Lu JH, Wei H, Zhang Y, Fei F, Huang HY, Dong QJ, Chen J, Ao DQ, Chen L, Li TY, Li Y, Dai Y. Effects of remote support courses on parental mental health and child development in autism: A randomized controlled trial. World J Psychiatry 2024; 14(12): 1892-1904 [DOI: 10.5498/wjp.v14.i12.1892]
Corresponding Author of This Article
Ying Dai, Doctor, Chief Physician, Growth, Development and Mental Health Center of Children and Adolescents, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, No. 136 Zhongshan Second Road, Yuzhong District, Chongqing 401146, China. dai@hospital.cqmu.edu.cn
Research Domain of This Article
Psychology
Article-Type of This Article
Clinical Trials Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Jia-Hui Lu, Hua Wei, Yu Zhang, Fan Fei, Hai-Yan Huang, Qiu-Jun Dong, Jing Chen, Dong-Qin Ao, Li Chen, Ting-Yu Li, Yan Li, Ying Dai, Growth, Development and Mental Health Center of Children and Adolescents, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing 401146, China
Author contributions: Li Y and Dai Y contributed equally to this work and should be considered co-corresponding authors. Lu JH and Dai Y contributed to conceptualization; Fei F contributed to data curation and project administration; Lu JH contributed to formal analysis and writing and editing; Lu JH, Huang HY, Dong QJ, Chen J and Ao DQ contributed to project administration; Wei H, Zhang Y, Chen L and Li Y contributed to collect resources; Wei H, Chen L, Li Y and Dai Y contributed to supervision; Li TY and Dai Y contributed to writing– review and editing. All authors have read and agreed to the published version of the manuscript.
Supported byThe National Key R and D Program of China, No. 2023YFC3604805; The Key Scientific and Technological Projects of Guangdong Province, No. 2018B030335001; and Guangzhou Science and Technology Program, No. 202007030002.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of Children's Hospital of Chongqing Medical University (Approval No. 276).
Clinical trial registration statement: It was registered with the Chinese Clinical Trial Registry (http: //www.chictr.org.cn/index.aspx, ID: ChiCTR2200064649).
Informed consent statement: The participants were informed of intervention methods of this study at the time of recruitment. Each participant voluntarily took part in this study and signed informed consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Upon reasonable request, the study data can be obtained from the corresponding author.
CONSORT 2010 statement: The authors have read the CONSORT 2010 statement, and the manuscript was prepared and revised according to the CONSORT 2010 statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ying Dai, Doctor, Chief Physician, Growth, Development and Mental Health Center of Children and Adolescents, Children’s Hospital of Chongqing Medical University, Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, No. 136 Zhongshan Second Road, Yuzhong District, Chongqing 401146, China. dai@hospital.cqmu.edu.cn
Received: August 28, 2024 Revised: September 22, 2024 Accepted: October 11, 2024 Published online: December 19, 2024 Processing time: 91 Days and 2.9 Hours
Abstract
BACKGROUND
Sustaining the mental health of autistic children’s parents can be demanding.
AIM
To determine the effect of remote support courses on the mental health of parents and the development of autistic children.
METHODS
Parents of 140 autistic children were randomly assigned to two groups receiving a 2-week intervention: The control group received caregiver-mediated intervention (CMI); the experimental group received CMI with remote family psychological support courses (R-FPSC). The Parenting Stress Index-Short Form, Parenting Sense of Competence Scale, Generalized Anxiety Disorder-7, and Patient Health Questionnaire-9 were used to measure parents’ mental health. The Childhood Autism Rating Scale and Gesell Developmental Schedules were used to evaluate children’s development.
RESULTS
Improved parenting stress, sense of competence, depression, and anxiety were found in both groups, but improvements in parenting stress (81.10 ± 19.76 vs 92.10 ± 19.26, P < 0.01) and sense of competence (68.83 ± 11.23 vs 63.91 ± 10.86, P < 0.01) were greater in the experimental group, although the experimental group showed no significant reduction in depression or anxiety. Children’s development did not differ significantly between the groups at follow-up; however, experimental group parents exhibited a short-term increase in training enthusiasm (12.78 ± 3.16 vs 11.57 ± 3.15, P < 0.05).
CONCLUSION
Integrating R-FPSC with CMI may be effective in reducing parenting stress, enhancing parents’ sense of competence, and increasing parents' training enthusiasm.
Core Tip: This study emphasizes the crucial impact of parental mental health on therapeutic interventions for children with autism spectrum disorder (ASD). Integrating remote family psychological support courses with traditional caregiver-mediated interventions (CMI) enhances parental competence and reduces stress more effectively than CMI alone. Employing a robust, single-blinded randomized controlled trial design, the findings demonstrate that remote interventions effectively support parental mental health, essential for managing ASD care. The research suggests mental health professionals incorporate remote psychological support into family interventions to expand access to crucial resources and potentially improve outcomes for both children and parents. Further research is needed to explore the long-term effects of such interventions and their direct impact on ASD symptoms in children, advocating for holistic, family-centered care models in psychiatry.
Citation: Lu JH, Wei H, Zhang Y, Fei F, Huang HY, Dong QJ, Chen J, Ao DQ, Chen L, Li TY, Li Y, Dai Y. Effects of remote support courses on parental mental health and child development in autism: A randomized controlled trial. World J Psychiatry 2024; 14(12): 1892-1904
Autism spectrum disorder (ASD) is a group of neurodevelopmental disorders characterized by difficulties in social interaction and verbal and nonverbal communication, as well as narrow interests, and repetitive behaviors. Long-term therapeutic training and special education are the main treatments for ASD[1]. An increasing amount of attention has been paid to family-oriented intervention models[2].
The literature shows that caregivers of children on the autism spectrum often experience more severe mental health issues than caregivers of children with other disabilities or those of typically developing children[3,4]. Some parents continuously worry about their child’s prognosis. Due to the particularity of the child’s performance and limited communication[5-7], parents will face numerous challenges in caring for their child[8], coupled with the added financial strain of long-term treatment[9]. These difficulties contribute to heightened levels of fatigue, anxiety, and depression, resulting in a decline in the parents' overall health and quality of life. Moreover, negative emotions can have a direct impact on the parent’s ideas, attitudes, and methods related to parenting, ultimately having an indirect effect on their child’s rehabilitation training[10]. The effects of these challenges indicates that interventions designed only for children diagnosed with ASD might not be sufficient[11]. As the primary implementers of the family intervention model, parents must be able to prioritize their physical and mental health, maintain a positive attitude[12], and believe in the positive effect of therapeutic training on their child’s symptoms, which is crucial for the child’s progress and the functional well-being of the entire family[13]. However, very few of the interventions include specific attention to the psychological health of caregivers. For the optimal development of children on the autism spectrum, it is imperative to adopt more holistic approaches that include interventions for both children and parents. Therefore, the integration of family psychological support with the existing family intervention model is required because it has significant implications for families with autistic children and for society. The current pilot study aimed to examine the efficacy of remote family psychological support courses for improving the mental health of parents and improving the therapeutic outcomes of children on the autism spectrum.
MATERIALS AND METHODS
Design
The present study used a single-blinded randomized controlled trial design.
Participants
From February to June 2023, parents of children on the autism spectrum, who were scheduled to participate in a caregiver-mediated intervention (CMI) program were recruited via convenience sampling, from the Department of Child Health Care, Children’s Hospital of Chongqing Medical University in Chongqing City, China.
The inclusion criteria for the prospective participants were as follows: (1) The children met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnostic criteria for ASD; (2) The children were 24 to 72 months old; (3) The children were newly diagnosed with ASD and did not receive any prior training; (4) The parents were able to understand and complete questionnaires independently; and (5) The parents volunteered to participate in the study and signed an informed consent form.
The exclusion criteria consisted of the following characteristics: (1) Parent with a serious physical or mental illness; (2) A child diagnosed with cerebral palsy, epilepsy, hearing impairment, genetic metabolic disease, or other serious disease; (3) Had other children in the family with a serious or chronic disease; (4) Had a parent and child dyad who withdrew from the study; or (5) Parents who had received any other psychological treatment within the past six months.
Sample size calculation
In this study, the total score of the parenting stress index-short form (PSI-SF) was used as the main evaluation index, and the formula[14] was used to calculate the sample size, which was suitable for the calculation of sample size in randomized controlled trials. N1 and N2 are the sample sizes of the experimental group and the control group, respectively. In our pre-test, the standard deviation was approximately 7.75, the difference between the mean numbers of the two samples was approximately 5.13, was 0.05, was 0.10; yielding a sample size of N1 = N2 = 48. Considering a loss rate of 30%, the overall sample size needed for both groups was at least 138. A total of 140 parents of children on the autism spectrum who agreed to participate in the study were included in the analysis.
Randomization and allocation concealment
The 140 participants were randomly divided into two groups using random numbers generated by SPSS software (V26, IBM Corporation, Armonk, NY, United States). The seed number was 20211207. Participants were assigned random numbers in the order in which they were enrolled in the study. Participants with odd random numbers were assigned to the control group, and those with even random numbers were assigned to the experimental group. A total of 71 participants were included in the experimental group, and 69 participants were included in the control group. The resulting random assignments were placed in sequential order, coded, sealed, and stored in opaque envelopes for safekeeping by a third party who was blinded to the trial. After the investigator determined the eligibility of the participants, the third party opened the envelopes in order and assigned the participants to the appropriate groups.
Intervention
The individuals in the control group participated in the CMI project[15], which was a family-oriented intervention model for autistic children and parents who had not previously received professional training, but did not participate in any family psychological support courses. There were two specific content areas of the CMI. First, theory teaching videos explaining CMI theory, with each video lasting approximately 20 minutes, were sent to one parent once a day through the WeChat online platform from Monday to Friday for two weeks; these videos included: (1) Training strategies for interventions; (2) Helping your child learn how to participate in a game; (3) Understanding and promoting communication; (4) Providing auxiliary skills; (5) Providing challenging behavior and coping strategies; (6) Training methods for cognitive development; (7) Training methods for fine motor skills; (8) Training methods for gross motor skills; (9) Training methods for social contact; and (10) Training methods for language comprehension and expression. Second, practical operation lessons consisted of a practical demonstration of the CMI to the parent and child and were conducted from Monday to Friday in the treatment room (90 minutes a day for two weeks); these lessons included: (1) Guidance from the theoretical courses, in which the parents learned how to help their children establish a learning routine and how to correct challenging behavior; (2) The integration of language, cognition, and movement training with children’s play and life activities; (3) The improvement of parents’ skills and confidence levels during family interventions; and (4) The help of children learn new skills. The practitioners were professional therapists who had undergone uniform training, were qualified to practice, and had a minimum of five years of work experience.
The experimental group participated in remote family psychological support courses (R-FPSC) in addition to the CMI. Researchers, psychologists, and psychotherapists produced and revised the R-FPSC, which was rooted in mindfulness-based cognitive therapy[16], acceptance and commitment therapy (ACT)[17], Bowen's family systems therapy[18], and Minuchin's structured family therapy[19]. As a combination of cognitive therapy and mindfulness-based stress reduction therapy, mindfulness-based cognitive therapy was to manage the recurrence of long-term depression. Rayan and Ahmad[20] demonstrated that the implementation of mindfulness-based interventions could alleviate psychological distress among Arab parents of children on the autism spectrum. The main premise of ACT is about accepting what one cannot control and making a commitment to take action to improve one’s quality of life. A study by Marino[21] used ACT for parents of children on the autism spectrum and showed that ACT could improve parents’ psychological flexibility, awareness states, personal values in everyday life, and parenting stress. Family systems therapy is guided by systems theory, cybernetics, information theory, and the radical constructivism epistemology. The main principle of structured family therapy is to rebuild the family structure and seek to change the patterns of the family’s interactions that sustain family problems or symptoms. Previous studies have confirmed the effectiveness of family therapy for treating ASD[22]. The R-FPSC included the following steps: (1) Recognize ASD; (2) Recognize common emotional and psychological changes in parents; (3) Accept emotions and respond kindly; (4) Improve time management; (5) Engage in career planning; (6) Establish a system for child assistance; (7) Promote ourselves; (8) Care for yourself and be kind to yourself; (9) Establish a good parent–child relationship; and (10) Practice the saying “right here, right now”. The specific procedure entailed delivering one session of the R-FPSC to parents via the WeChat online platform daily, with a reading duration of approximately 15 minutes, Monday through Friday, over a two-week period.
The professional therapist supervised parents to ensure daily viewing of the CMI theory teaching videos and the R-FPSC content.
Primary outcome
PSI-SF: The PSI-SF[23], a 36-item self-report questionnaire with a 5-point Likert scale that is designed to measure impressions and difficulties related to the role of parents. The PSI-SF consists of three subscales: The parenting distress (PD), parent-child dysfunctional interaction (PCDI), and difficult child (DC) subscales. The total score ranges from 36 to 180 points, with higher scores indicating higher levels of parenting stress and scores higher than 90 representing a positive threshold. This scale has high reliability and validity. An examination of the internal consistency of the PSI-SF revealed that = 0.91 for the PD subscale, = 0.85 for the PCDI subscale, and = 0.82 for the DC subscale[24].
Secondary outcomes
Parenting sense of competence scale: The parenting sense of competence (PSOC) is a questionnaire consisting of 17 items[25], which are divided into two subscales: Efficacy and satisfaction. Each item is rated on a 6-point scale (1 to 6 points), ranging from strongly agree to strongly disagree. The efficacy subscale, reflecting feelings of familiarity, competence, and problem-solving capability in the parenting role, contains 8 items, with a total possible score of 8 to 48. The Satisfaction subscale, which reflects feelings of anxiety, frustration, and motivation in the parenting role, contains 9 items, with a total possible score ranging from 9 to 54. Studies have shown the internal consistency of the PSOC to be acceptable: = 0.79-0.85 for the total score, = 0.75-0.80 for the Satisfaction subscale, and = 0.80-0.88 for the Efficacy subscale[26,27].
Generalized anxiety disorder-7: The generalized anxiety disorder-7 (GAD-7) includes 7 items in total and uses a 4-point scale (0 to 3 points)[28]. The total possible score ranges from 0 to 21. A score of 0 to 4 indicates no anxiety or no clinical significance, 5-9 indicates mild anxiety, 10-14 indicates moderate anxiety, and ≥ 15 is classified as severe anxiety. The GAD-7 has been found to be a valid and efficient tool in research on the Chinese population[29].
Patient health questionnaire-9: The patient health questionnaire-9 (PHQ-9) consists of 9 items scored on a 4-point scale (1 to 6 points). The total score ranges from 0 to 27. A total possible score of 0 to 5 indicates no depression or no clinical significance; 6-9 indicates mild depression, 10-14 indicates moderate depression, 15-21 indicates moderate depression, and ≥ 22 indicates severe depression. The Chinese version of the PHQ-9 has been developed and validated[30].
Childhood autism rating scale: The childhood autism rating scale (CARS), which was compiled by Schopler et al[31], was designed to diagnose ASD and evaluate the core symptoms of children. Using 15 items that are scored on a 4-point scale, the CARS is suitable for children older than 2 years. A score < 30 indicates no autism, 30-36 indicates mild to moderate autism, and a score of 37-60 with at least five items higher than 3 indicates severe autism.
Gesell developmental schedules: The Gesell developmental schedules (GDS) assess adaptive behavior, gross motor skills, fine motor skills, language, and personal-social behavior dimensions and are used to evaluate the development capability of children from 0 to 6 years of age[32]. The results of the evaluations are presented in the form of a developmental quotient (DQ). A score of 55-75 is classified as a mildly abnormal DQ, 40-55 is classified as a moderately abnormal DQ, 25-39 is classified as a severely abnormal DQ, and < 25 is classified as an extremely abnormal DQ.
Data collection procedure
The evaluator, who was blinded to the study allocation and had received professional training in psychological assessments of parents and children, provided instructions to the parents regarding the completion of the questionnaires and assessed the children in the hospital's treatment room. The demographic information of the participants was recorded before the intervention, while the duration of children’s engagement in therapeutic training was documented following the intervention. Data were collected to assess parents’ levels of mental health before and after the intervention. Three months after the intervention, the CARS and GDS scores were analyzed to evaluate the progress of the children.
Statistical analysis
This study used SPSS software (V26, IBM Corporation, Armonk, NY, United States) for the data analysis. Independent 2-sample t tests, χ2 tests, and Mann-Whitney U tests were used to analyze the information of the participants. Independent 2-sample t-tests were used to compare differences between the two study groups on each scale before and after the intervention. Paired-sample t tests were used to compare differences within the control group as well as between the experiment group before and after the intervention. A P value < 0.05 indicated a statistically significant difference. The explanation of statistical symbols: Lowercase letter n for sample number; italicized uppercase letter P for probability; italicized uppercase letter P for probability, and mean ± SD is expressed as mean ± SD.
RESULTS
Participant enrollment
A total of 163 child-parent dyads were recruited to participate in the study. Of these, 14.1% (n = 23) were ineligible for participation. Subsequently, 140 dyads were enrolled in the study and randomized into two groups. All of the parents completed the post-assessment; 71 and 69 of them were in the intervention group and control group, respectively. However, only 43 children completed the follow-up assessment after three months; 24 were in the intervention group, and 19 were in the control group (see Figure 1).
The demographic and clinical characteristics of the participants in this study are reported in Table 1. No significant differences in participants’ demographic or clinical variables were found between the two groups at baseline (all P > 0.05).
Table 1 Comparisons of the demographic characteristics between the two groups at baseline, n (%)/mean ± SD.
Comparisons of parenting stress between the two groups of parents: Table 2 shows no significant differences between the two groups in the total score or in the three subscale scores on the PSI-SF prior to the intervention (all P > 0.05). The total PSI-SF scores of both groups were greater than 90, indicating clinically elevated levels of stress. After the intervention, we observed a greater reduction in parenting stress in the experimental group than in the control group (all P < 0.05). The parenting stress of both groups decreased significantly compared with the parenting stress observed before the intervention (all P < 0.05), but a high stress level persisted among the parents in the control group (= 92.10). This finding implies that CMI had a partial effect on the reduction in parental stress among parents of children on the autism spectrum. Thus, adding R-FPSC to CMI interventions may significantly reduce parenting stress.
Table 2 Comparisons of scores on the parenting stress index-short form between two groups before and after the intervention, mean ± SD.
Comparison of parents’ sense of competence in the evaluation between the two groups: No significant differences were found in the PSOC scale score between the two groups before the intervention (Table 3). After the intervention, parents in the experimental group had greater parenting efficacy and greater satisfaction than did those in the control group (all P < 0.05). In comparison to the pre-experimental results, both groups of parents experienced a significant increase in parenting efficacy and satisfaction after the intervention (all P < 0.05). These findings suggest that CMI can enhance the sense of competence among parents of children with ASD. However, the inclusion of the R-FPSC was more effective at improving parents' sense of competence and subsequently increasing their happiness as parents.
Table 3 Comparisons between two groups on the parenting sense of competence scale before and after the intervention, mean ± SD.
Comparisons of the anxiety and depression of parents between the two groups: The initial assessments of the parents’ anxiety and depression revealed no significant differences between the experimental and control groups (Table 4). Following the interventions, both groups of parents experienced a significant reduction in their levels of anxiety and depression compared to their levels before the experiment (all P < 0.05), and the degree of reduction was similar in both groups. These findings showed that the R-FPSC intervention had no obvious effect on the alleviation of parents' anxiety or depression.
Table 4 Comparisons of scores on the generalized anxiety disorder-7 and patient health questionnaire-9 between two groups before and after the interventions, mean ± SD.
Comparisons of the training durations between the two groups of children: To evaluate parental motivation to engage their children in therapeutic training, we measured the children’s weekly training durations, which encompassed all the hours they spent receiving training in various settings, such as hospitals, institutions, homes, communities, and more. Prior to the intervention, none of the children had received any therapeutic training. As indicated in Table 5, the parents of the experimental group exhibited a significantly greater level of enthusiasm about taking their children for therapeutic training than did the parents of the control group (P < 0.05).
Table 5 Comparisons of the training duration between two groups after the intervention, mean ± SD.
Comparisons of the core symptoms and developmental abilities of the children between the two groups: Table 6 reveals that the severity of the core symptoms, adaptability, gross motor skills, fine motor skills, language development, and personal-social behavior levels were comparable between the two groups of children prior to the intervention (all P > 0.05). No significant improvement in core symptoms or developmental abilities was observed in the experimental group at the three-month follow-up (all P > 0.05). At the follow-up, the children in the experimental group had fewer core symptoms than they had before the intervention (P < 0.05), and the children in the control group had more progress in language development (P < 0.05).
Table 6 Comparisons of scores on the childhood autism rating scale and the Gesell developmental schedules between two groups before the intervention and at the follow-up, mean ± SD.
In this study, the R-FPSC was added to the CMI of the experimental group as part of the intervention. Parents’ mental health was assessed using the PSOC, GAD-7, and PHQ-9 scales, as well as the PSI-SF, as outcome measures. The CARS and GDS were used to evaluate the efficacy of the interventions among the children. The children’s training time was investigated to determine their parents' motivation to engage them in therapeutic training. This study revealed that the R-FPSC effectively relieved parenting pressure, increased parents' willingness to raise children on the autism spectrum, and promoted parents' care for children on the autism spectrum. These activities had a positive effect on the mental health of the parents.
The influence of the R-FPSC on the parenting stress of those raising children on the autism spectrum
Compared to parents who only received CMI, those who received CMI + R-FPSC experienced a significantly greater decrease in parenting stress, which refers to the pressure that parents feel while fulfilling their parental role and engaging in parent–child interactions. The level of parenting stress is mainly determined by three factors: Parents’ personality traits, characteristics of the child’s diagnosis, and overall family situation[33,34]. Both of the study groups experienced high levels of parenting stress prior to the intervention, reaching clinically elevated stress levels, which aligns with the findings of Staunton et al[35]. After the intervention, there was a significantly lower level of parenting stress in both study groups. Other studies have suggested that parent training programs may stabilize or reduce parenting stress[36,37]. Our results showed that providing parents with R-FPSC may enhance this potential. This finding is consistent with that of the study by Weitlauf et al[38], which might be related to parents’ correct understanding of ASD[39], their active seeking of assistance from multiple resources[40], their proper allocation of time[41], and their tendency to pay more attention to the present[42]. Despite the positive findings of this study regarding the effectiveness of R-FPSC in alleviating parenting stress, it is necessary to determine whether this effect can be sustained over the long term. Additionally, further research is needed to understand the mechanisms underlying the effects of R-FPSC on parenting stress. This approach will enable us to enhance the content and format of R-FPSC in order to offer more effective psychological support.
The influence of R-FPSC on the PSOC among parents of children on the autism spectrum
The use of R-FPSC has the potential to enhance parents’ sense of competence, which has been defined as the sense of self-perception and satisfaction during the process of raising children[43]. Researches have demonstrated that parents with higher parenting self-efficacy are more likely to employ positive parenting techniques, increase their confidence in educating their children, engage in active and effective parent-child interactions, and reduce their own psychological stress[44-46]. In the present study, the control group significantly improved their PSOC through the CMI, which is consistent with the results of a pilot trial conducted in Italy that evaluated the effectiveness of the parent skills training[47]. We also found that the R-FPSC could further improve parents’ efficacy and satisfaction in raising their children on the autism spectrum. First, the R-FPSC provides guidance for helping parents effectively address their children's emotional difficulties and challenging behaviors[48], so that their difficulties in parent-child interactions are alleviated, parents' views of the children's behaviors improve, and parents are better able to regulate their own negative cognitions[37]. Moreover, as reported by Arellano et al[46], parents' level of competence in parenting can be influenced by various factors, including overall family dysfunction, interpersonal tension, lack of family cohesion, and inadequate family support. Through the provision of psychological support, parents can prioritize the promotion of cooperation within the entire family, mobilize family resources, strengthen family cohesion, and obtain increased support from family members[49]. Consequently, their parenting competence is more likely to increase.
The influence of the R-FPSC on the anxiety and depression of parents of children on the autism spectrum
Anxiety and depression improved during active treatment in both study groups. However, the parents who received R-FPSC did not have a greater reduction in anxiety or depression symptoms than did the parents in the other group. A study[38] that compared the parent-implemented early start denver model (P-ESDM) to the P-ESDM + mindfulness-based stress reduction model in two intervention groups of parents of children on the autism spectrum yielded similar results, with both groups of parents experiencing a reduction in symptoms of depression and anxiety, but the positive effects of the intervention wore off at follow-up after 6 months, approaching initial baseline levels. Therefore, the study suggested that ongoing psychological interventions might help sustain the initial improvements in parents' mental health. It also reminded us of the importance of continuous intervention. At the same time, short-term improvements in children's autism symptoms and neuropsychological development might not have been sufficient to alleviate parental anxiety or depression. Furthermore, the durations of psychological support were relatively short, and the differences in the needs of parents at different stages should have been taken into consideration. For instance, during the early intervention stage, parents may require more emotional support and guidance to cope with the confusion and anxiety they may experience. As the training stage progresses, parents may benefit more from practical skill training and access to resources. Therefore, further exploration and development of customized support measures for different stages are necessary.
The influence of R-FPSC on the training duration of children on the autism spectrum
After receiving the R-FPSC intervention, the parents’ motivation to engage their children in training increased, which may be attributed to the emotional support and connection experienced during the R-FPSC. Parents’ emotional state became more stable, which enhanced their willingness to interact with their children and engage in their training[49]. Furthermore, the R-FPSC showed parents the benefits of persisting in training for children on the autism spectrum, bringing them hope. As a result, they were more willing to invest more effort and time in their children’s training. Future studies should further increase the follow-up time to see if this positive effect persists.
The influence of the R-FPSC on the development of children on the autism spectrum
The R-FPSC did not show obvious advantages in terms of improving children’s developmental levels or reducing their autism symptoms. First, the follow-up sample size was small, which may have affected the reliability and generalizability of the results. Second, as ASD is a complex neurodevelopmental disorder that is influenced by various factors, some autistic children may even experience regression during development[50]. Individual differences, specific training methods and quality, the qualifications of rehabilitation therapists, and parents' proficiency in training skills can also influence a child's developmental progress. Therefore, influenced by these factors, R-FPSC might not be associated with significant effects. Finally, the assessment tools used in the study may have certain limitations, as they may not comprehensively measure the efficacy of the R-FPSC in children. Hence, we recommend that future studies consider selecting alternative assessment tools, such as the Autism Treatment Evaluation Checklist, to evaluate the effectiveness of interventions for children.
CONCLUSION
Our findings indicate that using high-quality, low-cost, comprehensive R-FPSC is associated with reduced parental stress and increased confidence in parenting competence, which can help improve parent–child relationships, family atmosphere, and quality of life for families of children on the autism spectrum. The R-FPSC provides psychological support to parents through the WeChat online platform, not only by offering them professional knowledge and training skills related to ASD but also by providing emotional understanding and support. Additionally, it eliminates the geographical and temporal limitations faced by traditional face-to-face psychological therapy, offering parents a more convenient and economical way of receiving psychological support and further expanding the audience of psychotherapy. Therefore, offering psychological support to parents through online platforms appears to be a promising and feasible therapeutic approach. These findings may serve as a valuable reference for current family intervention models and have significance for families of children on the autism spectrum. However, we also need to recognize the limitations of this study. Given the study’s limited duration and small number of children at follow-up, the effectiveness of the R-FPSC in facilitating children's core symptoms and developmental levels remains uncertain, and the long-term effects on parents' mental health require further investigation. Future research should employ robust methodologies, larger sample sizes, and longer follow-up periods to ascertain the durability and stability of the effects of R-FPSC on parental mental health and intervention outcomes for children on the autism spectrum.
ACKNOWLEDGEMENTS
We extend our gratitude to both the children and parents who generously participated in this study, as well as to the institutions that provided financial support.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade B, Grade C
Novelty: Grade B, Grade C
Creativity or Innovation: Grade B, Grade B
Scientific Significance: Grade B, Grade B
P-Reviewer: Geoffroy PA; Hettich N S-Editor: Liu H L-Editor: A P-Editor: Zhao YQ
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