BACKGROUND AND OBJECTIVES:

Systems of care emphasize parent-delivered intervention for children with autism spectrum disorder (ASD). Meanwhile, multiple studies document psychological distress within these parents. This pilot longitudinal randomized controlled trial compared the parent-implemented Early Start Denver Model (P-ESDM) to P-ESDM plus mindfulness-based stress reduction (MBSR) for parents. We evaluated changes in parent functioning during active treatment and at follow-up.

METHODS:

Participants included children (<36 months old) with autism spectrum disorder and caregivers. Participants were randomly assigned to P-ESDM only (n = 31) or P-ESDM plus MBSR (n = 30). Data were collected at baseline, midtreatment, the end of treatment, and 1, 3, and 6 months posttreatment. Multilevel models with discontinuous slopes were used to test for group differences in outcome changes over time.

RESULTS:

Both groups improved during active treatment in all subdomains of parent stress (β = −1.42, −1.25, −0.92; P < 0.001), depressive symptoms, and anxiety symptoms (β = −0.62 and −0.78, respectively; P < 0.05). Parents who received MBSR had greater improvements than those receiving P-ESDM only in parental distress and parent-child dysfunctional interactions (β = −1.91 and −1.38, respectively; P < 0.01). Groups differed in change in mindfulness during treatment (β = 3.15; P < .05), with P-ESDM plus MBSR increasing and P-ESDM declining. Treatment group did not significantly predict change in depressive symptoms, anxiety symptoms, or life satisfaction. Differences emerged on the basis of parent sex, child age, and child behavior problems.

CONCLUSIONS:

Results suggest that manualized, low-intensity stress-reduction strategies may have long-term impacts on parent stress. Limitations and future directions are described.

What’s Known on This Subject:

Parents play an integral role in early intervention for young children with autism spectrum disorder. They also report high levels of stress and psychopathology. Training in mindfulness practice may help parents of older children with autism spectrum disorder.

What This Study Adds:

This pilot randomized controlled trial compares the functioning of parents who participated in child-focused, parent-mediated behavioral intervention alone to that of parents who also received stress-reduction training.

Symptoms of autism spectrum disorder (ASD) may become evident by age 18 months.13  Emerging evidence suggests that early behavioral intervention improves outcomes,4,5  with some intervention models including parents in critical roles.5  Parent-delivered early intervention may promote skill generalization and allow systems of care to spread therapist time and cost across more children. In parallel, however, multiple studies have documented high levels of psychological stress and distress within the parents of children with ASD,612  more so than in parents of children with other diagnoses.1316  Although this distress may negatively impact families during a critical time of diagnostic understanding and service initiation, little has been done to deliberately study and support parents as part of early intervention delivery.

Parent involvement in intervention may generalize strategy use across settings.17,18  Incorporating parents into treatment is a core component of many state early intervention systems19 ; as applied to autism, this framework offers opportunities for addressing not only child but also broader family functioning. However, rigorous studies of parent-mediated interventions for young children have yielded mixed results.5,17,2027  Although undoubtedly influenced by variability within the autism phenotype, parent and family characteristics may affect how such training programs are perceived and implemented.2830  Parent stress and coping strategies may be influenced by factors such as parent or child sex, child age, and child problem behaviors.28,29,3141  Some of these relations may be reciprocal, with parenting stress changing as a function of, but then also directly impacting, child functioning over time.16,28,29,31,32,4244  These chronic effects may therefore impact parent-training paradigms, which emphasize increased parental responsivity and active provision of learning opportunities.22,23,45,46 

Increasingly, studies have investigated ways to directly support parents of children with developmental disabilities.47  One promising avenue is mindfulness-based stress reduction (MBSR).48  Several studies have documented that MBSR may reduce stress, improve sleep and health, and increase life satisfaction for parents of individuals with developmental disabilities.9,14,4951  Parents trained in MBSR report more positivity toward their children, less negativity regarding their children’s impact on the family, lower reactivity, and more frequent use of positive reappraisal strategies.9,5153  Parents who practice self-compassion report lower levels of depression and parenting stress,44  with 2 studies finding sustained effects of mindfulness practice on parent psychological distress and emotional and behavioral outcomes.50,53  Although promising, these works primarily delivered MBSR in isolation to parents of older children. One previous study combined mindfulness-based training for adolescents with ASD with parallel parent training, with improvements seen in parental stress and child behavior problems.53 

Little is known about how the combination of MBSR and low levels of early parent-mediated behavioral intervention impacts the functioning of parents of young children with new ASD diagnoses. This work attempted to address parent stress and distress by providing parents with skills-focused stress-reduction strategies during the postdiagnostic period. The primary aim of this pilot randomized controlled trial was to compare the effectiveness of a parent-mediated behavioral intervention, the parent-implemented Early Start Denver Model (P-ESDM), to that intervention plus MBSR in enhancing parent functioning. We hypothesized that both groups would improve in parent functioning over time and that compared with the P-ESDM–only group, parents in P-ESDM plus MBSR would show greater reductions in stress, depression, and anxiety as well as increased self-reported life satisfaction and mindfulness. A second aim was to examine whether treatment response differed on the basis of 5 covariates: child age at treatment initiation, child sex, parent sex, child autism severity, and behavior problems.

Participating parents were recruited from a diagnostic clinic from 2015 to 2017. Eligibility criteria included having a child (<36 months of age at consent) with a gold standard ASD diagnosis and parental English fluency. Exclusion criteria included severe child sensorimotor impairment. All procedures were approved by the medical center institutional review board.

We used a random-number generator with a planned maximum enrollment of 70 participants. Allowing ∼10% attrition, this provides 80% power to detect an effect size of 0.71 for 1 primary outcome or an effect size of 0.91 if a multiple-comparison correction was applied for 7 coprimary outcomes. We placed half of the generated numbers into each group. Blinded staff obtained consent then accessed a unique computer file to determine group assignment.

Of 103 eligible families, 63 consented to participate (Fig 1). Two participants did not have data that could be included in analyses: 1 (P-ESDM only) provided inaccurate data and a second (P-ESDM plus MBSR) withdrew without providing any parental data. This yielded a final sample of 61 families included in analyses (Tables 1 and 2). Of these 61 families, 7 withdrew before completing their third P-ESDM session. Reasons for withdrawal included scheduling conflicts (n = 5) and repeatedly missed sessions (n = 2). An additional 8 families were lost to 6-month follow-up (moved away [n = 4] and lost to contact [n = 4]). This attrition rate is similar to that of other studies of parent-implemented, low-intensity ASD interventions14,23,54,55  and did not differ by group or demographics.

FIGURE 1

Participant recruitment and retention flowchart. T3, Time 3 (end of treatment); T6, Time 6 (end of study).

FIGURE 1

Participant recruitment and retention flowchart. T3, Time 3 (end of treatment); T6, Time 6 (end of study).

Close modal
TABLE 1

Baseline Child Demographics

P-ESDM (N = 31)P-ESDM Plus MBSR (N = 30)
Age treatment began, y, mean (SD) 2.46 (1.64) 2.30 (0.45) 
Sex, n (%)   
 Male 25 (81) 25 (83) 
 Female 6 (19) 5 (17) 
Race, n (%)   
 Asian American 2 (6) 2 (7) 
 Black or African American 1 (3) 1 (3) 
 Native Hawaiian or other Pacific Islander 2 (6) 0 (0) 
 White 26 (85) 27 (90) 
Ethnicity, n (%)   
 Hispanic or Latino 2 (7) 1 (3) 
 Non-Hispanic or non-Latino 29 (93) 29 (97) 
P-ESDM treatment length, wk, mean (SD) 16.25 (3.38) 15.47 (3.30) 
ADOS-2 Calibrated Severity Score, mean (SD) 8.38 (1.49) 7.93 (1.76) 
Child Behavior Checklist (Total Problems T-score), mean (SD) 59.82 (8.65) 57.70 (9.36) 
Mullen Scales of Early Learning, mean (SD)   
 Early Learning Composite 55.97 (13.48) 60.07 (10.18) 
 Visual Reception AE 19.59 (4.23) 21.71 (6.69) 
 Fine Motor AE 20.67 (3.85) 21.83 (5.19) 
 Receptive Language AE 14.56 (6.89) 21.46 (14.83) 
 Expressive Language AE 15.30 (7.69) 19.21 (11.19) 
VABS-II, mean (SD)   
 Adaptive Behavior Composite 74.41 (11.93) 75.79 (9.86) 
 Communication 76.04 (17.83) 81.00 (15.84) 
 Daily Living Skills 77.33 (13.11) 76.08 (11.19) 
 Socialization 72.56 (11.50) 73.50 (8.14) 
 Motor 82.78 (7.99) 84.71 (11.00) 
P-ESDM (N = 31)P-ESDM Plus MBSR (N = 30)
Age treatment began, y, mean (SD) 2.46 (1.64) 2.30 (0.45) 
Sex, n (%)   
 Male 25 (81) 25 (83) 
 Female 6 (19) 5 (17) 
Race, n (%)   
 Asian American 2 (6) 2 (7) 
 Black or African American 1 (3) 1 (3) 
 Native Hawaiian or other Pacific Islander 2 (6) 0 (0) 
 White 26 (85) 27 (90) 
Ethnicity, n (%)   
 Hispanic or Latino 2 (7) 1 (3) 
 Non-Hispanic or non-Latino 29 (93) 29 (97) 
P-ESDM treatment length, wk, mean (SD) 16.25 (3.38) 15.47 (3.30) 
ADOS-2 Calibrated Severity Score, mean (SD) 8.38 (1.49) 7.93 (1.76) 
Child Behavior Checklist (Total Problems T-score), mean (SD) 59.82 (8.65) 57.70 (9.36) 
Mullen Scales of Early Learning, mean (SD)   
 Early Learning Composite 55.97 (13.48) 60.07 (10.18) 
 Visual Reception AE 19.59 (4.23) 21.71 (6.69) 
 Fine Motor AE 20.67 (3.85) 21.83 (5.19) 
 Receptive Language AE 14.56 (6.89) 21.46 (14.83) 
 Expressive Language AE 15.30 (7.69) 19.21 (11.19) 
VABS-II, mean (SD)   
 Adaptive Behavior Composite 74.41 (11.93) 75.79 (9.86) 
 Communication 76.04 (17.83) 81.00 (15.84) 
 Daily Living Skills 77.33 (13.11) 76.08 (11.19) 
 Socialization 72.56 (11.50) 73.50 (8.14) 
 Motor 82.78 (7.99) 84.71 (11.00) 

ADOS-2, Autism Diagnostic Observation Schedule, Second Edition; AE, age equivalent in mo; VABS-II, Vineland Adaptive Behavior Scales–Second Edition.

TABLE 2

Baseline Participating Parent Demographics

P-ESDM (N = 31)P-ESDM Plus MBSR (N = 30)
Age treatment began, y, mean (SD) 33.79 (5.53) 33.27 (6.24) 
Sex, n (%)   
 Male 4 (13) 4 (13) 
 Female 27 (87) 26 (87) 
Race, n (%)   
 Asian American 2 (6) 3 (10.0) 
 Black or African American 1 (3) 1 (3) 
 Native Hawaiian or other Pacific Islander 0 (0) 0 (0) 
 White 28 (91) 26 (87) 
Ethnicity, n (%)   
 Hispanic or Latino 4 (13) 2 (6) 
 Non-Hispanic or non-Latino 27 (87) 28 (93) 
Employed, n (%)   
 Yes 18 (58) 24 (80) 
 No 12 (39) 3 (10) 
 Did not answer 1 (3) 3 (10) 
Annual household income, $, n (%)   
 <30 000 3 (10) 4 (13) 
 30 000–60 000 6 (19) 7 (24) 
 60 000–90 000 9 (29) 6 (20) 
 >90 000 12 (39) 10 (33) 
 Did not answer 1 (3) 3 (10) 
Highest educational attainment, n (%)   
 High school graduate or general equivalency diploma 4 (13) 5 (17) 
 Some college or technical school 5 (16) 8 (27) 
 Associate’s degree 2 (7) 2 (6) 
 Bachelor’s degree 12 (39) 5 (17) 
 Some postgraduate education 1 (3) 2 (6) 
 Graduate degree 7 (23) 5 (17) 
 Did not answer 0 (0) 3 (10) 
P-ESDM (N = 31)P-ESDM Plus MBSR (N = 30)
Age treatment began, y, mean (SD) 33.79 (5.53) 33.27 (6.24) 
Sex, n (%)   
 Male 4 (13) 4 (13) 
 Female 27 (87) 26 (87) 
Race, n (%)   
 Asian American 2 (6) 3 (10.0) 
 Black or African American 1 (3) 1 (3) 
 Native Hawaiian or other Pacific Islander 0 (0) 0 (0) 
 White 28 (91) 26 (87) 
Ethnicity, n (%)   
 Hispanic or Latino 4 (13) 2 (6) 
 Non-Hispanic or non-Latino 27 (87) 28 (93) 
Employed, n (%)   
 Yes 18 (58) 24 (80) 
 No 12 (39) 3 (10) 
 Did not answer 1 (3) 3 (10) 
Annual household income, $, n (%)   
 <30 000 3 (10) 4 (13) 
 30 000–60 000 6 (19) 7 (24) 
 60 000–90 000 9 (29) 6 (20) 
 >90 000 12 (39) 10 (33) 
 Did not answer 1 (3) 3 (10) 
Highest educational attainment, n (%)   
 High school graduate or general equivalency diploma 4 (13) 5 (17) 
 Some college or technical school 5 (16) 8 (27) 
 Associate’s degree 2 (7) 2 (6) 
 Bachelor’s degree 12 (39) 5 (17) 
 Some postgraduate education 1 (3) 2 (6) 
 Graduate degree 7 (23) 5 (17) 
 Did not answer 0 (0) 3 (10) 

Parent functioning variables were collected at each time point (see the Procedure section).

Parenting Stress

Parents completed the Parenting Stress Index (PSI), Third Edition, Short Form. This 36-item measure yields 3 subscale scores (Parent-Child Dysfunctional Interaction [PCDI], Parental Distress [PD], and Difficult Child [DC]) used in present analyses. Higher scores indicate more stress.

Mental Health

Parents completed the Center for Epidemiologic Studies Depression Scale (20 items) and the Beck Anxiety Inventory (21 items).56  Higher scores on these measures reflect more symptoms.

Life Satisfaction

Parents completed the Satisfaction With Life Scale,57  a measure of subjective wellbeing. Its 5 items are scored along a 7-point Likert scale (higher scores indicate more satisfaction).

Mindfulness

Parents completed the Five Facet Mindfulness Questionnaire.58  The Five Facet Mindfulness Questionnaire consists of 44 items that yield 5 subscales. The total score was used in analyses. Higher scores indicate more mindfulness.

Before random assignment, parents provided the following baseline information: relationship to child, birth date, educational attainment, race and/or ethnicity of self and child, employment status, and annual household income.

Autism Severity

The Autism Diagnostic Observation Schedule, Second Edition is a standardized clinical observation system for patients with developmental ages of 12 months and older.59  Each module yields Calibrated Severity Scores (range: 1–10) based on age group and language level, which were used in these analyses. Higher scores reflect higher levels of autism symptoms.

Cognitive Assessment

The Mullen Scales of Early Learning is a standardized developmental test for children up to age 5 years.60  It provides 4 domain scores (visual reception, fine motor, receptive language, and expressive language; mean = 50; SD = 10) and yields an overall ability index (Early Learning Composite; mean = 100; SD = 15). Higher scores reflect higher ability levels.

Adaptive Functioning

The Vineland Adaptive Behavior Scales–Second Edition Interview Form is a semistructured interview.61  It yields 4 domain standard scores (communication, daily living skills, socialization, and motor skills; mean = 100; SD = 15) and an overall Adaptive Behavior Composite (mean = 100; SD = 15). Higher scores reflect better adaptive behavior skills.

Behavior Problems

The Child Behavior Checklist for ages 1.5 to 5 years62  is a parent-completed checklist of internalizing and externalizing behaviors. It includes 100 symptoms scored from 0 to 2 (higher scores indicate more symptom presence) within the past 2 months. T-scores ≥64 are considered clinically significant for broadband scales. Because of the high correlation between internalizing and externalizing subscales in this work (r = 0.61; P < .001), we used the T-score of the Total Problems scale.

After random assignment, families were scheduled for their first P-ESDM session and, when applicable, paired with an MBSR therapist. MBSR sessions began after the second P-ESDM session. Data were collected at 6 time points: baseline (before treatment), midtreatment (6 weeks), end of treatment (12 weeks), and 1, 3, and 6 months posttreatment.

Intervention: P-ESDM

P-ESDM consisted of 12 consecutive, weekly, clinic-based sessions that were ∼1 hour long. P-ESDM began an average of 1.35 months after diagnosis (SD = 1.45). Because of variable family schedules, it took an average of 15.87 weeks (SD = 3.33) to complete 12 sessions. Six P-ESDM therapists (separate from MBSR therapists and blinded to group assignment) were licensed, board-certified behavior analysts who were trained in fidelity by ESDM-certified trainers. This manualized intervention has a detailed parent-training curriculum and a specific coaching intervention method.5  Therapists introduce skills through descriptions, modeling, and coaching with embedded emphasis on skill generalizability. Fidelity was monitored by using the Early Start Denver Model Fidelity Checklist. Therapists covered 94% of intended content across sessions with no significant differences seen between groups (P > .10).

Intervention: P-ESDM Plus MBSR

Parents who were randomly assigned to P-ESDM plus MBSR attended 6 additional 1-hour individual sessions. Child care was provided to maximize attendance. The 4 MBSR therapists were clinicians with at least a master’s degree and expertise in behavioral intervention and ASD supervised by a licensed clinical psychologist with formal MBSR training. Fidelity was monitored by therapist-completed content checklists.

The MBSR protocol was based on the work of Dykens et al14  and modified for individual administration for parents of young children with ASD. It was introduced as a skills-focused stress-reduction program rather than individual therapy. The clinic-based sessions covered topics such as an introduction to mindfulness for managing stress, awareness of the present moment, and cultivating gratitude. Weekly handouts offered written and pictorial practice cues for the home. Suggested homework exercises included formal practice (eg, guided meditation) as well as activities that are easily incorporated into daily routines (eg, breath awareness). Weekly homework logs tracked strategy use.

Multilevel models with discontinuous slopes, using Hierarchical Linear Modeling software,63  were used to test for group differences in outcome changes over time. This allowed for inclusion of all participants with at least 1 time point of data. We modeled discontinuous rates of individual change with 2 time epochs64 : (1) linear slope from the first to the third time point (baseline, 6 weeks into treatment, and immediately posttreatment), representing change during active treatment, and (2) change in linear slope from immediately posttreatment through the 6-month follow-up (immediately posttreatment and 1, 3, and 6 months posttreatment), reflecting change posttreatment. We estimated multilevel models for each outcome that included the between-subjects variable of treatment group, with groups centered on 0 (P-ESDM = −0.5; P-ESDM plus MBSR = 0.5). Overall slope estimates in these models reflect change across the entire sample. Including treatment group allowed us to determine if any of the slope estimates (slope representing change during active treatment and change in slope during posttreatment) significantly differed by treatment group. Additional between-persons covariates included child age at treatment initiation, sex of the child, sex of the parent, baseline autism severity, and child behavior problems. Because this is pilot work, no corrections for multiple comparisons were made. All covariates were grand mean centered.

No adverse events were reported. Baseline demographic and diagnostic information about children and participating parents are reported (Tables 1 and 2).

Aim 1: Treatment Effects on Parent Outcomes

Estimates from the longitudinal models conditioned on treatment group and covariates for each of the outcome variables are presented (Table 3).

TABLE 3

Estimates From Conditional Multilevel Models of Change in Parent Outcomes

Independent VariablesModel Estimates, Coefficient (SE)
PSI: PDPSI: PCDIPSI: DCDepressive SymptomsAnxiety SymptomsLife SatisfactionMindfulness
Initial status intercept, random 29.13 (0.68)*** 31.11 (0.82)*** 32.55 (0.64)*** 10.53 (0.74)*** 9.12 (0.77)*** 26.20 (0.79)*** 134.82 (2.20)*** 
 P-ESDM plus MBSR versus P-ESDM 3.24 (1.50)* 1.19 (1.90) 1.08 (1.37) 0.33 (1.50) 0.97 (1.76) 0.20 (1.62) −5.66 (4.53) 
 Child age −0.45 (1.36) −5.34 (2.11)* −2.71 (1.27)* −2.24 (1.61) −3.18 (1.73) 4.96 (2.23)* 5.64 (5.50) 
 Male child versus female child −0.53 (1.78) 1.75 (2.08) 2.22 (1.55) −2.27 (2.58) 1.53 (1.88) 2.08 (2.42) −0.49 (5.00) 
 Male parent versus female parent 4.40 (2.03)* 1.70 (2.00) 0.82 (2.19) −0.98 (1.34) −2.68 (2.03) −2.88 (2.33) 1.73 (6.93) 
 Parent education 0.41 (0.44) 0.36 (0.52) 0.42 (0.43) −0.10 (0.80) 0.08 (0.52) 0.61 (0.61) −1.32 (1.36) 
 Autism severity 0.18 (0.42) −0.18 (0.55) 0.13 (0.44) −0.74 (0.63) −0.28 (0.52) 0.60 (0.57) −1.60 (1.46) 
 Behavior problems 0.52 (0.07)*** 0.50 (0.10)*** 0.47 (0.06)*** 0.34 (0.12)** 0.41 (0.10)*** −0.20 (0.11) −1.17 (0.26)*** 
Active treatment slope, random −1.42 (0.23)*** −1.25 (0.23)*** −0.92 (0.22)*** −0.62 (0.21)** −0.78 (0.29)* 0.07 (0.17) −0.65 (0.58) 
 P-ESDM plus MBSR versus P-ESDM −1.91 (0.45)*** −1.38 (0.44)** −0.48 (0.48) −0.35 (0.45) −0.62 (0.65) 0.57 (0.40) 3.15 (1.44)* 
Child age −0.38 (0.49) 1.08 (0.60) 0.46 (0.46) 0.16 (0.46) 0.03 (0.71) −1.08 (0.39)** 0.95 (1.15) 
 Male child versus female child −0.27 (0.64) −0.51 (0.66) −0.73 (0.58) 0.47 (0.57) −0.60 (0.65) 0.66 (0.41) −1.00 (1.51) 
 Male parent versus female child −2.91 (0.87)** −1.29 (0.86) −1.26 (0.91) 0.46 (0.38) 1.00 (0.67) −0.44 (0.42) −4.23 (1.97)* 
 Parent education 0.09 (0.14) 0.02 (0.16) −0.01 (0.18) −0.13 (0.18) −0.13 (0.20) 0.03 (0.14) 0.41 (0.43) 
 Autism severity −0.13 (0.15) 0.01 (0.19) −0.18 (0.17) 0.07 (0.16) −0.09 (0.19) 0.14 (0.14) 0.69 (0.48) 
 Behavior problems −0.05 (0.02)* −0.07 (0.03)* −0.05 (0.03) −0.07 (0.03)* −0.06 (0.04) 0.02 (0.03) 0.07 (0.07) 
Posttreatment slope, random 1.67 (0.32)*** 1.52 (0.36)*** 1.19 (0.32)** 0.73 (0.24)** 0.58 (0.39) −0.22 (0.23) 0.80 (0.63) 
 P-ESDM plus MBSR versus P-ESDM 1.68 (0.69)* 1.13 (0.75) 0.03 (0.69) 0.46 (0.56) 0.76 (0.88) −0.53 (0.54) −3.18 (1.61) 
 Child age 0.83 (0.64) −1.49 (0.75)† −0.57 (0.60) −0.36 (0.54) 0.28 (0.98) 1.72 (0.56)** −0.86 (1.31) 
 Male child versus female child 0.04 (0.83) 0.64 (0.75) 0.63 (0.68) −0.62 (0.71) 0.72 (0.81) −1.42 (0.51)** 1.19 (1.65) 
 Male parent versus female child 4.42 (1.48)** 1.67 (1.65) 2.08 (1.52) −0.30 (0.43) −1.43 (0.90) 0.24 (0.55) 4.41 (1.82)* 
 Parent education −0.24 (0.25) −0.10 (0.31) −0.05 (0.29) 0.15 (0.23) 0.25 (0.30) 0.05 (0.19) −0.58 (0.49) 
 Autism severity 0.10 (0.24) −0.05 (0.30) 0.27 (0.25) −0.14 (0.20) 0.20 (0.27) −0.15 (0.18) −0.72 (0.52) 
 Behavior problems 0.05 (0.04) 0.06 (0.05) 0.06 (0.04) 0.07 (0.04) 0.07 (0.06) 0.01 (0.04) −0.16 (0.09) 
Independent VariablesModel Estimates, Coefficient (SE)
PSI: PDPSI: PCDIPSI: DCDepressive SymptomsAnxiety SymptomsLife SatisfactionMindfulness
Initial status intercept, random 29.13 (0.68)*** 31.11 (0.82)*** 32.55 (0.64)*** 10.53 (0.74)*** 9.12 (0.77)*** 26.20 (0.79)*** 134.82 (2.20)*** 
 P-ESDM plus MBSR versus P-ESDM 3.24 (1.50)* 1.19 (1.90) 1.08 (1.37) 0.33 (1.50) 0.97 (1.76) 0.20 (1.62) −5.66 (4.53) 
 Child age −0.45 (1.36) −5.34 (2.11)* −2.71 (1.27)* −2.24 (1.61) −3.18 (1.73) 4.96 (2.23)* 5.64 (5.50) 
 Male child versus female child −0.53 (1.78) 1.75 (2.08) 2.22 (1.55) −2.27 (2.58) 1.53 (1.88) 2.08 (2.42) −0.49 (5.00) 
 Male parent versus female parent 4.40 (2.03)* 1.70 (2.00) 0.82 (2.19) −0.98 (1.34) −2.68 (2.03) −2.88 (2.33) 1.73 (6.93) 
 Parent education 0.41 (0.44) 0.36 (0.52) 0.42 (0.43) −0.10 (0.80) 0.08 (0.52) 0.61 (0.61) −1.32 (1.36) 
 Autism severity 0.18 (0.42) −0.18 (0.55) 0.13 (0.44) −0.74 (0.63) −0.28 (0.52) 0.60 (0.57) −1.60 (1.46) 
 Behavior problems 0.52 (0.07)*** 0.50 (0.10)*** 0.47 (0.06)*** 0.34 (0.12)** 0.41 (0.10)*** −0.20 (0.11) −1.17 (0.26)*** 
Active treatment slope, random −1.42 (0.23)*** −1.25 (0.23)*** −0.92 (0.22)*** −0.62 (0.21)** −0.78 (0.29)* 0.07 (0.17) −0.65 (0.58) 
 P-ESDM plus MBSR versus P-ESDM −1.91 (0.45)*** −1.38 (0.44)** −0.48 (0.48) −0.35 (0.45) −0.62 (0.65) 0.57 (0.40) 3.15 (1.44)* 
Child age −0.38 (0.49) 1.08 (0.60) 0.46 (0.46) 0.16 (0.46) 0.03 (0.71) −1.08 (0.39)** 0.95 (1.15) 
 Male child versus female child −0.27 (0.64) −0.51 (0.66) −0.73 (0.58) 0.47 (0.57) −0.60 (0.65) 0.66 (0.41) −1.00 (1.51) 
 Male parent versus female child −2.91 (0.87)** −1.29 (0.86) −1.26 (0.91) 0.46 (0.38) 1.00 (0.67) −0.44 (0.42) −4.23 (1.97)* 
 Parent education 0.09 (0.14) 0.02 (0.16) −0.01 (0.18) −0.13 (0.18) −0.13 (0.20) 0.03 (0.14) 0.41 (0.43) 
 Autism severity −0.13 (0.15) 0.01 (0.19) −0.18 (0.17) 0.07 (0.16) −0.09 (0.19) 0.14 (0.14) 0.69 (0.48) 
 Behavior problems −0.05 (0.02)* −0.07 (0.03)* −0.05 (0.03) −0.07 (0.03)* −0.06 (0.04) 0.02 (0.03) 0.07 (0.07) 
Posttreatment slope, random 1.67 (0.32)*** 1.52 (0.36)*** 1.19 (0.32)** 0.73 (0.24)** 0.58 (0.39) −0.22 (0.23) 0.80 (0.63) 
 P-ESDM plus MBSR versus P-ESDM 1.68 (0.69)* 1.13 (0.75) 0.03 (0.69) 0.46 (0.56) 0.76 (0.88) −0.53 (0.54) −3.18 (1.61) 
 Child age 0.83 (0.64) −1.49 (0.75)† −0.57 (0.60) −0.36 (0.54) 0.28 (0.98) 1.72 (0.56)** −0.86 (1.31) 
 Male child versus female child 0.04 (0.83) 0.64 (0.75) 0.63 (0.68) −0.62 (0.71) 0.72 (0.81) −1.42 (0.51)** 1.19 (1.65) 
 Male parent versus female child 4.42 (1.48)** 1.67 (1.65) 2.08 (1.52) −0.30 (0.43) −1.43 (0.90) 0.24 (0.55) 4.41 (1.82)* 
 Parent education −0.24 (0.25) −0.10 (0.31) −0.05 (0.29) 0.15 (0.23) 0.25 (0.30) 0.05 (0.19) −0.58 (0.49) 
 Autism severity 0.10 (0.24) −0.05 (0.30) 0.27 (0.25) −0.14 (0.20) 0.20 (0.27) −0.15 (0.18) −0.72 (0.52) 
 Behavior problems 0.05 (0.04) 0.06 (0.05) 0.06 (0.04) 0.07 (0.04) 0.07 (0.06) 0.01 (0.04) −0.16 (0.09) 

Slope estimates are additive. Thus, the average slope at follow-up can be calculated by adding the active treatment slope and the posttreatment slope offset (eg, −1.42 + 1.67 = 0.25 for PD).

*

P < .05; ** P < .01*; *** P < .001; P < .10.

Overall Change

Model estimates (including β weights and SEs) for overall change across the sample for each outcome variable are plotted (Fig 2, Table 3). Across the sample, there was statistically significant average improvement during active treatment in all subdomains of parenting stress (PD, PCDI, and DC), depression symptoms, and anxiety symptoms. For the parenting stress subscales and depression symptoms, symptoms worsened slightly during posttreatment data collection (Fig 2). Change in posttreatment slope for anxiety was not statistically significant, indicating that improvement continued. There were no statistically significant average changes during active treatment or posttreatment in life satisfaction or mindfulness.

FIGURE 2

Model score plots showing average change across the sample during active treatment and follow-up. A, parental distress. B, parent-child dysfunctional interactions. C, difficult child. D, depression. E, anxiety. F, life satisfaction. G, mindfulness.

FIGURE 2

Model score plots showing average change across the sample during active treatment and follow-up. A, parental distress. B, parent-child dysfunctional interactions. C, difficult child. D, depression. E, anxiety. F, life satisfaction. G, mindfulness.

Close modal

Treatment Group Differences

Model estimates (including β weights and SEs) for each outcome variable by treatment condition are plotted (Fig 3, Table 3). Groups were similar at baseline on all outcome variables except for PD. During active treatment, P-ESDM plus MBSR had greater improvements than P-ESDM in PD and PCDI. There was also a statistically significant treatment effect on mindfulness, with the P-ESDM plus MBSR parents’ effect increasing during active treatment and the P-ESDM group’s effect declining (Table 3, Fig 3). For PD, treatment group significantly impacted the change in slope posttreatment: P-ESDM plus MBSR had greater slowing of improvement posttreatment, resulting in posttreatment slopes similar to those of the P-ESDM group (Fig 3). Treatment group did not significantly predict slopes (during active treatment or posttreatment) for DC, depressive symptoms, anxiety symptoms, or life satisfaction.

FIGURE 3

Model score plots showing change during active treatment and follow-up by treatment condition (P-ESDM plus MBSR versus P-ESDM) controlling for covariates. Covariates included age the child began treatment, child sex, parent sex, parent education, autism severity, and behavior problems. A, parental distress. B, parent-child dysfunctional interactions. C, difficult child. D, depression. E, anxiety. F, life satisfaction. G, mindfulness.

FIGURE 3

Model score plots showing change during active treatment and follow-up by treatment condition (P-ESDM plus MBSR versus P-ESDM) controlling for covariates. Covariates included age the child began treatment, child sex, parent sex, parent education, autism severity, and behavior problems. A, parental distress. B, parent-child dysfunctional interactions. C, difficult child. D, depression. E, anxiety. F, life satisfaction. G, mindfulness.

Close modal

Aim 2: Covariate Effects on Treatment Response

A second aim was to examine how key covariates impacted response to treatment. As seen in Table 3, the covariate most consistently related to parental functioning was child behavior problems. Higher levels of behavior problems related to poorer parental functioning on all baseline variables. Relative to parents of children with low levels of behavior problems, parents of those with high low levels of behavior problems were higher on PD, PCDI, and depression at baseline but experienced significantly greater response to intervention during active treatment (Supplemental Fig 4).

Parent sex significantly predicted all estimates of PD (Table 3, Supplemental Fig 5). Relative to mothers, fathers started out with higher PD scores at baseline, improved more rapidly during active treatment, but then had greater slowing of improvement during posttreatment with scores that began rising during this time (whereas mothers stayed more constant during posttreatment). Parent sex also predicted slopes for mindfulness. Only mothers in the P-ESDM plus MBSR group increased in mindfulness during active treatment. Fathers declined in mindfulness regardless of treatment group, although that decline was less pronounced if they were in P-ESDM plus MBSR. Change was attenuated in all groups during posttreatment.

Child age predicted initial life satisfaction, change in slope during active treatment, and change in slope posttreatment. Parents of younger children at baseline had life satisfaction scores that improved during treatment but then declined posttreatment. Parents of older children showed the opposite pattern, with scores that declined during treatment but improved posttreatment (Supplemental Fig 5).

Other covariates had minimal or no impact on treatment response. The sex of the child predicted posttreatment response for life satisfaction but not response during active treatment. Child autism severity did not relate to initial status or slopes for any parental outcome variables.

In addition to our primary analyses, we ran multilevel models to examine whether the point estimates of parent functioning at the end of active treatment (3 months) and the end of follow-up (9 months) differed by group. To do this, we reran the multilevel models for each outcome that included treatment group and covariates but changed the intercept from baseline to the 3-month follow-up and from baseline to the 9-month follow-up. Estimates representing the difference between groups at each of these time points are presented (Table 4). At the end of active treatment, P-ESDM plus MBSR had marginally lower scores on PD and PCDI. These marginally significant differences persisted through the end of follow-up for PCDI. Note that none of the group differences in point estimates reached statistical significance at P < .05.

TABLE 4

Relations Between Groups and Parent Outcomes at 3 and 9 Months After the Start of Treatment

3 mo9 mo
EstimateSEEstimateSE
PSI: PD −2.49 1.47 −3.88 2.53 
PSI: PCDI −2.95 1.59 −4.45 2.40 
PSI: DC −0.36 1.35 −3.08 1.93 
Depressive symptoms −0.72 1.01 −0.03 1.86 
Anxiety symptoms −0.89 1.81 −0.05 1.52 
Life satisfaction 1.89 1.59 2.12 2.00 
Mindfulness 3.80 4.34 3.65 4.79 
3 mo9 mo
EstimateSEEstimateSE
PSI: PD −2.49 1.47 −3.88 2.53 
PSI: PCDI −2.95 1.59 −4.45 2.40 
PSI: DC −0.36 1.35 −3.08 1.93 
Depressive symptoms −0.72 1.01 −0.03 1.86 
Anxiety symptoms −0.89 1.81 −0.05 1.52 
Life satisfaction 1.89 1.59 2.12 2.00 
Mindfulness 3.80 4.34 3.65 4.79 

The estimate is the difference between the P-ESDM plus MBSR (coded as 1) and the P-ESDM (coded as 0) groups.

P < .10.

This study provided MBSR to the parents of newly diagnosed young children with ASD undergoing low-intensity, parent-mediated early behavioral intervention. This combination treatment approach addressed the well-established risk for increased parenting stress and psychopathology while also teaching parents foundational skills for interacting with their children.

Relative to parents who received P-ESDM only, parents who received P-ESDM plus MBSR showed significantly greater reductions in PD and perceptions of dysfunctional child interactions. Other work has documented that parent training may stabilize65  or reduce66  parenting stress. Our results suggest that giving parents stress-reduction strategies may enhance that potential. Although there were differences in the rate of change, 3 months was not long enough for that to translate into statistically significant group differences in parent functioning at the end of treatment. This suggests that detecting specific point-in-time group-level differences may require a larger sample size or prolonged treatment exposure.

Self-rated mindfulness improved for P-ESDM plus MBSR but decreased for P-ESDM only. Gains in mindfulness made by the P-ESDM plus MBSR group during active treatment were maintained during follow-up, suggesting that the impact of brief, targeted MBSR training may persist past the intervention period. Both groups showed reduced depression and anxiety symptoms during active treatment. However, with the exception of anxiety, most improvements that were made during active treatment were slowly lost over time with scores that approached baseline levels by 6-month follow-up. Thus, families may benefit from ongoing treatment to maintain initial gains. This contrasts with the findings of Dykens et al,14  who noted sustained gains in most outcomes other than anxiety, especially for mothers of children with ASD.

Covariates emerged as significant predictors of some outcome variables. Fathers improved more during active treatment but had greater slowing of improvement during follow-up. Fathers may warrant specific attention within the literature as an understudied group with potentially different pathways of stress and coping.3941,6769  Parents who initiated treatment at a younger age reported higher levels of stress and distress at baseline, improved quickly during treatment, but had slowed progress during follow-up relative to slightly older children. Of note, children within our study were on the cusp of transitioning from Part C to Part B services within the Department of Education. The impact of changes in concurrent intervention use on parent outcomes will be examined in future publications.

Baseline child behavior problems were related to higher baseline levels of parenting stress and depression as well as more rapid improvements in these outcomes during intervention. It is unclear to what degree this may be a function of all 3 variables being self-reported or the phenomenon of regression to the mean. The relation between child behavior problems and parenting stress in ASD is well established7073  but complex, with recent work suggesting an iterative, interactive process.37  Future work should consider how all of these variables may interact over time given the potential bidirectional nature of these relationships.37 

This initial diagnostic period for young children represents a critical point worthy of attention. Higher levels of parent stress may impact a family’s ability to obtain and implement intervention.28,46,65  This period also represents an opportunity for increased understanding and relationship building between parents and young children, whose core social and communication symptoms may be especially challenging for parents to interpret. Importantly, however, baseline autism severity did not significantly impact initial scores on parenting outcomes nor change in outcomes over time. Rather, it was parent-reported levels of behavioral challenges that were significantly related to parental stress and depression.

Although this work was longitudinal, its follow-up time frame was relatively brief. Our sample size was underpowered to conduct subgroup analyses and test mechanisms of treatment response. Several participants were lost to attrition, which was similar across groups and split between families that were lost to contact and families that moved away. This suggests that adding an extra weekly MBSR visit was not too great a scheduling burden relative to P-ESDM only. Parents were allowed to reschedule missed sessions, which added variability to treatment length. Additionally, analyses included all participants who provided valid data regardless of level of participation; this provided a more conservative estimate of treatment effects. Although we collected information on fidelity of clinician P-ESDM implementation, fidelity of parent implementation was not tracked, preventing us from drawing conclusions about the impact of MBSR on parents’ treatment implementation. Most participants self-identified as white women, limiting generalizability of results to other groups, and information on parenting self-efficacy was not collected. Most participating families had limited access to high-intensity treatments, and it is unclear how MBSR would pair with other intervention models. Also, although random assignment of children to a no-treatment group would be unethical, without an untreated group, questions remain about which longitudinal effects are because of treatment versus maturation or another time-related correlate.

Finally, by nature of the study design, the P-ESDM plus MBSR group received more intervention sessions than the P-ESDM group. Thus, it is unclear whether additional parent functioning gains made by the P-ESDM plus MBSR group are due to greater attention or the MBSR program itself. Future work should include attention-matched groups to further evaluate standalone intervention impact. Examining mindfulness as a mediator of treatment on parenting stress will also be important when determining whether MBSR is the mechanism of action, as will investigating the impact of child response to intervention on parent outcomes.

This study suggests that high-quality, low-intensity early intervention was associated with improvements in PD and parenting stress. Adding MBSR resulted in additional improvements in parenting stress. At no point did parents in P-ESDM plus MBSR show more symptoms of stress than parents in P-ESDM only, suggesting that the additional requirements on parents’ time did not seem to be harmful within this time-limited intervention study. Findings may have implications for systems that partner with parents to care for young children as well as practitioners who work directly with parents independent of child intervention. Future analyses will explore whether particular profiles of children and families are more amenable to this combination.

Drs Weitlauf, Warren, Broderick, and Taylor conceptualized and designed the study, drafted the initial manuscript, contributed to statistical analyses, and reviewed and revised the manuscript; Drs Herrington and Stainbrook designed and conceptualized the study and collected data; Mr Juárez and Dr Dykens conceptualized the study; Ms Nicholson and Ms Santulli played critical roles in study coordination and data collection; and all authors approved the final manuscript as submitted.

This trial has been registered at www.clinicaltrials.gov (identifier NCT03889821).

FUNDING: Supported by the Health Resources and Services Administration and Maternal and Child Health Bureau (R40MC27706) with core support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (U54 HD08321). Funded by the National Institutes of Health (NIH).

     
  • ASD

    autism spectrum disorder

  •  
  • DC

    Difficult Child

  •  
  • MBSR

    mindfulness-based stress reduction

  •  
  • PCDI

    Parent-Child Dysfunctional Interaction

  •  
  • PD

    Parental Distress

  •  
  • PSI

    Parenting Stress Index

  •  
  • P-ESDM

    parent-implemented Early Start Denver Model

1
Landa
R
.
Early communication development and intervention for children with autism
.
Ment Retard Dev Disabil Res Rev
.
2007
;
13
(
1
):
16
25
2
Franchini
M
,
Hamodat
T
,
Armstrong
VL
, et al
.
Infants at risk for autism spectrum disorder: frequency, quality, and variety of joint attention behaviors
.
J Abnorm Child Psychol
.
2019
;
47
(
5
):
907
920
3
Sacrey
LR
,
Zwaigenbaum
L
,
Bryson
S
, et al
.
Parent and clinician agreement regarding early behavioral signs in 12- and 18-month-old infants at-risk of autism spectrum disorder
.
Autism Res
.
2018
;
11
(
3
):
539
547
4
Dawson
G
,
Jones
EJ
,
Merkle
K
, et al
.
Early behavioral intervention is associated with normalized brain activity in young children with autism
.
J Am Acad Child Adolesc Psychiatry
.
2012
;
51
(
11
):
1150
1159
5
Rogers
SJ
,
Estes
A
,
Lord
C
, et al
.
Effects of a brief Early Start Denver Model (ESDM)-based parent intervention on toddlers at risk for autism spectrum disorders: a randomized controlled trial
.
J Am Acad Child Adolesc Psychiatry
.
2012
;
51
(
10
):
1052
1065
6
Estes
A
,
Munson
J
,
Dawson
G
,
Koehler
E
,
Zhou
XH
,
Abbott
R
.
Parenting stress and psychological functioning among mothers of preschool children with autism and developmental delay
.
Autism
.
2009
;
13
(
4
):
375
387
7
Estes
A
,
Olson
E
,
Sullivan
K
, et al
.
Parenting-related stress and psychological distress in mothers of toddlers with autism spectrum disorders
.
Brain Dev
.
2013
;
35
(
2
):
133
138
8
Fernańdez-Alcántara
M
,
García-Caro
MP
,
Pérez-Marfil
MN
,
Hueso-Montoro
C
,
Laynez-Rubio
C
,
Cruz-Quintana
F
.
Feelings of loss and grief in parents of children diagnosed with autism spectrum disorder (ASD)
.
Res Dev Disabil
.
2016
;
55
:
312
321
9
Jones
L
,
Hastings
RP
,
Totsika
V
,
Keane
L
,
Rhule
N
.
Child behavior problems and parental well-being in families of children with autism: the mediating role of mindfulness and acceptance
.
Am J Intellect Dev Disabil
.
2014
;
119
(
2
):
171
185
10
Tomeny
TS
.
Parenting stress as an indirect pathway to mental health concerns among mothers of children with autism spectrum disorder
.
Autism
.
2017
;
21
(
7
):
907
911
11
Weitlauf
AS
,
Vehorn
AC
,
Taylor
JL
,
Warren
ZE
.
Relationship satisfaction, parenting stress, and depression in mothers of children with autism
.
Autism
.
2014
;
18
(
2
):
194
198
12
Carter
AS
,
Martínez-Pedraza
FL
,
Gray
SA
.
Stability and individual change in depressive symptoms among mothers raising young children with ASD: maternal and child correlates
.
J Clin Psychol
.
2009
;
65
(
12
):
1270
1280
13
Hamlyn-Wright
S
,
Draghi-Lorenz
R
,
Ellis
J
.
Locus of control fails to mediate between stress and anxiety and depression in parents of children with a developmental disorder
.
Autism
.
2007
;
11
(
6
):
489
501
14
Dykens
EM
,
Fisher
MH
,
Taylor
JL
,
Lambert
W
,
Miodrag
N
.
Reducing distress in mothers of children with autism and other disabilities: a randomized trial
.
Pediatrics
.
2014
;
134
(
2
).
15
Valicenti-McDermott
M
,
Lawson
K
,
Hottinger
K
, et al
.
Parental stress in families of children with autism and other developmental disabilities
.
J Child Neurol
.
2015
;
30
(
13
):
1728
1735
16
Picardi
A
,
Gigantesco
A
,
Tarolla
E
, et al
.
Parental burden and its correlates in families of children with autism spectrum disorder: a multicentre study with two comparison groups
.
Clin Pract Epidemiol Ment Health
.
2018
;
14
:
143
176
17
Carter
AS
,
Messinger
DS
,
Stone
WL
,
Celimli
S
,
Nahmias
AS
,
Yoder
P
.
A randomized controlled trial of Hanen’s ‘More Than Words’ in toddlers with early autism symptoms
.
J Child Psychol Psychiatry
.
2011
;
52
(
7
):
741
752
18
Strauss
K
,
Mancini
F
,
Fava
L
;
SPC Group
.
Parent inclusion in early intensive behavior interventions for young children with ASD: a synthesis of meta-analyses from 2009 to 2011
.
Res Dev Disabil
.
2013
;
34
(
9
):
2967
2985
19
Wainer
AL
,
Hepburn
S
,
McMahon Griffith
E
.
Remembering parents in parent-mediated early intervention: an approach to examining impact on parents and families
.
Autism
.
2017
;
21
(
1
):
5
17
20
Green
J
,
Charman
T
,
Pickles
A
, et al;
BASIS Team
.
Parent-mediated intervention versus no intervention for infants at high risk of autism: a parallel, single-blind, randomised trial
.
Lancet Psychiatry
.
2015
;
2
(
2
):
133
140
21
Schreibman
L
,
Dawson
G
,
Stahmer
AC
, et al
.
Naturalistic developmental behavioral interventions: empirically validated treatments for autism spectrum disorder
.
J Autism Dev Disord
.
2015
;
45
(
8
):
2411
2428
22
Kasari
C
,
Gulsrud
AC
,
Wong
C
,
Kwon
S
,
Locke
J
.
Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism
.
J Autism Dev Disord
.
2010
;
40
(
9
):
1045
1056
23
Kasari
C
,
Lawton
K
,
Shih
W
, et al
.
Caregiver-mediated intervention for low-resourced preschoolers with autism: an RCT
.
Pediatrics
.
2014
;
134
(
1
).
24
Wetherby
AM
,
Guthrie
W
,
Woods
J
, et al
.
Parent-implemented social intervention for toddlers with autism: an RCT
.
Pediatrics
.
2014
;
134
(
6
):
1084
1093
25
Nevill
RE
,
Lecavalier
L
,
Stratis
EA
.
Meta-analysis of parent-mediated interventions for young children with autism spectrum disorder
.
Autism
.
2018
;
22
(
2
):
84
98
26
Tarver
J
,
Palmer
M
,
Webb
S
, et al
.
Child and parent outcomes following parent interventions for child emotional and behavioral problems in autism spectrum disorders: a systematic review and meta-analysis
.
Autism
.
2019
;
23
(
7
):
1630
1644
27
Rogers
SJ
,
Estes
A
,
Lord
C
, et al
.
A multisite randomized controlled two-phase trial of the Early Start Denver Model compared to treatment as usual
.
J Am Acad Child Adolesc Psychiatry
.
2019
;
58
(
9
):
853
865
28
Karp
EA
,
Dudovitz
R
,
Nelson
BB
, et al
.
Family characteristics and children’s receipt of autism services in low-resourced families
.
Pediatrics
.
2018
;
141
(
suppl 4
):
S280
S286
29
Carr
T
,
Shih
W
,
Lawton
K
,
Lord
C
,
King
B
,
Kasari
C
.
The relationship between treatment attendance, adherence, and outcome in a caregiver-mediated intervention for low-resourced families of young children with autism spectrum disorder
.
Autism
.
2016
;
20
(
6
):
643
652
30
Strauss
K
,
Vicari
S
,
Valeri
G
,
D’Elia
L
,
Arima
S
,
Fava
L
.
Parent inclusion in Early Intensive Behavioral Intervention: the influence of parental stress, parent treatment fidelity and parent-mediated generalization of behavior targets on child outcomes
.
Res Dev Disabil
.
2012
;
33
(
2
):
688
703
31
Hartley
SL
,
Papp
LM
,
Bolt
D
.
Spillover of marital interactions and parenting stress in families of children with autism spectrum disorder
.
J Clin Child Adolesc Psychol
.
2018
;
47
(
sup1
):
S88
S99
32
Croen
LA
,
Shankute
N
,
Davignon
M
,
Massolo
ML
,
Yoshida
C
.
Demographic and clinical characteristics associated with engagement in behavioral health treatment among children with autism spectrum disorders
.
J Autism Dev Disord
.
2017
;
47
(
11
):
3347
3357
33
Seymour
M
,
Giallo
R
,
Wood
CE
.
The psychological and physical health of fathers of children with Autism Spectrum Disorder compared to fathers of children with long-term disabilities and fathers of children without disabilities
.
Res Dev Disabil
.
2017
;
69
:
8
17
34
Moody
EJ
,
Reyes
N
,
Ledbetter
C
, et al
.
Screening for autism with the SRS and SCQ: variations across demographic, developmental and behavioral factors in preschool children
.
J Autism Dev Disord
.
2017
;
47
(
11
):
3550
3561
35
Neuhaus
E
,
Beauchaine
TP
,
Bernier
RA
,
Webb
SJ
.
Child and family characteristics moderate agreement between caregiver and clinician report of autism symptoms
.
Autism Res
.
2018
;
11
(
3
):
476
487
36
McStay
RL
,
Dissanayake
C
,
Scheeren
A
,
Koot
HM
,
Begeer
S
.
Parenting stress and autism: the role of age, autism severity, quality of life and problem behaviour of children and adolescents with autism
.
Autism
.
2014
;
18
(
5
):
502
510
37
Rodriguez
G
,
Hartley
SL
,
Bolt
D
.
Transactional relations between parenting stress and child autism symptoms and behavior problems
.
J Autism Dev Disord
.
2019
;
49
(
5
):
1887
1898
38
Falk
NH
,
Norris
K
,
Quinn
MG
.
The factors predicting stress, anxiety and depression in the parents of children with autism
.
J Autism Dev Disord
.
2014
;
44
(
12
):
3185
3203
39
Dardas
LA
,
Ahmad
MM
.
Predictors of quality of life for fathers and mothers of children with autistic disorder
.
Res Dev Disabil
.
2014
;
35
(
6
):
1326
1333
40
Foody
C
,
James
JE
,
Leader
G
.
Parenting stress, salivary biomarkers, and ambulatory blood pressure: a comparison between mothers and fathers of children with autism spectrum disorders
.
J Autism Dev Disord
.
2015
;
45
(
4
):
1084
1095
41
McStay
RL
,
Trembath
D
,
Dissanayake
C
.
Stress and family quality of life in parents of children with autism spectrum disorder: parent gender and the double ABCX model
.
J Autism Dev Disord
.
2014
;
44
(
12
):
3101
3118
42
Bessette Gorlin
J
,
McAlpine
CP
,
Garwick
A
,
Wieling
E
.
Severe childhood autism: the family lived experience
.
J Pediatr Nurs
.
2016
;
31
(
6
):
580
597
43
Hsiao
YJ
,
Higgins
K
,
Pierce
T
,
Whitby
PJS
,
Tandy
RD
.
Parental stress, family quality of life, and family-teacher partnerships: families of children with autism spectrum disorder
.
Res Dev Disabil
.
2017
;
70
:
152
162
44
Neff
KD
,
Faso
DJ
.
Self-compassion and well-being in parents of children with autism
.
Mindfulness
.
2015
;
6
:
938
947
45
Davlantis
KS
,
Estes
A
,
Dawson
G
,
Rogers
SJ
.
A novel method for measuring learning opportunities provided by parents to young children with autism spectrum disorder
.
Autism
.
2019
;
23
(
6
):
1563
1574
46
Watson
LR
,
Crais
ER
,
Baranek
GT
, et al
.
Parent-mediated intervention for one-year-olds screened as at-risk for autism spectrum disorder: a randomized controlled trial
.
J Autism Dev Disord
.
2017
;
47
(
11
):
3520
3540
47
Catalano
D
,
Holloway
L
,
Mpofu
E
.
Mental health interventions for parent carers of children with autistic spectrum disorder: practice guidelines from a Critical Interpretive Synthesis (CIS) systematic review
.
Int J Environ Res Public Health
.
2018
;
15
(
2
):
E341
48
Kabat-Zinn
J
.
An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results
.
Gen Hosp Psychiatry
.
1982
;
4
(
1
):
33
47
49
Da Paz
NS
,
Wallander
JL
.
Interventions that target improvements in mental health for parents of children with autism spectrum disorders: a narrative review
.
Clin Psychol Rev
.
2017
;
51
:
1
14
50
Lunsky
Y
,
P Hastings
R
,
Weiss
JA
,
M Palucka
A
,
Hutton
S
,
White
K
.
Comparative effects of mindfulness and support and information group interventions for parents of adults with autism spectrum disorder and other developmental disabilities
.
J Autism Dev Disord
.
2017
;
47
(
6
):
1769
1779
51
Neece
CL
.
Mindfulness-based stress reduction for parents of young children with developmental delays: implications for parental mental health and child behavior problems
.
J Appl Res Intellect Disabil
.
2014
;
27
(
2
):
174
186
52
Rayan
A
,
Ahmad
M
.
Effectiveness of mindfulness-based interventions on quality of life and positive reappraisal coping among parents of children with autism spectrum disorder
.
Res Dev Disabil
.
2016
;
55
:
185
196
53
Ridderinkhof
A
,
de Bruin
EI
,
Blom
R
,
Bögels
SM
.
Mindfulness-based program for children with autism spectrum disorder and their parents: direct and long-term improvements
.
Mindfulness (N Y)
.
2018
;
9
(
3
):
773
791
54
Rogers
SJ
,
Estes
A
,
Vismara
L
, et al
.
Enhancing low-intensity coaching in parent implemented Early Start Denver Model intervention for early autism: a randomized comparison treatment trial
.
J Autism Dev Disord
.
2019
;
49
(
2
):
632
646
55
Kasari
C
,
Gulsrud
A
,
Paparella
T
,
Hellemann
G
,
Berry
K
.
Randomized comparative efficacy study of parent-mediated interventions for toddlers with autism
.
J Consult Clin Psychol
.
2015
;
83
(
3
):
554
563
56
Beck
AT
,
Epstein
N
,
Brown
G
,
Steer
RA
.
An inventory for measuring clinical anxiety: psychometric properties
.
J Consult Clin Psychol
.
1988
;
56
(
6
):
893
897
57
Diener
E
,
Emmons
RA
,
Larsen
RJ
,
Griffin
S
.
The satisfaction with life scale
.
J Pers Assess
.
1985
;
49
(
1
):
71
75
58
Baer
RA
,
Smith
GT
,
Hopkins
J
,
Krietemeyer
J
,
Toney
L
.
Using self-report assessment methods to explore facets of mindfulness
.
Assessment
.
2006
;
13
(
1
):
27
45
59
Lord
C
,
Risi
S
,
Lambrecht
L
, et al
.
The autism diagnostic observation schedule-generic: a standard measure of social and communication deficits associated with the spectrum of autism
.
J Autism Dev Disord
.
2000
;
30
(
3
):
205
223
60
Mullen
EL
. Mullen Scales of Early Learning.
Circle Pines, MN
:
American Guidance Service
;
1995
61
Sparrow
SS
,
Cicchetti
DV
.
Diagnostic uses of the Vineland Adaptive Behavior Scales
.
J Pediatr Psychol
.
1985
;
10
(
2
):
215
225
62
Achenbach
TM
. Achenbach Child Behavior Checklist.
Burlington, VT
:
ASEBA
;
2001
63
Raudenbush
SW
,
Bryk
AS
. Hierarchical Linear Models: Applications and Data Analysis Methods. vol.
Vol 1
.
Thousand Oaks, CA
:
Sage Publications
;
2002
64
Singer
JD
,
Willett
JB
. Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence.
New York, NY
:
Oxford University Press
;
2003
65
Estes
A
,
Vismara
L
,
Mercado
C
, et al
.
The impact of parent-delivered intervention on parents of very young children with autism
.
J Autism Dev Disord
.
2014
;
44
(
2
):
353
365
66
Iadarola
S
,
Levato
L
,
Harrison
B
, et al
.
Teaching parents behavioral strategies for autism spectrum disorder (ASD): effects on stress, strain, and competence
.
J Autism Dev Disord
.
2018
;
48
(
4
):
1031
1040
67
Jones
L
,
Totsika
V
,
Hastings
RP
,
Petalas
MA
.
Gender differences when parenting children with autism spectrum disorders: a multilevel modeling approach
.
J Autism Dev Disord
.
2013
;
43
(
9
):
2090
2098
68
Langley
E
,
Totsika
V
,
Hastings
RP
.
Parental relationship satisfaction in families of children with autism spectrum disorder (ASD): a multilevel analysis
.
Autism Res
.
2017
;
10
(
7
):
1259
1268
69
Hastings
RP
,
Kovshoff
H
,
Ward
NJ
,
degli Espinosa
F
,
Brown
T
,
Remington
B
.
Systems analysis of stress and positive perceptions in mothers and fathers of pre-school children with autism
.
J Autism Dev Disord
.
2005
;
35
(
5
):
635
644
70
Shattuck
PT
,
Seltzer
MM
,
Greenberg
JS
, et al
.
Change in autism symptoms and maladaptive behaviors in adolescents and adults with an autism spectrum disorder
.
J Autism Dev Disord
.
2007
;
37
(
9
):
1735
1747
71
Lounds
J
,
Seltzer
MM
,
Greenberg
JS
,
Shattuck
PT
.
Transition and change in adolescents and young adults with autism: longitudinal effects on maternal well-being
.
Am J Ment Retard
.
2007
;
112
(
6
):
401
417
72
Argumedes
M
,
Lanovaz
MJ
,
Larivée
S
.
Brief report: impact of challenging behavior on parenting stress in mothers and fathers of children with autism spectrum disorders
.
J Autism Dev Disord
.
2018
;
48
(
7
):
2585
2589
73
Lecavalier
L
,
Leone
S
,
Wiltz
J
.
The impact of behaviour problems on caregiver stress in young people with autism spectrum disorders
.
J Intellect Disabil Res
.
2006
;
50
(
pt 3
):
172
183

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.