Exploring the Effect of Autism Waiver Services on Family Outcomes

Careers and Quality of Life: Comparing Perceptions of Compound and Noncompound Caregivers

Study objectives were to compare differences in quality of life (QOL) and family quality of life (FQOL) between compound and noncompound caregivers and describe how career-related dimensions influence the global FQOL. Examination of survey data from 77 compound and 113 noncompound caregivers indicated that compound caregivers had lower QOL, global FQOL, and worse career outcomes than noncompound caregivers. Global FQOL was associated with greater career satisfaction, higher income, and noncompound caregiver type. For compound caregivers, global FQOL was associated with more career opportunities and positive perceptions of career stability. These findings have implications for supporting career pursuits of family caregivers.

Inequities in medicaid home- and community-based services waiver enrollment among people with intellectual and/or developmental disabilities: A nationwide claims-based analysis

BACKGROUND

States use Medicaid 1915(c) waiver programs to enable access to home- and community-based services for people with intellectual and/or developmental disabilities (I/DD). However, enrollment rates and potential inequities are not well documented, impeding efforts to improve care access and quality for waiver program enrollees, especially for racially minoritized beneficiaries experiencing compounded barriers to services and supports.

OBJECTIVE

To characterize year-by-year 1915(c) waiver program enrollment among Medicaid-enrolled adults with I/DD from 2016 to 2019 and to analyze population-level inequities by type of I/DD and racial/ethnic group.

METHODS

Our data source was 2016-2019 Medicaid Transformed Medicaid Statistical Information System Analytic Files Demographic and Eligibility files for beneficiaries with Down syndrome, autism, and intellectual disability. We used generalized estimating equation linear models to estimate the associations of type of I/DD and racial/ethnic group with the probability of 1915(c) waiver program enrollment and reported (1) unadjusted estimates and (2) estimates adjusted for demographics with state and year fixed effects.

RESULTS

From 2016 to 2019, across all types of I/DD and racial/ethnic groups, unadjusted 1915(c) waiver program enrollment rates ranged from 40 to 60 % nationwide. We found modest growth in 1915(c) I/DD waiver program enrollment but persistent inequities over time. Compared to beneficiaries with intellectual disabilities, beneficiaries with autism were less likely to enroll while beneficiaries with Down syndrome were more likely. While some racial/ethnic groups had higher unadjusted mean enrollment, after adjustment, racially minoritized beneficiaries were 3.66-12.0 percentage points less likely to enroll compared to white non-Hispanic beneficiaries.

CONCLUSIONS

Given extensive waiting lists for 1915(c) waiver programs, Medicaid programs should evaluate existing enrollment and authorization processes and consider alternative HCBS program authorities.

Family Support of Older Caregivers: Factors Influencing Change in Quality of Life

Understanding factors that can improve the quality of life (QOL) of older caregivers of people with intellectual and developmental disabilities (IDD) is important in broadening participation in family empowerment interventions. The purpose of this study was to identify the factors influencing the QOL of older caregivers (50+) of adults with IDD who participated in a peer-mediated state-wide family support project. The research study used a quasi-experimental research design grounded in the family quality of life (FQOL) framework, with pretest and posttest data gathered from 82 caregivers. Correlation and regression analyses were conducted to identify factors influencing changes in the QOL of study participants. Findings indicated that improvements in caregiver QOL after participating in the project could be explained by caregiver's employment status, increased global FQOL, and decreased caregiver stress and depression.

Quality of Life of Autistic Children and Supported Programs in Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Autism spectrum disorder (ASD) is a neurobehavioral condition marked by social interaction challenges, communication deficits, and repetitive behaviors, with studies in Saudi Arabia showing varying prevalence rates in different regions. This study aimed to evaluate the social context of autistic children and the quality of life (QOL) for families of children with autism utilizing the Beach Center Family Quality of Life Scale (BCFQOL).

METHODS

This cross-sectional study, conducted at King Abdulaziz Medical City in Saudi Arabia over a six-month period, included ASD children aged 1-14 years. The QOL was measured using the BCFQOL scale for families. Data were analyzed using the Jamovi software (Windows version 2.4.1, the Jamovi Project, retrieved from https://www.jamovi.org).

RESULTS

A total of 102 responses were collected in the study. The overall satisfaction score was 93.6±16.6 out of 125, with 85.3% of participants expressing satisfaction. Domains explored included family interaction (23.8±5.29 out of 30), parenting practices (23.9±3.83 out of 30), emotional well-being (13.1±4.16 out of 20), physical and material well-being (18.7±4.24 out of 25), and disability-related support (14.2±4.0 out of 20). In terms of specific sociodemographic factors, no statistically significant differences in satisfaction were observed across various categories.

CONCLUSION

Families of children with ASD in Saudi Arabia generally report high levels of satisfaction, as assessed by the BCFQOL. The study covered various domains, including family interaction, parenting practices, emotional well-being, physical well-being, and disability-related support, with most respondents expressing satisfaction in these areas. Notably, sociodemographic factors did not significantly influence satisfaction levels, underscoring the pervasive nature of the findings across different demographic groups. Further studies with a larger sample size and a longer follow-up period are required to validate these findings.

The Effects of Health Insurance Coverage on Workforce Engagement of Family Caregivers of Children With Intellectual Disability and Autism

For many families of children with intellectual disability and autism (ID/ASD), private health insurance and public programs, such as Medicaid and the Children's Health Insurance Program (CHIP), are critical sources of support. The purpose of this study was to examine the impact of health insurance coverage on workforce engagement of parents of children with ID/ASD. The study utilized 2014-2018 pooled National Health Interview Survey data to construct national estimates and test the effects of health insurance status on parent workforce outcomes. Primary findings indicate significantly higher odds of workforce absence (OR = 2.83, p < .0038) and unemployment (OR = 8.91, p < .0038) among parents with children with ID/ASD using public health insurance, compared to the reference group. Additionally, parents of children with ID/ASD who were uninsured were found to experience significantly higher unemployment (OR = 4.86, p < .0038) than the reference group. Findings have policy and research implications related to workforce engagement for parents, including issues impacting health insurance coverage, specifically related to Medicaid and CHIP.

Developing a new questionnaire of positive contributions to Chinese families by children with autism spectrum disorder

Background and Aims

A literature review of both Eastern and Western literature regarding families of children with autism spectrum disorder (ASD) revealed limited empirical research that examines ASD in China. Furthermore, most research in this area comes from a deficit model and there is a lack of research that comes from a strengths background. No previous study in China has looked at the positive contributions of children with ASD to their families. The present study came from a strengths-based perspective and aimed to develop a new questionnaire to evaluate the positive contributions made to families by children who have ASD in China and are raised by their respective families. It considered the severity level of the children's disorder and the impact this had on the parents. Besides examining the children's impairment levels, the study also examined positive contributions and their relationship with socio-demographic elements such as family income and employment status of the parents, which also seem to be related to the positive contributions experienced by the parents.

Methods

First, based on the literature review, an initial qualitative interview protocol was developed and administered to 10 parents of children with ASD. Then, based on the analyses of the interviews, a quantitative questionnaire was developed to assess the positive contributions of children with ASD to their families. The questionnaire was then administered to 156 parents of children with ASD. The internal structure of the questionnaire was analyzed by factor analysis. The questionnaire's reliability and validity were also examined. The data were then analyzed with multiple correlation comparisons and an independent sample T-test.

Results

Six factors emerged for families of children with ASD. The results showed that the cumulative explanatory variance of the six dimensions of the questionnaire was 65.42%. The Cronbach's coefficient of each dimension was between 0.7 and 0.9, and the combined Cronbach's coefficient of the total questionnaire was 0.945. This study found that the overall average positive contribution to families by children with ASD was 3.32, which is at a medium level, and all six dimensions were at a medium-to-high level. This study also found that the family's monthly income contributed to the overall positive contribution, intimacy and happiness, and gaining more special knowledge through experience dimensions. Furthermore, it was found that moderate severity of ASD, high income, and parental employment were all associated with more positive contributions.

Conclusion

This new questionnaire appears to have good reliability and validity and seems suitable for assessing the positive contributions to families by children with ASD in China.

Implications

The present study may be helpful for the parents of children with ASD and will likely help them focus on the strengths of their children rather than their shortcomings. The study might also benefit counselors and researchers who would be able to use the new questionnaire to evaluate the positive contributions made to families by children who have ASD.

Participants' Bias in Disability Research on Family Quality of Life during the 0-6 Years Stage

BACKGROUND

Over the past two decades, various research teams have designed and applied instruments to measure the quality of life of families with a member who has a disability. A recent systematic review on the state of the Family Quality of Life in early care identified that many of these studies collected data only from the mothers. The present study aimed to investigate whether there is a bias in participant selection in these types of studies.

METHOD

A systematic review of the scientific literature was conducted in three databases-Scopus, Web of Science, Eric-from 2000 to 2022. A total of 72 empirical studies were identified.

RESULTS

The findings indicate that most studies examining the Family Quality of Life were based on the information of a single informant per family unit. The profiles of participants according to the research objective are quite similar. In one-third of studies, the authors reported that family members who participate cannot be represented by only mothers or one participant per household.

CONCLUSIONS

Given the dynamic and collective nature of the construct, the application of a systemic approach is necessary.

Respite care models and practices for persons with intellectual disability: A scoping review

Background

Families are the primary caregivers for persons with intellectual disability (ID), offering informal support to ensure community living. Ensuring families are adequately supported is key to reduce the financial, physical, mental and social toll which long-standing inadequately supported care giving may evoke. Respite care is such a support service offered to caregivers and care-recipients with ID.

Objective

Part of a larger study aimed at developing a respite care service framework for persons with ID for South Africa, the review aimed to elucidate what principles and practices inform current respite care services for this population globally.

Method

The Joanna Briggs Institute (JBI) scoping review framework guided the review. Databases were searched using key and surrogate terms for relevant literature published from 2006 to 2021.

Results

Thirty-one sources met the inclusion criteria from 417 screened sources of evidence. These were published between 2006 and 2020, and included grey and peer-reviewed articles, the latter mostly mixed design. Information on respite care service characteristics, principles, practices, guidelines, evaluations and impacts were found for high- but not low-and-middle-income countries (LMICs).

Conclusion

There is an existing knowledge base that can be drawn on to inform the development of quality respite care. The lack of published information on respite care in LMICs necessitates further research to ensure contextually appropriate respite care developments in these settings.

Contribution

This study contributes to the knowledge base on respite care for persons with ID and points out the research gap in LMICs.

Relationship between parental perceptions, family income and support received with family quality of life in families with a child with an intellectual disability

Research has shown that families raising a child with intellectual disability (ID) face many challenges and need to implement adaptation strategies. Some authors suggest that positive parental perceptions and perceived control could reduce emotional impact and promote family wellbeing. Nevertheless, there are few studies about the relationship between parental perceptions and family quality of life (FQoL) in those families. In this study, we used data from a sample of 251 Spanish parents whose children have ID. Positive perceptions scale and control perceptions scale, Spanish FQoL scale under 18 years-old and a sociodemographic questionnaire were administered to those families. The results of bivariate analysis showed that some dimensions of positive perceptions were related to different areas of FQoL, for example, social inclusion and family accommodation. FQoL was associated with family income and support received. To predict the FQoL level, a multivariate linear regression analysis was conducted. Results indicated that FQoL scores can be predicted by a linear combination of positive perceptions and family income. Practical implications for promoting FQoL in these families are discussed.

Family quality of life among families who have children with mild intellectual disability associated with mild autism spectrum disorder

BACKGROUND

Intellectual disability (ID) and autism spectrum disorder (ASD) are often concomitant childhood developmental disorders. These disorders can alter family quality of life (FQoL).

OBJECTIVE

To investigate FQoL among families who have children with mild ID, associated with mild ASD.

METHODS

Cross-sectional descriptive study with 69 families who have children with mild ID and ASD, ranging from six to 16 years old, and who were provided with disability-related services in Brazil. Data were collected using a family sociodemographic questionnaire, an ID and ASD personal profile form, the Barthel index for activities of daily living and the Beach Center FQoL scale.

RESULTS

People with ID and ASD had an average score of 88.2±11.5 in the Barthel index, thus indicating moderate dependency in basic activities of daily living. The average total FQoL score (3.56±0.34) was lower than the scores for the "family interaction" (3.91±0.42; p<0.001), "parenting" (3.79±0.35; p<0.001) and "disability-related support" (3.98±0.16; p<0.001) domains; and higher than the scores for the "physical/material well-being" (3.19±0.64; p<0.001) and "emotional wellbeing" (2.75±0.62; p<0.001) domains. Parents' marital condition, monthly family income, family religious practice and effective communication skills among the people with ID and ASD were predictors for FQoL (R2=0.407; p<0.001).

CONCLUSIONS

FQoL was sustained through factors such as family interaction and parents' care for their children. Improving families' emotional wellbeing and physical and material conditions is likely to positively affect the FQoL of these families.

Key stakeholder perspectives on obstacles to an autism-specific Medicaid waiver service delivery model

BACKGROUND

Children and youth with autism spectrum disorder have significant, multi-system needs that require supports, such as the autism waiver (AW) service delivery model. This study aimed to identify and describe characteristics of the AW, define obstacles and strengths in the provision of adequate services and provide recommendations for improving overall effectiveness.

METHODS

This mixed-methods exploratory study used an electronic survey to gain information and perceptions of AW provider agency directors (n = 27) and service coordinators (n = 30).

RESULTS

The key barriers reported were the shortage of qualified staff, inadequate staff training, complexity of cases or symptom severity of clients and lack of communication at multiple levels throughout the agency as well as with parents.

CONCLUSIONS

Recommendations include reinforcing the workforce through higher salaries, greater training and communication interventions. These strategies may reduce staff turnover and shortage, lighten the caseload, reduce the waitlist period and improve the effectiveness and responsiveness of AW services.

The Association of the Medicaid 1915(c) Home and Community-Based Services Waivers with Emergency Department Utilization among Youth with Autism Spectrum Disorder

Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.

Service providers' perspectives in providing services to children with disabilities and their families in Bangladesh

PURPOSE

This study seeks to gain an understanding of access to rehabilitation services and disability allowances for children with disabilities and their families from the perspectives of service providers.

METHOD

We interviewed 21 service providers in Bangladesh and used thematic analysis to analyze data.

RESULTS

Participants reported their perspectives on two major themes: (a) challenges in providing services to children with disabilities (e.g., limited availability of services and favouritism); and (b) facilitators in providing services to children with disabilities (e.g., cooperation from community leaders and satisfaction).

CONCLUSION

Providers' perspectives revealed unique insights that might be interesting for policymakers, practitioners, and researchers. The findings reinforce the need to consider the availability of rehabilitation professionals and disability allowances to meet the greatest needs of children with disabilities and their families in Bangladesh. The findings also call for further research on policymakers' perspectives on addressing the systemic issues encountered by providers in providing support to children with disabilities and their families in Bangladesh.Implications for RehabilitationRehabilitation services are critical for children with disabilities to achieve optimal health, wellbeing and human rightsThe government of Bangladesh has increased rehabilitation services for children with disabilities, but there is a need for further investment to increase rehabilitation workforceIt is important to strengthen monitoring and evaluation of disability-specific programs to ensure equitable access to services for children with disabilities.

United States Medicaid home and community-based services for people with intellectual and developmental disabilities: A scoping review

Emerging research tests the impact of United States Medicaid home and community-based (HCBS) waiver policy on outcomes for people with intellectual and developmental disabilities; however, this body of work has yet to be synthesized. We conducted a scoping review to establish what is known about the impact of Medicaid HCBS policy on the lives of people with intellectual and developmental disabilities. Seven studies met final inclusion criteria. Their findings contribute to preliminary evidence that Medicaid HCBS waivers provide economic benefit at the state and federal level, reduce unmet healthcare needs, increase the likelihood that parents will be able to continue working, and reduce racial disparities in access to care. Additional work should compare HCBS waiver programmes, and their causal pathways, as well as draw international comparisons to similar programming, to determine essential infrastructure needed for a successful HCBS programme.

Testing a Tailored Social-Ecological Model for Autism Spectrum Disorders

OBJECTIVE

To propose a tailored social ecological model for Autism Spectrum Disorders and explore relationships between variables in a large nationally-representative dataset.

METHODS

A tailored social-ecological model was developed and examined across variables in the 2016/2017 National Survey of Children's Health. A series of iterative multivariable logistic regressions were performed including individual, family, and community/neighborhood variables. A multivariable logistic regression using state-level fixed effects was performed to understand dynamics related to macro-level policies.

RESULTS

In the full model, gender, disability severity, certain types of insurance coverage and household income were significantly related to ASD diagnosis. Females had lower odds of a diagnosis compared to males (aOR: 0.27; CI:0.18-0.41). Children with at least one other moderate/severe disability had odds 7.61 higher (CI:5.36-10.82) of a diagnosis than children without moderate/severe disabilities. Children with public insurance only (aOR:1.66; CI:1.14-2.41) or both private and public insurance coverage (aOR: 2.62; CI:1.6-4.16) had higher odds of a diagnosis compared to children with private insurance only. For those who reported it was "somewhat" or "very often" hard to cover basics with their income, odds of a diagnosis were higher compared to those who reported it was "never" or "hardly ever" hard to cover basics (aOR: 1.676; CI:0.21-2.56).

CONCLUSIONS FOR PRACTICE

Patterns of ASD diagnosis are related to individual and family characteristics. There is some evidence that a child's environment has some relationship to reported ASD diagnosis. Professionals should be aware of an individual's environmental factors or context when assessing for ASD.

Family support and family and child-related outcomes among families impacted by disability in low- and middle-income countries: A scoping review

There is a growing interest in understanding the relationship between family support and family or child-related outcomes in high-income countries. However, this has received little attention in low- and middle-income countries. The purpose of this review was to explore the relationship between family support and family and child-related outcomes among families affected by disability in low- and middle-income countries. We conducted a scoping review of five databases using search terms related to 'family', 'support', 'child', and 'disability'. A total of 13 articles met the inclusion criteria. Families of children with disabilities received most of their support from informal sources (e.g. immediate family members, friends, and parents support groups). Parental stress was most often evaluated as the family outcome and was negatively linked to emotional support and childcare assistance from immediate family members. Movement and mobility therapy offered by rehabilitation professionals was found to improve children's walking patterns. Positive attitudes from community members were key facilitators to participation of children with disabilities in social activities. The review calls for urgent attention to research in low- and middle-income countries, particularly the extent of support families are receiving from government-led support systems.

State of the Art of Family Quality of Life in Early Care and Disability: A Systematic Review

Background: In recent years, there has been a growing international interest in family quality of life The objective of this systematic review is to understand and analyze the conceptualization of the quality of life of families with children with disabilities between 0 and 6 years of age, the instruments for their measurement and the most relevant research results. Method: A bibliographic search was conducted in the Web of Science, Scopus and Eric databases of studies published in English and Spanish from 2000 to July 2019 focused on "family quality of life" or "quality of family life" in the disability field. A total of 63 studies were selected from a total of 1119 and analyzed for their theoretical and applied contributions to the field of early care. Results: The functional conceptualization of family quality of life predominates in this area, and a nascent and enriching holistic conceptualization is appreciated. There are three instruments that measure family quality of life in early care, although none of them is based on unified theory of FQoL; none of them focus exclusively on the age range 0-6 nor do they cover all disabilities. Conclusions: The need to deepen the dynamic interaction of family relationships and to understand the ethical requirement that the methods used to approach family quality of life respect the holistic nature of the research is noted.

Quality of Life in School-Aged Youth Referred to an Autism Specialty Clinic: A Latent Profile Analysis

We examined whether different profiles of quality of life (QoL) existed among youth referred to an autism spectrum disorder (ASD) specialty clinic and, if present, determined if these groups were associated with different characteristics. Data were from parental report of 5-17 year-old youth (N = 476) who were scheduled to receive an evaluation at an ASD clinic. Parents completed questionnaires, including the Pediatric Quality of Life Inventory, assessing child and family functioning; providers reported diagnostic impressions. A latent profile analysis found five distinct groups: Low Risk, School Problems, Only Social Emotional Problems, and two Physical/Social Emotional Problems. The groups differed on clinical characteristics and family functioning. These findings have implications for more efficient and effective evaluations in service delivery systems serving complex patients.

Family quality of life among Taiwanese children with developmental delay before and after early intervention

BACKGROUND

Although early intervention (EI) practitioners emphasise the importance of individualised family-centred services for families of children with developmental delay (DD), few empirical studies have evaluated whether EI can improve family quality of life (FQOL). This study aimed to investigate the trajectory of FQOL and its predictors among families of children with DD during the first 12 months of EI.

METHODS

This study employed a prospective cohort design. Data were collected using structured questionnaires at the placement meeting before the commencement of EI, as well as 3, 6 and 12 months later. We recruited 142 primary caregivers of children with DD in northern Taiwan from March 2015 to August 2016. FQOL was measured using the Mandarin Chinese version of the Beach Centre FQOL Scale. Family resilience (FR) was measured using the Mandarin Chinese version of the FR Assessment Scale. Other independent variables included socio-demographics, type of DD and EI services. Generalised estimating equations were used to perform multivariate analysis.

RESULTS

Family quality of life exhibited a significant quadratic trend in the 12 months surrounding EI. The score was the lowest before EI started (89.85), then increased to peak (94.87) at 6 months and then decreased slightly to 92.34 at 12 months. FR followed a significantly increased linear trend during the period. There were significant and positive correlations between FQOL and FR across all time points. Multivariate analysis showed that employed caregivers, FR, sufficient caregiving manpower and satisfaction with marital quality were positively associated with FQOL. Receiving more types of EI services and having fathers who were not Taiwanese nationals were negatively associated with FQOL.

CONCLUSIONS

Family quality of life and FR increased significantly after receiving EI, revealing the latter's effectiveness. Unemployment, poor marital quality, father being an immigrant, low FR and insufficient family caregiving manpower were associated with lower FQOL, suggesting that these families require more assistance.

Characterization of Family-Directed Care Coordination and Involvement in Behavioral Treatments in an Autism-Specific Medicaid Waiver

Services for children with autism spectrum disorder (ASD) and their families have evolved with the advent of the Medicaid waiver, leading to more family-based coordination of care. Evaluating family involvement, the current investigation compared 230 families of children with ASD receiving Medicaid waiver services to a propensity-score matched group of 230 families who were waiting for such services (i.e., registry families). Compared to the registry, waiver families reported more involvement in service planning tasks, but not activities related to future-planning, managing crisis situations, or searching for and securing funding. Additional analyses characterize waiver families as engaging in high levels of coordinating and delivering behavioral interventions for their child. Implications for family burden and future programming for waiver programs are discussed.

Families under pressure: stress and quality of life in parents of children with an intellectual disability

Objective

To evaluate stress and quality of life in parents of children with an intellectual disability (moderate–severe–profound), who attend a Child and Adolescent Mental Health Intellectual Disability Service (CAMHS ID), and to estimate the perceived levels of challenging behaviour and satisfaction with supports.

Methods

Data from children attending the service from 2014 to 2017, along with clinician and parent rating scales were collected.

Results

Most children had medical comorbidities, autism spectrum disorder (ASD), and challenging behaviours. Half had a diagnosis of a mental health disorder. Less than half received respite care. Challenging behaviours and ASD were found to be correlated with increased parental stress while perception of support was inversely correlated with stress. Intellectual disability, ASD, and parental stress were correlated with a decrease in perceived family quality of life.

Conclusions

This study concurs with previous studies, outlining that parents of children with intellectual disability, in particular, where there is a diagnosis of comorbid ASD and challenging behaviour, experience increased psychological distress and lower quality of life.

The Effect of Joint Control Training on the Performance of Multiply Controlled Behavior: A Systematic Literature Review Relevant to Children With Autism Spectrum Disorder and Other Developmental Disabilities

Skinner (1957) differentiated the roles of the speaker and the listener in a verbal encounter. Although not extensively emphasized, Skinner suggested an individual often behaves verbally even when responding as a listener. Children diagnosed with autism spectrum disorders (ASD) often display the absence of important, and basic verbal repertoires that limit their ability to engage in a variety of social skills or problem-solving skills. Joint control suggests that multiply controlled verbal responding involves functional control of two 2 or more stimuli or verbal operants. This systematic literature review provides a summary of publications specifying the relation and implications of the analysis of joint control and joint control training in the acquisition of multiply controlled, non-speaker behaviors (e.g., selection-based behavior; , sequencing behavior). The synthesis suggests that joint control training presents as a promising analytic tool in guiding interventions to teach complex, multiply controlled verbal and non-verbal repertoires to children diagnosed with autism ASD and/or other developmental disabilities. Recommendations for future research in joint control, as well as the implementation of joint control training, are provided.

Quality of Life in Families of Young Children With Autism Spectrum Disorder

The present study investigated family quality of life (FQOL) as experienced by 493 mothers and fathers (295 families) of young children with autism spectrum disorder (ASD) prior to receiving early intervention services in the province of Québec. These families were most satisfied with their physical and material well-being and least satisfied with their family interactions. Children's level of functioning across various standardized and subjective measures were positively associated with parents' FQOL. In both parents, family characteristics associated with financial and personal resources were also linked to FQOL. The child's age and the number of children were associated with mothers' FQOL. Overall, these findings provide a portrait of ASD-related stressors and resources relevant to both parents during the early childhood period.

Qualidade de vida de famílias de filhos com deficiência intelectual moderada

RESUMO Objetivo Investigar a qualidade de vida familiar (QVF) entre famílias brasileiras que têm filhos com deficiência intelectual (DI) moderada. Métodos Estudo transversal, realizado com 50 famílias com filhos com DI moderada de São Carlos, São Paulo, Brasil. Os dados foram coletados por meio de formulários, com informações sociodemográficas, os índices de funcionalidade de Barthel e de Lawton & Brody e a Escala de Qualidade de Vida Familiar do Beach Center. Resultados Os domínios mais fortemente correlacionados com a QVF total foram “interação familiar” (r = 0,870; p < 0,001) e “cuidado dos pais com os filhos” (r = 0,845; p < 0,001). Não houve diferenças na distribuição da QVF em relação às variáveis sociodemográficas investigadas. Observou-se correlação moderada (r = 0,326) e significativa (p = 0,021) entre o índice de funcionalidade de Lawton & Brody e a QVF. O modelo de regressão linear ajustado explicou 10,6% da variabilidade encontrada na QVF (p = 0,021) e mostrou que o aumento de uma unidade no valor do índice de Lawton & Brody representou aumento de 0,092 na QVF. Conclusão A QVF das famílias investigadas encontra-se aquém de outras amostras internacionais. Ações clínicas que fortaleçam o diálogo e a coesão familiar e a construção de um plano terapêutico individualizado podem ser meios efetivos de ajuda a essas famílias.

A psychometric study of the Family Resilience Assessment Scale among families of children with autism spectrum disorder

Background

The family system represents a critical context within which children develop. Although raising a child with a disability may represent a challenge to this dynamic system, research demonstrates that families have the capacity to demonstrate both maladaptation and resilience in the face of related stressors. In the current study, we examined the psychometric properties of the Family Resilience Assessment Scale (FRAS) among families of children with autism spectrum disorder (ASD). This tool is the only measure of family resilience that seeks to identify within-family protective factors, including the extent to which they rely on adaptive belief systems, organizational patterns, and communication processes. Identifying protective processes utilized by those who show resilience is critical within both clinical practice and research, as it aligns with a strength-based perspective that builds on what families are doing well.

Methods

Participants included 174 caregivers of individuals with ASD (84% mothers). Caregivers completed the FRAS, as well as the Beach Center Family Quality of Life Scale. The 54-item FRAS was submitted to an exploratory factor analysis, using the iterated principal factor method with a promax rotation.

Results

Fifty-one items across 3 factors (Family Communication and Problem Solving, Utilizing Social and Economic Resources, Family Spirituality) were retained, explaining 52% of the total variance. The final scale demonstrated convergent validity with the Family Quality of Life assessment tool.

Conclusions

It is our hope that identifying the optimal scale structure will encourage other researchers to utilize this measure with families of children with ASD, thus continuing to advance the study of family resilience within this unique context.

Changes in Healthcare Expenditures After the Autism Insurance Mandate

BACKGROUND

In recent years, most U.S. states have passed autism mandates requiring private insurers to cover autism spectrum disorders (ASD). Little is known about the post-mandate changes in healthcare expenditures.

METHOD

This study utilized 2006-2012 de-identified insurance claims data from the largest insurer in Pennsylvania (PA), where the mandate went into effect in 2009. Healthcare expenditures were defined as the amount the insurer paid for healthcare services and were adjusted to 2012 price level. A mixed model approach was used to analyze the expenditures.

RESULTS

A total of 9,471 children with ASD were included in the study. Although the pre-mandate total expenditures per child with ASD were similar, the post-mandate expenditures significantly increased for groups subject to the autism mandate (87% increase from $7,754 in 2008 to $14,486 in 2010) compared to the exempt groups (27% increase from $7,238 to $9,171). By insurance type, the change from 2008 to 2010 in ASD-related expenditures per child with ASD was $8,439 for fully insured large employer sponsored plans and $43 for the Children's Health Insurance Program (CHIP), both subject to the PA mandate; and $2,631 for the self-insured, $980 for small-employers, and $-92 for individual plans, all of which are exempt from the mandate. These increases were due to outpatient services but not inpatient or drug costs.

CONCLUSIONS

Healthcare expenditures increased significantly following the PA autism mandate. Nonexempt, large employer groups had the largest increase in spending. Some exempt, self-insured companies may have voluntarily covered ASD services, leading to a moderate increase.

Family perceptions of the impacts of a home and community based services autism waiver: Making family life possible

BACKGROUND

An important mechanism that provides support and services for families with a child/youth with autism spectrum disorder is the home- and community-based services (HCBS) Waiver authorized by Section 1915(c) of the Social Security Act or Medicaid.

METHODS

This study used qualitative research methods to explore parent perspectives about the impact of HCBS Waiver services on the child/youth with autism and their family. In-depth interviews focused on aspects of the programme they valued, identification of barriers and general issues they experienced.

RESULTS

Results of the qualitative study indicated that improved outcomes could be explained by providers of services who were well-trained, flexible and allowed parents' opportunities for choice regarding provision of services to meet child/youth and family needs.

CONCLUSION

The findings of this study provide guideposts for further research about factors that contribute to satisfaction of families receiving waiver services for quality of life and child progress.

Quality of life among parents of South African children with autism spectrum disorder

OBJECTIVE

To describe the quality of life (QOL) of South African parents caring for children with autism spectrum disorder (ASD) as compared with parents of typically developing (TD) children from the same community.

METHODS

A cross-sectional study was done evaluating the QOL of parents of 52 children (26 parents of children with ASD versus 26 parents of TD children) using a structured measure, (World Health Organization Quality of Life Assessment-BREF).

RESULTS

The mean age of the children with ASD was 64.9 months (SD 14.5) versus 60.1 months (SD 13.5) for TD group. There was a male predominance among group of children with ASD (48 boys, four girls). The mean parental age of the ASD group was 32.9 years (SD 7.8) compared with 33.8 years (SD 6.8) for the TD group. As compared with parents of the TD children, parents of children with ASD had lower mean QOL scores in the four QOL domains: physical, psychological, social and environmental health (p<0.0001). the domain where the discrepancy between groups was greatest was the physical domain Where the mean score was 52.1 (SD 18.7) in the ASD group and 92 (SD 10.4) in the TD group. Lower income, severity level of ASD and lack of access to school placement of children with ASD were found significantly associated with parents' QOL domains.

CONCLUSION

QOL of parents of children with ASD is significant lower than that of the parents of their TD peers across all domains and is an important component in management of the family which needs to be explored and addressed.

Comparing impact on the family and insurance coverage in children with cerebral palsy and children with another special healthcare need

BACKGROUND

Families and caregivers of children with special healthcare needs (CSHCN) often experience financial difficulties, have unmet physical and mental health needs, and are at increased risk of marital problems due to the stress caused by carrying for their child. Within the larger population of CHSCN, young people with cerebral palsy (CP) have more unmet needs due to the complexity and potential severity of the disability. The purpose of this study was to identify factors associated with differences in insurance coverage and impact on the family of children with CP and other CHSCN.

METHODS

The data were taken from the National Survey of Children with Special Health Care Needs, which was designed to examine state- and national-level estimates of CSHCN. Three variables examined differences in insurance coverage between those children diagnosed with CP versus all other CSHCN: insurance coverage for the previous year, current insurance coverage, and adequacy of insurance coverage. Four variables representing different indicators of family impact were used to assess differences between children with CP versus all other CSHCN: out-of-pocket expenses for healthcare, family financial burden, hours per week that family members spent caring for the child, and impact on family work life.

RESULTS

The results of this study showed significant differences between households with a child with CP and a child with another health special need in terms of insurance coverage, indicating a tendency of children with CP to be insured the entire year. As for the impact on the family in households with children with CP versus other CSHCN, there were significant differences in all four variables that were analysed.

CONCLUSIONS

There is limited evidence highlighting differences between the impact of caring for a child with CP and caring for other CSHCN. Caring for a child with CP has a significant impact on the family, despite insurance coverage.

A Global Family Quality of Life Scale: Preliminary psychometric evidence

PURPOSE

Psychometric data are reported for a new Global Family Quality of Life Scale (G-FQOLS) (3-items) evaluating family members, parents and adolescent/young adults (AYA).

METHODS

Families (N= 209) were interviewed in a study addressing secondary conditions and adaptation in families of AYA with and without spina bifida (SB). Principal component factor analysis with Varimax rotation, Cronbach alpha, and Intraclass correlation (ICC) for parent-AYA agreement of FQOL assessment were conducted.

RESULTS

A single factor with an eigenvalue greater than 1 was identified. Factor loadings were 0.79-0.94. Internal reliabilities were strong (α= 0.86-0.90). ICC coefficients between parent and AYA ratings were 0.38-0.48.

CONCLUSION

This study provides preliminary support for the G-FQOLS. This global appraisal of Family Quality of Life (FQOL) reflects a participant's personal weighting of domains important to him/her.

A comparison of families of children with autism spectrum disorders in family daily routines, service usage, and stress levels by regionality

PURPOSE

To explore whether family routines, service usage, and stress levels in families of children with autism spectrum disorder differ as a function of regionality.

METHODS

Secondary analysis of data was undertaken from 535 surveys. Univariate and multivariate analyses were performed to investigate differences between families living in densely populated (DP) areas and less densely populated (LDP) areas.

RESULTS

Families living in LDP areas were found to: (1) have reduced employment hours (a two-parent household: Exp (B) = 3.48, p < .001, a single-parent household: Exp (B) = 3.32, p = .011); (2) travel greater distance to access medical facilities (Exp (B) = 1.27, p = .006); and (3) report less severe stress levels (Exp (B) = 0.22, p = .014).

CONCLUSIONS

There were no differences in family routines; however, flexible employment opportunities and travel distance to medical services need to be considered in families living in LDP areas.

Factors associated with parent depressive symptoms and family quality of life in parents of adolescents and young adults with and without Spina Bifida

PURPOSE

The purpose of this study was to explore factors related to parental depressive symptoms (PDS) and family quality of life (FQOL) in parents of adolescents and young adults (AYA) with and without a specific chronic health condition (CHC), spina bifida.

METHODS

Two hundred and nine parents of AYA (112 with SB; and 97 without) and their AYA (46% males and 54% females) took part in a multi-site cross-sectional descriptive correlational study. In telephone interviews parents reported on measures of family satisfaction, resources, cohesion, stress, demographic and clinical data.

RESULTS

In the multivariate analyses, 38% of the variance of PDS was explained by family income, family resources and parent stress. Having a child with SB was not predictive of PDS. However, having a child with SB, along with family satisfaction, parent stress and PDS explained 49% of the variance of FQOL. PDS partially mediate the relationship of family resources and FQOL.

CONCLUSION

PDS, family stress, and resources should be evaluated routinely, especially for those with low income. Parents of AYA with SB who have elevated PDS are at increased risk of having lower reported FQOL.

State Design and Use of Medicaid 1915(c) Waivers and Related Benefits to Provide Services to Children and Youth With Autism Spectrum Disorder

Medicaid is the most significant source of funding for medical services for individuals with autism spectrum disorder (ASD). We surveyed state Medicaid directors or their designees regarding their use of autism specific 1915(c) waivers and other Medicaid benefits to provide services to children and youth with ASD, with a response rate of 84%. Ten states used autism-specific waivers to provide services. These waivers varied in the number of children served, eligibility criteria and services provided, among other characteristics. Issues related to the number of children to serve and the specific services to provide were perceived to be the most difficult waiver design issues, while provider geographic distribution, capacity and expertise were perceived to be the most difficult implementation concerns. States used a variety of additional Medicaid state plan services (e.g., the optional rehabilitation benefit) and 1915(c) waivers (e.g., a more general waiver serving individuals with intellectual and developmental disabilities) to provide services to children and youth with ASD. Thus, continuing to examine the adequacy and effectiveness of state use of a range of Medicaid benefits, including autism-specific 1915(c) waivers is critical. Expanding the evidence base for intervention effectiveness is important as well.

South African families raising children with autism spectrum disorders: relationship between family routines, cognitive appraisal and family quality of life

BACKGROUND

The purpose of this study was to investigate the relationship between family routines, cognitive appraisal of the impact of autism spectrum disorders (ASD) on the family and family quality of life (FQOL) in families raising children with ASD in South Africa.

METHODS

A sample of 180 families of young children with ASD who were receiving disability-related services in the Gauteng province of South Africa completed a self-administered survey. Structural equation modelling was used to examine the direct relationship between the regularity of family routines and FQOL, and the mediating effect of cognitive appraisal on this relationship.

RESULTS

The results suggested a direct, positive relationship between the regularity of family routines and families' satisfaction with their FQOL. Furthermore, cognitive appraisal of the impact of ASD on the family mediated this relationship in a partial manner.

CONCLUSION

A higher frequency of regular family routines was strongly associated with a higher satisfaction level of FQOL. Also, cognitive appraisal of the impact of ASD acted as a mechanism through which the regularity of family routines influenced FQOL. We discuss the research and clinical implications of these findings.

Family wellbeing of individuals with autism spectrum disorder: A scoping review

Families play an important role in supporting individuals with autism spectrum disorder across the lifespan. Indicators of family wellbeing can help to establish benchmarks for service provision and evaluation; however, a critical first step is a clear understanding of the construct in question. The purpose of the current scoping review was to (a) summarize current conceptualizations and measurements of family wellbeing, (b) synthesize key findings, and (c) highlight gaps and limitations in the extant literature. A final review of 86 articles highlighted the difficulty of synthesizing findings of family wellbeing in the autism spectrum disorder literature due to varied measurement techniques and the limited use of a common theoretical direction. Considerations for future research are presented with an eye toward policy relevance.

A cross-sectional cohort study of a large, statewide Medicaid home and community-based services autism waiver program

State-specific 1915(c) Medicaid Home and Community-Based Services waiver programs have become central in the provision of services specifically tailored to children with autism spectrum disorders (ASD). Using propensity score matching, 130 families receiving waiver services for a child with ASD were matched with and compared to 130 families waiting on the registry (i.e., control group). Results indicate that participants in the waiver group reported more improvement in independent living skills and family quality of life over the last year compared to those on the registry. More frequent intensive individual support services and therapeutic integration were statistically predictive of improvement in a variety of domains. The results suggest that the waiver program may be promising for improving child and family functioning.

Family well-being in a participant-directed autism waiver program: the role of relational coordination

BACKGROUND

Massachusetts is one of a very limited number of states exclusively employing participant-direction to deliver autism waiver services to children. A crucial element of this waiver program is the work conducted by the state's Department of Developmental Services (DDS) staff and state-approved providers with waiver families to facilitate the implementation of the participant-direction model. Our study investigates the effect of the collaboration between state providers and family caregivers on family well-being.

METHODS

We conducted a survey of 74 families who have been utilising waiver services for at least 6 months. Participants were asked to rate the coordination with providers as well as to report on parenting stress and impact of waiver services on family functioning. Data from in-home child and family assessments conducted by the state were also abstracted from program records.

RESULTS

After controlling for a host of variables hypothesised to affect the outcomes of interest, we found that the family's view of how well they coordinated with formal providers is significantly associated all of the outcomes. Families who reported greater coordination with state providers experienced lower parenting stress and reported a more positive impact on family functioning. Child externalising behavioural problems and caregiver's health rating also contributed to parenting stress and family functioning.

CONCLUSIONS

Our findings highlight the importance of establishing a collaborative partnership with waiver families in promoting family well-being. These results suggest that training and/or resources that foster team building and communication can positively impact family functioning among families with young children with autism.

Maternal stress and family quality of life in response to raising a child with autism: from preschool to adolescence

While the impact of raising a child with an Autism Spectrum Disorder (ASD) is well documented, with mothers reporting higher levels of stress than mothers of children with other disabilities, positive maternal outcomes have also been identified. What remains unclear, however, is the role of child age on maternal outcomes. We sought to clarify the role of child age in maternal stress and family quality of life (FQoL) in mothers raising a child with ASD. Participants included 140 mothers of children aged 3-16 years grouped to represent four key stages of childhood (preschool, early school years, middle school, early high school). Using a cross-sectional design, mothers completed questionnaires assessing potential risk (e.g., child problem behaviour, symptom severity) and protective (e.g., family characteristics) factors attributed to maternal outcomes. The results revealed significant age related group differences in child internalising behaviour and ASD symptomatology between the early and middle school years. Lower levels of adaptive social behaviour in older age groups were also found. Although mothers of older children reported significantly less support from professionals than mothers of younger children, no significant age effects were found to contribute to maternal reports of stress or FQoL. The current findings support the view that mothers appear to demonstrate stable levels of stress and FQoL despite fluctuations in key child variables and a reduction in supports, across age, highlighting the ongoing nature of maternal needs and heightened levels of child symptomatology during adolescence.

Home- and community-based waivers for children with autism: effects on service use and costs

We examined (a) the associations between Medicaid home and community-based waiver participation and service use and expenditures among children with ASD; and (b) how states' waiver spending moderates these effects. We used 2005 Medicaid claims to identify a sample of children with autism spectrum disorder (ASD). We selected two comparison groups who had no waiver participation: (a) children who were eligible for Medicaid through disability (disability group), and (b) children who had at least one inpatient/long-term care (IP/LT) episode (IP/LT group). Waiver participants were less likely to use IP/LT services and had lower associated expenditures than the disability group. As states' waiver spending increased, waiver participants became increasingly less likely to use IP/LT services. Waiver participants had more outpatient visits and associated expenditures; this difference increased as state waiver spending increased. Compared with the IP/LT group, waiver participants had lower IP/LT expenditures, more outpatient visits, and associated expenditures. Higher state waiver generosity increased this effect on outpatient visits and expenditures.

Unhappy (and happy) in their own way: a developmental psychopathology perspective on quality of life for families living with developmental disability with and without autism

Research on families living with developmental disability generally and autism specifically is dominated by a deficit view that elicits an elaborate representation of problems and risks without the benefit of considering families' potential for adaptation and resilience. A central tenet of developmental psychopathology is that the study of adaptive and maladaptive development is mutually informative. Specifically, one can examine resilience within the context of adversity and the multiple processes and pathways to adaptive and maladaptive developmental outcomes. We believe these concepts can also be extended to the study of families living with developmental disability as they transition through the family lifecycle. This paper provides an overview of the family quality of life (FQOL) construct, including its conceptualization and measurement, and a review of studies on FQOL among families of children with various developmental disabilities. Special attention is given to families of children with autism, as this is a circumstance characterized by unique adversity. We suggest benefits from adopting a developmental psychopathology perspective, and illustrate how relevant concepts can inform our methodologies as we move forward. We will demonstrate how such an integrated, systemic, and temporal approach will help generate more refined questions on FQOL among families caring for a child with developmental disability in order to provide the specific answers needed to directly inform policy and clinical practice.

Review: the development of family quality of life concepts and measures

Historically, intervention programmes in intellectual and developmental disabilities have targeted the individual's special needs independent of the family and environmental context. This trend has been changing over the past two decades. This paper presents a literature review on changing trends in family support and the development of family quality of life (FQOL) and intellectual disability from a construct to a theory. The evolution of research in quality of life from the perspective of the individual with the disability to the family is described. A description of the development of FQOL measures is included, specifically an introduction and comparison of the two leading comprehensive initiatives on measuring FQOL - international FQOL project and the FQOL initiative of the Beach Center on Disability, in the USA. This paper provides the conceptual background and context to the other papers presented in this special issue, which focus on FQOL measurement in specific contexts.