A Review of the Effectiveness of Parent

 

And Caregiver Mediated Interventions in Toddlers

 

With Autism Spectrum Disorder (ASD)

 

Abstract: the article focuses on comparisons of parent-mediated intervention andno intervention or parent-mediated intervention along with intervention and treatment as usual for people with ASD.

Keywords: autism spectrum disorder, intervention delivery, toddlers, parent-mediated intervention.

 

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ASD (Autism Spectrum Disorder) affects the neurological development of individuals resulting in a lifelong disability. Currently in the UK there are 700,000 people living with ASD affecting 2.8 million people daily due to the family members living closely to those individuals (The National Autistic So-ciety, 2016a). Therefore, research offers value for awareness of the impacts, interventions, and outcomes for people with ASD and those around them.

 

Prior research has been carried out around how ASD is diagnosed as well as the age of diagnosis. The most common age of diagnosis is three years of age (Barbaro and Dissanayake, 2009) and the earliest age is two (Lord and Luyster, 2006 and Woolfenden et al., 2012). These findings give focus to the toddler age group of the intervention delivery.

 

To formulate the research question, the PICO model (O’Connor et al.,

 

2008) was used. Firstly, the population used was toddlers with ASD with the par-ent/ caregivers forming dyads within the intervention groups. The term ‘children’ was not specific enough in the search process as it referred to under 18.

 

The interventions analyzed were parent-mediated due to them being the toddlers’ attachment figures at this age (Holmes, 1993, 68). Secondly, parent-mediated or caregiver/teacher are recommended for young children in the Na-tional Institute for Health and Care Excellence (NICE, 2013) guidelines.

 

The comparisons made were either be between parent-mediated inter-vention and no intervention or parent-mediated intervention along with inter-vention and treatment as usual.

 

The outcomes included measures of Joint Attention and Engagement along with ADOS-G scores which have been known for external validity (Green et al., 2010, 2159). Reliability and applicability of these different measures vary.

 

Methodology. To evaluate the effectiveness of various parent or care-giver mediated interventions for toddlers with ASD secondary research was carried out in the form of a literature review. Literature reviews are a good method to analyze research which has already been published and allow for any areas of limited research to be identified. They can also identify new dis-coveries and highlight any ‘Red Herrings’ as Aveyard (2014, 5) would de-scribe. This term used by Aveyard means single pieces of literature that do not fit in with the main body of research. Without a literature review, this may not have been recognized and may have been relied upon for evidence based prac-tice (Bowling, 2014, 169-170) by professionals.

 

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For this review, there were multiple inclusion and exclusion criteria. For example, studies published within the last 10 years were used; any literature found that was dated further back than 2006 was excluded to ensure that the research used had been carried out in recent years. Secondly, the journal arti-cles used within this literature review have been peer reviewed by other aca-demics and professionals within a similar field of work or research reviewing journals. It allows any new recommendations or criticisms to be made and re-duce bias.

 

Both qualitative and quantitative data have been used as Ross (2012,

 

states that mixed method data leads to greater reliability and validity due to different methods (qualitative and quantitative) potentially leading to simi-lar results.

 

As secondary research this work has been ethically approved by the University of Lincoln. However, it was assumed that the literature used throughout this review has undertaken sufficient ethical approval processes.

Critical Appraisal Skills Programme (CASP, 2017) tool has been used. It is advantageous to use a tool such as this as it enables a consistent process to analyze all the data to ensure the quality of analysis is of a high standard.

Results. There are common themes throughout the studies as listed be-

 

low: ADOS-G score as a measure of outcomes; Parental responsiveness and parental synchrony; Restricted and Repetitive Behaviors; Joint Attention and Joint Engagement.

 

Many of the studies that were included in the final review were RCTs (Siller et al., 2014, Kaale et al., 2012, Green et al., 2010 and Kasari et al., 2014). Other forms of literature included reviews, report and analyses (Oono et al., 2013, Harrop, 2015 and Tanner et al., 2015).

 

Some studies found no significant differences between the intervention group and control group between all aspects of assessment (Mahoney and Sol-omon, 2016). For those that did achieve significant findings it was for the time spent jointly engaged (Kaale et al., 2012), visual reception (Kasari et al., 2014) and expressive and receptive language (Green et al., 2010).

 

Out of the 14 studies many of them used the ADOS/ADOS-G score (Au-tism Diagnostic Observation Schedule-Generic) (Lord et al., 2000) as a meas-ure of outcomes. However, the results and changes in these scores differed throughout. Aldred et al., (2012) found that the intervention group had a re-duction in ADOS-G scores at post-intervention and follow up compared to the control group. On the other hand, Schertz et al., (2013) found no significant

 

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differences between the two groups. Krishnan et al. (2016) found that the re-duction in scores led to those with moderate to severe ASD being classified as mild to moderate at post-intervention assessment. However, one problem with using this as a measure of ASD is its lack of external validity. Although a child may receive a score on the ADOS scale does not necessarily coincide with a formal diagnosis.

 

Longitudinal research has already found that responsive parental respon-siveness can lead to a reliable prediction of subsequent language gains in children with ASD (Siller et al., 2012). Parental responsiveness, parent synchrony and fi-delity (Krishnan et al., 2016, 238) are all terms referred to throughout the of par-ent and caregiver mediated interventions. Due to the interventions reviewed be-ing parent/caregiver mediated there is an extra variable to consider. Many studies included parent synchrony or parental responsiveness as a secondary measure, primary in some cases (Siller et al., 2014). When combined with the results of the toddlers’ behavior, correlations between parental involvement and outcomes of the intervention can be seen. However, when identifying correlations, it is im-portant to note that cause and effect cannot be assumed.

 

Aldred et al. (2012) focused on parent synchrony and found significant improvement in parental synchronous communication acts. It was correlated to show the improvement of parental synchrony relating to a mean 4.5-point re-duction in ADOS score (Aldred et al., 2012, 449) of the toddlers.

 

Joint Attention (JA) and Joint Engagement (JE) are two outcomes which have been measured throughout many of the studies. Both focus on the social communication part of ASD and how this can be developed in toddlers.

 

This review found that results from individual studies varied and the outcomes are not consistent between different pieces of research. Whereas Ka-sari et al. (2014) didn’t find any significant changes in JA, Kaale et al. (2012) found that children in the JA-intervention group were almost five times more likely to demonstrate initiation of JA skills compared to the control group. However, there was no significant difference between the two groups on the duration of JE during the preschool teacher-child play.

 

In contrast, the mother-child play found the opposite with no significant differences at post-intervention in JA skills but significant in time spent in JE (Kaale et al., 2012). There were also differences found between initiating JA (IJA) and responding to JA (RJA) (Schertz et al., 2013) with RJA showing significant interactions between intervention and time.

 

 

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Restricted and repetitive behaviors (RRBs) are aspects which have been discussed by two papers (Harrop, 2015 and Tanner et al., 2015) stating the lack of focus of these within parent-mediated interventions. Harrop (2015) found that not one study solely focused on restricted and repetitive behaviors as a primary outcome. This review has confirmed those findings with all other studies observing and measuring the other characteristics mentioned in the previous sections.

 

Conclusion and Recommendations. From carrying out a rigoroussearching process, one common limitation of research found throughout ASD interventions is the small sample sizes often used. Future research should fo-cus on studies with a greater number of participants to be able to make more reliable conclusions with external validity.

 

A key recommendation for future research is carrying out longitudinal studies to evaluate the long-term impact of parent/caregiver mediated interven-tions. The research that included the follow up stage a period after intervention suggests that the effects were maintained (Kasari et al., 2015). However, these were 6 months, (Kasari et al., 2015) post intervention which therefore only represents a short period of consistency.

 

In conclusion, this research intended to review the effectiveness of par-ent-mediated intervention on the developmental outcomes of toddlers. Alt-hough the research question does not have a simplistic yes or no answer in terms of how effective the parent or caregiver mediated interventions are, many discoveries have been made throughout this review.

 

Literature

 

Aldred C., Green J., Emsley R. Brief Report: Mediation of TreatmentEffect in a Communication Intervention for Pre-School Children with Autism

 

Journal of Autism and Developmental Disorders. 2012. № 42. P. 447–454.

 

Aveyard H. Doing a Literature Review in Health and Social Care: apractical guide, 3^rd edition. Berkshire: Open University Press, 2014.

 

Barbaro J., Dissanayake C. Autism Spectrum Disorders in Infancyand Toddlerhood: A Review of the Evidence on Early Signs, Early Identifica-tion Tools, and Early Diagnosis // Journal of Developmental and Behavioral

Pediatrics, 30 (5) 447–459. URL: http://journals.lww.com/jrnldbp/Abstract/2009/10000/Autism_Spectrum_Diso rders_in_Infancy_and.15.aspx (accessed: 16 November 2016).

 

 

269

Bowling A. Research Methods In Health: Investigating Health AndHealth Services, 4^th edition. Berkshire: Open University Press, 2014.

 

CASP. Critical Appraisal Skills Programme (CASP) Makingsense of evidence. Oxford: CASP. URL: www.casp-uk.net (accessed: 15 December 2016).

 

Green J., Charman T., McConachie H. Parent-mediated communica-tion-focused treatment in children with autism (PACT): a randomised con-trolled trial // The Lancet. 2010. № 375. P. 2152–2160.

Harrop C. Evidence-based, parent-mediated interventions for youngchildren with autism spectrum disorder: The case of restricted and repetitive behaviors // Autism. 2015. № 19 (6). P. 662–672.

Holmes J. J ohn Bowlby and Attachment Theory. London:Routledge, 1993.

Kaale A., Smith L., Sponheim E. A randomized controlled trial ofpreschool-based joint attention intervention for children with autism // Journal of Child Psychology and Psychiatry. 2012. № 53(1). P. 97–105.

Kasari C., Gulsrud A., Paparella T. Randomized Comparative Effi-cacy Study of Parent-Mediated Interventions for Toddlers With Autism //Journal of Consulting and Clinical Psychology. 2015. № 83 (5). P. 554–563.

Kasari C., Siller M., Huynh L.N. Randomized controlled trial of pa-rental responsiveness intervention for toddlers at high risk for autism //Infant Behavior and Development. 2014. № 37. P. 711–721.

 

Krishnan R., Nesh M.T.J.A., Russell P.S.S. The effectiveness of anintensive, parent mediated, multi-component, early intervention for children with autism //Journal of Indian Association for Child and Adolescent Mental Health. 2016. № 12 (3). P. 230–252.

 

Lord, C., and Luyster, R. Early diagnosis of children with autismspectrum disorders // Clinical Neuroscience Research. 2006. № 6. P. 189–194.

Lord C., Risi S., Lambrecht L. The Autism Diagnostic ObservationSchedule–Generic: A Standard Measure of Social and Communication Defi-cits Associated with the Spectrum of Autism // Journal of Autism and Devel-opmental Disorders. 2000. № 30 (3). P. 205–223.

 

Mahoney G., Solomon R. Mechanism of Developmental Change inthe PLAY Project Home Consultation Program: Evidence from a Randomized Control Trial // Journal of Autism and Developmental Disorders. 2016. № 46. P. 1860–1871.

 

 

270

NICE Management and support in children and young people with autism // NICE. URL: http://pathways.nice.org.uk/pathways/autism-spectrum-disorder/management-and-support-in-children-and-young-people-with-autism#content=view-node%3Anodes-interventions-for-the-core-features-of-autism (accessed: 20 November 2016).

 

O’Connor D., Green S., Higgins J.P.T. (eds.) Cochrane Handbookfor Systematic Reviews of Interventions: Defining the review question and de-veloping criteria for including studies. Chichester: Wiley, 2008.

Oono I.P., Honey E.J., McConachie H. Parent-mediated early inter-vention for young children with autism spectrum disorders (ASD) (Review) // Evidence -based child health. 2013. № 8(6). P. 2380–2479.

Ross T. A Survival Guide For Health Research Methods. Berkshire:Open University Press, 2012.

Schertz H.H., Odom S.L., Baggett K.M. Effects of Joint AttentionMediated Learning for toddlers with autism spectrum disorders: An initial ran-domized controlled study // Early Childhood Research Quarterly. 2013. № 28. P. 249–258.

 

Siller M., Hutman T., Sigman M. A Parent-Mediated Intervention toIncrease Responsive Parental Behaviors and Child Communication in Children with ASD: A Randomized Clinical Trial // Journal of Autism Developmental Disorders. 2012. № 43. P. 540–555.

 

Siller M., Swanson M., Gerber A. A Parent-Mediated InterventionThat Targets Responsive Parental Behaviors Increases Attachment Behaviors in Children with ASD: Results from a Randomized Clinical Trial // Journal of Autism and Developmental Disorders. 2014. № 44. P. 1720–1732.

 

Tanner K., Hand B.N., O’Toole G. Effectiveness of Interventions toImprove Social Participation, Play, Leisure, and Restricted and Repetitive Be-haviors in People With Autism Spectrum Disorder: A Systematic Review // American Journal of Occupational Therapy. 2015. № 69 (5). P. 334–314.

 

The National Autistic Society Autism facts and history. London: The National Autistic Society. URL: http://www.autism.org.uk/about/what-is/myths-facts-stats.aspx (accessed: 7 November 2016).

 

Woolfenden, S., Sarkozy, V., Ridley, G., & Williams, K. A system-atic review of the diagnostic stability of autism spectrum disorder // Research in Autism Spectrum Disorders. 2012. № 6. P. 345–354.

 

 

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Siaka Koroma

 

University of Lincoln, BSc (Hons) Health and Social Care, UK, Lincoln Supervisor: John McCavish, University of Lincoln