Increasing Responsive Parent-Child Interactions and Joint Engagement: Comparing the Influence of Parent-Mediated Intervention and Parent Psychoeducation

Prenatal, perinatal and parental risk factors for autism spectrum disorder in China: a case- control study

BACKGROUND

Autism spectrum disorder (ASD) is heritable neurodevelopmental disorders (NDDs), but environmental risk factors have also been suggested to a play a role in its development. Prenatal, perinatal and parental factors have been associated with an increased risk of ASD in children. The aim of the present study was to explore the prenatal, perinatal, and parenting risk factors in children with autism spectrum disorder (ASD) from Beijing, China by comparing them with typically developing (TD) children.

METHODS

A sample of 151 ASD children's parents who from rehabilitation institutions in Beijing were enrolled in this study, and an additional 151 children from kindergartens in Beijing were recruited as a control group (child age: mean = 4.4 years). TD children were matched according to age, sex and maternal education. We explored the maternal AQ (Autism Spectrum Quotient) scores (mean:19.40-19.71, no significant difference between two groups) to referring the genetic baseline. This study evaluated 17 factors with unadjusted and adjusted analyses.

RESULTS

Birth asphyxia was associated with a more than a thirteen-fold higher risk of ASD (adjusted odds ratio (AOR) = 13.42). Breastfeeding difficulties were associated with a higher risk of ASD(AOR = 3.46). Parenting influenced the risk of ASD, with low responding (LR) and harsh or neglectful parenting associated with a higher risk of ASD in offspring (AOR = 2.37 for LR, AOR = 3.42 for harsh parenting and AOR = 3.01 for neglectful parenting). Maternal fever during pregnancy was associated with a higher risk of ASD in offspring (AOR = 3.81).

CONCLUSIONS

Many factors were associated with ASD in offspring. Further assessment is needed to elucidate the role of modifiable environmental factors to inform prevention strategies.

Perceived Parent Needs for Improving Parent Participation in School-Based Therapies for Children with Disabilities Using the Parent-Therapist Partnership Survey

Rehabilitative and habilitative therapies can help children with disabilities increase independence and overall wellbeing. However, children and their caregivers face many barriers to accessing these therapies and often rely on the school for therapy access. Given the limited resources available within the special education system, increasing parent involvement in special education therapies could improve service delivery. However, providers must first understand what parents need to participate in therapies before attempting to engage families. 217 parents completed an online survey consisting of the Parent-Therapist Partnership Survey and demographic questionnaires about theirfamiliesand their child[ren] with disabilities. The percentage of needs parents endorsed as important and thepercentageofimportantneedsendorsedasunmetwere calculated. Differences across demographic variables were assessed. Overall, parents reported an average of 75% of needs as important with significantly more needs endorsed as important regarding being an informed, engaged member of the child's care team (M = 83%) than needs related to support and guidance (M = 65%, p < 0.001). Furthermore, parentsreportedan average of 58% of important needs as unmet, with no significant differences in subscale averages. Significant associations were found for race/ethnicity, education, income, partner availability, number of children with disabilities in the household, transportation access, neighborhood opportunities, parent efficacy and social, emotional, and behavioral concerns. Parents reported a high percentage of needs as important, but a large percentage of these important needs were considered unmet. Significant disparities based on racial/ethnic identities and access to resources were found. In order to successfully engage parents in special education therapy activities, providers must work to understand and address parents' engagement needs, paying special attention to each family's unique circumstances to optimize engagement.

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.

Maternal History of Adversity and Subsequent Mother-Child Interactions at Early Ages: A Systematic Review

Adverse childhood experiences (ACEs) can negatively impact physical, emotional, cognitive, and social development, consequently affecting the next generation. The aim of the present study was to systematically review evidence from empirical studies on the association between maternal history of adversity in childhood (maltreatment and household dysfunction) and subsequent mother-child interactions at an early age. A search was performed in the PubMed, Web of Science, PsycINFO, EMBASE, Scopus, LILACS, and SciELO databases to identify studies, including measures of maternal childhood adversities and mother-child interaction, published between 2016 and 2022. Twenty-nine studies met the inclusion criteria. The results showed that in 90% of the studies, maternal childhood adversities negatively impacted subsequent mother-child interactions in early childhood, reducing maternal displays of affection, emotional availability, sensitivity, mother-child communication, and bonding. Biological factors (e.g., genetic and hormonal) and maternal emotional recognition moderated these associations. In addition, biological factors (i.e., neurobiological and hormonal) and psychosocial factors (e.g., depression, executive functioning, and violence) acted as mediators. Preventive interventions should be implemented to break out of the intergenerational cycle of violence that impacts mother-child interactions.

Examining Treatment Outcomes Across Contexts: How Do Child Baseline Characteristics Impact Measurement of Treatment Response?

The evaluation of the overlap between the ADOS BOSCC and Standard BOSCC as well as the exploration of child characteristics that may predict change are important steps in consolidating data-driven definitions of "improvement". Participants were seen between 2 and 5 times with Standard BOSCC and ADOS BOSCC observations over the course of early intervention trials (Grzadzinski et al. in J Autism Dev Disord 46:2464, 2016; Kim et al. in Autism 23:5, 2019). Results showed consistency between the Standard BOSCC and ADOS BOSCC, highlighting the utility of both as metrics of change and treatment outcome across contexts. Baseline characteristics may play a role in the tailoring of early intervention to maximize treatment outcome and may offer guidance when determining which outcome measures to use.

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.

Scoping review of behavioral coding measures used to evaluate parent responsiveness of children with autism or elevated risk of autism

LAY ABSTRACT

The topic of how parents react (e.g., how they talk and act) to their child with autism or elevated likelihood of autism, often called parent responsiveness, has been studied by researchers for over 50 years. Many methods for measuring behaviors around parent responsiveness have been created depending on what researchers were interested in discovering. For example, some include only the behaviors that the parent does/says in reacting to something the child does/says. Other systems look at all behaviors in a period of time between child and parent (e.g., who talked/acted first, how much the child or parent said/did). The purpose of this article was to provide a summary of how and what researchers looked at around parent responsiveness, describe the strengths and barriers of these approaches, and suggest a "best practices" method of looking at parent responsiveness. The model suggested could make it more possible to look across studies to compare study methods and results. The model could be used in the future by researchers, clinicians, and policymakers to provide more effective services to children and their families.

Psychological interventions targeting mental health and the mother-child relationship in autism: Systematic review and meta-analysis

AIM

To investigate the efficacy of psychological interventions delivered to mothers of young children with autism spectrum disorder (ASD) in improving maternal mental health and the parent-child relationship.

METHOD

Electronic databases were searched from inception to December 2021. Studies were included if they were randomized controlled trials (RCTs) of psychological interventions that targeted maternal mental health (primary outcome) and/or the parent-child relationship (secondary outcome), delivered to mothers of children (mean age < 60 months) with ASD. Meta-analyses of three parent mental health outcomes (stress, depressive symptomatology, and general mental health) and seven parent-child relationship outcomes (parent responsiveness, affect, directiveness, non-directiveness, child initiation, infant positive affect, and infant attentiveness) were conducted using both mean and standardized mean differences.

RESULTS

Thirty-two RCTs met the inclusion criteria (2336 participants). Six RCTs showed improved maternal mental health (Cohen's d = 0.41-1.15), with moderate certainty of evidence for improvement in parental stress. There was low and high certainty of evidence of treatment effect on parental depressive symptoms and general mental health respectively, which did not show significant treatment effects post-intervention. Seventeen RCTs showed improved parent-child relationship (d = 0.33-2.28; low certainty of evidence).

INTERPRETATION

Results demonstrated that parenting interventions promoting responsiveness had the largest positive effect on the parent-child relationship and a moderate effect on overall parenting stress; however, the studies were heterogeneous, making it difficult to identify the intervention components that were responsible for the positive treatment effects. There was no significant treatment effect for studies targeting depression or general mental health, likely due to the lack of an interventional component directly targeting mental health.

Play and Mothers' Relationships With Children in the Context of Breast Cancer

This interpretative phenomenological study explored play experiences between mothers who had completed, or were receiving treatment for, breast cancer and their young children and disease-related factors influencing those experiences. Six Puerto Rican mothers who had young children at the time of their primary treatment were interviewed. Interviews were recorded, transcribed, and analyzed through constant comparative method. Two themes emerged: (a) "changes and challenges," which contextualized disease-related factors affecting the maternal role; and (b) "play and relationships with children" described play moments and how treatment affected these. Participants emphasized the benefits of playing and relating with their children while in treatment. Play as a co-occupation and an effective means to connect mothers with their children must be considered in the practice of occupational therapy. Future studies with more diverse samples of mothers at different stages of the disease are warranted to expand this exploratory work.

[Formula: see text]Parental interaction style, child engagement, and emerging executive function in fetal alcohol spectrum disorders (FASD)

Children with fetal alcohol spectrum disorders (FASD) are known to experience cognitive and neurobehavioral difficulties, including in areas of executive function and social skills development. Interventions for these challenges have focused on a number of areas, including parent-based training. Despite the general consensus that specific parenting styles consistent with an "authoritative" - warm but firm - parenting approach may influence behavioral self-regulation, it is not known what specific parental interaction styles are associated with child engagement and emerging executive function in this population. The current study used an observation-based behavioral coding scheme during parent-child play interactions and associated parent report-based executive function measures in children with FASD. Here, we demonstrate that parental interaction styles with increased responsive/child-oriented behavior and parental affect are associated with higher levels of child play engagement, while parental interaction that has increased achievement-orientation is associated with higher levels of emerging executive function in children with FASD. These findings help inform future studies on behavioral targets in parent-based training programs and highlight the importance of considering certain parental interaction styles during parent-child play.

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).

Effects of Rhythmic Gymnastics on Joint Attention and Emotional Problems of Autistic Children: A Preliminary Investigation

The adaptive rhythmic gymnastics (ARG) course has been specially designed for children with autism spectrum disorders (ASD). The purpose of this study is to discover the influence of the course on the joint attention and emotional problems of ASD children. This study adopted A-B-A cross-subject multibaseline design in a single case research design. The joint attention behaviour of two 6-year-old ASD children was examined. The experiment process was recorded and coded, and the results were analysed. The results illustrated the following: (1) ARG is effective in promoting the development of joint attention in ASD children, but it has a better effect on increasing responding joint attention, and (2) to a certain extent, ARG can boost the classroom participation of ASD children and improve their emotional problems.

"Music Therapy Was Never on the Table": Perspectives of Parents of Young Autistic Children

Parent coaching of music interventions is emerging as a viable model for families with young autistic children, yet recruitment difficulties have been apparent in previous studies. Understanding parent perspectives of early intervention services is critical to ensure that interventions are acceptable, feasible, and effective for all family members. In order to understand possible parental resistance to this type of parent education, we explored perspectives regarding music therapy, research, and parent coaching in parents of young autistic children. Fourteen parents attended virtual focus groups to discuss their experiences. We used a descriptive phenomenological approach to uncover the essence of their experience. Our findings indicate that, contrary to our preconceptions, participants did not show negative dispositions towards music therapy, research, or parent coaching. Instead, most participants had very little or no knowledge of music therapy services. They had limited experience with research in general, and only two participants had experienced music therapy directly. Several participants had varying amounts of experience with parent participation or parent coaching outside of music therapy and shared positive experiences with it. Parents seemed willing and eager to learn music strategies to support their children and saw value in the use of music for their child's development. First-contact providers (i.e., early interventionists and diagnosticians) and social media seem influential in parents' decision-making as they navigate early intervention services soon after diagnosis. Music therapy organizations are encouraged to design targeted efforts to make information on music therapy available through these sources.

Intensive Family Intervention as Support for Professional Treatment: Evolution of Symptoms in a Diagnosed Case of Autism Spectrum Disorder

This article shows the progress achieved in a child who has received professional treatment combined with a family intervention at home. It discusses a 22-month-old patient identified as showing warning signs of autism spectrum disorder (ASD), a diagnosis that was subsequently confirmed through a standardized ADOS-2 test at 31 months of age. To establish the initial working objectives, a functional diagnosis was carried out at 23 months of age using the Battelle Developmental Inventory; a maturational delay was detected, situating the child at an age equivalent to 16 months. A professional intervention was designed in an early childhood care center, complemented by family intervention, so that the hours in which the child participated in learning experiences were increased. Notable advances were made in the areas of cognitive and motor skills, with more standard scores than when initially evaluated. Progress was also observed (though to a lesser extent) in other developmental areas such as language total, adaptive behavior, and self-help, while slight delays in the areas of socio-emotional development and reasoning and academic skills were found.

Caregiver responsiveness as a mechanism to improve social communication in toddlers: Secondary analysis of a randomized controlled trial

Early intensive behavioral interventions (EIBI) for children at elevated likelihood for a later diagnosis of autism spectrum disorder (EL-ASD), are often delivered through parent-mediated models. An area of current exploration is whether changes in caregiver behaviors are a mechanism through which to improve and track child behaviors in these interventions. Toddlers and their caregivers participated in an intervention trial (randomized controlled trial) and were randomized to either a parent-mediated intervention (adapted responsive teaching; ART) or a control condition (referral to early intervention and monitoring; REIM). Changes in toddler social communication (SC) behaviors and characteristics of caregiver responsiveness (CR) were quantified over 8 months. Analyses were conducted to assess whether changes in CR mediated the relation between group (ART vs. REIM) and changes in child SC. Results of the current study indicated that caregivers who participated in a parent-mediated intervention improved in three domains of CR (contingent verbal sensitivity, responsivity, affect). CR was also found to be a mechanism through which children's SC skills improved. This work provides evidence that qualities of CR serve as mechanisms through which to improve and monitor child behaviors over the course of EIBIs. These results may lead to novel intervention targets, methods for tracking change, and tailored treatment planning for toddlers with EL-ASD. The data used in this study comes from a clinical trial that was prospectively registered with the Registry of Efficacy and Effectiveness Studies (Registry ID: 316.1v1). LAY SUMMARY: Interventions for toddlers with high likelihood for a later diagnosis of autism often include the caregiver as an active participant in the intervention. In this study, we aimed to understand qualities of caregiver responsiveness (CR) that facilitate improvements in child behaviors during intervention. Results show that increasing verbal CR and affect are ways to improve child social skills over the course of intervention.

Feasibility of a school-based mental health program implementation to improve the status of depression and quality of life of mothers of children with autism spectrum disorders in urban Bangladesh: MENTHOL study

BACKGROUND

We assessed the feasibility of implementing psychological counseling services (PCS) for mothers of children with autism spectrum disorders (ASD) integrated within special education settings in urban Bangladesh.

METHOD

In two special education schools for ASD in Dhaka City, trained female psychologists screened mothers using the Patient Health Questionnaire (PHQ-9). PCS was administered to all the mothers irrespective of a diagnosis of depression. Mothers with a PHQ-9 score >4 who met criteria for a major depressive episode (MDE) based on the DSM-IV Structured Interview Axis I Disorders (SCID-I) were also administered skill-building training through monthly home visits to support ASD care. The level of depression was assessed by the Depression Measurement Scale (DMS), and quality of life (QoL) was measured by Visual Analogue Scale (VAS) of EQ5D5L scale before and after PCS.

RESULT

Among 188 mothers enrolled in the study, 81 (43%) received PCS, and 27.1% (22) had MDE. In the first month, 73 sessions were scheduled and 60 completed (85%). In the last month, 53 sessions were scheduled and 52 completed (98%). The mean DMS score decreased from 79.5 ± 23 to 60 ± 20 (p = 0.004), and DMS scores were significantly higher among mothers with MDE (97.8 ± 12.1 v. 69.9 ± 22.1; p < 0.001) compared to those without MDE (72.7 ± 22.6 v. 56.1 ± 18.1; p = 0.003). The mean VAS score improved from 70.3 ± 14.1 to 80.2 ± 13.3 (p = 0.001) between the first and the last session. Changes in DMS were negatively correlated with changes in VAS scores (β: -0.213, 95% CI 0.370 to -0.056).

CONCLUSION

Within special education schools for ASD in urban Bangladesh, it was feasible to administer an integrated program of PCS for mothers of children with ASD by trained psychologists who were able to screen and intervene to reduce their level of depression and improve their quality of life.

Effectivity of Play-Based Interventions in Children with Autism Spectrum Disorder and Their Parents: A Systematic Review

Evidence of the effectivity of play-based interventions in children with autism spectrum disorder (ASD) was evaluated by PRISMA-based literature study and a Risk of Bias (RoB) assessment. Many of the 32 eligible randomized controlled trials (RCT) reported improved social interaction, communication, daily functioning and play behaviour. They also reported decreased problem behaviour, better parental attunement and parent-child interaction. We assessed 25/32 of the RCTs with high RoB, mainly related to homogeneity of the study population, lack of power, and performance bias. We concluded with due care that the effectivity of play-based interventions differed across RCTs, most reported improvements are found in ASD symptoms, everyday functioning, and parental attunement. In future research, findings should be replicated, taking account of the RoB.

Pre-symptomatic intervention for autism spectrum disorder (ASD): defining a research agenda

Autism spectrum disorder (ASD) impacts an individual's ability to socialize, communicate, and interact with, and adapt to, the environment. Over the last two decades, research has focused on early identification of ASD with significant progress being made in understanding the early behavioral and biological markers that precede a diagnosis, providing a catalyst for pre-symptomatic identification and intervention. Evidence from preclinical trials suggest that intervention prior to the onset of ASD symptoms may yield more improved developmental outcomes, and clinical studies suggest that the earlier intervention is administered, the better the outcomes. This article brings together a multidisciplinary group of experts to develop a conceptual framework for behavioral intervention, during the pre-symptomatic period prior to the consolidation of symptoms into diagnosis, in infants at very-high-likelihood for developing ASD (VHL-ASD). The overarching goals of this paper are to promote the development of new intervention approaches, empirical research, and policy efforts aimed at VHL-ASD infants during the pre-symptomatic period (i.e., prior to the consolidation of the defining features of ASD).

Using the Ecological Validity Model to adapt parent-involved interventions for children with Autism Spectrum Disorder in the Latinx community: A conceptual review

BACKGROUND

Parent involvement in interventions for children with Autism Spectrum Disorder (ASD) provides parents with education about ASD diagnosis and treatment, improves parent-child interactions, and offers access to cost-effective resources. The Latinx population represents the fastest growing minority population in the United States and a growing percentage of children seeking ASD intervention services.

AIMS

Identify factors that impact Latinx parent involvement in interventions for children with ASD as an example of cultural considerations for diverse families and communities.

METHODS AND PROCEDURES

In this conceptual overview, we synthesize literature on cultural considerations for intervention design/adaptation for Latinx families and parent involvement in interventions for children with ASD through the lens of the Ecological Validity Model.

OUTCOMES AND RESULTS

Frameworks such as the Ecological Validity Model can be used when creating or adapting interventions for specific cultural groups. Parent-involved interventions for children with ASD in the Latinx community should consider language of intervention delivery, family make-up, community support, disability knowledge of the family, the therapeutic alliance, and methods of implementation.

CONCLUSIONS AND IMPLICATIONS

Incorporating cultural components into parent-involved interventions will best support intervention implementation and dissemination in diverse communities. Research is needed into the process and outcomes of intervention programs in order to increase understanding of how specific cultural dimensions impact participation in and efficacy of parent-involved interventions for Latinx families of children with ASD.

The effects of JASPER intervention for children with autism spectrum disorder: A systematic review

Naturalistic developmental behavioural interventions are promising approaches for young children with, or suspected of having, autism spectrum disorder. Joint attention, symbolic play, engagement and regulation intervention (JASPER) is a well-researched naturalistic developmental behavioural intervention but, to date, no reviews have specifically evaluated its effects. This systematic literature review examined the effects of JASPER intervention and its components on child, parent and educator outcomes. Of the 96 articles screened, 19 were eligible for inclusion in the review. Most studies found that children who received JASPER intervention showed significantly greater improvements in at least one outcome related to child joint attention, joint engagement, play skills and language skills compared to the comparison group. Implementation outcomes for parents and educators were generally positive. There were no consistent predictors or mediators of treatment effects. None of the studies met all of the quality indicators outlined by the Council of Exceptional Children, and the majority of outcome measures were classified as proximal. Overall, JASPER intervention appears promising in improving child outcomes directly targeted during treatment. More research is needed to determine whether it is also effective in improving a wider range of outcomes for children with autism spectrum disorder.Lay abstractInterventions which are delivered in natural contexts and use both developmental and behavioural techniques may be helpful for children with, or suspected of having, autism spectrum disorder. Joint attention, symbolic play, engagement and regulation (JASPER) is a type of intervention, which falls under this category. Although several studies have examined the effects of JASPER, this has not yet been summarised in a review. This systematic literature review examined the effects of JASPER intervention, and the techniques that make up JASPER, on child, parent and educator outcomes. We screened 96 articles and, of these, 19 were included in the review. Most studies found that children who received JASPER intervention showed significantly greater improvements in at least one outcome related to child joint attention, joint engagement, play skills, and language skills compared to children who did not receive JASPER intervention. Parents and educators were mostly able to use the JASPER techniques. There were no consistent child, parent, teacher or treatment characteristics that influenced the effects of the JASPER intervention. None of the studies met all of the indicators of being a good quality study outlined by the Council of Exceptional Children. Overall, JASPER intervention appears promising in improving child outcomes directly targeted during treatment. More research is needed to determine whether it is also effective in improving a wider range of outcomes for children with autism spectrum disorder.

Detecting joint attention events in mother-infant dyads: Sharing looks cannot be reliably identified by naïve third-party observers

Joint attention, or sharing attention with another individual about an object or event, is a critical behaviour that emerges in pre-linguistic infants and predicts later language abilities. Given its importance, it is perhaps surprising that there is no consensus on how to measure joint attention in prelinguistic infants. A rigorous definition proposed by Siposova & Carpenter (2019) requires the infant and partner to gaze alternate between an object and each other (coordination of attention) and exchange communicative signals (explicit acknowledgement of jointly sharing attention). However, Hobson and Hobson (2007) proposed that the quality of gaze between individuals is, in itself, a sufficient communicative signal that demonstrates sharing of attention. They proposed that observers can reliably distinguish “sharing”, “checking”, and “orienting” looks, but the empirical basis for this claim is limited as their study focussed on two raters examining looks from 11-year-old children. Here, we analysed categorisations made by 32 naïve raters of 60 infant looks to their mothers, to examine whether they could be reliably distinguished according to Hobson and Hobson’s definitions. Raters had overall low agreement and only in 3 out of 26 cases did a significant majority of the raters agree with the judgement of the mother who had received the look. For the looks that raters did agree on at above chance levels, look duration and the overall communication rate of the mother were identified as cues that raters may have relied upon. In our experiment, naïve third party observers could not reliably determine the type of look infants gave to their mothers, which indicates that subjective judgements of types of look should not be used to identify mutual awareness of sharing attention in infants. Instead, we advocate the use of objective behaviour measurement to infer that interactants know they are ‘jointly’ attending to an object or event, and believe this will be a crucial step in understanding the ontogenetic and evolutionary origins of joint attention.

Play interactions of parents toward children with autism spectrum disorder: NeuroPLAY parent play behavior assessment scale

PROBLEM

The aim of this study is to analyze the changes that NeuroPLAY, which is an intensive early intervention method for children with autism spectrum disorder (ASD) and ages of 12-42 months, has created in the play skills of the parents of children with ASD by using method strategies.

METHODS

The study cohort includes 91 children ages ranging from 18 to 42 months old. The study is designed for repetitive measurements performed pre- and post-intervention. Within the scope of the study, children's ASD symptoms were evaluated with the Childhood Autism Rating Scale (CARS) and changes in the play skills of parents were evaluated using NeuroPLAY Parental Play Behavior Assessment Scale (NPPBAS).

RESULTS

The NPPBAS score at the beginning of the intervention was 12.55; repeated measurements (46.22 after 3 months, 45.95 after 6 months, and 48.53 after 12 months) were observed to increase core. The older age of the parents in the intervention program is associated with lower final NPPBAS scores. However, it was determined that the CARS score, which is an indicator of the autism spectrum, will decrease after intervention regardless of the parents' age.

CONCLUSION

The results showed that NeuroPLAY led to significant improvement in play behaviors of the parents.

What are the odds? Predicting the likelihood of a negative episode in a sample of toddlers with autism spectrum disorder

LAY ABSTRACT

Children with autism spectrum disorder sometimes have challenges with regulating their negative emotions. These difficulties can impact children's social outcomes and how well they respond to intervention. We know that caregivers of children with autism spectrum disorder can help their children regulate negative emotions in a process known as co-regulation, but not much is known about how child and caregiver strategy use impacts children's negativity in real time. In this study, 71 caregivers of toddlers with autism spectrum disorder were asked to encourage their child to unlock a locked toy box, a task which is designed to elicit frustration. Video observations of the participants completing the task were used to examine whether specific child and caregiver behaviors increased or decreased the likelihood that the child will become upset. No child strategies were predictive of a decreased likelihood of a child becoming upset, but when children used high-energy behaviors that did not serve a purpose, such as running back and forth, they were more likely to then show signs of being upset a few seconds later. The way that caregivers responded to their child was a potent caregiver predictor of the likelihood of children's negativity, with caregivers' unresponsiveness and proactiveness both emerging as salient predictor of increased likelihood of the child being upset a few moments later. These findings give insight into how children with autism spectrum disorder and their caregiver navigate challenging and frustrating tasks, and have the potential to influence clinical practice by giving an indication off which parent and child behaviors are most effective in reducing children's negativity while interacting with parents and caregivers.

Parent Experiences of Autism Spectrum Disorder Diagnosis: a Scoping Review

The purpose of this review was to identify the quantity, breadth, and methodological characteristics of literature examining parent perspectives of autism spectrum disorder diagnosis, synthesize key research findings, and highlight gaps in the current literature. A systematic search was conducted for the period January 1994–February 2020. One hundred and twenty-two articles underwent data extraction. The majority of studies took place in Europe and North America in high-income countries. Over half of the studies used qualitative methodology. Four key components of the diagnostic experience were identified: journey to assessment, assessment process, delivery of the diagnosis and feedback session, and provision of information, resources, and support. Themes of parental emotions and parental satisfaction with the diagnostic process were also found.

The Efficacy of WeChat-Based Parenting Training on the Psychological Well-being of Mothers With Children With Autism During the COVID-19 Pandemic: Quasi-Experimental Study

BACKGROUND

During the COVID-19 pandemic, special education schools for children in most areas of China were closed between the end of January and the beginning of June in 2020. The sudden interruption in schooling and the pandemic itself caused parents to be anxious and even to panic. Mobile-based parenting skills education has been demonstrated to be an effective method for improving the psychological well-being of mothers with children with autism. However, whether it can improve the psychological states of mothers in the context of the COVID-19 pandemic is a subject that should be urgently investigated.

OBJECTIVE

The aim of this study is to evaluate the efficacy of WeChat-based parenting training on anxiety, depression, parenting stress, and hope in mothers with children with autism, as well as the feasibility of the program during the COVID-19 pandemic.

METHODS

This was a quasi-experimental trial. A total of 125 mothers with preschool children with autism were recruited in January 2020. The participants were assigned to the control group (n=60), in which they received routine care, or the intervention group (n=65), in which they received the 12-week WeChat-based parenting training plus routine care, according to their preferences. Anxiety, depression, parenting stress, hope, satisfaction, and adherence to the intervention were measured at three timepoints: baseline (T0), postintervention (T1), and a 20-week follow-up (T2).

RESULTS

In total, 109 mothers completed the T1 assessment and 104 mothers completed the T2 assessment. The results of the linear mixed model analysis showed statistically significant group × time interaction effects for the intervention on anxiety (F=14.219, P<.001), depression (F=26.563, P<.001), parenting stress (F=68.572, P<.001), and hope (F=197.608, P<.001). Of all mothers in the intervention group, 90.4% (48.8/54) reported that they were extremely satisfied with the WeChat-based parenting training. In total, 40.0% (26/65) logged their progress in home training each week and 61.5% (40/65) logged their progress more than 80% of the time for all 20 weeks.

CONCLUSIONS

The WeChat-based parenting training is acceptable and appears to be an effective approach for reducing anxiety, depression, and parenting stress, as well as increasing hope in mothers with children with autism during the global COVID-19 pandemic. Future studies with rigorous designs and longer follow-up periods are needed to further detect the effectiveness of the WeChat-based parenting training.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000031772; http://www.chictr.org.cn/showproj.aspx?proj=52165.

Parents of children with autism spectrum disorder’s perception on parent-implemented home-based developmental, individual-difference and relationship (DIR)/Floortime® intervention

Purpose

The developmental, individual-difference and relationship (DIR)/Floortime® approach is a commonly used parent-implemented intervention with children with autism spectrum disorder (ASD). Currently, no evidence is available about the intervention’s implementation and utility in Malaysia. The aim of this paper is to investigate the applicability and impact of implementing the parent-implemented home-based DIR/Floortime® intervention program for children with ASD and their parents in a Malaysian context from parents’ perspectives.

Design/methodology/approach

A qualitative study using semi-structured interviews with eight mothers and four fathers of children with ASD was conducted. The interviews were analysed using qualitative content analysis.

Findings

Five themes were developed. Theme 1 described the implementation of DIR/Floortime® intervention; Theme 2 reported challenges parents faced when implementing the intervention; Theme 3 explored parents’ perspective on play; Theme 4 explained the improvements and changes in children with ASD and parents’ abilities and skills; and Theme 5 reported parents’ comments and suggestions about the intervention program.

Research limitations/implications

Involvement of a limited number of participants and an absence of baseline data limits the interpretation of the impacts of the DIR/Floortime® program’s implementation by parents with their children with ASD.

Originality/value

Utilization of DIR/Floortime® intervention is practical and appropriate in the Malaysian context. From the parents’ perspective, the DIR/Floortime® approach was beneficial for children with ASD and parents’ skill development and well-being. Further refinement to the program and involvement of participants from various cultural backgrounds are recommended. A greater emphasis for parents on child-led interaction style and play with children are also recommended.

Early Life Experiences Moderate the Relationship Between Genetic Risk of Autism and Current and Lifetime Mental Health

Although individuals with autism are at greater risk of mental health challenges than others, we know little about the relationship between the mental health of older adults (50+) and autism because they are less likely to be diagnosed. Identifying the risk and protective factors that are associated with mental health can increase educational awareness, inform clinical practice, and provide information to help diagnose and treat older adults with autism. This study used longitudinal panel data of the 2008-2016 waves of the Health and Retirement Study. It estimated individual random-effect models by interacting a genetic propensity toward autism and early life experiences to test whether the latter has a moderating effect on the relationships between genetics and the Center for Epidemiologic Studies Depression (CES-D) score, self-reported depression, and history of psychiatric problems. Results suggest that individuals with a higher genetic propensity for autism are less likely to develop psychiatric problems if they report a positive maternal relationship early in life. Further, a combined effect of police encounters early in life and genetic risk for autism is associated with higher CES-D scores, increased odds of self-reported depression, and a history of psychiatric problems. Clinical applications of these findings include the need to establish and support high-quality relationships by addressing both child and caregiver needs. Further, these findings support the need to design and implement proactive interventions to teach police and autistic individuals how to successfully navigate these encounters.

Play-based interventions to support social and communication development in autistic children aged 2-8 years: A scoping review

BACKGROUND AND AIMS

Play is used by practitioners from across disciplinary backgrounds as a natural and enjoyable context for providing intervention and support in early childhood. In the case of autism interventions, many therapies are based on the association between social play and the development of social skills, language development, and communication skills, as these are often particular areas of challenge for autistic children. However, play is a wide-ranging concept and the extant literature on play-based interventions is large and heterogeneous. This means it is challenging for practitioners and families to navigate the evidence base and make choices about differing intervention strategies. This review aims to provide a comprehensive map of the research on this topic and to develop a conceptual framework to inform clinical decision-making.

METHODS

An initial stakeholder consultation confirmed the relevance of the topic to practitioners and autistic people. A scoping review methodology (preregistered) was used to identify relevant literature. We systematically searched seven databases to find peer-reviewed primary intervention studies of play-based approaches targeting language, social and communication outcomes for autistic children aged 2-8 years. We then summarised the literature using narrative synthesis and Evidence Gap Maps (EGMs). The literature was summarised according to a range of characteristics, including study design, population characteristics, agent of intervention and outcomes measured, among others. These summaries were then used to develop a framework for some key considerations for practitioners appraising play-based approaches.

RESULTS

388 studies met inclusion criteria. Approximately 21% of studies were RCTs, and over 50% had ≤10 participants. Over 45% of studies reported multiple relevant outcomes, with social play skills being the most common single intervention target. Girls and minority background groups are under-represented. A range of intervention types were identified, and some high-level categorisations are proposed.Main contribution: On the basis of the evidence synthesis we suggest important dimensions for appraisal of play-based interventions, including the role of play within an intervention (as a context, a key developmental mechanism, or a component of a larger approach), the underpinning philosophy (e.g. behaviourist or developmental), and the role of the practitioner (providing parent feedback, 1:1 intervention, group facilitation).

CONCLUSIONS

The wide range of approaches uncovered by this review is a testament to the wonderful diversity inherent to both play and autism. However, research could usefully focus on consolidating the evidence base for existing approaches, rather than aiming for further diversification. Implications: The conceptual framework proposed in this review can help practitioners appraise the literature and aid their advice to families when making shared intervention decisions.

Differential responses to child communicative behavior of parents of toddlers with ASD

BACKGROUND AND AIMS

The quality of parent verbal input-diverse vocabulary that is well-matched to the child's developmental level within interactions that are responsive to their interests-has been found to positively impact child language skills. For typically developing (TD) children, there is evidence that more advanced linguistic and social development differentially elicits higher quality parent input, suggesting a bidirectional relationship between parent and child. The purpose of this study was to evaluate if toddlers with ASD also differentially elicit parental verbal input by (1) analyzing the quality of parent input to the communicative behavior of their toddlers with ASD, (2) examining if parents respond differentially to more advanced toddler communicative behavior, as measured by the coordination of multiple communicative behaviors, and (3) exploring the relationship between parental responsiveness to child communicative behaviors and change in child communication and social skills.

METHODS

Participants were 77 toddlers with ASD age 18-39 months and a parent who participated in a larger RCT. Ten-minute parent-toddler interactions were recorded prior to a 12-week intervention. Parent response to child communicative behaviors was coded following each child communicative behavior as no acknowledgment, responsive, directive, or nonverbal acknowledgment. Parent number of different words and difference between parent and child MLU in words were calculated separately for responsive and directive parent utterances. Child growth in language and social skills was measured using the Vineland II Communication and Socialization domain scores, respectively.

RESULTS

(1) Parents were largely responsive to their toddler's communication. When being responsive (as opposed to directive), parents used a greater number of different words within utterances that were well-matched to child language; (2) when toddlers coordinated communicative behaviors (versus producing an isolated communicative behavior), parents were more likely to respond and their replies were more likely to be responsive; and (3) parent responsiveness to child coordinated communication was significantly correlated with change in Vineland II Socialization but not Communication. A unique role of gaze coordinated child communication in eliciting responsive parental behaviors and improving growth in child social skills emerged.

CONCLUSIONS

Our results support a bidirectional process between responsive parent verbal input and the social development of toddlers with ASD, with less sophisticated child communicative behaviors eliciting lower quality parent input.Implications: Our findings highlight the critical role of early parent-mediated intervention for children with ASD generally, and to enhance eye gaze through parent responsivity more specifically.

Early Intervention with Parents of Children with Autism Spectrum Disorders: A Review of Programs

The aim of this article was to analyze the evidence regarding the effectiveness of intervention programs for children with autism based on the participation of their parents. To obtain the data, a systematic search was carried out in four databases (PsycARTICLES (ProQuest), ERIC (ProQuest), PubMed (ProQuest), and Scopus). The retrieved documents were refined under the inclusion/exclusion criteria, and a total of 51 empirical studies were selected. These studies were first classified according to the function of the intervention objective and, later, by the methodology applied (19 studies were based on comprehensive interventions, 11 focused on the nuclear symptoms of autism spectrum disorder (ASD), 12 focused on the promotion of positive parenting, and nine interactions focused on child play). Once all of the documents had been analyzed, the evidence indicated scientific efficacy in most studies, mainly in those based on child development and the application of behavioral analysis principles. Moreover, the positive influence of parent participation in such programs was demonstrated.

Investigating joint attention in a guided interaction between a child with ASD and therapists: A pilot eye-tracking study

Introduction

Deficits in joint attention are commonly seen in children with autism spectrum disorder. Research examining joint attention in autism spectrum disorder commonly uses two broad strategies to cue and measure joint attention: behavioral observation and eye tracking. These strategies trade off prioritizing ecological validity vs. gaze measurement accuracy, with a focus on one sacrificing the other. The purpose of this case study was to develop a method to accurately measure gaze position while maintaining an ecologically valid dyadic interaction.

Methods

A child with autism spectrum disorder completed two developmentally appropriate tabletop activities. Each activity was guided by a different occupational therapist who purposefully used a different interaction style with the child. Mobile eye trackers worn by both the child and the therapist recorded the dyadic interactions. Data collection included audio and video recording of interactive behaviors, eye movements and visual fixations in regions of shared interest.

Results

Differences were detected in gaze use and interactive joint attention behaviors between the therapists working with the child and within the child’s respective dyadic interactions.

Conclusions

The proof of concept method maintained both ecological validity and measurement accuracy of therapist–child joint attention. This method has promise to be scaled for larger studies.

Parental Responsiveness During Musical and Non-Musical Engagement in Preschoolers with ASD

BACKGROUND

Parent-child play interactions offer an important avenue for supporting social development in children with autism spectrum disorder (ASD). Musical play is a natural and ubiquitous form of parent-child play. As a familiar, reinforcing, and predictable activity, musical play may support parent-child interactions by scaffolding children's attention to the play activities, while also providing parents with a familiar and accessible context to promote parental responsiveness. However, musical play may also impede interactions due to its sensory and repetitive components.

METHOD

12 parent-child dyads of preschoolers with ASD were video-recorded during a ten-minute play session that included musical and non-musical toys. Interactions were coded for parent and child musical engagement, as well as parental responsiveness.

RESULTS

Parent-child dyads varied in their amount of musical engagement during play, which was not related to children's language level. Overall, parents showed similar levels of responsiveness to children's play across musical and non-musical activities, but type of parental responsiveness differed depending on the play context. Parents provided significantly more physical play responses and significantly fewer verbal responses during musical vs. non-musical engagement with their child.

CONCLUSIONS

There are substantial individual differences in children with ASD's musical engagement during a parent-child free play. Children's musical engagement impacted type of parental responsiveness, which may relate to the familiarity, accessibility, and sensory nature of musical play/toys. Results suggest that musical play/toys can both support and hinder different types of parental responsiveness with implications for incorporation of musical activities into interventions.

Sequential Associations Between Communication Acts of Children With and Without Autism Spectrum Disorder and Maternal Verbal Responses

In this study, the sequential associations between child communication acts, including spontaneous communication (SC) and elicited communication (EC), and the types of verbal responses of Iranian mothers (follow-in nondirective, follow-in directive, and redirective responses) were compared between children with autism spectrum disorder (ASD) and young typically developing (TD) children. Participants were 29 children with ASD aged 3-6 years and 40 TD children aged 13-18 months, matched on expressive vocabulary. Using time-window sequential analysis, maternal verbal responses within a time interval of 3 sec following child communication were examined during 15 min of video-recorded mother-child free play interaction. Mothers in the two groups had broadly similar patterns of response to child communication acts, but some differences in responding to child EC. Across both groups, sequential associations were stronger for maternal follow-in nondirective responses to child SC than for this type of response to child EC, and were stronger for follow-in directive responses to child EC than for follow-in directive responses to child SC. Child EC and SC acts were less likely to be followed by redirective responses than other maternal responses, again across both groups. Finally, mothers of children with ASD were more likely than mothers of TD children to follow-in to child EC with both nondirective and directive responses. Our findings suggest that mothers of children with ASD synchronize their responses with their child's SC acts to the same extent as mothers of TD children, and are more synchronous in responding to their child's EC acts. LAY SUMMARY: This observational study examined how Iranian mothers verbally responded to their children's communication acts, based on whether the children's communication was spontaneous (unprompted) or elicited (prompted by the mother). Mothers of children with autism spectrum disorder or typical development responded to their children's spontaneous communication acts in similar ways, but showed some differences in responding to children's elicited communication. By prompting their children to communicate, mothers create opportunities to give additional verbal responses to their children, which may help to support children's further language development.

A Pilot Trial of a Manualized Psychoeducation Module for Parents of Children with Autism with Intellectual Disability and Intellectual Disability Alone

Objectives

Children with autism with/without intellectual disability (ID) and ID alone require regular interventions. Psychoeducation (PE) can empower parents with intervention strategies. The aim of this study was to develop the test efficacy of a simple, short manualized PE module for parents of children with autism with/without comorbid ID and for ID alone. We focused on both autism and ID (A-ID) because we felt that both the groups could benefit from this module.

Methods

A special module for PE was developed after literature review, inputs from a study group, and discussion with experts. Parents attended eight fortnightly intervention sessions. Children were assessed on the Developmental Screening Test, Indian Scale for Assessment of Autism (ISAA), and the Behavioral Assessment Scale for Indian Children with Mental Retardation (BASIC-MR) before starting and 1 month after completing PE.

Results

Consenting parent of parents/of 16 children with A-ID and 14 with ID completed sessions with pre- and postassessment. There was a significant improvement in the majority of domains of ISAA and BASIC-MR Part B in children with both conditions.

Conclusions

PE has a wide scope for use across various developmental disorders. The module developed is promising for a wide variety of field workers.

Applying the Developmental Systems Approach to Inclusive Community-Based Early Intervention Programs: Process and Practice

A developmentally oriented framework is presented designed to establish or enhance the quality of inclusive community-based early intervention systems. This conceptually and empirically integrated developmental approach supports a comprehensive family-centered model. Outlined is a process that coordinates children's goals with family priorities, identifies developmental pathways most likely to influence those goals, guides the selection of objectives and intervention activities, and provides an approach for evaluation and problem solving. Principles of relationships, comprehensiveness, and continuity are central to this framework and address the general problem of "what to implement" in inclusive community-based early childhood programs.

Project AIM: Autism intervention meta-analysis for studies of young children

In this comprehensive systematic review and meta-analysis of group design studies of nonpharmacological early interventions designed for young children with autism spectrum disorder (ASD), we report summary effects across 7 early intervention types (behavioral, developmental, naturalistic developmental behavioral intervention [NDBI], TEACCH, sensory-based, animal-assisted, and technology-based), and 15 outcome categories indexing core and related ASD symptoms. A total of 1,615 effect sizes were gathered from 130 independent participant samples. A total of 6,240 participants, who ranged in age from 0-8 years, are represented across the studies. We synthesized effects within intervention and outcome type using a robust variance estimation approach to account for the nesting of effect sizes within studies. We also tracked study quality indicators, and report an additional set of summary effect sizes that restrict included studies to those meeting prespecified quality indicators. Finally, we conducted moderator analyses to evaluate whether summary effects across intervention types were larger for proximal as compared with distal effects, and for context-bound as compared to generalized effects. We found that when study quality indicators were not taken into account, significant positive effects were found for behavioral, developmental, and NDBI intervention types. When effect size estimation was limited to studies with randomized controlled trial (RCT) designs, evidence of positive summary effects existed only for developmental and NDBI intervention types. This was also the case when outcomes measured by parent report were excluded. Finally, when effect estimation was limited to RCT designs and to outcomes for which there was no risk of detection bias, no intervention types showed significant effects on any outcome. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Parental perception of stress and emotional-behavioural difficulties of children with autism spectrum disorder and specific language impairment

BACKGROUND AND AIMS

The daily challenges of caring for a child with autism spectrum disorder affect many areas of everyday life and parental well-being, as well as parents' ability to manage the needs of the family and the child concerned. A better understanding of parents' perception of their child's characteristics can allow better support for them and individualize intervention protocols in a more accurate way. The main objective of this study is the evaluation of the perception of stress by parents of children with autism compared to parents of children with specific language impairment.

METHODS

The parents of 87 children aged between 2 and 6 years were included in this study, 34 children with a specific language impairment diagnosis and 53 children with an autism spectrum disorder diagnosis (ASD) or at risk of developing it. They were asked to complete a self-report on perceived stress and rating scales on adaptive/problematic behaviours, executive functions and sensory profile of the child.

RESULTS

The results reveal that parents of ASD children, compared to the control group, showed significantly higher levels of stress, mainly due to the difficulty of managing unexpected events, the feeling of loss of control over one's life and the fear of not being able to cope with the adversities they were experiences. The most critical area, both for ASD and control group, concern the executive function related to emotional reactions.

CONCLUSIONS

Thus, we argue that the difficulties in self-control, sensory modulation and emotional regulation, represent an element of stress for parents of children with developmental disorders.Implications: Regarding the difficulties of children with ASD, supporting the ways in which caregivers adapt to the signals of children is an important strategy, which has now become a key element of treatments for autism mediated by parents.

Pathways Early ASD Intervention as a Moderator of Parenting Stress on Parenting Behaviors: A Randomized Control Trial

We examined the relationship between initial parenting stress and change in parental responsivity for 56 culturally and socioeconomically diverse families in a 12 week randomized control trial of Pathways Early ASD Intervention. Families were randomized into the Pathways (n = 32) or treatment-as-usual (TAU n = 24) group. Overall, Pathways parents experienced decreased stress, while TAU parents experienced an increase. The relationship between initial parental stress and change in parent responsivity was moderated by group membership. Pathways parents became more responsive but responsivity was not influenced by initial parental stress. In contrast, responsivity was negatively affected by initial parenting stress in the TAU group. Results are discussed in terms of components of a parent-mediated ASD intervention that may reduce parental stress.

Implementation and effectiveness of non-specialist mediated interventions for children with Autism Spectrum Disorder: A systematic review and meta-analysis

INTRODUCTION

In recent years, several non-specialist mediated interventions have been developed and tested to address problematic symptoms associated with autism. These can be implemented with a fraction of cost required for specialist delivered interventions. This review represents a robust evidence of clinical effectiveness of these interventions in improving the social, motor and communication deficits among children with autism.

METHODS

An electronic search was conducted in eight academic databases from their inception to 31st December 2018. A total of 31 randomized controlled trials were published post-2010 while only 2 were published prior to it. Outcomes pertaining to communication, social skills and caregiver-child relationship were meta-analyzed when reported in > 2 studies.

RESULTS

A significant improvement was noted in child distress (SMD = 0.55), communication (SMD = 0.23), expressive language (SMD = 0.47), joint engagement (SMD = 0.63), motor skills (SMD = 0.25), parental distress (SMD = 0.33) parental self-efficacy (SMD = 0.42) parent-child relationship (SMD = 0.67) repetitive behaviors (SMD = 0.33), self-regulation (SMD = 0.54), social skills (SMD = 0.53) symptom severity (SMD = 0.44) and visual reception (SMD = 0.29).

CONCLUSION

Non-specialist mediated interventions for autism spectrum disorder demonstrate effectiveness across a range of outcomes for children with autism and their caregivers.

Mothers of children with autism spectrum disorders: Play behaviors with infant siblings and social responsiveness

Mother-infant interactions are a proximal process in early development and may be especially salient for children who are at risk for social difficulties (i.e. infant siblings of children with autism spectrum disorder). To inform how indices of maternal behaviors may improve parent-mediated interventions designed to mitigate autism spectrum disorder risk, the present study explored maternal social responsiveness ratings and social behaviors during dyadic play interactions. Dyads were recruited from families with at least one older child with autism spectrum disorder (high-risk group, n = 90) or families with no history of autism spectrum disorder (low-risk group, n = 62). As part of a prospective study, interactions were coded when infant siblings were 6, 9, and 12 months of age, for gaze, affect, vocalizations, and multimodal bids or responses (i.e. social smiles). Maternal social responsiveness was indexed via the Social Responsiveness Scale. Mothers in both risk groups had comparable Social Responsiveness Scale scores and social behaviors during play. Two maternal behaviors emerged as positive correlates of infant social behaviors and are thus of high relevance to parent-mediated interventions. Specifically, more maternal positive affect and the use of multimodal bids or responses were associated with more infant positive affect, vocalizations, gaze to face, and multimodal bids or responses.

Development of the WHO Caregiver Skills Training Program for Developmental Disorders or Delays

Globally, 52.9 million children under the age of 5 experience a developmental disability, such as sensory impairment, intellectual disability, and autism spectrum disorders. Of these 95% live in low-and-middle-income countries. Most of these children lack access to care. In light of the growing evidence that caregivers can learn skills to support their children's social communication and adaptive behavior and to reduce their challenging behavior, the World Health Organization developed a novel Caregiver Skills Training Program (CST) for families of children with developmental disorders or delay to address such treatment gap. This report outlines the development process, content, and global field-testing strategy of the WHO CST program. The CST program is designed to be feasible, scalable, and adaptable and appropriate for implementation in low-resource settings by nonspecialists. The program was informed by an evidence review utilizing a common elements approach and was developed through extensive stakeholder consultation and an iterative revision process. The program is intended for a global audience and was designed to be adapted to the cultural, socioeconomic, geographic, and resource context in which it is used to ensure that it is comprehensible, acceptable, feasible, and relevant to target users. It is currently undergoing field-testing in more than 30 countries across all world regions.

Communication interventions for autism spectrum disorder in minimally verbal children

BACKGROUND

Autism spectrum disorder (ASD) has an estimated prevalence of around 1.7% of the population. People with ASD often also have language difficulties, and about 25% to 30% of children with ASD either fail to develop functional language or are minimally verbal. The ability to communicate effectively is an essential life skill, and difficulties with communication can have a range of adverse outcomes, including poorer academic achievement, behavioural difficulties and reduced quality of life. Historically, most studies have investigated communication interventions for ASD in verbal children. We cannot assume the same interventions will work for minimally verbal children with ASD.

OBJECTIVES

To assess the effects of communication interventions for ASD in minimally verbal children.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase as well as 12 other databases and three trials registers in November 2017. We also checked the reference lists of all included studies and relevant reviews, contacting experts in the field as well as authors of identified studies about other potentially relevant ongoing and unpublished studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of communication-focused interventions for children (under 12 years of age) diagnosed with ASD and who are minimally verbal (fewer than 30 functional words or unable to use speech alone to communicate), compared with no treatment, wait-list control or treatment as usual.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

This review includes two RCTs (154 children aged 32 months to 11 years) of communication interventions for ASD in minimally verbal children compared with a control group (treatment as usual). One RCT used a verbally based intervention (focused playtime intervention; FPI) administered by parents in the home, whereas the other used an alternative and augmentative communication (AAC) intervention (Picture Exchange Communication System; PECS) administered by teachers in a school setting.The FPI study took place in the USA and included 70 participants (64 boys) aged 32 to 82 months who were minimally verbal and had received a diagnosis of ASD. This intervention focused on developing coordinated toy play between child and parent. Participants received 12 in-home parent training sessions for 90 minutes per session for 12 weeks, and they were also invited to attend parent advocacy coaching sessions. This study was funded by the National Institute of Child Health and Human Development, the MIND Institute Research Program and a Professional Staff Congress-City University of New York grant. The PECS study included 84 minimally verbal participants (73 boys) aged 4 to 11 years who had a formal diagnosis of ASD and who were not using PECS beyond phase 1 at baseline. All children attended autism-specific classes or units, and most classes had a child to adult ratio of 2:1. Teachers and parents received PECS training (two-day workshop). PECS consultants also conducted six half-day consultations with each class once per month over five months. This study took place in the UK and was funded by the Three Guineas Trust.Both included studies had high or unclear risk of bias in at least four of the seven 'Risk of bias' categories, with a lack of blinding for participants and personnel being the most problematic area. Using the GRADE approach, we rated the overall quality of the evidence as very low due to risk of bias, imprecision (small sample sizes and wide confidence intervals) and because there was only one trial identified per type of intervention (i.e. verbally based or AAC).Both studies focused primarily on communication outcomes (verbal and non-verbal). One of the studies also collected information on social communication. The FPI study found no significant improvement in spoken communication, measured using the expressive language domain of the Mullen Scale of Early Learning expressive language, at postintervention. However, this study found that children with lower expressive language at baseline (less than 11.3 months age-equivalent) improved more than children with better expressive language and that the intervention produced expressive language gains in some children. The PECS study found that children enrolled in the AAC intervention were significantly more likely to use verbal initiations and PECS symbols immediately postintervention; however, gains were not maintained 10 months later. There was no evidence that AAC improved frequency of speech, verbal expressive vocabulary or children's social communication or pragmatic language immediately postintervention. Overall, neither of the interventions (PECS or FPI) resulted in maintained improvements in spoken or non-verbal communication in most children.Neither study collected information on adverse events, other communication skills, quality of life or behavioural outcomes.

AUTHORS' CONCLUSIONS

There is limited evidence that verbally based and ACC interventions improve spoken and non-verbal communication in minimally verbal children with ASD. A substantial number of studies have investigated communication interventions for minimally verbal children with ASD, yet only two studies met inclusion criteria for this review, and we considered the overall quality of the evidence to be very low. In the study that used an AAC intervention, there were significant gains in frequency of PECS use and verbal and non-verbal initiations, but not in expressive vocabulary or social communication immediately postintervention. In the study that investigated a verbally based intervention, there were no significant gains in expressive language postintervention, but children with lower expressive language at the beginning of the study improved more than those with better expressive language at baseline. Neither study investigated adverse events, other communication skills, quality of life or behavioural outcomes. Future RCTs that compare two interventions and include a control group will allow us to better understand treatment effects in the context of spontaneous maturation and will allow further comparison of different interventions as well as the investigation of moderating factors.

Play, Playfulness, and Self-Efficacy: Parental Experiences with Children on the Autism Spectrum

Background

Play serves as an essential medium for parent-child interaction; however, engaging children with ASD through play can be a challenge for parents.

Purpose

The purpose of this phenomenological study was to explore the perspectives of parents with children on the autism spectrum regarding play experiences and self-efficacy during play encounters.

Method

Semistructured interviews were administered to 8 parents of children 3–7 years of age with ASD. The analysis was guided by the constant comparison method.

Findings

Parental narratives denoted playful experiences reflecting components of Skard and Bundy's model of playfulness. The facilitation of framing and suspension of reality were generally more challenging than facilitating intrinsic motivation and internal control. Participants associated self-efficacy during play with their perceived ability to interact with their child and with positive emotions experienced during play. Fathers generally derived a greater sense of self-efficacy from play encounters than mothers, and this was explained by differences in fathers' and mothers' motivations for playing. Mothers were motivated to play for outcome-oriented reasons (e.g., promote the child's progress) whereas fathers' motivations depicted greater emotional emphasis, reflecting a better match between motivation and perceived indicators of efficacy during play.

Conclusion

The results suggest that a good match between motivation for playing and perceived indicators of efficacy during play is important for a parental sense of self-efficacy. Occupational therapists should utilize coaching strategies to increase parents' understanding of play and playfulness and how they can affect a sense of parental self-efficacy.

Integrating a Parent-Implemented Blend of Developmental and Behavioral Intervention Strategies into Speech-Language Treatment for Toddlers at Risk for Autism Spectrum Disorder

Naturalistic developmental behavioral interventions include an explicit focus on coaching parents to use therapy techniques in daily routines and are considered best practice for young children with autism. Unfortunately, these approaches are not widely used in community settings, possibly due to the clinical expertise and training required. This article presents the work of the Bond, Regulate, Interact, Develop, Guide, Engage (BRIDGE Collaborative), a multidisciplinary group of service providers (including speech-language pathologists), parents, funding agency representatives, and researchers dedicated to improving the lives of young children with autism spectrum disorder and their families. The group selected and adapted a parent coaching naturalistic developmental behavioral intervention specifically for use with toddlers and their families for community implementation. Lessons learned from the implementation process include the importance of therapist background knowledge, the complexity of working with parents of young children, and needed supports for those working closely with parents, including specific engagement strategies and the incorporation of reflective practice.

Early interaction in autism spectrum disorder: Mothers' and children's behaviours during joint engagement

BACKGROUND

More knowledge about the interaction between young children with autism spectrum disorder and their parents is one way to improve intervention. This study aims to investigate the behaviours of mothers and children with autism spectrum disorder during joint engagement, with a focus on pacing or rate (i.e., incidences per minute) of their behaviours when being in this state.

METHOD

Video recordings of 10 min of free-play between 58 children (2-4 years) diagnosed with childhood autism and their mothers were used to examine rate of mothers' and children's behaviours (i.e., toy introduction, toy expansion, positive affect, and language) during joint engagement, the association between rate of mothers and children's behaviours, the relation between rate of mothers' behaviours and time in joint engagement, and how child factors might be associated with the latter.

RESULTS

Mothers^(m) and children^(c) showed similar rate of positive affect (M^m  = 0.6/M^c  = 0.5) and toy expansion (M^m  = 0.7/M^c  = 0.7) per minute, whereas mothers talked almost three times more than their children (M^m  = 10.2/M^c  = 3.8). In contrast, mothers introduced fewer toys compared to the children (M^m  = 0.7/M^c  = 1.2). Rate of mothers' toy introduction, toy expansion, and positive affect was inversely related to time in joint engagement (Regression coefficient = -70.7 to -48.5, p = .006 to .024). Rates of mothers' and children's behaviours were associated (Spearman rank order coefficient = .53 to .29, p < .001 to .03), but neither rate of children's behaviours nor mental age was associated with the observed relation between rate of these maternal behaviours and time in joint engagement.

CONCLUSION

Time in joint engagement was related to rate of mothers' behaviours and children's mental age but not to rate of children's behaviours in this study. Thus, intervention teaching parents of young children with autism strategies designed to increase time in joint engagement may be vital. The complex nature of the interaction between mother and child behaviours in promoting joint engagement warrants further elucidation.