was a significant predictor of independent living only, with Dutch participants more likely living in care facilities than Chinese participants. In conclusion, our study shows that autistic adults with high support needs generally face similar challenges in both China and the Netherlands.

How are parental mental health and parenting practices associated with externalizing behaviors among young children with autism in China? A cross-sectional study and indirect effect analysis

Children with autism are more likely to exhibit externalizing behaviors than children without autism. A cross-sectional study was undertaken to investigate how parental mental health status and parenting practices contributed to the variance in externalizing behaviors among families of young children with autism in Chinese mainland, and whether parenting behaviors had any indirect effects on the relationship between parental mental health symptoms and externalizing behaviors. Data were drawn from the baseline assessment of a quasi-experimental study of a parent training program delivered to Chinese caregivers of children with autism aged 3 to 6 from diverse backgrounds (N = 111). Results showed that parental mental health symptoms and parenting behaviors explained the variance in child externalizing behaviors. Parental mental health problems and parental over-reactivity were linked to higher levels of child externalizing behaviors, whereas positive parenting was associated with less frequent externalizing behaviors. Positive parenting partially explained the relationship between parental mental health symptoms and externalizing behaviors. The findings of this study highlight the importance of actively attending to the psychological and parenting needs of caregivers in autism treatment programs. It points to the need for the development of culturally sensitive strategies to promote parental mental health and increase the use of positive parenting skills among parents of children with autism.

The Relationship Between Parenting Stress and Parental Burnout Among Chinese Parents of Children with ASD: A Moderated Mediation Model

This study investigated the role of resilience as a mediator and the place of residence as a moderator of parenting stress and parental burnout. The Parenting Stress Index-Short Form, Parental Burnout Assessment, and Connor-Davidson Resilience Scale were administered to 249 Chinese parents of children with ASD (M = 33.95 years, SD = 7.6). Results show that resilience partially mediates the relation between parenting stress and parental burnout. Besides, both the effect of parenting stress on parental burnout and the mediating effect of resilience are moderated by rural/urban residence. This study highlights parenting stress is a risk factor for parental burnout and resilience is the potential mechanism underlying this relation. These findings provide implications for family services for parents of children with ASD.

Explaining differences in autism detection timing: Age of diagnosis and associated individual and socio-familial factors in Chinese children

LAY ABSTRACT

Timely detection is an issue of paramount importance in the care of children with autism spectrum disorder. Whether the delayed autism spectrum disorder diagnosis can be explained by children's clinical presentations and socio-familial status in China is a question to be addressed. We investigated 1235 autism spectrum disorder children from 132 rehabilitation organisations in Shenzhen, China. These children were found to have a mean age of diagnosis of 31.4 ± 12.7 months and a median age of diagnosis of 30.0 months. The majority of these children were able to receive their diagnosis during toddlerhood. However, about one in six were not diagnosed until they entered preschool or later, thus missing the golden window of opportunity for early intervention. The age of diagnosis was likely to be late if the children were older, were less severe and presented with no intellectual impairment. The odds of having a delayed autism spectrum disorder diagnosis were more than 9 times higher among migrant autism spectrum disorder children than among those with local household registrations, thus underscoring the importance of identifying culturally sensitive socio-economic determinants in autism spectrum disorder detection, as these factors are likely to affect the quality of life of many autism spectrum disorder children and their families.

The importance of parenting self-efficacy and social support for family quality of life in children newly diagnosed with autism spectrum disorder: A one-year follow-up study

Improving the quality of family life (FQoL) is one of the ultimate goals for autism spectrum disorder (ASD) intervention, and parenting self-efficacy and social support are critical for the well-being of families. However, longitudinal studies focusing on FQoL and its predictors for families of children with ASD are scarce. This study aims to describe the characteristics of FQoL among parents of children newly diagnosed with ASD at two waves (newly diagnosed and diagnosed after one year) and to explore the predictors of FQoL at two waves. It was conducted at a tertiary hospital in Guangzhou, China. A total of 156 parents and their children were included in Wave 1, followed up with 110 in Wave 2 after 1 year. The overall satisfaction of FQoL improved (t = -2.128, p < 0.05), while satisfaction with physical/material well-being decreased (t = 5.972, p < 0.01). Additionally, the overall importance rating of FQoL improved but did not have statistical significance (p > 0.05). Parents with higher parenting self-efficacy (β = 0.716, P < 0.01), and more subjective social support (β = 1.127, p < 0.001) reported higher satisfaction with FQoL, and those with better social support utilization (β = 1.066, p < 0.05) reported higher importance for FQoL. FQoL needs to be improved in the early stage of ASD diagnosis, and parental self-efficacy and social support can serve as the intervention targets.

Formal social support and quality of life of caregivers with autistic children: a large-scale nationwide survey in China

Introduction

Caregivers of children with autism spectrum disorder (ASD) were reported poor quality of life (QOL). Formal social support might improve the QOL of caregivers, however, limited research to date has focused on this association in China and formal social support for this group is conspicuously lacking. The study was aim to understand the QOL in male and female caregivers with ASD children in China and to explore the relationship between QOL and formal social support for caregivers with children with ASD through a large-scale nationwide survey.

Methods

An online questionnaire was used to conduct a cross-sectional study with a sample of 6,120 caregivers of children with ASD. Relationship between Quality of Life and several potential predictors is measured and analyzed. Quality of life were measured by Medical Study Short-Form Health Survey version 2 (Chinese version). Multivariate logistic regression analysis was used to analyze the factors affecting caregivers' QOL.

Results

The results revealed that the QOL of caregivers of autistic children in China was poor especially male caregivers. Social support was a positive predictor. More importantly, formal social support from rehabilitation institutions can improve caregivers' physical QOL. Caregivers' satisfaction with the rehabilitation institutions affecting their physical and mental QOL.

Conclusion

The formal social support provided by rehabilitation institutions plays a positive role in improving the quality of life of caregivers.

Improving early detection, diagnosis and intervention for children with autism spectrum disorder: A cross-sectional survey in China

BACKGROUND

Detection and diagnosis of autism spectrum disorder (ASD) are prerequisites for early interventions. However, few studies focused on this topic.

AIM

This study aims to characterize the timing from symptom detection to intervention in children with ASD and identify predictors of age at ASD diagnosis, presence of intervention, and the time lag between detection and diagnosis.

METHODS AND PROCEDURES

A cross-sectional survey was conducted with 303 parents (111 fathers and 192 mothers, 21-54 years) of children with ASD in Guangzhou, China.

OUTCOMES AND RESULTS

The median time from symptom observation to the first doctor visit was 3 months, while the time to ASD diagnosis averaged 6 months. Most children (76.24 %) were diagnosed within one year after detection, and 25.58 % had no intervention after diagnosis. Predictors of earlier ASD diagnosis included ASD-related symptoms identified at an older age, less serious symptoms, and initial symptoms with atypical motor development and sensory anomalies. ASD-related symptoms observed at an older age, initial symptoms with social deficits, sensory anomalies, and without language impairment, primary caregivers other than parents, families with lower income, and less social support utilization increased the odds of a time lag between detection and diagnosis. Children with fathers having lower education were less likely to receive interventions.

CONCLUSIONS AND IMPLICATIONS

Earlier ASD identification and intervention might be facilitated by health education on typical symptoms of ASD for parents with young children and incorporating ASD screening during routine health examinations for children. For children whose primary caregivers are not their parents and from lower-income families, additional support may be required for timely diagnosis after reporting ASD-related symptoms. Moreover, more intervention supports are expected for children whose fathers have lower education levels. Helping families take full advantage of support is also important for early diagnosis and intervention.

Early identification of autism spectrum disorder by multi-instrument fusion: A clinically applicable machine learning approach

Autism spectrum disorder (ASD), developmental language disorder (DLD), and global developmental delay (GDD) are common neurodevelopmental disorders in early childhood; however, the differential diagnosis of these disorders is difficult because of overlapping symptoms. Drawing on a cohort of 2004 children with ASD, DLD, or GDD, this study developed machine learning classifiers using decision trees, support vector machines, eXtreme gradient boosting (XGB), logistic regression, and neural networks by combining several easily accessible behavioral and developmental assessment instruments. The best-performing XGB model was further simplified into a two-stage decision model (TS-DM) to achieve better interpretability. Model performance was tested and compared with that of 12 pediatricians on an external dataset of 60 children. The accuracies of the resident pediatricians, senior pediatricians, TS-DM, and XGB were 53.3%, 66.7%, 75.0%, and 78.3%, respectively. Machine learning has the potential to identify these three neurodevelopmental disorders by integrating information from multiple instruments and thereby may increase our understanding of the roles of different behavioral and developmental characteristics in the different diagnoses.

Daily experiences and well-being of Chinese parents of children with autism

LAY ABSTRACT

The present study examined the influences of child-related stress, parental coping and social support on parental daily subjective well-being (i.e. positive and negative affect, life satisfactory) in Chinese families of children with autism spectrum disorder. For 14 days, a total of 76 parents (58 mothers) participated in the study and completed daily diaries. For mothers, child-related stress was related to lower life satisfaction; social support was related to higher life satisfaction that day. These daily relations were not found for fathers. Across all parents, avoidant coping was associated with higher negative affect and lower positive affect on the same day. Notably, daily positive coping was related to greater same-day positive affect as well as greater same-day and next-day life satisfaction. Interventions aimed at increasing positive coping and social support, and reducing child-related stress and avoidant coping are important to help parents maintain well-being, particularly for mothers of children with autism.

Parents' pandemic stress, parental involvement, and family quality of life for children with autism

Background

Research has shown that parents of children with autism spectrum disorder (ASD) suffered high levels of stress during the COVID-19 pandemic and faced poor family quality of life (FQOL). However, little is known about the inherent dynamic interaction between pandemic stress and FQOL, especially in the Chinese cultural context.

Aims

This study provides preliminary evidence by examining the relationships among pandemic stress, parental involvement, and FQOL for children with autism in mainland China.

Method

A total of 709 parents of children with autism completed measures of FQOL, parental involvement, and pandemic stress. Structural equation modeling was employed to examine the interrelations among these variables.

Results

Pandemic stress has direct effect and indirect effect mediated by parental involvement on FQOL. Two dimensions of pandemic stress had a direct effect on FQOL (β1 = 0.11; β2 = -0.55) and three dimensions had an indirect effect on FQOL through parental involvement (β1 = -0.097; β2 = 0.257; β3 = 0.114).

Conclusion

Stress related to the COVID-19 pandemic affects family quality of life for children with autism in complex ways. Policies may be developed to enhance parental pragmatic hopefulness in the anti-epidemic victory and alleviate negative physical and mental reactions caused by the pandemic.

Familiarity of evidence based practices in Chinese caregivers of autistic children

Although researchers have investigated special educators' and clinicians' knowledge and use of evidence-based practices (EBPs), there is very little research on caregivers' perception of the importance of EBPs for their autistic children. Moreover, there is even less research on how EBPs have been translated or disseminated in international communities not within the English-speaking, Western population. In order to provide appropriate support for caregivers of autistic children in all communities, we need more information to identify possible barriers that may affect caregiver involvement. We used a survey to ask 81 Chinese caregivers of autistic children in Guangzhou, China to investigate their familiarity with EBPs for autistic individuals and any external sources used inform their decision about treatment options for their autistic child. Results showed that 58.6% of the participants had no knowledge of what an EBP was and an additional 29.7% of the participants had heard of EBPs but not sure what they were. These results amplify the need for increased dispersion of ASD intervention knowledge to global communities and how to increase caregiver knowledge on treatment options for their autistic child.

A virtuous circle: Stakeholder perspectives of a short-term intensive parent training programme delivered within the context of routine services for autism in China

While much knowledge about autism derives from high-income countries, most people diagnosed with autism reside in low- and middle-income countries, where little is documented in terms of local interventions. This is also true for parent training programmes for families of autistic children. An evaluation was conducted to understand the effects of a short-term intensive parent training programme delivered in routine services for families of autistic children in China. This study reported results from the in-depth interviews with 14 participating caregivers and group discussions with eight group leaders. The interviews and discussions were aimed at learning (1) to what extent the programme components were deemed acceptable, (2) what affected caregivers' attendance and engagement in the programme and (3) what affected group leaders' delivery of the programme. Findings suggested that future parent training programmes provide adequate opportunities for caregivers to practice and receive feedback; group support; coaching experience tailored to individual challenges; more autism-related knowledge, resources and activities for children and extended family members; and organisational support to group leaders. This study highlights the value of qualitative research and points to the need for more empirical studies to address the recommendations, so that research findings can be better utilised to promote practices.

Parents' knowledge and attitude and behavior toward autism: a survey of Chinese families having children with autism spectrum disorder

BACKGROUND

In recent years, parent-mediated intervention for children with autism spectrum disorder (ASD) has increased. Therefore, implementing effective parent training programs for parents of children with autism is of paramount importance, particularly in low- and middle-income countries. However, little is known about the status of and gaps in parents' knowledge on ASD, which may hinder the development of valid parental training programs. Herein, we aimed at exploring the status of Chinese parents' knowledge, attitude and behavior toward ASD, and potential factors affecting the acquisition of correct knowledge.

METHODS

This study used a self-designed parental knowledge questionnaire of autism (PKQA) comprising 20 questions alongside another questionnaire comprising additional 17 questions covering the aspects of family demographics, attitudes, and behaviors of parents. In total, we included 394 parents who visited the outpatient department of the Child's Development and Behavior Center of the Third Affiliated Hospital of Sun Yat-Sen University between December 2018 and May 2019, with their children meeting the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for ASD.

RESULTS

The median knowledge score in the PKQA was 15 [interquartile range (IQR), 13-17]. Advanced paternal age and longer time interval from diagnosis to enrolling into the parent training program were associated with a lower total knowledge score (all P<0.001). Higher maternal education attainment, higher family income, child being currently under intervention, and family members sharing a common perception of the diagnosis were associated with a higher total knowledge score (all P<0.01). Reading autism-related books (P<0.001) or attending professional lectures (P=0.019) were also associated with a higher total knowledge score.

CONCLUSIONS

Taken together, this study revealed that family demographics and parents' attitudes and behaviors toward ASD may significantly influence their knowledge about autism, suggesting the need for promoting more targeted parental skills training programs.

Sense of Parenting Efficacy, Perceived Family Interactions, and Parenting Stress Among Mothers of Children With Autistic Spectrum Disorders

This study examined the relationship between maternal sense of parenting efficacy and parental stress in children with autism and the moderating effect of family interaction. A total of 263 mothers of children with autism were investigated with the Parenting Ability Scale, Family Interaction Scale (FIS), and Parental Stress Scale. The results showed that (1) maternal sense of parenting efficacy significantly predicted parental stress in children with autism; and (2) family interaction significantly moderated the relationship between maternal sense of parenting efficacy and parental stress in children with autism, that is, when family interaction was lower than -1.54 standard deviation (SD), the sense of parenting efficacy did not significantly predict parental stress. When family interaction was higher than -1.54 SD, parenting efficacy had a significant negative predictive effect on parenting stress.

Mindfulness and Stress Among Parents of Children with Autism Spectrum Disorder in China

Parenting a child with autism spectrum disorder (ASD) can be tremendously challenging. It is important to identify factors associated with parenting stress. This study examined the indirect effect of parental dispositional mindfulness on their anxiety and depressive symptoms and family quality of life (FQOL) through mindful parenting and then parenting stress. Seventy-nine Chinese parents (24.1% fathers) of children with ASD aged 3-13 years completed self-report questionnaires. Results indicated that higher dispositional mindfulness was associated with higher mindful parenting, which was related to lower parenting stress, and further related to lower anxiety and depressive symptoms and higher FQOL. The findings provide valuable insight into the potential pathways through which general mindfulness and mindful parenting may positively impact parental outcomes.

Parental stress, involvement, and family quality of life in mothers and fathers of children with autism spectrum disorder in mainland China: A dyadic analysis

BACKGROUND

Research shows that parents of children with autism spectrum disorder (ASD) are burdened with childcare responsibilities and at increased risk for elevated stress and poor family quality of life (FQOL). Little is known, however, about the dynamic interactions between mothers' and fathers' perceived parenting stress in relating to parental involvement and FQOL, especially in the Chinese cultural context.

AIMS

This study examined the intrapersonal and interpersonal effects of parenting stress on parental involvement and FQOL for families of children with ASD in mainland China.

METHOD

A total of 210 Chinese couples (total N = 420) completed measures of caregiving involvement, perceived parenting stress, and FQOL. The Actor-Partner Interdependence Mediation Model (APIMeM) was employed to examine the dyadic relationships among the variables.

RESULTS

Both parents' parenting stress was negatively associated with their own involvement and FQOL. Moreover, fathers' parenting stress was indirectly related to mothers' perceptions of FQOL through their involvement in the care of their child with ASD.

CONCLUSIONS

The findings highlight the important roles of fathers' parenting stress and involvement in affecting their own and their partners' satisfaction with FQOL within Chinese families raising a child with ASD.

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.

The resilience of parents who have children with autism spectrum disorder in China: a social culture perspective

BACKGROUND

Parenting children with autism spectrum disorder (ASD) continues to be challenging worldwide, especially in the Chinese context where there lacks support for parents.

METHOD

Five parents of children with ASD of high level of resilience in China were interviewed about their experiences of raising children with ASD and influencing factors of developing resilience.

RESULTS

Findings highlighted the process of developing resilience shaping from the interaction between different social system, including introspect and self-cultivation in micro system, acceptance of ASD, playing various roles for their children, and expanded social network in the interactions between micro and mezzo systems and accept the worst results in the interactions between micro and macro systems. The characteristics of resilience for Chinese parents of children with ASD were that parents built positive relationships with themselves and outsides though active interaction and changed their social environment as an outcome.

CONCLUSION

The results of this study may reveal the process and characteristics of resilience for Chinese parents having children with ASD, which can be a starting point for other parents to understand and learn from them. Besides, it provides insight for service providers into paying attention to the whole experience of parents and help them to expand the relative network to support them.

Examining the relationships of parental stress, family support and family quality of life: A structural equation modeling approach

BACKGROUND

Research has shown that support for families with children with autism spectrum disorder (ASD) in the United States has led to reduce parental stress. To better understand the situation in China, it is crucial to evaluate the current status of family support and provide clear evidence of the impact of family support on positive family outcomes.

AIMS

This study aims to provide initial evidence to examine these interrelations among family support, parental stress, and family quality of life in mainland China.

METHOD

A total of 226 parents of children with ASD completed two questionnaires (Beach Center Family Quality of Life (FQOL) Scale and the Family Support Scale for Chinese Children with ASD) and a demographic family information form. Structural equation modeling was used to examine the interrelation among parental stress, family support, and FQOL.

RESULTS

Parents perceived a moderate to low level of family support and FQOL and high level of parental stress. Family support had a direct positive effect on FQOL (β = .54) and an indirect effect on FQOL through parental stress (β = .06).

CONCLUSION

Resources should be devoted to establishing a family support system that promotes FQOL and buffers parental stress for families of children with ASD.