Caring for a child with autism spectrum disorder and parents' quality of life: application of the CarerQol

The association between intolerance of uncertainty and psychological burden among caregivers of children with autism and the impact on their quality of life

Introduction

Caregivers of children with Autism Spectrum Disorder (ASD) often face significant stressors, including financial strain, social stigma, emotional exhaustion, and unpredictable daily routines. These challenges can severely impact their quality of life (QoL). This study aimed to examine the relationship between intolerance of uncertainty, caregiver burden, and QoL among caregivers of children with autism.

Methods

A cross-sectional study was conducted with 59 caregivers from six branches of the Obour Company for Human Development in Riyadh. Data were collected electronically using a sociodemographic data sheet, the Intolerance of Uncertainty Scale, the Zarit Burden Interview (short form), and the World Health Organization Quality of Life Scale (brief form).

Results

Findings revealed that two-thirds of caregivers experienced high to moderate levels of intolerance to uncertainty and a moderate burden, while 13.6% reported a high burden. Nearly 60% of participants reported low overall QoL, particularly in the psychological and social domains. A significant positive correlation was found between intolerance of uncertainty and caregiver burden. Additionally, significant negative associations were observed between QoL scores and both intolerance of uncertainty and caregiver burden, except in the environmental domain. Intolerance of uncertainty emerged as a significant inverse predictor of overall QoL.

Discussion

These results emphasize the psychological toll of caregiving for children with ASD. Interventions such as family- and community-based support programs and child behavioral training are essential to reduce caregiver burden and enhance QoL. Tailored services should be prioritized in clinical practice to support caregivers more effectively.

The use of video feedback to promote developmentally supportive parent-child interactions with young children with ASD or at risk: study protocol for a randomized controlled trial (VIFEPOPA-RCT)

BACKGROUND

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by difficulties in social communication and interaction, and repetitive and restrictive behaviors and interests from an early age. ASD often negatively affects caregiver-child interactions, caregiver emotional well-being and self-efficacy, and quality of family life. Positive caregiver-child interactions are crucial for good developmental outcomes, leading to the development of Parent-Mediated Interventions (PMIs). PMIs tend to follow an expert model where professionals provide direct instruction on treatment techniques and parental behaviors. However, research supports a shift towards a more collaborative and reflective approach, using coaching strategies that highlight caregiver strengths and encourage self-reflection. This study tests a video-feedback intervention (VFI) with parents of young children at risk of ASD.

METHODS

A randomized controlled trial (RCT) with 60 families, recruited from Early Intervention Centers in Spain, meeting inclusion criteria: adequate use of internet, child aged 24-36 months with a high risk of ASD (M-CHAT-R score ≥ 8), and participant primary caregiver (mother or father) with high anxiety, depression, or parental stress (score ≥ 1 SD above M), and low or medium-low developmentally supportive parental behaviors (PICCOLO score ≤ 40). Families will be randomly assigned to an intervention group (receiving usual services plus VFI) or a control group (usual services). The intervention includes twelve bi-weekly 90-min sessions over six months, with the caregiver. Outcome measures include parenting behaviors, emotional state, self-efficacy, family quality of life, and child development collected at pre-intervention, post- intervention and six-month follow-up.

DISCUSSION

The study will assess whether the intervention enhances developmentally supportive parental behaviors, emotional well-being, self-efficacy, and family quality of life, with a secondary positive impact on child development. If proven effective, it could be a cost-effective intervention with both short and long-term benefits.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT06604988. Registered on September 17, 2024. Retrospectively registered.

Quality of Life in Hungarian Parents of Autistic Individuals

PURPOSE

Parents of autistic individuals have been known to have a lower overall quality of life (QQL) than those of typically developing children. We present the first Hungarian large-sample study whose objective was to explore the differences in QOL between parents of autistic individuals (AS) and those of neurotypical (NT) persons.

METHODS

Based on the ABCX model we developed a questionnaire comprising standardized scales to characterize the life of parents involved. Our data came from parents of 842 individuals (ASD = 521, NT = 321) between 0 and 49 years. Battery deployed standardized instruments to examine quality of life (WHO-QQL BREF and Quality of Life in Autism questionnaire, QOLA). We assessed the families' socio-economic/demographic characteristics, parents' psychological well-being, the autistic/neurotypical individuals' characteristics, and the interventions.

RESULTS

Our data showed significantly lower QOL in parents of autistic individuals in all domains of questionnaires. We analyzed 20 relevant factors to uncover the predictors of parental QOL. We confirmed the existence of most but not all predictors present in earlier literature and identified intervention-related predictors.

CONCLUSION

Our study confirms the importance of supporting parents in their role, and of providing health and social supports that focus on quality of life, in addition to child care.

Depression and psychological help-seeking attitude among Turkish mothers of children with autism: problem-focused coping as a mediator

Studies demonstrate that mothers of children with autism spectrum disorder (ASD) experience depression and are less likely to seek professional psychological help. This study examined the roles of coping strategies in predicting psychological help-seeking attitudes among mothers of children with ASD. A total of 250 Turkish mothers of children with autism were recruited using purposive sampling during their training at the autism center in Istanbul. The results showed that depression was positively associated with problem-focused coping and negatively associated with psychological help-seeking attitudes. Psychological help-seeking attitudes and problem-focused coping were positively correlated with avoidant coping. Mediation analysis demonstrated that problem-solving plays a mediating role in the relationship between depression and psychological help-seeking attitudes. When addressing the psychological help-seeking attitudes of mothers of children with autism, future prevention and intervention programs may have to take into account mothers' depressive symptoms, and how they view and cope with depression and challenges related to parenting their child with autism.

The economic impact of caregiving for individuals with Angelman syndrome in the United States: results from a caregiver survey

BACKGROUND

Angelman syndrome (AS) is a rare neurogenetic disorder characterized by persistent cognitive and functional impairments that necessitate lifelong care. Caring for individuals with AS leads to substantial household costs, as well as impacts on work productivity, leisure time, and quality of life for caregivers. The economic value of these impacts in the United States (US) has not been well studied. We conducted a survey of US caregivers for persons with AS to quantify the annual economic impact of caregiving. Information on AS-related economic impacts was gathered, including household costs, employment impacts, leisure time loss, and caregiver healthcare costs. The survey did not gather information on direct medical care costs borne by healthcare insurers or other economic impacts to the US government and other stakeholders.

RESULTS

A total of 105 caregivers completed the survey and 105 individuals with AS were represented. Most caregivers were female (89.5%), white (83.8%), and identified as the primary caregiver (75.2%). Most individuals with AS represented in the sample were age < 18 (82.9%). The annual economic impact of caregiving for persons with AS averaged $79,837 (SD $55,505). Costs related to employment impacts and lost work productivity in the past 12 months accounted for most (53%) of this impact and averaged $42,697 (SD $28,309). Household costs incurred in the past 12 months for goods and services to better accommodate individuals with AS were $29,680 (SD $47,753). Leading contributors included vehicle purchases and modifications (mean $6,717; SD $17,791), professional caregiving (mean $6,123; SD $17,335), home modifications and repairs (mean $4,387; SD $15,734), and supportive therapy (mean $3,269; SD $7,564). Economic impacts in the past 12 months from lost leisure time and incremental healthcare costs for caregivers were estimated to be $6,634 (SD $4,652) and $827 (SD $2,072), respectively.

CONCLUSIONS

Caregivers incur substantial costs to accommodate individuals with AS, as well as substantial impacts related to employment and leisure time. This study's findings may be utilized in future research to better estimate the value from therapeutic advances in AS and direct resources toward mitigating economic impacts for households.

How the Occupational Competence and Quality of Life in Parents of Children with Autism Spectrum Disorder Changed During the COVID-19 Pandemic: A Mixed Design Study

This study aimed to evaluate the impact of the pandemic on the occupational competence and quality of life of parents of children with autism using a mixed-methods design. It compared 220 parents of children with autism to 300 parents of neurotypical children, utilizing the Occupational Self-Assessment, Short Form 36 Health Survey, and qualitative interviews for data collection. Quantitative results revealed significant differences in occupational competence and quality of life between the two groups. Qualitative interviews underscored changes in parents' professional and social roles, along with reductions in self-care, productivity, and recreational activities, particularly affecting parents of children with autism.

Exploring the effect of diet programs on the behavior of Sudanese children with autism and the prevalence and association of gastrointestinal symptoms: a multi-center cross-sectional study

Background and aims

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by social difficulties, speech and nonverbal communication issues, and restricted behaviors. Nutritional issues, such as food allergies and intolerances, can affect children with ASD. This study aimed to evaluate the impact of diet programs on ASD behavior and gastrointestinal symptoms, which would be considered as a starting point to increase the family's knowledge about how to practice healthy and suitable dieting for their children.

Materials and methods

The study was a cross-sectional observational study on 45 children with an autism spectrum disorder in four centers aged 2-18 in Khartoum state. Data was collected through an interview questionnaire, which included sociodemographic, diet, gastrointestinal, and behavioral assessments. The data was analyzed using SPSS to find the correlation between the various variables. Independent t-test, Analysis of Variance, and Mann-Whitney test were used in univariant analysis to assess the association between study variables, while multiple linear regression was used in multivariant analysis for the same purpose.

Results

The study involved a large number of children with autism spectrum disorder (ASD), with 80% being male and 73.3% being school-aged. Most had parents as guardians and 71.1% were in intermediate financial status. About 20% were overweight or obese, and 57.8% did not have a specific diet program. Food selectivity was prevalent, with 22.7% having allergies to milk and wheat. ASD children experienced vomiting, gastric reflux, abdominal pain, and changes in stool characteristics. A significant link was found between financial status, behavioral status and gastrointestinal changes. High financial status was significantly different from intermediate and low statuses based on behavioral changes. However, no significant association was found in multivariant analysis.

Conclusion

The study found that ASD children generally have good nutritional health, with a higher degree of dietary selection. The financial status of guardians significantly influenced behavioral and gastrointestinal changes in the children. Further interventional studies are recommended to assess the direct impact of diet programs on these symptoms.

The diagnosis of ASD with MRI: a systematic review and meta-analysis

While diagnosing autism spectrum disorder (ASD) based on an objective test is desired, the current diagnostic practice involves observation-based criteria. This study is a systematic review and meta-analysis of studies that aim to diagnose ASD using magnetic resonance imaging (MRI). The main objective is to describe the state of the art of diagnosing ASD using MRI in terms of performance metrics and interpretation. Furthermore, subgroups, including different MRI modalities and statistical heterogeneity, are analyzed. Studies that dichotomously diagnose individuals with ASD and healthy controls by analyses progressing from magnetic resonance imaging obtained in a resting state were systematically selected by two independent reviewers. Studies were sought on Web of Science and PubMed, which were last accessed on February 24, 2023. The included studies were assessed on quality and risk of bias using the revised Quality Assessment of Diagnostic Accuracy Studies tool. A bivariate random-effects model was used for syntheses. One hundred and thirty-four studies were included comprising 159 eligible experiments. Despite the overlap in the studied samples, an estimated 4982 unique participants consisting of 2439 individuals with ASD and 2543 healthy controls were included. The pooled summary estimates of diagnostic performance are 76.0% sensitivity (95% CI 74.1-77.8), 75.7% specificity (95% CI 74.0-77.4), and an area under curve of 0.823, but uncertainty in the study assessments limits confidence. The main limitations are heterogeneity and uncertainty about the generalization of diagnostic performance. Therefore, comparisons between subgroups were considered inappropriate. Despite the current limitations, methods progressing from MRI approach the diagnostic performance needed for clinical practice. The state of the art has obstacles but shows potential for future clinical application.

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

LAY ABSTRACT

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

The Relationship Between Fatigue and Quality of Life in the Turkish Mothers of Children with Autism Spectrum Disorder

This study aimed to investigate the different effects of fatigue and health-related quality of life in the Turkish mothers of children with autism spectrum disorder (ASD) through comparisons with mothers of typically developing children, and to evaluate the relationship between different aspects of maternal fatigue, depression, and maternal health-related quality of life. The study included a total of 103 mothers, comprising 60 mothers of children with ASD and 43 mothers of typically developing children. The Nottingham Health Profile and Quality of Life in Autism Questionnaire-Parent Version were used to assess the health-related quality of life. Fatigue was assessed comprehensively with the Fatigue Impact Scale and the Fatigue Severity Scale. The Nottingham Health Profile total and physical mobility domain and the quality of life were the strongest factors, explaining with a variance of 66.7% the fatigue impact on cognitive function. The mothers' quality of life accounted for 64.8% of the variance in factors that explained fatigue. Physical mobility, social isolation and quality of life were associated with the physical impact of fatigue and were explained with a variance of 52.4%. Emotional reactions and quality of life were explained with a variance of 52.7% in the fatigue of psychosocial function. The current study has highlighted that the fatigue of Turkish mothers of children with ASD has a greater impact on cognitive, physical and psychosocial functions. Furthermore, the quality of life, physical mobility, social isolation, and emotional reactions of mothers have a significant impact on maternal fatigue.

Trajectory of health-related quality of life in parents of children treated with epilepsy surgery versus medical therapy

PURPOSE

Child health-related quality of life (HRQOL) has been shown to improve after epilepsy surgery and is linked to parent HRQOL. We postulated that the HRQOL of parents whose children underwent epilepsy surgery would improve over two years compared to those treated with medical therapy. The aim of the study was to evaluate the trajectory of HRQOL of parents whose children received treatment with epilepsy surgery or medical therapy over two years.

METHODS

This multi-center study recruited parents whose children were evaluated for epilepsy surgery. Parents completed measures of care-related QOL (CarerQOL) at the time of their children's surgical evaluation, 6 months, 1 year, and 2 years later. Additional measures included parent anxiety and depression, satisfaction with family relationships, family resources and demands, and child clinical variables. A linear mixed model was used to compare the trajectories of parent HRQOL of surgical and medical patients, adjusting for baseline clinical, parent, and family characteristics.

RESULTS

There were 111 children treated with surgery and 154 with medical therapy. The trajectory of parent HRQOL was similar among parents of surgical and medical patients over the two-year follow-up. However, HRQOL of parents of surgical patients was 3.0 points higher (95%CI - 0.1, 6.1) across the follow-up period compared to parents of medical patients. Parents of seizure-free children reported 2.3 points (95%CI 0.2, 4.4) higher HRQOL relative to parents of non-seizure-free children across the two-year follow-up.

CONCLUSION

Parent HRQOL did not improve after their children were treated with epilepsy surgery, possibly related to ongoing comorbidities in children.

Factors Impacting Parental Quality of Life in Preschool Children on the Autism Spectrum

This study examined connections between parental quality of life (QoL) and features of children (autism severity, cognitive ability, behavioral profile, and sociodemographic factors). Parents of 97 children attending an autism-specific preschool completed the Quality of Life in Autism, Vineland Adaptive Behavior Scales and Child Behavior Checklist. The Autism Diagnostic Observation Schedule and Mullen Scales of Early Learning were also administered. Reduced restrictive/repetitive behavior and higher socialization and play/leisure scores were associated with better parental QoL. Better behavioral regulation and attention also predicted better QoL, as did stronger communication and reduced internalising behaviours. Findings indicate that a child's level of autism specific traits, adaptive functioning and behavioral profile has greater impact on parental QoL than cognitive level.

Recommendations for Emerging Good Practice and Future Research in Relation to Family and Caregiver Health Spillovers in Health Economic Evaluations: A Report of the SHEER Task Force

BACKGROUND

Omission of family and caregiver health spillovers from the economic evaluation of healthcare interventions remains common practice. When reported, a high degree of methodological inconsistency in incorporating spillovers has been observed.

AIM

To promote emerging good practice, this paper from the Spillovers in Health Economic Evaluation and Research (SHEER) task force aims to provide guidance on the incorporation of family and caregiver health spillovers in cost-effectiveness and cost-utility analysis. SHEER also seeks to inform the basis for a spillover research agenda and future practice.

METHODS

A modified nominal group technique was used to reach consensus on a set of recommendations, representative of the views of participating subject-matter experts. Through the structured discussions of the group, as well as on the basis of evidence identified during a review process, recommendations were proposed and voted upon, with voting being held over two rounds.

RESULTS

This report describes 11 consensus recommendations for emerging good practice. SHEER advocates for the incorporation of health spillovers into analyses conducted from a healthcare/health payer perspective, and more generally inclusive perspectives such as a societal perspective. Where possible, spillovers related to displaced/foregone activities should be considered, as should the distributional consequences of inclusion. Time horizons ought to be sufficient to capture all relevant impacts. Currently, the collection of primary spillover data is preferred and clear justification should be provided when using secondary data. Transparency and consistency when reporting on the incorporation of health spillovers are crucial. In addition, given that the evidence base relating to health spillovers remains limited and requires much development, 12 avenues for future research are proposed.

CONCLUSIONS

Consideration of health spillovers in economic evaluations has been called for by researchers and policymakers alike. Accordingly, it is hoped that the consensus recommendations of SHEER will motivate more widespread incorporation of health spillovers into analyses. The developing nature of spillover research necessitates that this guidance be viewed as an initial roadmap, rather than a strict checklist. Moreover, there is a need for balance between consistency in approach, where valuable in a decision making context, and variation in application, to reflect differing decision maker perspectives and to support innovation.

Socio-economic status and autism spectrum disorder: A case-control study in Bangladesh

There are unexpectedly a few statistics about the socio-economic status (SES) and related socio-demographic factors (SDFs) of parents having child with ASD in Bangladesh. The prevalence of ASD might correlate with SES and related SDFs. A case-control study was conducted in 24 locations across 21 districts, encompassing all divisions, to assess the association between SES and the risk of developing ASD in Bangladesh. The structured questionnaire was administered through face-to-face interviews with 620 parents of the subject (310 ASD and 310 healthy controls) from January 2020 to June 2021. For univariate, bivariate and multivariate analyses, IBM SPSS version 23 was employed. The significance level was set at P ≤ 0.05, and the Odds Ratio (OR) within a 95 % CI was used to determine whether the variable poses a higher odd or not. After adjusting all significant covariates of binary logistic regression (including some dummy variables) in forward logistic regression model analysis, the higher level of SES, advanced level of father's education (≥master), 22-35 years old age group of the father, and nuclear family were strongly associated with decreased odds of ASD compared to healthy controls. Only the male gender was strongly associated with an increased odds of ASD compared to the control. The results will aid policymakers in developing plans considering the SES and related SDFs that influence the risk of developing ASD in Bangladesh. Further research using population-based cohorts or nested case-control designs with matched control is necessary to observe and generalize the association.

Brief Report: Gender-Based Stereotypical Roles of Parents Caring for Autistic Children in Nigeria and South Africa

In Nigeria and South Africa, women often have less voice and are less visible given cultural norms and related gender stereotypes. It is important to understand parents' gender roles in the context of caregiving for children with autism spectrum disorder because inequality in caregiving roles may influence the health of children with autism and that of their parents. We explored the lived caregiving experiences of male and female parents with autistic children in Nigeria (n = 15) and South Africa (n = 10) using structured and unstructured questionnaire. Results showed that women often experienced stress in relationship to multiple and substantial caregiving roles while men commonly limited their caregiving roles based on a patriarchal ideology related to their culture.

Co-occurrence of Neurodevelopmental Disorders Predict Caretaker Mental Health in a Latinx Sample

Caretakers to children and adults with neurodevelopmental disorders (NDDs) experience more emotional distress compared to community control samples. Risk factors for poorer mental health among this population include symptom severity and an autism spectrum disorder diagnosis. This study aimed to ascertain a relationship between NDD severity and caretakers' mental health. It was hypothesized that co-occurrence of multiple diagnoses would predict higher anxiety and depressive symptomatology and suicidality. Data was collected from a sample of 93 Latinx caregivers to a child or adult with at least one NDD. Multiple NDDs predicted higher levels of anxiety and depression compared to the symptom severity endorsed by caregivers to those with a single NDD diagnosis, but did not predict increased suicidality endorsement. Because caregivers to those with multiple NDDs are at an elevated risk for depression and anxiety, clinicians should consider screening for internalizing disorders in caregivers when treating individual with an NDD.

A Randomized, Community-Based Feasibility Trial of Modified ESDM for Toddlers with Suspected Autism

A randomized feasibility trial of a parent coaching (PC) intervention was conducted across 16 community agencies in a Canadian province. Parents of toddlers with suspected autism were assigned to either a PC group (n = 24) or an enhanced community treatment (ECT) group (n = 25). PC participants received 24 weeks of coaching support from community service providers trained in the project. Children in both groups also received available community services and supplementary materials. PC children made significantly greater gains in word understanding and PC parents had significantly higher quality of life, satisfaction, and self-efficacy scores. Results are discussed in terms of the challenges of conducting feasibility studies in community settings and the lessons learned in the project.

Effects of COVID-19 on children with autism

The coronavirus disease 2019 (COVID-19) pandemic affects all countries and populations worldwide, significantly impacting people with autism with a high risk of morbidity and mortality due to COVID-19. Approximately 25% of children with autism have an asymptomatic or symptomatic immune deficiency or dysfunction. In addition, they frequently have various comorbid conditions that increase the severity of COVID-19. In addition, severe COVID-19 during pregnancy may increase the risk of autism in the offspring. Furthermore, severe acute respiratory syndrome coronavirus 2 could target human nervous system tissues due to its neurotrophic effects. The COVID-19 pandemic intensely impacts many patients and families in the autism community, especially the complex management of autism-associated disorders during the complete lockdown. During the complete lockdown, children with autism had difficulties coping with the change in their routine, lack of access to special education services, limited physical space available, and problems related to food and sleep. Additionally, children with autism or intellectual disabilities are more liable to be abused by others during the pandemic when the standard community supports are no longer functioning to protect them. Early detection and vaccination of children with autism against COVID-19 are highly indicated. They should be prioritized for testing, vaccination, and proper management of COVID-19 and other infectious diseases. In this review, we discuss the various effects of COVID-19 on children with autism, the difficulties they face, the increased risk of infection during pregnancy, how to alleviate the impact of COVID-19, and how to correct the inequalities in children with autism.

Relationship between parental mental health and developmental disorders in early childhood

Social intervention with children with disabilities and their families should be understood through the principles of family-centred practice. In Spain, early intervention is understood as interventions aimed at children from 0 to 6 years old and their families. Professionals carry out the reception, assessment and intervention. This study aims to analyse the relationship between mental and physical health, caregivers' levels of anxiety and depression and the child's development during the fostering and assessment phase. The sample is made up of 135 families using child development centres in the Balearic Islands. Four questionnaires were completed: Health-Related Quality of Life SF-12, Anxiety and Depression Scale, Child Behaviour Checklist (CBCL 1½-5) and socio-demographic questionnaire. The results show that parents of children with disabilities have higher levels of mental health impairment than physical health impairment. They also score higher on anxiety than on depression. It is worth noting that professional discipline is a variable to be taken into account in relation to parents' perception of their child's developmental improvement. In addition, the association between the developmental subscales, where the more the child is affected, the more the parents' mental health is affected. The same pattern occurs with caregivers' levels of anxiety and depression. In short, we propose a reflection on the application of family-centred practices during interventions, understanding the lack of professional training as a predictor of the quality of early intervention.

Quality of life of parents of children with Autism Spectrum Disorder: An integrative literature review

PURPOSE

This paper presents an integrated literature review of the quality of life (QOL) in parents of individuals with Autism Spectrum Disorder (ASD). The rate of ASD is increasing. Parents of children with ASD have higher levels of stress and burden, which may lead to lower QOL.

DESIGN AND METHODS

A comprehensive, electronic search was performed to retrieve 15 relevant articles, including 5565 participants. An integrative review was performed to appraise and synthesize findings.

RESULTS

QOL was found to be lower in parents of children with ASD in physical, psychological, and social health and in spirituality, as compared with adults who were not parents of children with ASD. The strongest risk factor for parental QOL was the severity of the diagnosis of ASD. Protective factors for parental QOL were parent education level and levels of severity of ASD in the child.

PRACTICE IMPLICATIONS

Nurses can support families impacted by ASD, particularly severe ASD, through tailored resources to support early diagnosis and intervention, through the support of policies affecting low-income families, and through increased awareness of severe ASD and its' impact on the child and the family.

Mental Health and Resilient Coping in Caregivers of Autistic Individuals during the COVID-19 Pandemic: Findings from the Families Facing COVID Study

Many caregivers of autistic people experience mental health issues, and the impact of disruptions due to COVID-19 may present additional challenges for these individuals. This study characterized caregiver stress, anxiety, and resilient coping during COVID-19 and investigated the impact of COVID-19 disruptions, demographic variables, and resilient coping on mental health. The majority of caregivers reported some degree of disruption associated with COVID-19, and more than half reported moderate levels of stress and high anxiety. Resilient coping did not emerge as a moderator between COVID-19 disruptions and caregiver mental health, but instead had a direct effect on outcomes. Future research is needed to understand additional factors impacting the mental health of caregivers of autistic people during the COVID-19 pandemic.

Sensory integration therapy for children with autism and sensory processing difficulties: the SenITA RCT

BACKGROUND

Carers report unmet need for occupational therapy services addressing sensory difficulties in autism, yet insufficient evidence exists to recommend a therapeutic approach.

OBJECTIVES

Our aim was to determine the clinical effectiveness and cost-effectiveness of sensory integration therapy for children with autism and sensory difficulties across behavioural, functional and quality-of-life outcomes.

DESIGN

We carried out a parallel-group randomised controlled trial, incorporating an internal pilot and a process evaluation. Randomisation utilised random permuted blocks.

SETTING AND PARTICIPANTS

Children were recruited via services and self-referral in Wales and England. Inclusion criteria were having an autism diagnosis, being in mainstream primary education and having definite/probable sensory processing difficulties. Exclusion criteria were having current/previous sensory integration therapy and current applied behaviour analysis therapy.

INTERVENTION

The intervention was manualised sensory integration therapy delivered over 26 weeks and the comparator was usual care.

OUTCOMES

The primary outcome was problem behaviours (determined using the Aberrant Behavior Checklist), including irritability/agitation, at 6 months. Secondary outcomes were adaptive behaviour, functioning and socialisation (using the Vineland Adaptive Behavior Scales); carer stress (measured using the Autism Parenting Stress Index); quality of life (measured using the EuroQol-5 Dimensions and Carer Quality of Life); functional change (according to the Canadian Occupational Performance Measure); sensory processing (determined using the Sensory Processing Measure™ at screening and at 6 months to examine mediation effects); and cost-effectiveness (assessed using the Client Service Receipt Inventory). Every effort was made to ensure that outcome assessors were blind to allocation.

RESULTS

A total of 138 participants were randomised (n = 69 per group). Usual care was significantly different from the intervention, which was delivered with good fidelity and adherence and minimal contamination, and was associated with no adverse effects. Trial procedures and outcome measures were acceptable. Carers and therapists reported improvement in daily functioning. The primary analysis included 106 participants. There were no significant main effects of the intervention at 6 or 12 months. The adjusted mean difference between groups on the Aberrant Behavior Checklist - irritability at 6 months post randomisation was 0.40 (95% confidence interval -2.33 to 3.14; p = 0.77). Subgroup differences in irritability/agitation at 6 months were observed for sex of child (intervention × female = 6.42, 95% confidence interval 0.00 to 12.85; p = 0.050) and attention deficit hyperactivity disorder (intervention × attention deficit hyperactivity disorder = -6.77, 95% confidence interval -13.55 to -0.01; p = 0.050). There was an effect on carer stress at 6 months by region (intervention × South England = 7.01, 95% confidence interval 0.45 to 13.56; p = 0.04) and other neurodevelopmental/genetic conditions (intervention × neurodevelopmental/genetic condition = -9.53, 95% confidence interval -18.08 to -0.98; p = 0.030). Carer-rated goal performance and satisfaction increased across sessions (p < 0.001), with a mean change of 2.75 (95% confidence interval 2.14 to 3.37) for performance and a mean change of 3.34 (95% confidence interval 2.63 to 4.40) for satisfaction. Health economic evaluation suggests that sensory integration therapy is not cost-effective compared with usual care alone.

LIMITATIONS

Limitations included variability of the intervention setting (i.e. NHS vs. private), delay for some receiving therapy, an error in administration of Vineland Adaptive Behavior Scales and no measurement of comparator arm goal performance.

CONCLUSIONS

The intervention did not demonstrate clinical benefit above standard care. Subgroup effects are hypothesis-generating only. The intervention is likely to be effective for individualised performance goals, although it is unclear whether effects were in addition to standard care or were maintained.

FUTURE WORK

Further investigation of subgroup effects is needed.

TRIAL REGISTRATION

This trial is registered as ISRCTN14716440.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 29. See the NIHR Journals Library website for further project information.

The Influence of ASD Severity on Parental Overload: The Moderating Role of Parental Well-Being and the ASD Pragmatic Level

The aim of the present study is to analyze the relation between the severity of symptoms in people with ASD on their parents' overload, moderated by parental well-being and the ASD pragmatic level. A sample consisted of 28 fathers and mothers whose children had ASD. The obtained results showed that the higher the ASD severity, the better the parental overload was perceived if parents had low well-being levels. However, this relation did not occur if the parental well-being level was high. Moreover, the relation between severity and parental overload moderated by parental well-being occurred regardless of the pragmatic language level. Therefore, the main results of this study are that the responsibility for parental overload depends more on parental well-being than on the symptom severity of the person with ASD. The relevance of carrying out interventions with not only people with ASD, but also with their parents or caregivers for their well-being is highlighted.

How Do Sleep Disturbances Relate to Daytime Functions, Care-related Quality of Life, and Parenting Interactions in Mothers of Children with Autism Spectrum Disorder?

Sleep disturbance is prevalent in caregivers and associated with negative physical, mental, and functional outcomes. This study examined the effects of sleep disturbance on daytime functions (sleepiness, fatigue, mood, cognitive alertness), care-related quality of life, and daily parenting interactions in 20 mothers of children with autism spectrum disorder for 10 consecutive days using ecological momentary assessment design. Participants responded about daytime functions four times and care-related quality of life and daily parenting interactions once using an online survey. Sleep disturbance was significantly related to all daytime functions and frustration with childcare. Therefore, development of sleep hygiene interventions is warranted to effectively reduce the impact of sleep disturbance and enable these mothers to better tackle daily physical and mental challenges.

Homicide Incidents Involving Children with Autism Spectrum Disorder as Victims Reported in the US News Media, 2000-2019

Recent research indicates that children with autism are at increased risk of maltreatment. We examined news media reports on homicide incidents involving children with autism as victims in the United States between 2000 and 2019. Of the 52 victims studied, 47 (90.4%) were male. Age of victims ranged from 2 to 20 years (mean = 10.4 ± 5.3 years). Parents and other caregivers accounted for 63.5% and 13.5% of the perpetrators, respectively. The leading injury mechanism was gunshot wounds (23.1%), followed by drowning (19.2%), and suffocation, strangulation, or asphyxiation (19.2%). The most commonly cited contributing factor (47.1%) was overwhelming stress from caring for the autistic child. These results underscore the importance of supporting services for caregivers of children with autism.

Who’s waiting for a school? Rates, socio-demographics, disability and referral profile of children with autism spectrum disorder awaiting school placement in the Western Cape Province of South Africa

In this study, we examined the demographic, disability, referral and service needs profile of children with autism spectrum disorder waiting for school placement in the Western Cape Province of South Africa and combined our findings with those of a previous study on children with autism spectrum disorder attending schools in the province over the same period of time. In June 2016, there were 744 children with autism spectrum disorder or suspected autism spectrum disorder waiting for an appropriate school placement, 478 children were pre-school age and 266 children were school-going age. Fifty-three percent (53%) of pre-school age children and 38% of school-going age children were reported to be at home and receiving no educational or other intervention while they waited for a school. More than half the children on the waiting list had been waiting for services for more than a year. The combined data on children with autism spectrum disorder in school and waiting for schools showed a total of 1684 known children with autism spectrum disorder in the Western Cape in June 2016, representing less than 0.1% of the childhood population in the province. The results highlight the need for education systems strengthening to accommodate all children with autism spectrum disorder in appropriate educational settings from as early as possible. We propose multi-stakeholder engagement to develop contextually appropriate policies, best practice guidelines and actions for the education of children with autism spectrum disorder in South Africa.

Lay abstract

In South Africa, there are limited educational opportunities for children with autism spectrum disorder and many children with autism spectrum disorder have to wait for school placement. This study examined the education waiting list for children with autism spectrum disorder in the Western Cape Province of South Africa and reported on the demographic, disability, referral and service provision characteristics of these children. In June 2016, there were 744 children with definite autism spectrum disorder or possible autism spectrum disorder between the ages of 1 and 17 years waiting for school placement. There were children of compulsory school-going age who were reported to be at home and not receiving any intervention while they waited. More than half the children on the waiting list had been waiting for more than a year. We then combined the findings of this study with the findings of a previous study on children with autism spectrum disorder already attending schools in the province over the same period of time. We found a total of 1684 children known to have autism spectrum disorder – this was less than 0.1% of all young people in the province at the time. Between 2012 and 2016, there was a 276% increase in the number of children with autism spectrum disorder waiting for schools in the Western Cape. The results show that education systems in the Western Cape need to be strengthened to accommodate all children with autism spectrum disorder in appropriate education settings from as early as possible. We recommend engaging with different stakeholders to develop policies, best practice guidelines and actions for autism spectrum disorder education in South Africa.

Caregiver strain and its predictors among parents of autistic children: a cross-sectional study

Objective: This study estimates the frequency and predictors of caregiver strain (CGS) among parents of autistic children.Methods: Demographic details and CGS were collected through a validated tool from 403 parents of autistic children in Karachi, Pakistan. Regression modelling was performed to report associations between social, behavioural, and communication problems and socioeconomic predictors of CGS. Results were reported using adjusted beta-coefficients with 95% confidence intervals.Results: In total, 88.3% of the parents reported moderate to severe CGS. A high family income (β = -4.31, 95% CI -7.55, -0.11), and caregiver's higher level of education (β = -4.73, 95% CI -8.84, -0.61), along with care-recipient age group (β = -9.35, 95% CI -15.17, -3.52) significantly predicted lower CGS. Diagnosis of more than 5 years (β = 7.57, 95% CI 2.36, 12.79), tendency to self-harm (β = 10.75, 95% CI 6.62, 14.88), and social withdrawal in the care-recipient (β = 4.56, 95% CI 1.68, 7.44) were significantly associated with higher CGS.Conclusion: Parents of children on the autistic spectrum suffer from high CGS. There is a need to introduce tailored parenting interventions at the individual and community levels to help parents reduce the CGS, ultimately benefiting their child.

Effectiveness of Online-Delivered Project ImPACT for Children With ASD and Their Parents: A Pilot Study During the COVID-19 Pandemic

OBJECTIVE

During the COVID-19 pandemic, face-to-face intervention services for families of children with autism spectrum disorder (ASD) were limited. This study aimed to evaluate the effectiveness of an 8-week, online-delivered Project ImPACT program for children with ASD and their parents in China during the COVID-19 pandemic.

METHODS

A pilot non-randomized study with a waitlist control group was conducted in 68 children with ASD and their parents in the Department of Developmental and Behavioral Pediatrics between April 15, 2020 and March 19, 2021. Participants were allocated to either the intervention (IG) or the waitlist group (WLG) according to their order of recruitment. Parents in the IG immediately received 8 weeks of the online-delivered Project ImPACT program, and the WLG received the same program with a delay when the IG had completed all sessions. Participants in both groups received treatment as usual during the research period.

RESULTS

The online-delivered Project ImPACT program significantly improved the parent-reported social communication skills of children with ASD. Furthermore, parent's involvement in the training program produced a collateral reduction in parenting stress and an increase in perceived competence in the parental role. Parents rated the program acceptable in terms of curriculum schedule, session content, homework assignments, and therapist feedback.

CONCLUSIONS

The 8-week, online-delivered Project ImPACT program is a feasible and effective social skill training program for families of children with ASD in China during the COVID-19 pandemic. Due to the methodological limitations, randomized controlled studies with larger sample sizes are suggested to provide more solid evidence.

Age of diagnosis, service access, and rights of autistic individuals in Argentina: Caregivers reports of changes and similarities across time

BACKGROUND

Many countries have developed health initiatives to protect those with disabilities and developmental concerns in the past few years. However, the needs of autistic individuals are still short of being fulfilled. Partially due to limited research expenditure, which would allow bridging the gap between evidence and practice, the long time it takes to implement passed laws, and the limited operationalization of inclusive policies.

OBJECTIVE

To quantitatively examine changes in the child's age at the time of caregiver's first developmental concerns and age of diagnosis of their autistic child across 5 years. Also, to address challenges experienced by caregivers (e.g., reported service barriers) and the work still needing to be done in Argentina based on caregivers' reports of their priorities (e.g., ensuring their child receives better services).

METHODS

Two independent samples of caregivers of autistic individuals were surveyed by the Red Espectro Autista Latinoamerica (REAL) in 2015 (n = 763) and the World Health Organization (WHO) in 2020 (n = 422). Similar items in both surveys were compared through descriptive inferential analysis and chi-square tests for categorical variables.

RESULTS

Compared to the 2015 sample, for the 2020 sample, more caregivers reported an earlier age of first concerns and an earlier age of a professional diagnosis. In the 2020 sample, more children diagnosed before the age of three had a doctor or a teacher noticing the first developmental concern. Also, in this sample, fewer caregivers reported service barriers (e.g., limited availability, waitlist, costs, etc.) and a need for better social support and better health services. However, rates of caregivers indicating a need for more rights for autistic individuals and greater protection of existing rights increased. There was no change in the reported rate of family members who stopped working to care for the autistic individual. For both samples, there was statistically significant differences in individual (physician, teacher, caregiver) noticing first developmental concern and the age of diagnosis, with the majority having a caregiver noticing the first concern.

CONCLUSION

The 5 years that separate both samples show an improvement in developmental concerns being noticed, a decrease in age of diagnosis, and an improvement in several service areas such as community awareness. Also, caregivers reported fewer barriers to service accessibility, thus suggesting a positive impact stemming from changes in public policies, non-profit organizations' work through awareness campaigns, and advocates' strives toward greater awareness. Nonetheless, a similar proportion of family members reported ceasing working to care for autistic individuals and perceived that the fundamental rights of their autistic children needed to be protected. These results imply that despite better care pathways in Argentina, there are still gaps when attempting to meet the needs of autistic individuals and their families. The present study provides a meaningful understanding of existing gaps and help exemplify the perceived improvements when non-profit agencies and advocates promote increased rights and community awareness in addition to the established laws focusing on ASD.

Investigating the Associations Between Child Autistic Symptoms, Socioeconomic Context, and Family Life: A Pilot Study

Objective: The day-to-day experience of families with an Autistic child may be shaped by both, child characteristics and available resources, which often are influenced by the socioeconomic context of the family. Using a socioecological approach, this study explored the quantitative associations between child autistic symptoms, family socioeconomic status, and family life.

Methods: Data came from the Pediatric Autism Research Cohort—PARC Study (pilot). Parents of children with a recent diagnosis of autism completed a set of assessments, including the Autism Family Experience Questionnaire, Autism Impact Measure, and a Sociodemographic Questionnaire. A series of multiple, iterative linear regression models were constructed to ascertain quantitative associations between child autistic symptoms, socioeconomic context, and family life.

Results: A total of 50 children (mean age: 76 months; SD: 9.5 months; and 84% male) with data on the variables of interest were included in the analysis. The frequency of child autistic symptoms was associated with family life outcomes (p = 0.02 and R² = 24%). Once autistic symptom frequency, symptom impact, and sociodemographic variables were considered, parents of higher educational attainment reported worse family life outcomes compared to their lesser-educated counterparts. This cumulative regression model had considerable explanatory capability (p = 0.01, R² = 40%).

Conclusion: This study demonstrates the utility of using a socioecological approach to examine the dynamic interplay between child characteristics and family circumstances. Our findings suggest that family life for parents (of an autistic child) who have obtained higher education is reported (by the parents themselves) as less satisfactory compared to that of parents without higher education, once adjusted for the autistic symptom frequency of child, symptom impact, and income. These findings can inform the design and delivery of more family-centered care pathways during the years following a diagnosis of autism.

Caring for Children with an Autism Spectrum Disorder: Factors Associating with Health- and Care-Related Quality of Life of the Caregivers

This study investigated the association of child, caregiver, and caregiving measurements with the quality of life (QoL) in 81 caregivers (mostly parents) of clinically referred children with autism spectrum disorder (ASD). We used the EuroQol five-dimensional (EQ-5D) questionnaire and the care-related QoL questionnaire (CarerQol) to respectively assess health-related QoL and care-related QoL. Health-related QoL was associated with the caregiver’s internalizing problems and adaptive coping, explaining 38% of the variance. Parenting stress and adaptive coping were associated with the care-related QoL and explained 60% of the variance. Child variables were not associated with the caregiver’s health- and care-related QoL if caregiver and caregiving variables were taken into account. Findings indicate the importance of the caregiver’s mental health, coping, and parenting stress in caring for children with ASD.

The relationship between irritability and autism symptoms in children with ASD in COVID-19 home confinement period

OBJECTIVE

This study investigated the impact of COVID-19 home confinement on autism spectrum disorder (ASD) symptoms and irritability in children and adolescents with ASD.

METHOD

The study participants included 46 drug-naive children aged 4-17 years diagnosed with ASD. Parents of the participants completed the Autism Behaviour Checklist (AuBC) and Affective Reactivity Index (ARI) scales for both normal conditions and COVID-19 home confinement.

RESULTS

All subscale scores for AuBC (sensory, relating, body and object use, language, and social and self-help) and ARI scores significantly increased during the COVID-19 home confinement period (P < .05). The participants' irritability and ASD symptoms were significantly worse during the COVID-19 outbreak and home confinement period compared to normal conditions. The variables that predicted irritability were the social and self-help subscales of AuBC.

DISCUSSION

These results have alerted us of the importance of focusing on the symptoms such as irritability exhibited by extremely vulnerable populations during disease outbreaks and of the necessity of developing new strategies to avoid such adverse outcomes in similar situations.

Quality of Life and Child's Autism-Specific Difficulties among Malaysian Main Caregivers: A Cross-Sectional Study

Caring for children with autism spectrum disorder (ASD) negatively impacts quality of life (QoL). This cross-sectional study aimed to determine the factors associated with perceived QoL and how problematic a child's autism-specific difficulties are among the main caregivers of children with ASD who attend specialized preschool programs at the National Autism Society of Malaysia and IDEAS Autism Centre located in Selangor and Kuala Lumpur. Utilizing the questions from Parts A and B of the Quality of Life in Autism Questionnaire (QoLA), the data from 116 responders were analyzed using univariate and multivariate linear regression. The mean scores of Part A and Part B were 88.55 ± 17.25 and 56.55 ± 12.35, respectively. The QoL was significantly associated with staying in an apartment/flat -11.37 (95%CI: -19.52, -1.17, p = 0.008), main caregivers attending two training sessions 10.35 (95%CI: 1.17, 19.52, p = 0.028), and more than three training sessions 13.36 (95%CI: 2.01, 24.70, p = 0.022). Main caregiver perceptions of their child's autistic-specific difficulties were significantly associated with not receiving additional help for childcare: no maid -13.54 (95%CI: -24.17, -12.91, p = 0.013); no grandparent -8.65 (95%: -14.33, -2.96, p = 0.003); and main caregivers not having asthma 8.44 (95%CI: 0.02, 16.86, p = 0.049). These identified factors can be considered to inform main caregivers and health care providers on targeted ways to improve the QoL of main caregivers.

Challenges of the Caregivers in Managing a Child with Autism Spectrum Disorder- A Qualitative Analysis

BACKGROUND

Autism spectrum disorder (ASD) is a complex neurological condition resulting in impaired social interaction and difficulty in understanding verbal and nonverbal communication. Caring for children with ASDs is challenging for both children and their caregivers. The child suffering from ASD starts to show the developmental outcome during early 2.5-3 years and continues thereafter till the child turns to an adult. Many caregivers face severe financial crises, high out-of-pocket healthcare expenses, and unemployment. Previous studies have reported a plethora of psychosocial problems affecting caregivers of children with ASD, ranging from stress, depression, anxiety, restrictions of activities, strain in marital relationships, and diminished physical health.

OBJECTIVE

This article aims to explore the concerns of the caregivers of children suffering from ASD. Aggregate themes were prepared based upon Corley and Gioia's method of data structuring.

METHODS

After development and validation of an interview schedule, verbatim of seven caregivers of children with ASD were imported on the Atlas.ti version 8. Initial coding and final coding were followed by extracting the aggregate themes. Lincoln and Guba's framework was used to assess the quality criteria as a part of qualitative analysis.

RESULTS

Caregivers face various challenges while caring for a child with ASD, with a negative impact on physical health, psychological well-being, societal reactions, and financial balance. Caregivers reported concerns related to service availability for ASD, poorly coping with the diagnostics, and disease processes.

CONCLUSIONS

Caregivers undergo a lot of problems while taking care of a child with ASD. Health professionals must have an understanding of these problems and must provide the education and information for a better management. Furthermore, the findings of this study have policy implications for the health authorities for providing better health services to children diagnosed with ASD.

Quality of Life in Caregivers of Children and Adolescents with Autistic Spectrum Disorder: Development and Validation of the Questionnaire

Studies have shown that children and adolescents with autism and their relatives present a high level of stress and more family problems, impacting parents' and caregivers' quality of life (QoL). Despite studies on this subject, there is no specific questionnaire to evaluate QoL in parents or caregivers of children and adolescents with an autistic spectrum disorder (ASD) in Brazil. Therefore, this study's primary purpose was to develop and validate a specific questionnaire to evaluate QoL in these individuals. The study was performed using the following steps: development of the ASD Parent/caregiver QoL questionnaire (autistic spectrum disorder parent/caregiver quality of life-ASDPC-QoL), subjective evaluation, validation of the questionnaire by the Delphi method, assessment of internal consistency, responsiveness, and reliability of the ASLPC-QoL, and administration of the questionnaire to 881 Brazilian ASD caregivers or parents. ASDPC-QoL comprises 28 questions divided into four domains (social, concerns, physical and mental health) with good psychometric properties (reproducibility, reliability, internal consistency, responsiveness, and validity). Our data showed that worries and physical health were the domains with the lowest scores in ASDPCA-QoL. ASDPCA-QoL did not differ among gender and age of child considering the total and all domains. Older participants (≥41 y/o) presented the best scores for social and worries domains but did not differ in other domains and the total. Parents or caregivers of ASD children diagnosed for more than three years have better mental and physical health domains than those recently diagnosed (up to 1 year) but did not differ in the total and other domains. Individuals with a partner and with the highest educational level present the best score for the social domain. Employed individuals showed better scores than unemployed ones for all domains and the total, except for worries, which did not differ. It also occurred comparing the individuals that do not use antidepressants and the ones that use them. Assessing and better understanding the QoL of caregivers is highly relevant. By understanding the social, worries, physical, and emotional health domains of caregivers, it is possible to track harmful aspects, prevent and treat pathologies, in addition to assisting in the implementation of effective public policies.

A peer interview qualitative study exploring support for carers of people with comorbid autism and eating disorders

BACKGROUND

Carers of people with eating disorders (EDs) are known to experience a lack of support, high levels of unmet needs and resulting distress. Specific support and interventions for carers may benefit both the carer, and their loved one with an ED. Individuals with co-occurring autism and EDs may present with additional needs and difficulties relating to their Autism Spectrum Condition (ASC) that impact their carers. However, there is a lack of research exploring whether carers of people with ASC and EDs have specific support needs, and what kinds of support may be most beneficial for this population.

METHODS

This study used a qualitative interview design, utilising peer interviews. Eleven carers participated in interviews about their experiences as a carer, and their views on existing support systems and potential improvements. As the study took place during the initial UK coronavirus lockdown, the impact of the lockdown also emerged as a topic during the interviews. Interviews were transcribed and analysed using thematic analysis.

RESULTS

Five themes were identified: challenges associated with co-occurring Autism and EDs, a lack of existing support for carers from healthcare services, the personal impact of caring for someone with both ASC and EDs, ideas for how carers can be best supported, and the impact of the coronavirus on carers.

CONCLUSIONS

Carers of loved ones with both ASC and EDs described the experience as having a significant personal impact on their lives, but also experienced a lack of support from healthcare services. There was a perception that caring for someone with both an ASC and EDs presents additional challenges compared to caring for someone with an ED only, and that this population therefore requires specialised support. Recommendations for possible support options, and for further research, are outlined.

Grant Report on mCARE: Mobile-Based Care for Children with Autism Spectrum Disorder (ASD) for Low- and Middle-Income Countries (LMICs)

In low- and middle-income countries, especially in Bangladesh, Autism Spectrum Disorder (ASD) may be considered an anathema, and social-cultural-financial constraints mean that there are few facilities available for treatment for ASD children. The revolution in the use of the mobile phone (~80%) by the majority of people in Bangladesh in recent years has created an opportunity to improve the overall scenario in the treatment or remote monitoring process for children with ASD. In this grant project, we planned and developed a mobile phone-based system to remotely monitor children with ASD and help their treatment process both at the caregiver and care practitioner ends. In developing mCARE, we utilized a Remote Experience Sampling Method to design, build, deploy, and study the impact of mobile based monitoring and treatment of children with ASD in Bangladesh. We developed a mobile application using the Experience Sampling Method (ESM). A caregiver routinely reported the behavioral and milestone parameters of their children with ASD. The care practitioners monitored the longitudinal data that helped them in decision-making in a particular patient’s treatment process. The Value Sensitive Design (VSD) was used to make this mobile application more user friendly with consideration of the local economic, social, and cultural values in Bangladesh.

What's the Cost? Measuring the Economic Impact of Pediatric Sepsis

Sepsis, life-threatening organ dysfunction secondary to infection, hospitalizes nearly 75,000 children each year in the United States. Most children survive sepsis. However, there is increasing recognition of the longer-term consequences of pediatric sepsis hospitalization on both the child and their family, including medical, psychosocial, and financial impacts. Here, we describe family spillover effects (the impact of illness on caregivers) of pediatric sepsis, why measurement of family spillover effects is important, and the ways in which family spillover effects can be measured.

A validation study of the CarerQol instrument in informal caregivers of people with dementia from eight European countries

PURPOSE

Informal care constitutes an important part of the total care for people with dementia. Therefore, the impact of the syndrome on their caregivers as well as that of health and social care services for people with dementia should be considered. This study investigated the convergent and clinical validity of the CarerQol instrument, which measures and values the impact of providing informal care, in a multi-country sample of caregivers for people with dementia.

METHODS

Cross-sectional data from a sample of 451 respondents in eight European countries, collected by the Actifcare project, were evaluated. Convergent validity was analysed with Spearman's correlation coefficients and multivariate correlations between the CarerQol-7D utility score and dimension scores, and other similar quality of life measures such as CarerQol-VAS, ICECAP-O, and EQ-5D. Clinical validity was evaluated by bivariate and multivariate analyses of the degree to which the CarerQol instrument can differentiate between characteristics of caregivers, care receivers and caregiving situation. Country dummies were added to test CarerQol score differences between countries.

RESULTS

The mean CarerQol utility score was 77.6 and varied across countries from 74.3 (Italy) to 82.3 (Norway). The scores showed moderate to strong positive correlations with the CarerQol-VAS, ICECAP-O, and EQ-5D health problems score of the caregiver. Multivariate regression analysis showed that various characteristics of the caregiver, care receiver and caregiving situation were associated with caregiver outcomes, but there was no evidence of a country-level effect.

CONCLUSION

This study demonstrates the convergent and clinical validity of the CarerQol instrument to evaluate the impact of providing informal care for people with dementia.

Validation of the Hungarian version of the CarerQol instrument in informal caregivers: results from a cross-sectional survey among the general population in Hungary

Purpose

The CarerQol instrument has been designed and validated as an instrument able to measure both the positive and the negative impacts of caregiving on the quality of life of informal caregivers (CarerQol-7D), as well as their general happiness (CarerQol-VAS). The aim of this study was to assess the construct validity of the CarerQol in the Hungarian context.

Methods

The CarerQol was translated into Hungarian. Subsequently, in a cross-sectional online survey, representative for the general Hungarian population (N = 1000), informal caregivers were identified (N = 149, female 51.2%, mean age 53.2). Clinical, convergent and discriminant validity of the CarerQol were evaluated in relation to the caregivers’ and care recipients’ EQ-5D-5L health status, and caregiving situation characteristics.

Results

Average CarerQol-7D and CarerQol-VAS scores were 76.0 (SD 16.2) and 6.8 (SD 2.3), respectively. CarerQol-7D and CarerQol-VAS scores were significantly correlated with caregiving time (r = − 0.257; − 0.212), caregivers’ EQ-5D-5L scores (r = 0.453; 0.326) and the CarerQol-7D also with care recipients’ EQ-5D-5L scores (r = 0.247). CarerQol-7D scores differed significantly with relevant caregiving characteristics (e.g. nature and severity of care recipients’ health status, sharing household) and both the CarerQol-7D and CarerQol-VAS with the overall care experience.

Conclusion

Our findings confirmed the validity of the Hungarian language version of the CarerQol and support the cross-cultural validity of the instrument. CarerQol-7D scores performed better in distinguishing caregiving situation characteristics than the general happiness measure CarerQol-VAS. Care recipients’ health status was only weakly associated with informal caregivers’ care-related quality of life and happiness. Caregivers’ own health and caregiving circumstances were more strongly associated with these scores.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02662-8) contains supplementary material, which is available to authorized users.

The relationship between chronotype, sleep, and autism symptom severity in children with ASD in COVID-19 home confinement period

This study aimed to investigate the relationship between chronotype preference/sleep problems and symptom severity of children with Autism spectrum disorder (ASD) during the confinement and social isolation of the COVID-19 outbreak. This study included 46 drug-naive children aged 4-17 y diagnosed with ASD. The Autism Behavior Checklist (AuBC), Children's Sleep Habits Questionnaire (CSHQ), and Children's chronotype questionnaire (CCQ) were filled out before and at the end of the COVID-19 mandated home confinement by the children's parents. Children with ASD during the home confinement reported higher chronotype scores, i.e., eveningness chronotype, sleep problems, and autism symptom scores compared to the normal non-hone confinement state. The chronotype score and sleep problems of children with ASD during the home confinement period varied according to the AuBC score. The sleep problems of the children with ASD during the home confinement period mediated the relationship between chronotype score and severity of autism symptoms. It is essential to validate the role of the mediator effect of sleep problems and chronotype in larger samples of children with ASD with restricted to home confinement during the pandemic period. If sleep problems can be controlled with parental education, pharmacotherapy, and psychotherapeutic interventions, the impact on children with ASD of home confinement can be reduced.

"Mom Let's Go to the Dentist!" Preliminary Feasibility of a Tailored Dental Intervention for Children with Autism Spectrum Disorder in the Italian Public Health Service

Children with autism spectrum disorder (ASD) show worse oral health than their peers. Their access to health services is, at present, inadequate: few high-quality interventions have been designed and implemented to improve their care procedures so far. The purpose of this study is to describe an experience of dental care supported by Information and Communication Technologies (ICT), for children with ASD in a public health service. In our study, 59 children (mean age 9.9 years; SD = 5.43) participated in the MyDentist project. It integrates classic dental care techniques with new practices for desensitization and fear control, delivered through an enhanced customized ICT-based intervention aiming at familiarizing the child with ASD with the medical setting and procedures. Two questionnaires were filled out by parents to describe the acceptability of the MyDentist experience for their children. Significant results were shown from T0 (before initiating MyDentist) to T1 (after 6 months of the MyDentist experience) regarding improved oral hygiene and cooperation during dental treatments. Families positively assessed the use of ICT support. In conclusion, the project demonstrated acceptability by parents, suggesting that public health dental care and prevention can be successfully implemented without resorting to costly pharmacological interventions (with potential side effects), taking better care of children's health.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

FUTURE WORK

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

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068303.

FUNDING

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

Children with an Autism Spectrum Disorder and Their Caregivers: Capturing Health-Related and Care-Related Quality of Life

This study investigated health-related QoL (HRQoL) and care-related quality of life (CarerQol) in clinically referred children with an autism spectrum disorder (ASD), and their primary and secondary caregivers. The EuroQol five-dimensional (EQ-5D) and the CarerQol questionnaires were used to respectively measure health-related QoL and care-related QoL. Primary caregivers reported pain/discomfort (42%) and anxiety/depression (40%). In caring, they mostly experienced problems in the relationship with the child (84%), and in combining care with daily activities (51%). Children with ASD had a relevantly lower QoL. Despite negative effects, almost all caregivers (96%) derived fulfillment from caring for their affected children. HRQoL and CarerQol reports of primary caregivers and children were correlated, both providing useful information to ASD measurement and treatment.

Quality of Life Among Informal Caregivers of Patients With Degenerative Cervical Myelopathy: Cross-Sectional Questionnaire Study

Background

Degenerative cervical myelopathy (DCM) is a common, chronic neurological condition that severely affects individuals by causing a range of disabling symptoms, frequently at a time around the peak of their careers. Subsequently, individuals with DCM often become dependent on informal care arrangements. The significant economic contribution of informal care and its burden on care providers are becoming increasingly recognized.

Objective

This study aimed to measure the quality of life of DCM informal caregivers and provide preliminary insight into possible contributing factors.

Methods

Carers of individuals with DCM completed a Web-based survey hosted by Myelopathy.org, an international DCM charity. Carer quality of life was assessed in the form of caregiver happiness and 7 dimensions of carer burden using the Care-Related Quality of Life (CarerQol) instrument. The relationships between patient disease severity, patient pain, and carer quality of life were investigated. Differences in carer quality of life were assessed across patient and carer demographic groups, including between UK and US carers.

Results

DCM caregivers experienced substantial burden as a result of their caregiving (mean CarerQol-7D=64.1; 95% CI 58.8-69.5) and low happiness (mean CarerQol-VAS [Visual Analog Scale]=6.3; 95% CI 5.7-6.9). Burden was high and happiness was low in DCM carers when compared with a large, mixed-disease study of adult informal carers where CarerQol-7D was 79.1 and CarerQol-VAS was 7.1. No significant relationship was found between DCM carer quality of life and patient disease severity and pain scores. DCM carer quality of life appeared uniform across all patient and carer demographic groups.

Conclusions

Caring for individuals with DCM is associated with reduced quality of life in the form of significant burden and reduced happiness. Reductions appear greater in DCM than in other diseases investigated. However, no simple relationship was identified between individual patient or carer factors and carer quality of life.

Practice Patterns for Early Screening and Evaluation for Autism Spectrum Disorder Diagnosis in Bulgaria

The aims of this study were to describe the practice patterns for early screening and evaluation for ASD diagnosis in Bulgaria, as well as to identify potential barriers and facilitators in this process. We surveyed a sample of pediatricians and pediatric psychiatrists to analyze the use of standardized instruments, application of biomarkers, parental collaboration and future policy prospects. We found a significant support for the idea of a national program for ASD in Bulgaria. These insights provide an evidence-based analysis that could help improve services, guide research and inform policies in regard to ASD. Further work is necessary to better understand other stakeholders' opinions and perspectives, especially those of patients and their families.

Spillover Effects on Caregivers' and Family Members' Utility: A Systematic Review of the Literature

BACKGROUND

A growing body of research has identified health-related quality-of-life effects for caregivers and family members of ill patients (i.e. 'spillover effects'), yet these are rarely considered in cost-effectiveness analyses (CEAs).

OBJECTIVE

The objective of this study was to catalog spillover-related health utilities to facilitate their consideration in CEAs.

METHODS

We systematically reviewed the medical and economic literatures (MEDLINE, EMBASE, and EconLit, from inception through 3 April 2018) to identify articles that reported preference-based measures of spillover effects. We used keywords for utility measures combined with caregivers, family members, and burden.

RESULTS

Of 3695 articles identified, 80 remained after screening: 8 (10%) reported spillover utility per se, as utility or disutility (i.e. utility loss); 25 (30%) reported a comparison group, either population values (n = 9) or matched, non-caregiver/family member or unaffected individuals' utilities (n = 16; 3 reported both spillover and a comparison group); and 50 (63%) reported caregiver/family member utilities only. Alzheimer's disease/dementia was the most commonly studied disease/condition, and the EQ-5D was the most commonly used measurement instrument.

CONCLUSIONS

This comprehensive catalog of utilities showcases the spectrum of diseases and conditions for which caregiver and family members' spillover effects have been measured, and the variation in measurement methods used. In general, utilities indicated a loss in quality of life associated with being a caregiver or family member of an ill relative. Most studies reported caregiver/family member utility without any comparator, limiting the ability to infer spillover effects. Nevertheless, these values provide a starting point for considering spillover effects in the context of CEA, opening the door for more comprehensive analyses.

Parent Preferences for Health Outcomes Associated with Autism Spectrum Disorders

BACKGROUND

Few studies have used preference-based quality-of-life outcomes to assess how autism spectrum disorders (ASDs) affect children and parents, and none have examined variation by ASD severity.

OBJECTIVE

Our objective was to derive parent valuations of child and parent health associated with varying ASD severity levels.

METHODS

Parents of children aged 3-17 years with and without ASD were selected from a nationally representative research panel to complete a survey. We asked parents time trade-off (TTO) questions to value their own and their child's current health. Parents of children with ASD were asked to report the severity of their child's core ASD symptoms. We calculated utility values from each TTO amount, and used a two-part regression model to estimate the change in parent-reported child health utility, as well as parent health utility, associated with ASD diagnosis and increasing symptom severity, controlling for respondent and child characteristics.

RESULTS

Sixty-nine percent of parents responded (final sample size was 135 in the ASD group and 120 in the comparison group). In adjusted analyses, there was a 0.12 (95% confidence interval [CI] 0.03-0.21) decrease in the parent-reported health utility of children with ASD, a 15% decrease from the mean health utility of children without ASD. On average, having a child with ASD was not significantly associated with a decrease in parent health utility, but there was a 0.14 (95% CI 0.01-0.26) reduction in health utility among parents of children with severe ASD, a 15% decrease from the comparison group mean.

CONCLUSIONS

Overall, ASD had a significant impact on parent-reported child health utility, and the health utility of parents of children with severe ASD.

Measuring Health Spillover Effects in Caregivers of Children with Autism Spectrum Disorder: A Comparison of the EQ-5D-3L and SF-6D

BACKGROUND AND OBJECTIVE

Healthcare interventions that improve the health of children with autism spectrum disorder (ASD) have the potential to affect the health of caregivers. This study compares the three-level EuroQoL-5 Dimension (EQ-5D-3L) and the Short Form-6 Dimension (SF-6D) in their ability to value such spillover effects in caregivers.

METHODS

Clinical data collected from two Autism Treatment Network (ATN) sites was combined with survey data of caregivers of children diagnosed with ASD. Caregivers completed instruments by proxy describing child health and completed the EQ-5D-3L and SF-6D preference-weighted instruments to describe their own health.

RESULTS

There was a strong correlation between the health utility scores of the two preference-weighted instruments (ρ = 0.6172, p < 0.001) measuring caregiver health-related quality of life. There was a similar correlation between both the SF-6D and EQ-5D-3L scores with a previously validated care-related quality of life measure (Care-related Quality of Life instrument [CarerQol-7D]) (ρ = 0.569, p < 0.001 and ρ = 0.541, p < 0.001, respectively). The mean SF-6D scores for caregivers differed significantly in relation to four of the five child health or behavior measures whereas the EQ-5D-3L differed for only two of them.

CONCLUSIONS

Health utility values of caregivers for children with ASD vary by the health characteristics of the child, suggesting significant potential for spillover effects. The comparison of the EQ-5D-3L and SF-6D demonstrated that both instruments can be used to estimate spillover effects of interventions to improve child health, but the SF-6D exhibited greater sensitivity to child health among children with ASD.