Examining treatment adherence among parents of children with autism spectrum disorder

Transcranial Pulsed Current Stimulation and Social Functioning in Children With Autism: A Randomized Clinical Trial

Importance

Transcranial pulsed current stimulation (tPCS) may improve social functioning and sleep disorders in children with autism spectrum disorder (ASD). Prior trials have been limited by small sample sizes, single-center designs, and often a lack of sham controls.

Objective

To examine the safety and efficacy of tPCS in improving social functioning and sleep disorders in children with ASD.

Design, Setting, and Participants

This multicenter, double-blind, 2-armed, sham-controlled randomized clinical trial, conducted from May 1, 2022, through November 30, 2023, assessed children aged 3 to 14 years with ASD at 8 medical centers in China.

Interventions

Participants underwent daily 20-minute sessions of active tPCS (0.7 mA) or sham tPCS (brief 0.7 mA ramp-up and ramp-down) for 20 sessions over 4 weeks with anode over the right cerebellar hemisphere and cathode over the left dorsolateral prefrontal cortex (12.56-cm2-circular, 4-cm-diameter circular electrodes). Each day after tPCS, all participants received 1 hour of standard therapy.

Main Outcomes and Measures

Social functioning was assessed using the Autism Treatment Evaluation Checklist as the primary outcome. Secondary outcomes included the Autism Behavior Checklist and the Childhood Sleep Habits Questionnaire.

Results

A total of 312 participants (155 in the active group and 157 in the sham group; 248 [79.5%] boys; mean [SD] age, 5.1 [1.6] years; 276 [88.5%] aged 3-6 years and 36 [11.5%] aged 7-14 years) completed the trial. After 20 sessions, the mean Autism Treatment Evaluation Checklist total score improved by 4.13 points (5.8%) in the sham tPCS group and 7.17 points (10.7%) in the active tPCS group. Analysis of covariance showed significantly greater improvement in the active tPCS group (difference, -3.50; 95% CI, -5.56 to -1.43; P < .001). Both treatments were well tolerated.

Conclusions and Relevance

In this randomized clinical trial of prefrontal-cerebellar tPCS in children aged 3 to 14 years with ASD, 20 sessions over 4 weeks improved social functioning and sleep. These findings suggest that tPCS may serve as a viable nonpharmacologic alternative for ASD.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2200059118.

A Cross-Sectional Retrospective Review of Neuropsychiatric Comorbidities in Children With Non-Alcoholic Fatty Liver Disease

This single-center cross-sectional retrospective chart review sought to define the prevalence of neuropsychiatric (NP) disorders among children with non-alcoholic fatty liver disease (NAFLD) compared to the general population. The prevalence rate of NP disorders was determined at diagnosis among children evaluated from 2006 to 2016. The NP disorder prevalence rates were compared to those reported in the 2016 National Survey of Children's Health (NSCH). 24.3% of 254 children with NAFLD reported to have at least 1 NP disorder compared to 16.9% of those in NSCH (relative risk [RR] = 1.44; P < .0001). More children had intellectual disability (ID) (4.5% vs 0.8%; RR = 5.43, P < .0001), depression (3.9% vs 2.2%; RR = 1.82, P = .0009), or autism spectrum disorder (ASD) (3.3% vs 2.0%; RR = 1.67, P = .047) in the Boston Children's Hospital (BCH) NAFLD cohort. The prevalence of 1 NP disorder was 29.4% in our cohort compared to 22.3% in NSCH (RR = 1.32; P = .007). Children with NAFLD have a higher rate of NP disorders compared to the general population.

Association between adherence to behavioral intervention and capability well-being among parents of autistic children: a cross-sectional study from China

BACKGROUND

High adherence to behavioral interventions among parents of autistic children contribute to improvement in children's behaviors and parental outcomes. However, most of previous studies focused on the effects of intervention adherence on health-related well-being among parents, which is inadequate to capture the multi-dimensional parental burden of caring for autistic children. The aim of this study is to assess the association between parents' adherence to behavioral intervention and their capability well-being.

METHODS

A cross-sectional study was conducted among caregivers of autistic children aged 1-17 years with a confirmed diagnosis in China. A total of 213 parents of autistic children who were currently receiving behavioral intervention were considered in this study. Parental adherence to behavioral intervention was evaluated by the 5-item General Adherence subscale of the Medical Outcome Study. Capability well-being was assessed using the Investigating Choice Experiments Capability Measures for Adults (ICECAP-A), including the domains of stability, attachment, autonomy, achievement, and enjoyment. The index scores for each domain were computed based on the preference-based value set in the United Kingdom, ranging from 0 to 1. Multivariate linear regression analyses were conducted to assess the relationship between intervention adherence and parental well-being. Intervention adherence as well as the variables with p < 0.1 in the univariate analyses were included in multivariate linear regression analyses.

RESULTS

The mean overall score of ICECAP-A was 0.681 (0.205). In the univariate analyses, intervention adherence was positively associated with stability, autonomy, achievement, and enjoyment (p < 0.05), while the relationship between intervention adherence and attachment was not significant (p = 0.07). After controlling for the confounders in the multivariate linear regression analyses, intervention adherence was positively associated with achievement (β = 0.0004) and enjoyment (β = 0.0004).

CONCLUSIONS

The overall capability well-being among parents of autistic children was worse than that of the general population and caregivers of adult patients with chronic diseases. Adherence to behavioral interventions was positively associated with parental well-being in terms of achievement and enjoyment. Health professionals should involve parents in behavioral interventions and encourage them to implement therapeutic strategies on a routine basis. Customized interventions are warranted to improve capability well-being targeting at vulnerable groups.

Remote Physiotherapy for Children with ASD during the COVID-19 Pandemic: A Thematic Analysis of Physical Therapists' Perspectives

Background: Physical therapy plays a crucial role in addressing the physical challenges faced by individuals with autism spectrum disorder (ASD). Amidst the COVID-19 pandemic lockdown, physical therapists (PTs) working in special education centers for ASD children were tasked with deploying remote telehealth interventions (RTIs), an uncommon approach in physical therapy until then. The present article aims to describe and discuss the PTs' perspective of using RTI with children with ASD during the national Israeli COVID-19 lockdown. Methods: Reports from 13 experienced PTs who treated and supported 244 children with ASD using RTIs over six weeks were analyzed. The study employed quantitative research methods, including freely written reports and discussions addressing the question "what were your experiences as a PT treating ASD children remotely during the nationwide COVID-19 lockdown?" Results: the reports were categorized into four main themes: (a) the implications of RTIs on the children; (b) the implications of RTIs on the PTs; (c) modifications for applying RTI; and (d) PTs' family rapport as a necessary basis for RTI. Noteworthy findings include the unaffected implementation of RTIs by ASD severity level and the dependence of RTI's success on parental availability and the ability of parents to tailor activities for their child. Conclusions: The findings of the current research suggest that PT services through RTIs are well-suited for individuals with ASD and their families.

Exploring adolescent and parent perspectives on facilitating health self-management in adolescents with autism spectrum disorder

Background

As many as 95% of individuals across the lifespan with autism spectrum disorder (ASD) have at least one comorbidity. While research focused only on the health of autistic adolescents is limited, we do know that fewer than 14% of these youth receive appropriate transition services to self-manage their health. These limitations have resulted in poor outcomes and premature mortality. Little is known about how parents and their adolescent children address this health burden.

Objective

The objective of this study is twofold. First to compare the perceptions of adolescents with ASD and their parents regarding adolescents' contextual and process variables (depressive symptoms, health knowledge, health communication/planning, self-efficacy, self-determination) and health self-management (HSM) behavior. The second is to examine social facilitation for HSM behaviors in adolescents with ASD and their parents.

Methods

In this community-based study, an online survey was used to compare the perspectives of 40 adolescents with ASD aged 12 to 22 years and their parents on the adolescents' HSM behaviors. Contextual and process variable measures (PROMISE, Starx, General Self-efficacy Scale, AIR Self-determination Scale, Social Facilitation Questionnaire) were completed by both adolescents (adolescent/pediatric version) and parents (parent version).

Results

Descriptive analysis indicated that parents were teaching self-management to adolescents for monitoring and preventing illness, including medication knowledge and how to talk to their doctor. The largest differences were found between parents' and adolescents' perceptions regarding teaching and learning about independent management of existing health conditions. Additionally, adolescents rated their self-efficacy (t (38) = 3.62, p < .001) and self-determination (t (39) = 4.55, p < .001) significantly higher than their parents did.

Conclusions

This study contributes perspectives on what parents and adolescents are doing to enhance adolescents' health self-management. Adolescence is a developmental period of social facilitation when parents may teach their adolescent children with ASD to self-manage their health and when those adolescents may learn to do so. During this period, providers should offer adequate planning and guided training to support parents and their adolescent children with ASD to improve adolescents' self-management behaviors and improve health outcomes for this vulnerable population.

Characteristics for Medical Cannabis Treatment Adherence among Autistic Children and Their Families: A Mixed-Methods Analysis

Introduction

Medical cannabis treatment for autistic children has recently become popular, and studies have focused on examining the treatment's effects on children's symptom presentation, reported side effects, and dropout rates. However, no previous study has investigated the factors influencing adherence and dropout rates in cannabis treatment.

Method

This explanatory sequential mixed-methods study explored these factors by examining the characteristics of 87 autistic children and their families and deepening parents' perspectives and experiences of the 6-month CBD-rich cannabis treatment's benefits and barriers.

Results

We found this treatment to have a high (75%) adherence rate, relatively mild side effects, and substantial reported benefits for the children and families. However, this treatment was not free of barriers; the intake regime, some side effects, and in some cases, unrealistic parental expectations made adherence difficult for some families.

Conclusion

Our results highlight the importance of providing professional guidance and knowledge to parents of autistic children, enhancing their understanding of the impact of CBD-rich cannabis treatment on their children and expected related challenges, and coordinating realistic treatment expectations. We hope that addressing these important aspects will influence parents' ability to adhere to and enjoy the benefits of cannabis treatment for their autistic children.

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

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

Predictors of Attrition in a Randomized Trial of a Social Communication Intervention for Infant-Toddlers at Risk for Autism

Addressing factors that make it more likely for families to attrite from early intervention trials will allow researchers to ensure that families reap the full benefits of participation. This study was an analysis of 78 children (Mage = 18.38 months, SD = 5.78) at risk for autism participating in a university-based randomized controlled trial of two 8-week long early intervention programs. Overall, attrition through 8-weeks was low, approximately 13%, however by the one-year follow-up attrition rates were approximately 50%. The most consistent predictor of attrition was the distance that families had to travel to the university. These data highlight the importance of providing services and support (e.g., financial and logistic) during follow-up to families to maximize their participation. Clincaltrials.gov Identifier: NCT01874327, 6/11/2013.

Advances in Supporting Parents in Interventions for Autism Spectrum Disorder

The rising prevalence of autism spectrum disorder (ASD) calls for clear referral and treatment guidelines for children with ASD and their caregivers. Caregiver involvement in intervention is a standard practice of care and research suggests that teaching intervention strategies to caregivers can improve child outcomes and increase caregiver efficacy. Caregiver-mediated interventions that are naturalistic, developmental, and behavioral are effective in improving social and communication skills for children with ASD. Caregiver training models that use behavioral strategies are effective in reducing challenging behaviors. Finally, reducing caregiver barriers to treatment implementation, including stress and strain, are becoming critical components for improving the well-being and care of children with ASD and their families.

Factors related to treatment adherence behaviors among old-age hemodialysis patients in Hamadan, Iran: the application of the extended theory of planned behavior during Covid-19 pandemic

Purpose

This study aimed to identify the factors related to treatment adherence behaviors among old-age hemodialysis patients in Hamadan based on the Extended Theory of Planned Behavior (ETPB) during the covid-19 pandemic.

Methods

This cross-sectional study was conducted from January to March 2021 in Hamadan, Iran. 191 hemodialysis patients were recruited who were referred to hemodialysis centers via the census method. Data were collected by a questionnaire containing items on socio-demographic information, End-Stage Renal Disease Adherence (ESRD-Adherence) Questionnaire, and ETPB constructs scale. Data analysis was performed using descriptive statistics and structural equation modeling.

Results

The mean (SD) age of participants was 62.49 (10.66). Also, the mean (SD) hemodialysis vintage/Month of them was 36.56 (43.34). Moreover, Treatment Adherence Behaviors are associated with education level, sex, and marital status (p < 0.001). Besides, Perceive Behavior Control (β = 0.414, t-value = 3.810) associated with intention. Also, intention (β = 0.158, t-value = 1.976) was associated to adherence behaviors. No significant associations were observed between positive attitudes, subjective norms, a perceived threat with intention, and adherence behaviors. The model explained about 54% of the variance of adherence behaviors. Finally, the goodness of fit index of 0.78, indicating the model good fit.

Conclusion

The present study demonstrates that some of the ETPB constructs such as perceived behavior control and intention are useful to improve adherence among the oldest hemodialysis patients. Also. This framework is revealed alongside the theory of planned behavior (TPB) applicable in the treatment adherence of old-age hemodialysis patients.

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.

Equity, acceptability and feasibility of using polyunsaturated fatty acids in children and adolescents with autism spectrum disorder: a rapid systematic review

INTRODUCTION

Some recent randomized controlled trials (RCTs) assessed the efficacy and safety of polyunsaturated fatty acids (PUFAs) for the treatment of autism spectrum disorder (ASD). To optimally inform the Italian guideline for the management of ASD in children and adolescents, we reviewed the impact on equity, acceptability and feasibility for developing a pilot recommendation for PUFAs.

METHODS

We performed a rapid systematic review of observational and experimental studies on PUFAs for children and adolescents with ASD, extracting data on resources required, equity, acceptability, and feasibility of PUFAs. We followed the framework provided by the grading of recommendations assessment, development and evaluation (GRADE) methodology, and we assessed risk of bias and methodological quality of included studies. Results were synthesized both narratively and quantitatively to address clinically relevant questions on equity, acceptability, and feasibility.

RESULTS

We found 14 papers related to equity. PUFAs did not seem to impact equity importantly. We did not find variation in effectiveness across subgroups and in a base case scenario, the cost of a 12 weeks cycle of therapy with 1.155 g/day of PUFAs was €65.51 euro. The acceptability of PUFAs was evaluated in 17 studies, 9 of which were RCTs. PUFAs were widely used among children and adolescents with ASD (18 to 51%), and 50% of parents considered nutritional supplementation as useful. Difficulty in swallowing capsules and bad taste were identified as possible causes of poor compliance, but treatment adherence, when measured in included RCTs, was judged to be good to excellent. Discontinuation due to any cause for PUFAs could not differ from placebo (low certainty of evidence). The feasibility of using PUFAs was assessed in 12 studies. PUFAs were probably sustainable, and no particular critical issue emerged from the feasibility assessment. However, the evidence appeared scarce and indirect.

CONCLUSIONS

We found the administration of PUFAs in children and adolescents with ASD to be potentially equitable, acceptable and feasible. These results are limited by the limited number and quality of retrieved documents, and need to be viewed in light of efficacy and safety data to formulate clinical recommendations.

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.

Measures of Parent Engagement for Children Receiving Developmental or Rehabilitation Interventions: A Systematic Review

AIM

To examine the conceptual and clinometric properties of measures for parent engagement in developmental or rehabilitation interventions for children and youth (<18 years of age).

METHODS

Four electronic databases were searched. Studies were included if they reported measures of at least one domain of parent engagement (i.e. affective, cognitive or behavioral). Reviewers independently identified measures and evaluated studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and the CanChild Outcome Measures Rating Form.

RESULTS

A total of 9,500 unique papers were retrieved, and 36 reported parent engagement measurement. Four measures met inclusion criteria: the Parent Involvement Index (PII), the Parent Participation Measure (PPM), the General Adherence subscale of the Medical Outcomes Study (GAMOS) and the Triadic Intervention and Evaluation Rating Scale (TIERS). No measure captured all domains of in-session parent engagement. Two addressed out-of-session parent engagement. There were limitations in validity and reliability.

CONCLUSIONS

Few measures of parent engagement are available. Existing measures mostly captured the behavioral domain of in-session engagement, and none assessed cognitive or affective aspects of engagement. Out-of-session engagement was infrequently captured. There is currently no comprehensive measure of parent engagement in pediatric developmental and rehabilitation services that demonstrates good clinical utility or is conceptually and psychometrically sound.

Measuring the burden of treatment for chronic disease: implications of a scoping review of the literature

BACKGROUND

Although there has been growing research on the burden of treatment, the current state of evidence on measuring this concept is unknown. This scoping review aimed to provide an overview of the current state of knowledge as well as clear recommendations for future research, within the context of chronic disease.

METHODS

Four health-based databases, Scopus, CINAHL, Medline, and PsychInfo, were comprehensively searched for peer-reviewed articles published between the periods of 2000-2016. Titles and abstracts were independently read by two authors. All discrepancies between the authors were resolved by a third author. Data was extracted using a standardized proforma and a comparison analysis was used in order to explore the key treatment burden measures and categorize them into three groups.

RESULTS

Database searching identified 1458 potential papers. After removal of duplications, and irrelevant articles by title, 1102 abstracts remained. An additional 22 papers were added via snowball searching. In the end, 101 full papers were included in the review. A large number of the studies involved quantitative measures and conceptualizations of treatment burden (n = 64; 63.4%), and were conducted in North America (n = 49; 48.5%). There was significant variation in how the treatment burden experienced by those with chronic disease was operationalized and measured.

CONCLUSION

Despite significant work, there is still much ground to cover to comprehensively measure treatment burden for chronic disease. Greater qualitative focus, more research with cultural and minority populations, a larger emphasis on longitudinal studies and the consideration of the potential effects of "identity" on treatment burden, should be considered.

Parent perceived challenges to treatment utilization in a publicly funded early intensive behavioral intervention program for children with autism spectrum disorder

Background: In recent years, the delivery of early intensive behavioral intervention (EIBI) for children with autism spectrum disorder (ASD) in the United States has significantly changed. More children with ASD than ever before are eligible to use publicly funded EIBI. Yet, the challenges to large-scale implementation of EIBI remain unclear. Specific Aims: We examined parent perceived challenges to treatment utilization, predictors of increased challenges to treatment utilization, and parent recommendations for increasing utilization in a statewide EIBI program. Method: Using a cross-sectional design, we surveyed parents of children with ASD receiving EIBI through South Carolina's Pervasive Developmental Disorder Program (N = 145). To examine the contributions of parent demographic characteristics, parent social support, and child challenging behaviors to perceived challenges to utilization, we used multiple linear regression. Parent recommendations were collected using a single open-ended question. Findings: The most frequently endorsed challenges included the child's school schedule (62.1%) and the child being overburdened with other treatment demands (65.2%). Greater child challenging behaviors were associated with a greater degree of perceived challenges, and social support was associated with a lesser degree of perceived challenges. Discussion: Parents perceived various challenges to utilization, and child and family characteristics may increase the risk for experiencing challenges to utilization. As the delivery of EIBI continues to evolve in the United States and elsewhere, these findings have implications for policy, programming, and future research.