Feasibility of Group Parent Training for Children with Autism Spectrum Disorder and Disruptive Behavior: A Demonstration Pilot

Pharmacological treatment in autism: a proposal for guidelines on common co-occurring psychiatric symptoms

BACKGROUND

The prevalence of autism spectrum disorder (ASD) has surged, with an estimated 1 in 36 eight-year-olds in the United States meeting criteria for ASD in 2020. Autistic individuals face elevated rates of co-occurring medical, psychiatric, and behavioral conditions compared to non-autistic individuals. The rising ASD-patient demand is increasingly outpacing the capacity of ASD-specialty clinics, resulting in urgent need for autism-competent providers in general practice settings. This work aims to empower healthcare providers, especially primary care providers (PCPs), with guidelines for the recognition and safe pharmacologic management of common co-occurring psychiatric and behavioral conditions in ASD.

METHODS

Lurie Center for Autism medical providers, who have extensive experience in ASD care, delineated approaches for recognition and pharmacological treatment of sleep disturbances, attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, and irritability tailored to ASD patients. Pharmacological guidelines were iteratively refined until consensus was reached. Treatment differences relative to standard of care (SOC) of non-autistic individuals are noted. Key literature and clinical trial results were reviewed to supplement clinical experience.

RESULTS

The pharmacological treatment pathways reflect how appropriate medication options for ASD patients can depend on many factors unique to the patient and can differ from established non-autistic SOC. Key takeaways include: For sleep disturbances in ASD, initial strategies align with non-autistic SOC, emphasizing sleep hygiene and melatonin use. First-line recommendations for treating ADHD, anxiety, and depression in ASD differ from non-autistic SOC; α2-adrenergic agonists are more suitable than stimulants for some ASD-ADHD patients, buspirone and mirtazapine are preferred to selective serotonin reuptake inhibitors (SSRIs) for anxiety, and duloxetine, mirtazapine, bupropion, and vortioxetine are recommended ahead of SSRIs for depression. Addressing irritability in ASD requires interdisciplinary evaluation of contributing factors, and guanfacine, risperidone, or aripiprazole may be appropriate, depending on severity.

CONCLUSIONS

Recognition and treatment of co-occurring psychiatric and behavioral conditions in autistic patients must account for differences in clinical presentation and medication effectiveness and tolerability. Drawing on evidence-based clinical insights, these guidelines seek to support PCPs in making informed decisions when prescribing medications for ASD patients with co-occurring psychiatric and behavioral conditions, ultimately enhancing access to timely, comprehensive care for all individuals with ASD.

Efficacy of a Parent-Implemented Pivotal Response Treatment for Children with Autism Spectrum Disorder

PURPOSE

Pivotal response treatment (PRT) is a well-established intervention addressing core symptoms of autism spectrum disorder (ASD), with parent involvement as a key component. The current study aimed to examine the effects of PRT parent training on parent fidelity and provide descriptive analyses of parent-child interactions before and after parent training. It also probed parental acceptance and satisfaction with the program.

METHODS

A concurrent multiple baseline design across participants was used to evaluate the effectiveness of the parent training program. Four parents (range 32-47 years old) and their children with ASD participated in the study. The intervention comprised 12 one-on-one parent training sessions over six consecutive weeks. The visual analysis and effect size calculation (Tau-U) were used to evaluate functional relationship between independent and dependent variables. The descriptive analysis was used to analyze parent-child interaction data.

RESULTS

The findings reveal that all parents learned and maintained PRT with a high level of fidelity, they also enhanced awareness to create more opportunities for interactions during free play, and the parents were very satisfied with the program. The results also indicate that the six-week parent training program is effective in teaching parents to implement PRT with their children.

CONCLUSION

These results suggest that the parent training program may be a promising treatment model that is effective, efficient, and cost-effective. Implications for future research and practice are then discussed.

Cultural Adaptation of RUBI Intervention with Korean Families (K-RUBI): A Mixed Method Study

Challenging behaviors of young autistic children remain a major parenting challenge for many of their family members, including caregivers. Caregivers from underrepresented cultural or linguistic backgrounds may experience exacerbated difficulties related to challenging behaviors due to limited access to culturally sustaining and responsive interventions. Evidence-based behavior parent training programs, such as RUBI, are highly effective in increasing caregivers' capacity in preventing and responding to these behaviors in naturalistic settings using behavior analytic principles. Therefore, the purpose of this study was to examine the effectiveness, acceptability, and feasibility of the culturally adapted RUBI program with underserved families. We conduct a convergent mixed-methods study using a pilot randomized controlled trial with a waitlist control group and focus group interviews with 31 Korean families of young children with or suspected of autism. The Korean RUBI underwent rigorous cultural adaptation using the Cultural Adaptation Checklist, including the use of multiple community advisory boards to inform cultural adaptation. Both quantitative and qualitative findings revealed significant improvements in parents' confidence and knowledge in behavioral principles and decrease in severity of challenging behaviors, which suggest clinical utility of RUBI in an underrepresented, low-resourced community. A culturally adapted intervention for a different population can be perceived as a newly constructed intervention. This study provides insight on the systematic process of cultural adaptation of an established autism intervention and effectiveness, feasibility, and acceptability of RUBI.

Feasibility study of a parent-driven intervention for youth with Down syndrome

BACKGROUND

Children with Down syndrome present with behavioural and emotional difficulties, including noncompliance, rule-breaking, emotion dysregulation and delays in executive functioning. Few behavioural interventions have been designed specifically for children with Down syndrome. The Research Units in Behavioral Intervention (RUBI) Parent Training for Disruptive Behaviors is a structured empirically supported parent training programme developed for caregivers of children with autism. This feasibility trial explored the feasibility and acceptability of an abbreviated RUBI intervention with caregivers of children with Down syndrome and identified promising outcome measures to target in future larger clinical trials.

METHOD

A double-blind randomised feasibility pilot clinical trial allocated participants to a behavioural intervention (BEH) or educational (EDU) group. BEH and EDU consisted of five individual sessions over the course of 5 to 8 weeks. Measures were administered to 20 caregivers and their youth with Down syndrome at three time points.

RESULTS

Both BEH and EDU were rated as feasible with high parental adherence and acceptable with high treatment satisfaction. Both BEH and EDU demonstrated decreased externalising behaviours, irritability and hyperactivity and improved behavioural regulation in executive functioning over time. No impact was noted on caregiver functioning.

CONCLUSION

The feasibility trial has strong findings regarding feasibility and satisfaction and has promising findings regarding the selection of measures for future trials testing an adapted RUBI programme and an education programme to reduce behavioural challenges in children with Down syndrome. Larger scale clinical trials are needed to confirm promising findings of these feasible treatments.

Irritability as a Transdiagnostic Risk Factor for Functional Impairment in Autistic and Non-autistic Toddlers and Preschoolers

Trait irritability in toddlerhood is a powerful risk factor for later internalizing and externalizing challenges in non-autistic children, but the predictive clinical utility of irritability is unknown in autism. Irritability is a trait-level emotional response (i.e., frustration) to a blocked goal and is one source of disruptive behavior. Irritability has two facets: Frustration is the degree to which emotion is elevated after a blocked goal, while soothability is the rate of recovery from peak distress. We aimed to: (1) compare and describe the two facets of irritability in non-autistic and young autistic children, and (2) assess whether children's reward sensitivity and executive function moderate the relation between irritability and clinical symptoms. Participants were 90 autistic (n=43) and non-autistic (n = 47) 2- and 4-year-olds. Autistic children did not have different levels of frustration but were more difficult to soothe compared to non-autistic children, according to parents. Further, frustration and soothability were less strongly correlated for autistic compared to non-autistic children. For all children, executive function (specifically, inhibition) moderated, or ameliorated the strength of, the relation between irritability (both soothability and frustration) and externalizing challenges. This study provides evidence for irritability as a transdiagnostic risk factor for clinically significant emotion regulation challenges. Further, the effect of trait irritability may be ameliorated by children's executive function in a transdiagnostic manner. Future work should examine the unique aspects of soothability to how irritability presents within autism, as well as evaluate and modify emotion regulation interventions for autistic toddlers and preschoolers.

Families' experiences of the Low Arousal Approach: a qualitative study

Background

Parents and carers supporting a family member presenting with behaviors of concern experience heightened stress. The Low Arousal Approach is a crisis management strategy which recognizes that stress, or physiological arousal, can be expressed through behaviors of concern. This approach aims to equip parents and carers to manage behaviors in a person-centered and non-confrontational way. There is a paucity of published research exploring the experiences of families applying this approach.

Methods

Seventeen parents who had received training in the Low Arousal Approach were interviewed to gain their perspectives on supporting their family members using this approach.

Results

Thematic analysis revealed themes relating to parental stress, which was related to external pressures, isolation, family stress, and challenges in their caring role. They described encountering negative narratives relating to self-criticism and negative judgments from others. Training in the Low Arousal Approach was related to being empowered through access to evidence, increased confidence, and increased ability to advocate for their family member's needs. Low Arousal was described as a "lifestyle" that enabled increased coping for the family unit as a whole.

Discussion/conclusion

Findings indicate that it is vitally important to recognize the views of parents and carers, and these are equally as important as the views of professionals. We must understand parents' and carers' needs in order to provide adequate support.

Behavioral Parent Training via Telehealth for Autistic Children: Further Exploration of Feasibility During the COVID-19 Pandemic

Objectives

Many autistic children exhibit challenging and disruptive behaviors that can present challenges for both children and their families by interfering with acquisition of adaptive skills and affecting family and peer relationships. Behavioral parent training (BPT) is an evidence-based approach to reducing autistic children's disruptive behavior, but many families face a number of barriers to accessing BPT, such as availability of BPT in their community, and transportation and scheduling challenges. Therefore, we sought to explore the feasibility and promise of effectiveness of adapting an established BPT program to a telehealth format during the COVID-19 pandemic.

Methods

A feasibility trial of BPT via telehealth was conducted with fourteen parents of autistic children.

Results

Parents and clinicians were able to implement BPT via telehealth with a high degree of fidelity, and parents rated both BPT and the telehealth format favorably. The program also showed promise of effectiveness in reducing autistic children's disruptive behavior, improving their adaptive skills, as well as reducing parents' stress, and improving parents' sense of parenting competence.

Conclusions

The findings replicate and extend findings from previous studies, further demonstrating the promise of telehealth as a viable alternative format for delivering BPT. We also explore implications for future research, including the opportunity for more thorough evaluation of the effectiveness of BPT via telehealth.

From Clinic Room to Zoom: Delivery of an Evidence-Based, Parent-mediated Intervention in the Community Before and During the Pandemic

Disruptive behaviors (DBs) are common in children with autism, affecting child and family quality of life. Parent-mediated interventions (PMIs) are a cost-effective and accessible way to decrease DBs. COVID-19 increased need for telehealth interventions. This study explored a group delivery of an evidence-based PMI (RUBI), delivered face-to-face and virtually in Israel, before and during the pandemic. Fifty-five families of children with autism and DB participated, 24 receiving face-to-face intervention and 31 receiving virtual. Outcome measures included the Aberrant Behavior Checklist and Home Situations Questionnaires. Results indicate reduction of DBs across groups, with > 50% of treatment-responders showing reliable change. This study is the first to assess RUBI outside the US among a sociodemographically diverse population, in both in-person and virtual contexts.

Training Culturally Diverse Caregivers to Decrease Their Child's Challenging Behaviors: A Systematic Review and Meta-analysis

Parents are the primary source of support for their children and can become principal interventionists for preventing and treating their child's challenging behavior. Yet, providing adequate and adapted training for culturally diverse families can be difficult due to the increase of international migration and the diversity of languages spoken worldwide. This systematic review and meta-analysis evaluated 13 studies that implemented training for caregivers with limited proficiency in the majority language. Overall, the results suggested a moderate-small treatment effects on positive and negative parenting practices. The results also indicated moderate-small treatment effects on challenging behaviors exhibited by both individuals with developmental disabilities and typically developmental. Findings are discussed in terms of strategies used and recommendations for future research and practice.

Pivotal Response Treatment (PRT) - Parent Group Training for Young Children with Autism Spectrum Disorder: A Qualitative Study on Perspectives of Parents

Pivotal Response Treatment (PRT) is considered to be an empirically supported parent-mediated treatment for children with autism spectrum disorder (ASD), but research on parental experiences is lacking. This qualitative study examined the perspectives of parents of young children with ASD who participated in a 14-week PRT with parent group training (PRT-PG). Semi-structured interviews (n = 12) were carried out, based on Grounded Theory principles. Results indicated that facilitators and barriers were related to timing and expectations, training setting and characteristics, and participant characteristics. Perceived effects were related to improved child’s social-communication skills and well-being, parental insights into their child’s needs and own habitual patterns in communication and behavior, and positive changes in family cohesion. The findings indicate that in general parents value PRT-PG as feasible and effective.

Effects of Acceptance and Commitment Training Plus Behavior Parent Training on Parental Implementation of Autism Treatment

The objective of this study was to examine the effects of acceptance and commitment training (ACT) plus behavior parent training (BPT), when delivered via telehealth, on parental implementation of behavioral strategies, experiential avoidance (EA), and stress. The study also examined the subsequent effects on the parents' autistic children's behaviors. A multiple baseline design was implemented across four parent-child dyads who participated in the online training. The findings showed that ACT+BPT resulted in parental implementation reaching and maintaining high levels. The training also decreased EA and stress in three parents. Moreover, the parents' ratings of their children's challenging behaviors decreased. However, such a trend was not as clearly depicted by direct measures of the children's behaviors. A social validity interview revealed parents found ACT beneficial in assisting them to learn and use the BPT strategies. Implications and suggestions for future research are discussed.

A Novel Group Parenting Intervention for Emotional and Behavioral Difficulties in Young Autistic Children: Autism Spectrum Treatment and Resilience (ASTAR): A Randomized Controlled Trial

OBJECTIVE

To examine the feasibility and preliminary efficacy of a group behavioral parenting intervention for emotional and behavioral problems (EBPs) in young autistic children.

METHOD

This was a feasibility pilot randomized controlled trial comparing a 12-week group behavioral parenting intervention (Predictive Parenting) to an attention control (Psychoeducation). Parents of 62 autistic children 4 to 8 years of age were randomized to Predictive Parenting (n = 31) or Psychoeducation (n = 31). The primary outcome was a blinded observational measure of child behaviors that challenge. Secondary outcomes were observed child compliance and parenting behaviors; parent- and teacher-reported child EBPs; self-reported parenting practices, stress, self-efficacy, and well-being. Cost-effectiveness was also explored.

RESULTS

Recruitment, retention, completion of measures, treatment fidelity, and parental satisfaction were high for both interventions. There was no group difference in primary outcome: mean log of rate 0.18 lower (d, 90% CI = -0.44 to 0.08) in Predictive Parenting. Differences in rates of child compliance (0.44, 90% CI = 0.11 to 0.77), facilitative parenting (0.63, 90% CI = 0.33 to 0.92) and parent-defined target symptom change (-0.59, 90% CI -0.17 to -1.00) favored Predictive Parenting. There were no differences on other measures. Predictive Parenting was more expensive than Psychoeducation, with a low probability of being more cost-effective.

CONCLUSION

Feasibility was demonstrated. There was no evidence from this pilot trial that Predictive Parenting resulted in reductions in child EBPs beyond those seen following Psychoeducation; in addition, the effect size was small, and it was more expensive. However, it showed superiority for child compliance and facilitative parenting with moderate effect sizes. Future, definitive studies should evaluate whether augmented or extended intervention would lead to larger improvements.

CLINICAL TRIAL REGISTRATION INFORMATION

Autism Spectrum Treatment and Resilience (ASTAR); https://www.isrctn.com/; 91411078.

A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes

Youth with autism spectrum disorder (ASD) have high rates of co-occurring mental health needs that necessitate mental health interventions. Given the unique clinical characteristics of youth with ASD, there have been significant efforts to adapt and test mental health interventions for this population. Yet, characterization of the nature and types of interventions adaptations is limited, especially across the wide range of interventions tested for youth with ASD with a focus on implementation factors. Additionally, understanding how these interventions may be implemented in community services is limited. The aims of this systematic review are to characterize the (1) types of interventions tested for co-occurring mental health conditions for youth with ASD; (2) adaptations to mental health interventions for use with youth with ASD; and (3) implementation strategies, outcomes, and determinants of mental health interventions to inform their translation to community service settings. Eighty-three articles testing interventions targeting mental health symptoms in youth with ASD that included implementation factors in analyses were reviewed. The Stirman et al. (2013; 2019) FRAME adaptation, Powell et al. (2012;2015) implementation strategies, and Proctor et al. (2011) implementation outcomes taxonomies were applied to characterize the nature and types of adaptations for use with youth with ASD and types of implementation strategies, outcomes, and determinants used, when available, respectively. Of the interventions examined, the majority (64.1%) were originally designed to target youth mental health concerns and were then adapted to be used with ASD. The most common adaptations included those to the intervention content, particularly adding elements with tailoring or refining aspects of the intervention while maintaining core functions. Half of the articles described at least one implementation strategy used during intervention testing. Fidelity and acceptability were the most frequently examined implementation outcomes, with some examination of appropriateness and feasibility. Nineteen percent of articles described implementation determinants (i.e. barriers/facilitators) of these implementation outcomes. The common adaptations for ASD provide direction for future intervention development and for training community therapists. Further examination, specification, and reporting of implementation strategies and outcomes within ongoing efforts to adapt and interventions to meet the co-occurring mental health needs of youth ASD are needed to facilitate their translation to community settings. Areas for future research as well as clinical implications are discussed.

Correction to: A Systematic Review of Mental Health Interventions for ASD: Characterizing Interventions, Intervention Adaptations, and Implementation Outcomes

Due to the errors occurred in the originally published version, this article is being reprinted in its entirety as Correction. All errors have been corrected. It is the correct version.

Many Young Children with Autism Who Use Psychotropic Medication Do Not Receive Behavior Therapy: A Multisite Case-Control Study

OBJECTIVES

To explore how many pre-school aged children with autism spectrum disorder (ASD) used psychotropic medication, child and geographic factors associated with psychotropic medication use, and how many children who used psychotropic medication did or did not ever receive behavior therapy.

STUDY DESIGN

Children 2-5 years of age were enrolled from 2012 to 2016 in a multisite case-control study designed to investigate the development and risk factors of ASD. Children with a positive ASD screen or ASD diagnosis upon enrollment were asked to complete a comprehensive evaluation to determine ASD status and developmental level. Caregivers completed a Services and Treatments Questionnaire and multiple self-administered questionnaires to determine child use of psychotropic medication, ever receipt of behavior therapy, and presence of co-occurring symptoms.

RESULTS

There were 763 children who were classified as ASD and had data collected on the Services and Treatments Questionnaire. Of those, 62 (8.1%) used psychotropic medication to treat behavioral symptoms and 28 (3.7%) were ≤3 years of age when medication was first started. Attention problems (aOR, 7.65; 95% CI, 3.41-16.1; P < .001) and study site (aOR, 2.62; 95% CI, 1.04-6.56; P = .04) were significantly associated with psychotropic medication use after controlling for maternal race/ethnicity. More than one-half (59.7%) of those who used psychotropic medication did not ever receive behavior therapy.

CONCLUSIONS

Many preschool-aged children with ASD who use psychotropic medication do not receive behavior therapy. Pediatricians are an important resource for children and families and can help facilitate behavioral treatment for children with ASD and other disorders.

Adaption and pilot implementation of an autism executive functioning intervention in children's mental health services: a mixed-methods study protocol

BACKGROUND

Youth with autism spectrum disorder (ASD) represent a growing population with significant service needs. Prominent among these needs are high rates of co-occurring psychiatric conditions that contribute to increased functional impairments and often necessitate mental health services. Executive functioning deficits are associated with ASD as well as common co-occurring conditions (e.g., attention-deficit/hyperactivity disorder) and an evidence-based intervention has been developed and tested to address executive functioning within the school context. There is an urgent need to implement indicated evidence-based interventions for youth with ASD receiving care in community mental health settings. Interventions that optimally "fit" the mental health services context as well as the complex and co-occurring mental health needs of these youth have the potential to improve key clinical outcomes for this high priority population.

METHODS

This mixed-methods developmental study will apply the Exploration, Preparation, Implementation, Sustainment implementation framework and a community-academic partnership approach to systematically adapt and test an evidence-based executive functioning intervention for youth with ASD for delivery in community mental health settings. Specific aims are to (1) conduct a need and context assessment to inform the systematic adaptation an executive functioning evidence-based intervention; (2) systematically adapt the clinical intervention and develop a corresponding implementation plan, together entitled "Executive Functioning for Enhancing Community-based Treatment for ASD," (EFFECT for ASD); and (3) conduct a feasibility pilot test of EFFECT for ASD in community mental health settings.

DISCUSSION

Tailoring evidence-based interventions for delivery in community-based mental health services for youth with ASD has the potential to increase quality of care and improve child outcomes. Results from the current study will serve as the foundation for large-scale hybrid implementation and effectiveness trials and a generalizable approach for different service systems of care and clinical populations.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04295512.