Meta-analysis of parent-mediated interventions for young children with autism spectrum disorder

'I wouldn't want one or the other': Understanding parents' preferences for direct support or parent coaching for young autistic children

LAY ABSTRACT

Professionals often support autistic children by working with them directly (direct support) or by coaching their parents. We know a lot about what parents think about parent coaching, but we do not know as much about what they think about direct support. We also do not know whether parents prefer parent coaching or direct support. The current study involved 22 parents who each received 2 h a week of direct support for their autistic child and up to 1 h a week of parent coaching for 6 months. At the end of 6 months, all these parents indicated in a survey whether they preferred parent coaching or direct support. Eleven of these participating parents also chose to take part in an interview to understand more about these preferences. Our findings suggest that parents generally liked both supports and believed they worked well together; however, they preferred direct support over parent coaching. While parents think that both approaches are beneficial, there are strengths and challenges of each. These findings emphasise the importance of parent choice in the delivery of support. It may also be possible to adapt both approaches to address some of the identified challenges and improve the whole family's experience.

The Efficacy of a Culturally-Adapted Group-based Parent Coaching Program for Autistic Children in China via Telehealth: A Randomized Controlled Trial

The study aimed to examine the efficacy of a culturally-adapted, group-based parent coaching program for autistic children in China delivered via telehealth. A randomized controlled trial was conducted, with 18 parents allocated to the self-directed group that received the intervention through an online learning platform, and 19 parents allocated to the web + group therapy group, which included the same program along with weekly 1.5-hour group coaching sessions via videoconferencing. The primary outcomes were parents' mental health and children's adaptive functioning, while the secondary outcomes focused on the child behaviors, parenting stress and parenting style, and family quality of life. Linear Mixed Models were used to evaluate treatment effects across time and to model longitudinal trajectories of outcomes in both children and parents. Both intervention groups showed significant improvements in children's communication skills (F (1, 60.27) = 29.86, p < 0.001) and social engagement (F (1, 60.07) = 11.73, p = 0.001), as well as reductions in parenting stress (F (1, 59.07) = 8.76, p = 0.004) and anxiety levels (F (1, 57.62) = 4.84, p = 0.032). Additionally, the group-based parent coaching via videoconferencing was associated with greater improvements in children's quality of life (F (1, 59.95) = 5.90, p = 0.018) and parents' anxiety outcomes (F (1, 57.62) = 4.84, p = 0.032). This study demonstrated the efficacy of a culturally adapted telehealth intervention for both autistic children and their parents. The preliminary findings suggest positive outcomes in children's adaptive functioning and parents' mental well-being. Group-based parent coaching through videoconferencing could be a promising and practical model for in-home services, particularly for families with limited access to in-person services.

Telehealth general case parent training for children at risk for autism

Parent-mediated interventions for infants and young children with an increased likelihood of autism may help ameliorate developmental concerns; however, generalization of parents' teaching strategies to novel child target skills has not been consistently demonstrated. This study expanded our parent training program, Parent Intervention for Children at-Risk for Autism (PICARA), by incorporating telehealth general case training (PICARA-TGCT) to promote generalization of teaching skills. Five parent-child dyads participated. Child target skills were chosen from the categories of imitation, receptive language, and expressive language. A concurrent multiple-baseline-across-participants design was used to evaluate the effect of training across two cohorts of parent-child dyads. Dependent variables included the percentage of correct parent teaching skills and the percentage of child correct responses. Parent teaching skills increased across all participants for both trained and untrained child target skills, as did child skills. This study provides support for PICARA-TGCT as an efficacious and efficient early intervention model.

Adherence and Opportunity Frequency as Predictors of Communication Outcomes from Pivotal Response Parent Training

PURPOSE

Access to intervention is a barrier for children with autism. As parent-mediated interventions have emerged to address this need, understanding implementation components contributing to child gains is critically important. Existing literature documents relationships between parent treatment adherence and child progress; however, less is understood about components, such as frequency of learning opportunities, which could also affect child outcomes.

METHODS

This study is a secondary analysis of data from a randomized controlled trial evaluating Pivotal Response Treatment group parent training (PRTG) compared to psychoeducation. Linear regression and mediational models were employed to identify potential predictors and mediators of outcome.

RESULTS

PRTG produced large increases in adherence and learning opportunities. In general, greater frequency of learning opportunities and adherence predicted better child outcomes. The best-fitting cross-sectional mediational models indicated at least partial mediational effects, whereby increased learning opportunities mediated the relationship between greater adherence and improved child outcomes.

CONCLUSIONS

This study provides preliminary evidence of how early gains in adherence may support parents to provide more frequent learning opportunities, which, in turn, yield positive effects on child social communication. Future large-scale research, with greater granularity of measurement, is needed to further understand the temporal relationships between these variables.

Effectiveness of online responsive teaching in young children with developmental disabilities: a pilot study

BACKGROUND

Responsive teaching (RT) interventions, which enhance developmental outcomes by improving children's engagement behaviors, are traditionally delivered in person. However, the coronavirus disease 2019 pandemic complicated this approach.

PURPOSE

This study aimed to evaluate the efficacy and acceptance of online RT in children with developmental disabilities and their parents.

METHODS

This pilot study was conducted in Jinju, South Korea, and enrolled parent-child dyads referred to Gyeongsang National University Hospital for developmental concerns between April and September 2022. The children underwent a comprehensive developmental evaluation. The parents received a 5-session RT intervention via ZOOM on a mostly weekly basis. The first 2 sessions involved child development and RT lectures, while the others involved coaching on 3 of the 66 RT strategies. Problem behaviors, parent-child interactions, and parenting stress were assessed pre- versus postintervention using the Korean versions of the Child Behavior Checklist, Maternal/Child Behavior Rating Scale, and Parent Stress Index 4th Edition Short Form, respectively. Acceptability was evaluated using a self-administered questionnaire.

RESULTS

Of the 30 recruited parent-child pairs, 23 (76%) completed the intervention and assessments. The children (mean age, 2.66±0.86 years) included 12 with language delays, 7 with autism spectrum disorder, and 4 with global delays. Predominantly mothers (96%) participated. Online RT significantly improved pivotal behaviors- including joint attention (P=0.04), cooperation (P=0.01), and affect (P=0.01)-and reduced overall problem behaviors (P=0.04). Parents reported less parenting stress (P=0.01), improved interactive behaviors with increased responsiveness (P<0.01), and decreased directiveness (P<0.01). High satisfaction with online RT interventions was also previously reported.

CONCLUSION

These findings suggest that online RT can improve children's emotional and behavioral outcomes and maternal interaction styles and reduce parenting stress, offering accessible interventions amid challenges such as limited access and pandemics.

Computer Vision Analysis of Caregiver-Child Interactions in Children with Neurodevelopmental Disorders: A Preliminary Report

We report preliminary results of computer vision analysis of caregiver-child interactions during free play with children diagnosed with autism (N = 29, 41-91 months), attention-deficit/hyperactivity disorder (ADHD, N = 22, 48-100 months), or combined autism + ADHD (N = 20, 56-98 months), and neurotypical children (NT, N = 7, 55-95 months). We conducted micro-analytic analysis of 'reaching to a toy,' as a proxy for initiating or responding to a toy play bout. Dyadic analysis revealed two clusters of interaction patterns, which differed in frequency of 'reaching to a toy' and caregivers' contingent responding to the child's reach for a toy by also reaching for a toy. Children in dyads with higher caregiver responsiveness had less developed language, communication, and socialization skills. Clusters were not associated with diagnostic groups. These results hold promise for automated methods of characterizing caregiver responsiveness in dyadic interactions for assessment and outcome monitoring in clinical trials.

Caregiver skills training for caregivers of individuals with neurodevelopmental disorders: A systematic review and meta-analysis

AIM

To systematically review the effectiveness of caregiver and parent skills training programs, including caregiver-mediated interventions, for caregivers of individuals with neurodevelopmental disorders.

METHOD

We conducted a systematic review with a random-effects meta-analysis. We searched 11 electronic databases through July 2021 and used a snowball methodology to locate relevant articles of randomized controlled trials. Effect size estimates were pooled using Hedges' g from data extracted from study reports and through author requests using random-effects meta-analyses for three child outcome categories (child development, adaptive behavior, and problem behavior) and three caregiver outcome categories (parenting skills and knowledge, psychological well-being, and interpersonal family relations).

RESULTS

We located 44 910 records, from which 75 randomized controlled trials involving 4746 individuals with neurodevelopmental disorders and their caregivers were included. Random-effects meta-analyses showed improvements in child development (g = 0.30; 99% confidence interval [CI] = 0.07-0.53) and reduction in reported problem behaviors (g = 0.41; 99% CI = 0.24-0.59), but not a statistically significant improvement in adaptive behavior (g = 0.28; 99% CI = -0.42 to 0.98). Caregivers showed improvements in parenting skills and knowledge (g = 0.72; 99% CI = 0.53-0.90), psychological well-being (g = 0.52; 99% CI = 0.34-0.71), and interpersonal family relations (g = 0.76; 99% CI = 0.32-1.20).

INTERPRETATION

Caregiver skills training programs benefit both caregivers and children with neurodevelopmental disorders. Skills training programs improve child development and behavior, improve parenting skills, reduce caregiver mental health issues, and improve family functioning. Programs using culturally appropriate training material to improve the development, functioning, and participation of children within families and communities should be considered when caring for children with neurodevelopmental disorders.

WHAT THIS PAPER ADDS

Caregiver skills training programs are effective interventions for both caregivers and children. Children with neurodevelopmental disorders benefit from improvements in development and reduction of problematic behaviors. Caregivers benefit from enhanced skills and psychological well-being. Improvements in interpersonal family relationships have also been documented.

A Mixed-methods Examination of Culturally Responsive Adaptation to an Evidence-based Parent-mediated Intervention Implemented for Autistic Children

Parent-mediated interventions (PMIs) are considered an evidence-based practice for fostering social communication skills in young autistic children and for promoting parent responsivity and empowerment, yet barriers to caregiver engagement are evident when PMIs are implemented within historically underserved community settings. Issues of caregiver engagement can reflect a lack of fit between PMIs and the needs of diverse families. We used a mixed methods approach to examine barriers to participating in an evidence-based PMI, Project ImPACT (Ingersoll & Dvortcsak, 2019), within an outpatient setting, as well as strategies that clinicians reported using to deliver and adapt Project ImPACT for minoritized families. Participants included 134 caregivers of a child 13 to 48 months with autism or other social communication differences and six clinicians delivering Project ImPACT. Findings suggest that caregivers experience barriers to participating in Project ImPACT and that these barriers are associated with caregivers' ability to complete the program. Although quantitative findings indicate that adaptation to Project ImPACT did not differ by caregiver and child background, qualitative findings highlighted that clinicians attempt to deliver Project ImPACT to respond to the needs of families from minoritized backgrounds by actively considering the family's culture, psychosocial experiences, goals, and specific barriers. Further, both qualitative and quantitative findings suggest that culturally responsive care and adaptations may support caregiver engagement, including rapport, trust, buy-in, and attendance. Approaches to center cultural alongside contextual/psychosocial considerations within family-centered care in the implementation of PMIs are also highlighted.

Health Care for Autistic Children: A Public Health Perspective

Autism has been the subject of large-scale public health investment. These investments are increasingly shifting toward mitigating the lifelong disability and impairment associated with autism. Key efforts include bolstering screening schedules, accelerating the path to diagnosis and early entry into evidence-based therapies, and providing preventive management of common co-occurring conditions. Enhancing their implementation will necessitate addressing neurodiversity and health equity. Pediatric primary care teams continue to be important stewards in population-level initiatives to promote autistic health. To thrive in this role, these providers will benefit from specific educational and logistical supports from the health care system.

The effectiveness of parent-Child observation in parent-Mediated programmes for children with developmental disabilities and externalizing disorders: A systematic review and meta-analysis

This systematic review evaluated the treatment effects of communication-focused parent-mediated interventions (CF-PMT), a form of intervention that involves therapists observing parent-child interactions and giving feedback to parents on how they can practice positive parenting strategies to prevent or reduce externalizing behaviours in children with developmental disabilities. A literature search was conducted on three electronic databases. To be included in the review, studies had to: evaluate CF-PMT where therapists give feedback after observing parent-child interactions; examine changes in externalizing behaviours amongst children with any forms of developmental disability; and adopt a randomised controlled trial study design. Fifteen studies met eligible criteria for the literature review, of those, 13 studies had available data on changes in the primary (child externalizing behaviours) and secondary outcomes (parental stress, child linguistic abilities and child social responsiveness). We found significant treatment effects for CF-PMT in reducing child externalizing behaviours (d = -.60) but not for any of the secondary outcomes. A sensitivity analysis showed a small but significant treatment effect for parental stress (d = -.18). Considerable bias was observed due to the lack of available information reported by studies on aspects measured by the Mixed Methods Appraisal Tool. Overall, we found evidence to support the benefits of complex interventions which incorporate direct parent-child observations and feedback to improve behavioural outcomes amongst children with developmental disabilities.

A mixed-methods evaluation of organization and individual factors influencing provider intentions to use caregiver coaching in community-based early intervention

BACKGROUND

Most psycho-social interventions contain multiple components. Practitioners often vary in their implementation of different intervention components. Caregiver coaching is a multicomponent intervention for young autistic children that is highly effective but poorly implemented in community-based early intervention (EI). Previous research has shown that EI providers' intentions, and the determinants of their intentions, to implement caregiver coaching vary across components. Organizational culture and climate likely influence these psychological determinants of intention by affecting beliefs that underlie attitudes, norms, and self-efficacy to implement an intervention. Research in this area is limited, which limits the development of theoretically driven, multilevel implementation strategies to support multi-component interventions. This mixed methods study evaluated the relationships among organizational leadership, culture and climate, attitudes, norms, self-efficacy, and EI providers' intentions to implement the components of caregiver coaching.

METHODS

We surveyed 264 EI providers from 37 agencies regarding their intentions and determinants of intentions to use caregiver coaching. We also asked questions about the organizational culture, climate, and leadership in their agencies related to caregiver coaching. We used multilevel structural equation models to estimate associations among intentions, psychological determinants of intentions (attitudes, descriptive norms, injunctive norms, and self-efficacy), and organizational factors (implementation climate and leadership). We conducted qualitative interviews with 36 providers, stratified by strength of intentions to use coaching. We used mixed-methods analysis to gain an in-depth understanding of the organization and individual-level factors.

RESULTS

The associations among intentions, psychological determinants of intentions, and organizational factors varied across core components of caregiver coaching. Qualitative interviews elucidated how providers describe the importance of each component. For example, providers' attitudes toward coaching caregivers and their perceptions of caregivers' expectations for service were particularly salient themes related to their use of caregiver coaching.

CONCLUSION

Results highlight the importance of multi-level strategies that strategically target individual intervention components as well as organization-level and individual-level constructs. This approach holds promise for improving the implementation of complex, multicomponent, psychosocial interventions in community-based service systems.

Strategies for addressing the needs of children with or at risk of developmental disabilities in early childhood by 2030: a systematic umbrella review

BACKGROUND

There are over 53million children worldwide under five with developmental disabilities who require effective interventions to support their health and well-being. However, challenges in delivering interventions persist due to various barriers, particularly in low-income and middle-income countries.

METHODS

We conducted a global systematic umbrella review to assess the evidence on prevention, early detection and rehabilitation interventions for child functioning outcomes related to developmental disabilities in children under 5 years. We focused on prevalent disabilities worldwide and identified evidence-based interventions. We searched Medline, Embase, PsychINFO, and Cochrane Library for relevant literature from 1st January 2013 to 14th April 2023. A narrative synthesis approach was used to summarise the findings of the included meta-analyses. The results were presented descriptively, including study characteristics, interventions assessed, and outcomes reported. Further, as part of a secondary analysis, we presented the global prevalence of each disability in 2019 from the Global Burden of Disease study, identified the regions with the highest burden and the top ten affected countries. This study is registered with PROSPERO, number CRD42023420099.

RESULTS

We included 18 reviews from 883 citations, which included 1,273,444 children under five with or at risk of developmental disabilities from 251 studies across 30 countries. The conditions with adequate data were cerebral palsy, hearing loss, cognitive impairment, autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder. ASD was the most prevalent target disability (n = 8 reviews, 44%). Most reviews (n = 12, 67%) evaluated early interventions to support behavioural functioning and motor impairment. Only 33% (n = 10/30) of studies in the reviews were from middle-income countries, with no studies from low-income countries. Regarding quality, half of reviews were scored as high confidence (n = 9/18, 50%), seven as moderate (39%) and two (11%) as low.

CONCLUSIONS

We identified geographical and disability-related inequities. There is a lack of evidence from outside high-income settings. The study underscores gaps in evidence concerning prevention, identification and intervention, revealing a stark mismatch between the available evidence base and the regions experiencing the highest prevalence rates of developmental disabilities.

Mediation of 6-year mid-childhood follow-up outcomes after pre-school social communication (PACT) therapy for autistic children: randomised controlled trial

BACKGROUND

There are very few mechanistic studies of the long-term impact of psychosocial interventions in childhood. The parent-mediated Paediatric Autism Communication Therapy (PACT) RCT showed sustained effects on autistic child outcomes from pre-school to mid-childhood. We investigated the mechanism by which the PACT intervention achieved these effects.

METHODS

Of 152 children randomised to receive PACT or treatment as usual between 2 and 5 years of age, 121 (79.6%) were followed 5-6 years after the endpoint at a mean age of 10.5 years. Assessors, blind to the intervention group, measured Autism Diagnostic Observation Scale Calibrated Severity Score (ADOS CSS) for child autistic behaviours and Teacher Vineland (TVABS) for adaptive behaviour in school. Hypothesised mediators were child communication initiations with caregivers in a standard play observation (Dyadic Communication Measure for Autism, DCMA). Hypothesised moderators of mediation were baseline child non-verbal age equivalent scores (AE), communication and symbolic development (CSBS) and 'insistence on sameness' (IS). Structural equation modelling was used in a repeated measures mediation design.

RESULTS

Good model fits were obtained. The treatment effect on child dyadic initiation with the caregiver was sustained through the follow-up period. Increased child initiation at treatment midpoint mediated the majority (73%) of the treatment effect on follow-up ADOS CSS. A combination of partial mediation from midpoint child initiations and the direct effect of treatment also contributed to a near-significant total effect on follow-up TVABS. No moderation of this mediation was found for AE, CSBS or IS.

CONCLUSIONS

Early sustained increase in an autistic child's communication initiation with their caregiver is largely responsible for the long-term effects from PACT therapy on autistic and adaptive behaviour outcomes. This supports the theoretical logic model of PACT therapy but also illuminates fundamental causal processes of social and adaptive development in autism over time: early social engagement in autism can be improved and this can have long-term generalised outcome effects.

"We were the best people to do the job": Caregivers' reported outcomes of a virtual caregiver-delivered program for autistic preschoolers

Background and aims

Caregiver-delivered programs are a recommended best practice to support young autistic children. While research has extensively explored children's outcomes quantitatively, minimal qualitative research has been conducted to understand caregivers' perspectives of program outcomes for themselves and their children. Hearing directly from caregivers is an important step in ensuring these programs are meeting the needs of those who use them. This study explored caregivers' perceived outcomes following one virtual caregiver-delivered program, The Hanen Centre's More Than Words® (MTW) program.

Methods

This study was a secondary analysis of data from individual interviews conducted with 21 caregivers who had recently participated in a virtual MTW program. A hybrid codebook thematic analysis approach was taken to analyze the interview data. Program outcomes were coded and analyzed within the International Classification Functioning, Disability, and Health (ICF) framework. Additionally, caregivers completed an online survey and rated Likert Scale items about perceived program outcomes, which were analyzed descriptively.

Results

Five themes were identified: (1) caregivers learned new strategies to facilitate their child's development, (2) caregivers developed a new mindset, (3) children gained functional communication skills, (4) caregiver-child relationships improved, and (5) caregivers gained a social and professional support network. These themes fell within four of five ICF framework components (activities, participation, personal factors, and environmental factors). No themes were identified under Body Structures and Functions. Survey results indicated most caregivers reported learning new communication strategies (n = 20, 95%), and identifying new teaching opportunities with their child (n = 21, 100%).

Conclusions

Some reported outcomes, related to Activities and Participation, were consistent with previous reports in the literature on the MTW program. In line with previous research, caregivers learned strategies to support their child's communication development. Contrary to previous quantitative studies, caregivers in this study rarely commented on gains in vocabulary and instead focused on gains in skills that positively impacted their child's ability to engage in meaningful social interaction. Novel outcomes were identified within the Participation, Personal Factors, and Environmental Factors components of the ICF framework.

Implications

Caregivers in this study identified important outcomes for themselves and their child that have not been the focus of prior research, suggesting it is important to integrate their perspectives in the development and evaluation of caregiver-delivered programs. Clinicians should include goals that address outcomes identified as important by caregivers, including those that address children's Participation, and those that target caregivers' Personal and Environmental Factors. Developers of caregiver-delivered programs could integrate identified goals to ensure they are meeting families' needs.

Behavioral Interventions for Autism Spectrum Disorder: A Brief Review and Guidelines With a Specific Focus on Applied Behavior Analysis

We conducted a comprehensive review of behavioral and educational interventions for individuals with autism spectrum disorder (ASD). The most prominent type of intervention, Comprehensive Early Intervention, often referred to as Early Intensive Behavioral Intervention (EIBI), has been found to be particularly effective in improving intelligence and adaptive behaviors. The naturalistic developmental behavioral intervention, designed to enhance social and communication abilities, showed effectiveness in improving language, cognitive function, and social initiation. However, more studies are needed to examine its effectiveness. Intensive individualized intervention, which provides a tailored intervention for a specific target behavior, was effective in improving social skills and communication, as well as reducing sleep, eating, and toileting problems. Cognitive behavioral therapy (CBT) is the most effective method for dealing with emotional difficulties, but it has not been widely used because of the shortage of trained experts. Parent-mediated intervention (PMI) involves parents acquiring knowledge and specific skills to improve their child's functioning or reduce challenging behaviors. Speech and language therapy, sensory integration, Treatment and Education of Autistic and related Communications Handicapped Children, developmental approaches, and social stories are frequently used interventions. However, evidence of their effectiveness has yet to be well established. Based on these findings, intervention recommendations for autism include EIBI, Early Start Denver Model, intensive individualized intervention, CBT, and PMI. The choice of intervention should be tailored to the individual's needs and delivered by qualified professionals with expertise in the specific intervention.

Supporting caregivers of children with developmental disabilities: Findings from a brief caregiver well-being programme in South Africa

LAY ABSTRACT

Young children with developmental disabilities and delays who live in low- and middle-income countries are at significant risk of not reaching their full potential. We know that daily interactions with their caregivers (parents or other people taking care of them) play an important role in promoting their development. However, having a child with developmental disabilities can have a negative impact on carers' mental health and well-being, which in turn can influence their capacity to care for their children. To date, very little attention has been given to the caregivers' capacity to care. The World Health Organization developed a Caregiver Skills Training programme which includes a brief, three-session module that focuses on improving caregivers' well-being and mental health. This well-being programme is based on acceptance and commitment therapy. Acceptance and commitment therapy shows increasing evidence of helping people respond to their stressors, thoughts, feelings and experiences a little differently and commit to small changes that are in line with their personal values. Acceptance and commitment therapy has shown promise in improving feelings of well-being in caregivers of children with developmental disabilities. We adapted the World Health Organization Caregiver Skills Training Caregiver well-being module to suit the South African context. The resultant 'Well Beans for Caregivers' was then delivered to caregivers from a rural, low-resource setting in South Africa. We found the intervention easy to implement, highly acceptable to caregivers and showed promising impacts on caregivers' well-being and mental health. This intervention has the potential to be implemented widely and sustainably to build caregivers' capacity to care for their children.

Effects of Parent-Implemented Interventions on Outcomes of Children with Autism: A Meta-Analysis

Children with autism spectrum disorder (ASD) have been shown to benefit from parent-implemented interventions (PIIs). This meta-analysis improved on prior reviews of PIIs by evaluating RCTs and multiple potential moderators, including indicators of research quality. Fifty-one effect sizes averaged moderately strong overall benefits of PIIs (g = 0.553), with studies having lower risk of research bias yielding lower estimates (g = 0.47). Parent and observer ratings yielded similar averaged estimates for positive behavior/social skills (g = 0.603), language/communication (g = 0.545), maladaptive behavior (g = 0.519), and to a lesser extent, adaptive behavior/life skills (g = 0.239). No other study, intervention, or participant characteristic moderated outcomes. PIIs with children with ASD tend to be effective across a variety of circumstances.

Examining provider decisions around the delivery and adaptation of a parent-mediated intervention within an Early Intervention system

LAY ABSTRACT

Parent-mediated interventions are an evidence-based practice for autism in which providers support caregivers in learning and applying strategies that support their child's development. Research has begun to study whether parent-mediated interventions can be effectively delivered in Part C Early Intervention systems. This research has been promising; however, it has been difficult to determine how Early Intervention providers deliver and adapt parent-mediated interventions to meet the needs of the families they serve. Examining how parent-mediated interventions are delivered and adapted may help us understand whether parent-mediated interventions are a good fit in these systems. The current study examined the delivery of an evidence-based parent-mediated intervention, Project ImPACT, when delivered by providers within an Early Intervention system. Results from 24 Early Intervention providers demonstrated that, on average, providers delivered Project ImPACT with higher quality during their time in training and consultation. However, there was also variability in how providers delivered Project ImPACT, with some delivering the program inconsistently, some increasing their quality throughout consultation, and others having consistently high-quality delivery. In addition, qualitative data demonstrated that a variety of events arose within Project ImPACT sessions that drove providers to adapt the program. Results suggest the importance of carefully examining how and why providers deliver evidence-based interventions within Early Intervention systems.

Parent Involvement in Mental Health Treatment for Autistic Children: A Grounded Theory-Informed Qualitative Analysis

Cognitive behavior therapy (CBT) is an effective treatment for many autistic children experiencing mental health problems, and parents are particularly involved in their psychotherapy. This study presents a conceptual framework of successful parent involvement in CBT for autistic children. Seventeen therapists (94% female) and 11 mothers were interviewed about their involvement in a CBT program for autistic children ages 8-13 years. The conceptual framework depicts how parent involvement varies depending on child, parent, and environmental factors. Parents' contributions to therapy were grouped into five main roles. Parents' beliefs and attitudes toward therapy also influenced their involvement. This is the first study to empirically investigate how parents of autistic children contribute to the therapeutic process in CBT.

Association of Parental Support with Reduced Stereotypy in Children with Autism Spectrum Disorder: A Cross-Sectional Study

Background and Objectives: To analyze the influence of parental presence and use of risperidone on social interaction and apathy among patients with Autism Spectrum Disorder (ASD). Materials and Methods: Cross-sectional study in a reference center for patients with ASD in a city in northeastern Brazil. The research was carried out using a sociodemographic questionnaire, the Dimensional Apathy Scale, and the Social Communication Questionnaire (SCQ) with the domains of social interaction, language, stereotypy, and communication. The referred questionnaire was answered by the parents or guardians of the children with ASD according to the DSM V criteria. Data were analyzed via independent t-test using the SPSS software version 20. Results: Interviews were conducted with 51 parents/guardians of autistic children with a mean age of 8.8 years (±2.95) and a predominance of males, 34 (66.7%). Of this total, 49 (96.1%) of the children attended school; 40 (78.4%) children were on medication, of which 38 (74.5%) were on risperidone. Those children on risperidone had a higher score on the SCQ scale (p = 0.049) and on the domain of stereotyped behaviors (p = 0.033), which indicated greater impairment. Another statistically relevant variable was the presence of married parents, whereby children who did not have the presence of married parents had a higher average of stereotyped behaviors compared to those who had married parents. Conclusions: The results showed differences in the means of social interactions for children on risperidone, especially regarding stereotyped behaviors. However, it is not possible to state whether this difference was due to the use of risperidone or whether they used risperidone precisely because of these behaviors. Also important was that children who had the presence of married parents showed fewer stereotyped behaviors. There was no difference in apathetic behavior between children.

Developing the Parent-Coaching Assessment, Individualization, and Response to Stressors (PAIRS) Tool for Behavior Analysts

Parent engagement in early behavioral intervention is essential to achieving meaningful intervention outcomes. However, parents may experience multiple barriers to engagement. The Parent-coaching Assessment, Individualization, and Response to Stressors (PAIRS) was developed to help practitioners assess families' barriers and facilitators, individualize their intervention, and respond to stressors using a contextual, functional approach. An expert panel of Board Certified Behavior Analysts ® (BCBAs) evaluated the content validity of the PAIRS. Average scale values (S-CVI/Ave) were 0.92 for relevance, 0.85 for effectiveness, and 0.91 for appropriateness. The PAIRS was revised, and a follow-up evaluation was conducted to rate the tool's utility. This led to the final version of the PAIRS. Clinical implications and future directions are discussed.

Optimizing Parent Training to Improve Oral Health Behavior and Outcomes in Underserved Children with Autism Spectrum Disorder

A randomized controlled trial established initial efficacy of a novel parent training (PT) intervention for improving oral hygiene and oral health in underserved children with ASD (Fenning et al., 2022), a population at risk for unmet dental needs. The present study describes our emic approach to PT development alongside treatment outcome data examining feasibility, acceptability, and engagement. Families with Medicaid-eligible children with ASD ages 3 to 13 years (85% male, 62% with intellectual disability) were assigned to receive PT (n = 60) or a psychoeducational toolkit (n = 59). Results indicate strong retention, fidelity, and adherence, with quantitative and qualitative metrics revealing high treatment satisfaction and utilization. Discussion focuses on implications for individualizing treatment to optimize engagement of underrepresented families.

Psychosocial interventions for autistic children and adolescents delivered by non-specialists in low- and middle-income countries: a scoping review

Background

Most autistic individuals reside in low- and middle-income countries (LMIC) and have limited access to medical providers and specialists. Support for delivery of psychosocial interventions by non-specialists is growing to address this mental health care gap. This scoping review involved a systematic analysis of studies of non-specialist delivered psychosocial interventions for children and adolescents diagnosed with autism and living in low- and middle-income countries.

Methods

The primary objective of this review was to identify psychosocial interventions for autistic children and adolescents in LMIC delivered by non-specialists (parent, teacher, peer, community, multi-level) and to summarize resulting effects on targeted outcomes. The search strategy was completed in four databases with predetermined inclusion and exclusion criteria. The systematic search generated 3,601 articles. A total of 18 studies met inclusion/exclusion criteria. Data extraction was completed, and results summarized by; (1) participant sample; (2) intervention procedures; (3) implementation by non-specialists; (4) effect on evaluated outcomes; and (5) assessment of risk of bias. Studies examined a range of child and adolescent outcomes including assessment of communication skills, social skills, motor skills, functional and adaptive behaviors, emotional regulation, attention and engagement, sensory challenges, depression, anxiety, and quality of life. Several studies also evaluated intervention effects on family relationships, parent/caregiver stress and parent/caregiver mental health.

Results

Collectively, the 18 studies included a total of 952 ASC participants ranging in age from 2 to 16 years. Of the included studies, 8 studies were parent/caregiver-mediated, 1 study was peer-mediated, 2 studies were teacher-mediated, and 7 studies included multi-level non-specialist mediated components. Effects on evaluated outcomes are reported.

Conclusion

Non-specialist delivered interventions for autistic children and adolescents are effective for an array of outcomes and are particularly well suited for low- and middle-income countries. Implications for future research are discussed.

An initial trial of OPT-In-Early: An online training program for caregivers of autistic children

LAY ABSTRACT

Early intervention can help children learn language and improve social communication. However, many barriers, including the expense of services and an insufficient number of providers, prohibit families from accessing services when their children are young. We developed a comprehensive online program for caregivers of autistic children. The program, Online Parent Training in Early Behavioral Intervention (OPT-In-Early), uses text and video demonstrations to teach caregivers effective methods for improving their children's language, social, and adaptive skills (e.g. using utensils, toilet training), and reducing their children's disruptive behavior. Sixty-three parents from three states participated in the study. Half of the parents received access to the OPT-In-Early program. After 4 months, parents who had access to the OPT-In-Early program learned more effective intervention strategies, and started using these strategies during interactions with their children, than parents who did not receive access to the program. Parent participation in OPT-In-Early did not significantly influence children's social communication compared to children whose parents did not have access to OPT-In-Early. A longer duration of parents using learned intervention skills with their children may be needed for children's social communication skills to improve.

How effective are group-based psychoeducation programs for parents of children with ASD in Turkey? A systematic review and meta-analysis

Recent research shows that group-based psychoeducation programs designed for parents of children with ASD have grown in popularity over time. The international evidence for the effectiveness of psychoeducation programs designed for parents of children with ASD in developed societies emphasizes the importance of providing a synthesis of the effectiveness of programs in developing societies. This study's primary aim is to assess the efficacy of group-based psychoeducation programs in Turkey for parents of children with ASD. The second aim is to investigate how the programs are influenced by the potential moderators (type of involvement, research design, number of sessions, duration of sessions, and number of participants). For these purposes, a database search was conducted that included group-based psychoeducation programs for parents of children with ASD implemented in Turkey. Twelve group-based psychoeducation programs that met the inclusion criteria were included in the study. The results showed that group-based psychoeducation programs for parents of children with ASD had "medium" effects on psychological symptoms [ES(SE) = 0.65 (.08), 95%CI (0.48-0.81)], "low" effects on social skills [ES(SE) = 0.32 (.16), 95%CI (0.02-0.62)], and "high" effects on well-being [ES(SE) = 1.05 (.19), 95%CI (0.66-1.43)]. According to moderator analyses, the type of involvement and the number of sessions were statistically significant moderators of psychological symptoms, but not the research design, duration of sessions, or number of participants.

The earlier the better: An RCT of treatment timing effects for toddlers on the autism spectrum

LAY ABSTRACT

Behavioral interventions that incorporate naturalistic, developmental strategies have been shown to improve outcomes for young children who receive an autism spectrum disorder (ASD) diagnosis. Although there is broad consensus that children on the spectrum should begin supports as soon as possible, the empirical evidence for this is relatively limited and little is known about the optimal age to start autism-specific interventions. Our team conducted a randomized controlled trial (RCT) to test the effects of starting intervention at different ages, using the Early Social Interaction (ESI) model, a parent-implemented intervention for toddlers on the spectrum. Participants included 82 autistic toddlers and their caregiver(s) who received 9 months of Individual-ESI and 9 months of Group-ESI, with the timing/order of these two treatment conditions randomized. Thus, families received the more intensive and individualized Individual-ESI at either 18 or 27 months of age. Results revealed that children who received Individual-ESI earlier showed greater treatment gains than those who received this intervention later. Gains were demonstrated in several areas, which included the use and understanding of language, social use of communication skills, and self-help skills. Importantly, these findings were specific to the intensive and individualized parent coaching model compared to group-based treatment, allowing us to rule out the possibility that these timing effects were due to children getting older rather than the treatment itself. Our results suggest that even a narrow window of 18 versus 27 months may have an impact on outcomes and underscore the importance of screening and evaluation as young as possible.

Non-pharmacological interventions for autistic children: An umbrella review

LAY ABSTRACT

What is already known about the topic?The delivery of evidence-based interventions is an important part of the clinical pathway for many autistic children and their families. However, parents, practitioners, and policymakers face challenges making evidence informed decisions, due to the wide variety of interventions available and the large, and often inconsistent, body of evidence regarding their effectiveness.What this paper adds?This is a comprehensive umbrella review, also known as a 'review of reviews', which examined the range of interventions available, the evidence for their effectiveness, and whether effects were influenced by factors relating to individual children (e.g. chronological age, core autism characteristics, and related skills) or the ways interventions were delivered (by whom and in what setting, format, mode, and amount). There was evidence for positive therapeutic effects for some, but not all, interventions. No single intervention had a positive effect for all child and family outcomes of interest. The influence of child and delivery characteristics on effects was unclear.Implications for practice, research, and policyThe findings provide parents, practitioners, and policymakers with a synthesis of the research evidence to inform decision-making and highlight the importance of individualised approaches in the absence of clear and consistent evidence. The findings also highlight the need to improve consistency and completeness in reporting of research studies, so that the same questions may be answered more comprehensively in the future.

Parent-Implemented Telepractice Autism Intervention: A Case Study of Maintenance and Generalization

The extent to which people maintain new skills and generalize those skills to new contexts without support are two aspects of intervention research that can be difficult to examine, especially over a sustained period of time and across a variety of contexts. In past research, we have explored teaching parents and caregivers to implement evidence-based communication strategies with their young children with autism who are minimally verbal. When a former research participant contacted us with a request to participate in our project again, four years later and with a different son, we used this as an opportunity to ask questions about her maintenance of the skills in using the targeted strategies, and her generalization of those skills to a different child. Using the data collected with her older son, Ali, and new data collected four years later with her younger son, Rami, we present a case study of this mother. We discuss the implications of the findings on interpreting the efficacy of the telepractice intervention's programming for generalization, identifying opportunities for refining the intervention, and insights useful for other intervention research.

Autism Spectrum Disorder: A Review

IMPORTANCE

Autism spectrum disorder (ASD), characterized by deficits in social communication and the presence of restricted, repetitive behaviors or interests, is a neurodevelopmental disorder affecting approximately 2.3% children aged 8 years in the US and approximately 2.2% of adults. This review summarizes evidence on the diagnosis and treatment of ASD.

OBSERVATIONS

The estimated prevalence of ASD has been increasing in the US, from 1.1% in 2008 to 2.3% in 2018, which is likely associated with changes in diagnostic criteria, improved performance of screening and diagnostic tools, and increased public awareness. No biomarkers specific to the diagnosis of ASD have been identified. Common early signs and symptoms of ASD in a child's first 2 years of life include no response to name when called, no or limited use of gestures in communication, and lack of imaginative play. The criterion standard for the diagnosis of ASD is a comprehensive evaluation with a multidisciplinary team of clinicians and is based on semistructured direct observation of the child's behavior and semistructured caregiver interview focused on the individual's development and behaviors using standardized measures, such as the Autism Diagnostic Observation Schedule-Second Edition and the Autism Diagnostic Interview. These diagnostic measures have sensitivity of 91% and 80% and specificity of 76% and 72%, respectively. Compared with people without ASD, individuals with ASD have higher rates of depression (20% vs 7%), anxiety (11% vs 5%), sleep difficulties (13% vs 5%), and epilepsy (21% with co-occurring intellectual disability vs 0.8%). Intensive behavioral interventions, such as the Early Start Denver Model, are beneficial in children 5 years or younger for improvement in language, play, and social communication (small to medium effect size based on standardized mean difference). Pharmacotherapy is indicated for co-occurring psychiatric conditions, such as emotion dysregulation or attention-deficit/hyperactivity disorder. Risperidone and aripiprazole can improve irritability and aggression (standardized mean difference of 1.1, consistent with a large effect size) compared with placebo. Psychostimulants are effective for attention-deficit/hyperactivity disorder (standardized mean difference of 0.6, consistent with a moderate effect size) compared with placebo. These medications are associated with adverse effects including, most commonly, changes in appetite, weight, and sleep.

CONCLUSIONS AND RELEVANCE

ASD affects approximately 2.3% of children aged 8 years and approximately 2.2% of adults in the US. First-line therapy consists of behavioral interventions, while co-occurring psychiatric conditions, such as anxiety or aggression, may be treated with specific behavioral therapy or medication.

Protein kinase C beta relieves autism-like behavior in EN2 knockout mice via upregulation of the FTO/PGC-1α/UCP1 axis

Increasing evidence suggests that disruption of neuron activity contributes to the autistic phenotype. Thus, we aimed in this study to explore the role of protein kinase C beta (PKCβ) in the regulation of neuron activity in an autism model. The expression of PKCβ in the microarray data of autism animal models was obtained from the Gene Expression Omnibus database. Then, mice with autism-like behavior were prepared in EN2 knockout (^-/- ) mice. The interaction between PKCβ on fat mass and obesity-associated protein (FTO) as well as between PGC-1α and uncoupling protein 1 (UCP1) were characterized. The effect of FTO on the N⁶ -methyladenosine (m6A) modification level of proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) was assayed. Following transfection of overexpressed PKCβ and/or silenced UCP1, effects of PKCβ and UCP1 in autism-like behaviors in EN2^-/- mice were analyzed. Results showed that PKCβ was downregulated in EN2^-/- mouse brain tissues or neurons. PKCβ promoted the expression and stability of FTO, which downregulated the m6A modification level of PGC-1α to promote its expression. Moreover, PGC-1α positively targeted the expression of UCP1. PKCβ knockdown enhanced sociability and spatial exploration ability, and reduced neuron apoptosis in EN2^-/- mouse models of autism, which was reversed by UCP1 overexpression. Collectively, PKCβ overexpression leads to activation of the FTO/m6A/PGC-1α/UCP1 axis, thus inhibiting neuron apoptosis and providing neuroprotection in mice with autism-like behavior.

Content analysis of parent training programs for children with neurodisabilities and mental health or behavioral problems: a scoping review

PURPOSE

Several systematic reviews have examined parent training programs for families of children with autism spectrum disorder (ASD). The present review expands on this literature by describing the components, delivery methods, and level of parent involvement in parent training programs that target families of children with any neurodisability and comorbid disruptive behavior or other mental health problem.

MATERIALS AND METHODS

Following a scoping review protocol, the search strategy included randomized controlled trials of parent training programs conducted with families of children with neurodisabilities and comorbid disruptive behavior or mental health problems. Study characteristics, program content, delivery methods, and theoretical frameworks were extracted from eligible studies.

RESULTS

A total of 22 articles were included from the 453 full-text articles initially screened. Thirteen different programs fell into two general categories based on whether they targeted child disruptive behavior or anxiety. Analysis of the content yielded five themes: child skill enhancement, parenting as enacted, parenting as experienced, disability-related parenting, and parent-child relationships. The theoretical underpinnings were identified, when possible, from each study.

CONCLUSIONS

Parent training programs for parents of children with neurodisabilities targeting child anxiety involved parents in a complementary role in treatment while those targeting disruptive behavior involved parents in a primary role in creating behavior change. We suggest that the extent of parent involvement in interventions be guided by theory rather than diagnosis of the child.Implications for rehabilitationParents of children living with neurodisabilities play a key role in delivering interventions to address comorbid mental health or behavioral problems.Parent training programs for families of children with neurodisabilities vary in relation to their aims, involvement of parents in delivering interventions, disability-specific content, and delivery methods.When referring families, rehabilitation professionals should be aware of aspects of child, parent, and family relational well-being targeted by parent training programs and, when feasible, give families a choice of the style of program to meet their needs.

Balancing Fidelity and Flexibility: Usual Care for Young Children With an Increased Likelihood of Having Autism Spectrum Disorder Within an Early Intervention System

Naturalistic developmental behavioral interventions (NDBIs) are evidence-based interventions for young children with autism spectrum disorder. There has been growing interest in implementing manualized NDBIs within the early intervention (EI) system without a clear understanding of how these programs and the broader strategies encompassed within them are already used by EI providers. This study examined the use of manualized NDBI programs and broader NDBI strategies within an EI system and factors that impacted their use. Eighty-eight EI providers completed a measure of NDBI program and strategy use. Thirty-three providers participated in a supplemental focus group or interview. Overall, providers described using broader NDBI strategies and the need to adapt manualized NDBI programs. Provider-, intervention-, and organization-level factors impacted their use of NDBI programs and strategies.

A Longitudinal RCT of P-ESDM With and Without Parental Mindfulness Based Stress Reduction: Impact on Child Outcomes

This randomized controlled trial (NCT03889821) examined Mindfulness Based Stress Reduction (MBSR) in conjunction with the Parent-implemented Early Start Denver Model (P-ESDM). A previous report described improved metrics of parental distress (Weitlauf et al. in Pediatrics 145(Supplement 1):S81-S92, 2020). This manuscript examines child outcomes. 63 children with ASD (< 36 months) and their parents received 12 P-ESDM sessions. Half of parents also received MBSR. Longitudinal examination of whole sample means revealed modest improvements in autism severity, cognitive, and adaptive skills. There was not a significant time × group interaction for children whose parents received MBSR. Future work should examine more proximal markers of child or dyadic change to enhance understanding of the impact of providing direct treatment for parents as part of early intervention initiatives.

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.

Using implementation science frameworks to explore barriers and facilitators for parents' use of therapeutic strategies following a parent-mediated autism intervention

LAY ABSTRACT

Many early autism interventions teach parents therapeutic strategies to help them adjust their communication style with their children. Research has shown that this behaviour change in parents leads to improvements in child communication. It is, therefore, important to learn what factors support or hinder parents in their use of therapeutic strategies learned in such interventions. This study set out to interview parents who had participated in a research trial of the Paediatric Autism Communication Therapy-Generalised intervention. We interviewed 27 caregivers and explored their use of the strategies up to 2 years after the end of the research trial. Qualitative frameworks were used to inform interview questions and data analysis. These frameworks focused on a range of contextual factors, including parents' characteristics, their context and features of the intervention. Parents reported barriers and facilitators to using Paediatric Autism Communication Therapy-Generalised strategies across three themes: Motivating Factors; Opportunity and Support; Parent Characteristics. One of these themes, Motivating Factors, was further divided into the subthemes Compatibility and Buy-In and Alignment of Goals and Outcomes. Almost all parents reported continued use of the Paediatric Autism Communication Therapy-Generalised strategies. Facilitators included parental confidence in using the strategies and barriers included child's behaviour. Consideration of these factors can inform ways to better support parents in future autism interventions.

A systematic review of emotion regulation in parent-mediated interventions for autism spectrum disorder

Autistic individuals are at elevated risk for difficulties with emotion regulation (ER) that emerge early in life and are associated with a range of internalizing and externalizing disorders. Existing interventions that support ER have focused on school-age autistic children and adolescents as well as adults. Proactive approaches to improving ER in early childhood are thus needed, as is understanding the approaches by which ER skills can be feasibly supported in this young population. This review summarizes how ER has been measured within parent-mediated interventions for children at or under the age of 6 years and the extent to which ER is measured concurrently with or distinctly from observable behaviors that have been referenced in existing literature as externalizing or challenging behavior. Using PsycInfo, EBSCOhost, and PubMed databases, we searched for peer-reviewed journal articles published through August 2021, that focused on the use of parent-mediated interventions targeting ER and/or challenging behavior. The systematic search resulted in 4,738 publications; following multi-stage screening, the search yielded 20 studies. Eighteen of 20 studies were designed to target challenging behavior using manualized curricula or behavior analytic methodologies and assessed child outcomes through validated caregiver rating scales and/or direct behavioral observation. One study measured changes in ER as secondary to the social communication skills that were targeted in the intervention. Only one study specifically supported ER skill development and measured changes in ER as the primary intervention outcome. Findings highlight the need for better assessment of ER outcomes within the context of parent-mediated interventions for toddlers and young autistic children.

The Efficacy of Early Interventions for Children with Autism Spectrum Disorders: A Systematic Review and Meta-Analysis

The superiority of early interventions for children with autism spectrum disorders (ASDs) compared to treatment as usual (TAU) has recently been questioned. This study was aimed to investigate the efficacy of early interventions in improving the cognitive ability, language, and adaptive behavior of pre-school children with ASDs through a systematic review of randomized controlled trials (RCTs). In total, 33 RCTs were included in the meta-analysis using the random effects model. The total sample consisted of 2581 children (age range: 12-132 months). Early interventions led to positive outcomes for cognitive ability (g = 0.32; 95% CI: 0.05, 0.58; p = 0.02), daily living skills (g = 0.35; 95% CI: 0.08, 0.63; p = 0.01), and motor skills (g = 0.39; 95% CI: 0.16, 0.62; p = 0.001), while no positive outcomes were found for the remaining variables. However, when studies without the blinding of outcome assessment were excluded, positive outcomes of early interventions only remained for daily living skills (g = 0.28; 95% CI: 0.04, 0.52; p = 0.02) and motor skills (g = 0.40; 95% CI: 0.11, 0.69; p = 0.007). Although early intervention might not have positive impacts on children with ASDs for several outcomes compared to controls, these results should be interpreted with caution considering the great variability in participant and intervention characteristics.

Implementing the WHO caregivers skills training program with caregivers of autistic children via telehealth in rural communities

Background

For families with autistic children living in rural areas, limited access to services partly results from a shortage of providers and extensive travel time. Telehealth brings the possibility of implementing alternative delivery modalities of Parent Mediated Interventions (PMIs) with the potential to decrease barriers to accessing services. This study aimed to evaluate the feasibility and acceptability of implementing the World Health Organization-Caregivers Skills Training program (WHO-CST) via an online, synchronous group format in rural Missouri.

Methods

We used a mixed methods design to collect qualitative and quantitative data from caregivers and program facilitators at baseline and the end of the program, following the last home visit. Caregivers of 14 autistic children (3-7 years), residents of rural Missouri, completed nine virtual sessions and four virtual home visits.

Results

Four main themes emerged from the focus groups: changes resulting from the WHO-CST, beneficial aspects of the program, advantages and disadvantages of the online format, and challenges to implementing the WHO-CST via telehealth. The most liked activity was the demonstration (36%), and the least liked was the practice with other caregivers. From baseline to week 12, communication skills improved in both frequency (p < 0.05) and impact (p < 0.01), while atypical behaviors decreased (p < 0.01). For caregivers' outcomes, only confidence in skills (p < 0.05) and parental sense of competence (p < 0.05) showed a positive change.

Conclusion

Our results support the feasibility of implementing the WHO-CST program via telehealth in a US rural setting. Caregivers found strategies easy to follow, incorporated the program into their family routines, and valued the group meetings that allowed them to connect with other families. A PMI such as the WHO-CST, with cultural and linguistic adaptations and greater accessibility via telehealth-plays an essential role in closing the treatment gap and empowering caregivers of autistic children.

Implementation of a Parent-Mediated Discrete Trial Teaching Intervention for Children with Autism Spectrum Disorder

For young children with autism spectrum disorder (ASD), early intensive intervention is imperative. The Bridge Skill Development Program is a parent-mediated intervention designed to “bridge the gap” during the period after a diagnosis of ASD while children wait for intensive intervention. This program introduces applied behavior analysis (ABA) teaching techniques, including the use of parent-mediated discrete trial teaching (DTT), to promote skill acquisition of target behaviors. Significant improvements were observed across four target behaviors taught to all participants. The program also aims to connect participants to intensive ABA programming.

Parent-mediated play-based interventions to improve social communication and language skills of preschool autistic children: A systematic review and meta-analysis protocol

Early years interventions have shown to be effective in improving the social communication and language skills of autistic children. Therefore, various play-based interventions have been developed to support those developmental areas of autistic children. Although researchers have previously reported the overall effectiveness of different types of play-based interventions on the social communication and language skills of autistic children, no previous systematic reviews have yet evaluated the effectiveness of parent-mediated play-based interventions in preschool autistic children. The overarching aims of the study will be to (i) report the key characteristics and (ii) synthesise the results of studies evaluating parent-mediated play-based interventions targeting the social communication and language skills of preschool autistic children using experimental designs. A comprehensive search for and screening of the relevant studies published between 2000 and 2021 will be undertaken. To be included, studies will have to (i) use either a randomised control trial or quasi-experimental design, (ii) focus on preschool autistic children aged six years old or younger, (iii) deliver a play-based intervention in non-educational settings, and (iv) include at least one parent as the mediator of the intervention. Data extraction of all included studies will be undertaken using a specially devised template and they will also be assessed for risk of bias using an adapted form from the Cochrane Risk of Bias tool. The overall characteristics of the included studies will be reported and a narrative synthesis of the results of the included studies will be undertaken. A meta-analysis may be performed (if justified) to report the pooled effect size of the parent-mediated play-based interventions on the social communication and language skills of preschool autistic children. Trial registration: The current study protocol was pre-registered with the international prospective register of systematic reviews (PROSPERO: CRD42022302220).

Assessing the Satisfaction and Acceptability of an Online Parent Coaching Intervention: A Mixed-Methods Approach

Background

Parent-mediated intervention (PMI) has been studied in promoting skill acquisition or behavior change in the children with autism spectrum disorder. Most studies emphasize on the improvement of child's core symptoms or maladaptive behaviors, making parental perceived competence and self-efficacy secondary. Yet, the evaluations of intervention implementation are under-reported, especially when translating such interventions into a new population or context. This research investigated the intervention implementation of a 12-week parent coaching intervention which was delivered through telehealth and tailored to Chinese population. The intervention was based on the Parent-mediated Early Start Denver Model with culturally adapted lectures, manuals, and demonstration and commentary videos. This study aimed to evaluate the intervention implementation by assessing parents' satisfaction, acceptability, appropriateness, and feasibility.

Method

A randomized controlled trial was conducted with two telehealth conditions: self-directed and web+group therapy. Parents in the self-directed condition received intervention individually through the online learning platform. The web+group therapy condition navigated the same program with weekly 1.5-h group coaching sessions via videoconferencing. This mixed-methods study used a concurrent convergent design to evaluate the intervention implementation at post-intervention. The quantitative data was collected from the Program Evaluation Survey and the qualitative data was collected from five focus groups.

Results

Parents in self-directed group reported significantly lower scores in total perceived competence than parents in web+group therapy condition, while there was no group difference on the total self-efficacy. Tailored feedback, demonstration and commentary videos, peer commenting, live coaching, and guided reflection were the top-five acceptable telehealth strategies that were strongly endorsed by parents. Family centered care, home-based intervention, strategies relative to daily activities, the remote learning platform, and the program-based community were elements that parents considered when evaluating the program's appropriateness. Parent modeling, step-by-step instructions, and tailored feedback were key components in making intervention strategies feasible for parents to implement at home.

Conclusion

Findings indicate the application of telehealth was acceptable, appropriate, and feasible for Chinese parents. Group-based parent coaching intervention via videoconferencing could be a promising home-based service model to increase parental perceived competence. A large-scale RCT is needed to investigate the effectiveness of group-based PMI via telehealth.

Parent-Mediated Interventions for Infants under 24 Months at Risk for Autism Spectrum Disorder: A Systematic Review of Randomized Controlled Trials

Prodromal symptoms of Autism Spectrum Disorder (ASD) have been detected within the first year of life. This review evaluated evidence from randomized controlled trials (RCTs) of parent-mediated interventions for infants under 24 months who are at risk for ASD. Electronic databases, including grey literature, were searched up till November 2019. Seven RCTs were identified. There was substantial heterogeneity in recruitment, outcome measures and effect size calculations. Interventions did not reduce the risk of later ASD diagnosis and post-intervention effects on infant outcomes were inconsistent, with five studies reporting significant improvements across both treatment and control groups. Moderate level of evidence of intervention effects on parental interaction skills and the small number of RCTs, and significant limitations restrict generalizability across studies.

Evaluating a Two-Tiered Parent Coaching Intervention for Young Autistic Children Using the Early Start Denver Model

OBJECTIVES

Early intervention can improve the outcomes of young autistic children, and parents may be well placed to deliver these interventions. The Early Start Denver Model (ESDM) is a naturalistic developmental behavioral intervention that can be implemented by parents with their own children (P-ESDM). This study evaluated a two-tiered P-ESDM intervention that used a group parent coaching program, and a 1:1 parent coaching program. We evaluated changes in parent use of the ESDM and parent stress, as well as child engagement, communication, and imitation.

METHODS

Seven autistic or probably autistic children (< 60 months old) and their parents participated. A multiple-baseline design was used to compare individual changes between Baseline 1, Group Coaching (Tier 1), Baseline 2, and 1:1 Coaching (Tier 2). Parent and child behaviors were analyzed from weekly videos and graphed. Parenting stress was measured.

RESULTS

All parents improved in their use of ESDM strategies after the Tier 1 intervention. Changes in parent fidelity during Tier 2 were mixed, but all parents maintained higher than baseline levels of fidelity. Six parents demonstrated above 75% ESDM fidelity in at least one session. There were positive changes in parent stress levels pre- post-intervention. Positive results were found for most children's levels of engagement, imitation, and communication. There were significant positive relationships between parent fidelity and both child engagement and child functional utterances.

CONCLUSIONS

Group P-ESDM is a promising approach for improving parent fidelity and some child outcomes. Future randomized and controlled studies of group P-ESDM, using standardized outcome measures, are warranted.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s41252-022-00264-8.

Pivotal Response Treatment (PRT) parent group training for young children with autism spectrum disorder: a pilot study

Pivotal Response Treatment (PRT) is a promising intervention addressing core symptoms of autism spectrum disorder (ASD), with parent involvement as key component. Parent group-delivered PRT may be an effective treatment model, but currently the evidence is limited. Also, little attention has been paid to therapeutic involvement of multiple important contexts (e.g. home, school, community) of the young child. The current study explores a 14-week protocol of PRT parent group training (PRT-PG), complemented with individual parent–child sessions and involvement of teachers and other childcare providers. Children aged 2–6 years old with ASD and their parents (n = 20) were included. Preliminary results showed a significant increase in spontaneous initiations during a semi-structured therapist-child interaction together with widespread gains in clinical global functioning. No significant improvement on parent-rated general social-communication skills was observed. These findings justify further research on parent group delivered PRT models.

Cultural Adaptations to Parent-Mediated Autism Spectrum Disorder Interventions for Latin American Families: A Scoping Review

PURPOSE

This scoping review maps research in parent-mediated autism spectrum disorder interventions culturally adapted for Latin American populations, to provide an overview of the available evidence across perspectives and disciplines and to identify gaps in the research knowledge base.

METHOD

A systematic search for relevant articles was conducted using six databases and archival and forward hand searches of articles that met inclusion criteria. Titles and abstracts were reviewed by three authors, followed by full-text reviews of remaining articles. Twenty-one articles met inclusion criteria and were retained for data extraction. The ecological validity framework was used to frame data analysis and results.

RESULTS

In total, 19 studies described unique implementations of 16 different interventions, which spanned 21 articles, representing a range of study designs and implementing a variety of adaptations. Most adaptations consisted of surface-structure changes, spanning the dimensions of language, concepts, methods, context, and persons. Few articles were identified that described international studies or studies examining direct parent-mediated strategies with large sample sizes and strong methodological designs.

CONCLUSIONS

Several intervention adaptations that have potential for clinical utility are presented. Clinicians working with Latin American families are encouraged to discuss potential adaptations openly with families before choosing and implementing specific strategies.

Controlled Trial of a Short-term Intensive Parent Training Program within the Context of Routine Services for Autistic Children in China

Recent systematic reviews found limited rigorous research conducted to date of the effectiveness of parent training programs in reducing behavioral problems for autistic children in low- and middle-income countries. This study is aimed at evaluating the effectiveness of a short-term intensive parent training program for autistic children aged three to six in the context of routine service provision in China. A quasi-experiment was conducted involving the local implementing organization and using a waitlist control. Data were collected at baseline and immediate post-intervention. The primary outcome was child behavioral problems measured using the Child Behavior Checklist Externalizing scale. Between-group comparisons used a difference-in-differences design with propensity score weighting to reduce sources of bias. A process evaluation was undertaken in parallel to assess participant involvement, program acceptability, and delivery. The protocol was prospectively registered with ClinicalTrials.gov (NCT04257331). The final sample size was 111 (treatment: 63; comparison: 48). Results suggest that the program was associated with improvements in child externalizing behaviors (b = -2.71, 95% CI [-5.23, -0.18]), parental mental health symptoms (b = -5.96, 95% CI [-11.74, -0.17]), over-reactive parenting (b = -0.63, 95% CI [-0.98, -0.27]), and parental knowledge (b = 2.08, 95% CI [2.07, 2.17]). Exploratory analysis of factors related to implementation indicated that baseline parental mental health was related to participant engagement, and that satisfaction and engagement levels were potentially linked to positive treatment effects. Findings suggest that short-term intensive parent training programs that are provided by trained non-specialists, could potentially be used as an alternative to traditional prohibitively costly services that are delivered intensively for consecutive years in low-resource contexts. Follow-ups are needed to investigate its long-term benefits.

Characterizing Parent–Child Interactions in Families of Autistic Children in Late Childhood

Parent–child interactions are influential to a wide range of positive developmental processes in neurotypical children, yet contributions to our understanding of these interactions using observational methods in families of children on the autism spectrum are lacking. The aim of the current study is to investigate how autism symptoms might impact these interactions. We use a family discussion task to: (1) compare families of autistic children aged 8–12 years (n = 21) to families of typically developing children (n = 21, matched on age and cognitive abilities) on the observed levels of supportive and directive behaviors in the parent–child relationship, and (2) examine the associations between parent–child interaction characteristics and child functioning. Results showed no differences in the observed levels of supportive behavior exhibited by parents, but significantly less supportive behavior in autistic children compared to neurotypical children. In addition, parents of autistic children had higher levels of observed directive behavior compared to parents of neurotypical children. Levels of supportive behavior in parents and autistic children were negatively associated with child ADHD symptoms. Findings reinforce literature on younger children describing positive parenting characteristics and further rebuke historical accounts of negative parenting qualities of parents of autistic children.