Mindfulness-Based Stress Reductionfor Parents Implementing EarlyIntervention for Autism: An RCTAmy S. Weitlauf, PhD,a Neill Broderick, PhD,a J. Alacia Stainbrook, PhD,a Julie Lounds Taylor, PhD,a

Catherine G. Herrington, PhD,a Amy G. Nicholson, MA,a,b Madeline Santulli, BS,a Elisabeth M. Dykens, PhD,a,b,d

A. Pablo Juárez, MEd,a,b,c Zachary E. Warren, PhDa,b,c

abstractBACKGROUND AND OBJECTIVES: Systems of care emphasize parent-delivered intervention for childrenwith autism spectrum disorder (ASD). Meanwhile, multiple studies document psychologicaldistress within these parents. This pilot longitudinal randomized controlled trial comparedthe parent-implemented Early Start Denver Model (P-ESDM) to P-ESDM plus mindfulness-based stress reduction (MBSR) for parents. We evaluated changes in parent functioningduring active treatment and at follow-up.

METHODS: Participants included children (,36 months old) with autism spectrum disorder andcaregivers. Participants were randomly assigned to P-ESDM only (n = 31) or P-ESDM plusMBSR (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 testfor group differences in outcome changes over time.

RESULTS: Both groups improved during active treatment in all subdomains of parent stress(b = 21.42, 21.25, 20.92; P , 0.001), depressive symptoms, and anxiety symptoms(b = 20.62 and 20.78, respectively; P , 0.05). Parents who received MBSR had greaterimprovements than those receiving P-ESDM only in parental distress and parent-childdysfunctional interactions (b = 21.91 and 21.38, respectively; P , 0.01). Groups differedin change in mindfulness during treatment (b = 3.15; P , .05), with P-ESDM plus MBSRincreasing and P-ESDM declining. Treatment group did not significantly predict change indepressive symptoms, anxiety symptoms, or life satisfaction. Differences emerged on thebasis of parent sex, child age, and child behavior problems.

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

WHAT’S KNOWN ON THIS SUBJECT: Parents play an integralrole in early intervention for young children with autismspectrum disorder. They also report high levels of stress andpsychopathology. Training in mindfulness practice may helpparents of older children with autism spectrum disorder.

WHAT THIS STUDY ADDS: This pilot randomized controlledtrial compares the functioning of parents who participated inchild-focused, parent-mediated behavioral intervention aloneto that of parents who also received stress-reduction training.

To cite: Weitlauf AS, Broderick N, Stainbrook J Alacia, et al.Mindfulness-Based Stress Reduction for Parents ImplementingEarly Intervention for Autism: An RCT. Pediatrics. 2020;145(s1):e20191895K

Departments of aPediatrics and bPsychiatry and Behavioral Sciences, Vanderbilt University Medical Center,Nashville, Tennessee; and cDepartments of Special Education and dPsychology and Human Development,Vanderbilt University, Nashville, Tennessee

Drs Weitlauf, Warren, Broderick, and Taylor conceptualized and designed the study, drafted theinitial 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 criticalroles in study coordination and data collection; and all authors approved the final manuscriptas submitted.

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

DOI: https://doi.org/10.1542/peds.2019-1895K

Accepted for publication Jan 27, 2020

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Symptoms of autism spectrumdisorder (ASD) may become evidentby age 18 months.1–3 Emergingevidence suggests that earlybehavioral intervention improvesoutcomes,4,5 with some interventionmodels including parents in criticalroles.5 Parent-delivered earlyintervention may promote skillgeneralization and allow systems ofcare to spread therapist time and costacross more children. In parallel,however, multiple studies havedocumented high levels ofpsychological stress and distresswithin the parents of children withASD,6–12 more so than in parents ofchildren with other diagnoses.13–16

Although this distress may negativelyimpact families during a critical timeof diagnostic understanding andservice initiation, little has been doneto deliberately study and supportparents as part of early interventiondelivery.

Parent involvement in interventionmay generalize strategy use acrosssettings.17,18 Incorporating parentsinto treatment is a core component ofmany state early interventionsystems19; as applied to autism, thisframework offers opportunities foraddressing not only child but alsobroader family functioning. However,rigorous studies of parent-mediatedinterventions for young childrenhave yielded mixed results.5,17,20–27

Although undoubtedly influencedby variability within the autismphenotype, parent and familycharacteristics may affect how suchtraining programs are perceived andimplemented.28–30 Parent stress andcoping strategies may be influencedby factors such as parent or child sex,child age, and child problembehaviors.28,29,31–41 Some of theserelations may be reciprocal, withparenting stress changing asa function of, but then also directlyimpacting, child functioning overtime.16,28,29,31,32,42–44 These chroniceffects may therefore impact parent-training paradigms, which emphasize

increased parental responsivity andactive provision of learningopportunities.22,23,45,46

Increasingly, studies haveinvestigated ways to directly supportparents of children withdevelopmental disabilities.47 Onepromising avenue is mindfulness-based stress reduction (MBSR).48

Several studies have documented thatMBSR may reduce stress, improvesleep and health, and increaselife satisfaction for parents ofindividuals with developmentaldisabilities.9,14,49–51 Parents trainedin MBSR report more positivitytoward their children, less negativityregarding their children’s impact onthe family, lower reactivity, and morefrequent use of positive reappraisalstrategies.9,51–53 Parents who practiceself-compassion report lower levelsof depression and parenting stress,44

with 2 studies finding sustainedeffects of mindfulness practiceon parent psychological distressand emotional and behavioraloutcomes.50,53 Although promising,these works primarily deliveredMBSR in isolation to parents ofolder children. One previous studycombined mindfulness-basedtraining for adolescents with ASDwith parallel parent training, withimprovements seen in parental stressand child behavior problems.53

Little is known about how thecombination of MBSR and low levelsof early parent-mediated behavioralintervention impacts the functioningof parents of young children with newASD diagnoses. This work attemptedto address parent stress and distressby providing parents with skills-focused stress-reduction strategiesduring the postdiagnostic period. Theprimary aim of this pilot randomizedcontrolled trial was to compare theeffectiveness of a parent-mediatedbehavioral intervention, the parent-implemented Early Start DenverModel (P-ESDM), to that interventionplus MBSR in enhancing parentfunctioning. We hypothesized that

both groups would improve in parentfunctioning over time and thatcompared with the P-ESDM–onlygroup, parents in P-ESDM plus MBSRwould show greater reductions instress, depression, and anxiety as wellas increased self-reported lifesatisfaction and mindfulness. Asecond aim was to examine whethertreatment response differed on thebasis of 5 covariates: child age attreatment initiation, child sex, parentsex, child autism severity, andbehavior problems.

METHODS

Participants

Participating parents were recruitedfrom a diagnostic clinic from 2015 to2017. Eligibility criteria includedhaving a child (,36 months of age atconsent) with a gold standard ASDdiagnosis and parental Englishfluency. Exclusion criteria includedsevere child sensorimotorimpairment. All procedures wereapproved by the medical centerinstitutional review board.

We used a random-number generatorwith a planned maximum enrollmentof 70 participants. Allowing ∼10%attrition, this provides 80% power todetect an effect size of 0.71 for 1primary outcome or an effect size of0.91 if a multiple-comparisoncorrection was applied for 7coprimary outcomes. We placed halfof the generated numbers into eachgroup. Blinded staff obtained consentthen accessed a unique computer fileto determine group assignment.

Of 103 eligible families, 63 consentedto participate (Fig 1). Twoparticipants did not have data thatcould be included in analyses: 1(P-ESDM only) provided inaccuratedata and a second (P-ESDM plusMBSR) withdrew without providingany parental data. This yielded a finalsample of 61 families included inanalyses (Tables 1 and 2). Of these 61families, 7 withdrew before

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completing their third P-ESDMsession. Reasons for withdrawalincluded scheduling conflicts (n = 5)and repeatedly missed sessions (n =2). An additional 8 families were lostto 6-month follow-up (moved away

[n = 4] and lost to contact [n = 4]).This attrition rate is similar tothat of other studies of parent-implemented, low-intensity ASDinterventions14,23,54,55 and did notdiffer by group or demographics.

MEASURES

Dependent Variables: ParentFunctioning

Parent functioning variables werecollected at each time point (see theProcedure section).

Parenting Stress

Parents completed the ParentingStress Index (PSI), Third Edition,Short Form. This 36-item measureyields 3 subscale scores (Parent-ChildDysfunctional Interaction [PCDI],Parental Distress [PD], and DifficultChild [DC]) used in present analyses.Higher scores indicate more stress.

Mental Health

Parents completed the Center forEpidemiologic Studies DepressionScale (20 items) and the Beck AnxietyInventory (21 items).56 Higher scoreson these measures reflect moresymptoms.

FIGURE 1Participant recruitment and retention flowchart. T3, Time 3 (end of treatment); T6, Time 6 (end ofstudy).

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)

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

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Life Satisfaction

Parents completed the SatisfactionWith Life Scale,57 a measure ofsubjective wellbeing. Its 5 items arescored along a 7-point Likert scale(higher scores indicate moresatisfaction).

Mindfulness

Parents completed the Five FacetMindfulness Questionnaire.58 TheFive Facet Mindfulness Questionnaireconsists of 44 items that yield 5subscales. The total score was used inanalyses. Higher scores indicate moremindfulness.

Demographic and Child Variables

Before random assignment, parentsprovided the following baselineinformation: relationship to child,birth date, educational attainment,race and/or ethnicity of self and child,

employment status, and annualhousehold income.

Autism Severity

The Autism Diagnostic ObservationSchedule, Second Edition isa standardized clinical observationsystem for patients withdevelopmental ages of 12 monthsand older.59 Each module yieldsCalibrated Severity Scores (range:1–10) based on age group andlanguage level, which were used inthese analyses. Higher scores reflecthigher levels of autism symptoms.

Cognitive Assessment

The Mullen Scales of Early Learning isa standardized developmental test forchildren up to age 5 years.60 Itprovides 4 domain scores (visualreception, fine motor, receptivelanguage, and expressive language;mean = 50; SD = 10) and yields anoverall ability index (Early Learning

Composite; mean = 100; SD = 15).Higher scores reflect higher abilitylevels.

Adaptive Functioning

The Vineland Adaptive BehaviorScales–Second Edition InterviewForm 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 overallAdaptive Behavior Composite(mean = 100; SD = 15). Higher scoresreflect better adaptive behavior skills.

Behavior Problems

The Child Behavior Checklist for ages1.5 to 5 years62 is a parent-completedchecklist of internalizing andexternalizing behaviors. It includes100 symptoms scored from 0 to 2(higher scores indicate moresymptom presence) within the past 2months. T-scores $64 are considered

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)

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clinically significant for broadbandscales. Because of the high correlationbetween internalizing andexternalizing subscales in this work(r = 0.61; P , .001), we used theT-score of the Total Problems scale.

Procedure

After random assignment, familieswere scheduled for their first P-ESDMsession and, when applicable, pairedwith an MBSR therapist. MBSRsessions began after the secondP-ESDM session. Data were collectedat 6 time points: baseline (beforetreatment), 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 anaverage of 1.35 months after diagnosis(SD = 1.45). Because of variable familyschedules, it took an average of15.87 weeks (SD = 3.33) to complete12 sessions. Six P-ESDM therapists(separate from MBSR therapists andblinded to group assignment) werelicensed, board-certified behavioranalysts who were trained in fidelityby ESDM-certified trainers. Thismanualized intervention has a detailedparent-training curriculum anda specific coaching interventionmethod.5 Therapists introduce skillsthrough descriptions, modeling, andcoaching with embedded emphasis onskill generalizability. Fidelity wasmonitored by using the Early StartDenver Model Fidelity Checklist.Therapists covered 94% of intendedcontent across sessions with nosignificant differences seen betweengroups (P . .10).

Intervention: P-ESDM Plus MBSR

Parents who were randomly assignedto P-ESDM plus MBSR attended 6additional 1-hour individual sessions.Child care was provided to maximizeattendance. The 4 MBSR therapistswere clinicians with at least a master’sdegree and expertise in behavioral

intervention and ASD supervised bya licensed clinical psychologist withformal MBSR training. Fidelity wasmonitored by therapist-completedcontent checklists.

The MBSR protocol was based on thework of Dykens et al14 and modifiedfor individual administration forparents of young children with ASD. Itwas introduced as a skills-focusedstress-reduction program rather thanindividual therapy. The clinic-basedsessions covered topics such as anintroduction to mindfulness formanaging stress, awareness of thepresent moment, and cultivatinggratitude. Weekly handouts offeredwritten and pictorial practice cues forthe home. Suggested homeworkexercises included formal practice(eg, guided meditation) as well asactivities that are easily incorporatedinto daily routines (eg, breathawareness). Weekly homework logstracked strategy use.

Data Analysis

Multilevel models with discontinuousslopes, using Hierarchical LinearModeling software,63 were used totest for group differences in outcomechanges over time. This allowed forinclusion of all participants with atleast 1 time point of data. Wemodeled discontinuous rates ofindividual change with 2 timeepochs64: (1) linear slope from thefirst to the third time point (baseline,6 weeks into treatment, andimmediately posttreatment),representing change during activetreatment, and (2) change in linearslope from immediatelyposttreatment through the 6-monthfollow-up (immediatelyposttreatment and 1, 3, and 6 monthsposttreatment), reflecting changeposttreatment. We estimatedmultilevel models for each outcomethat included the between-subjectsvariable of treatment group, withgroups centered on 0 (P-ESDM =20.5; P-ESDM plus MBSR = 0.5).Overall slope estimates in these

models reflect change across theentire sample. Including treatmentgroup allowed us to determine if anyof the slope estimates (sloperepresenting change during activetreatment and change in slope duringposttreatment) significantly differedby treatment group. Additionalbetween-persons covariates includedchild age at treatment initiation, sexof the child, sex of the parent, baselineautism severity, and child behaviorproblems. Because this is pilot work,no corrections for multiplecomparisons were made. Allcovariates were grand mean centered.

RESULTS

Sample Characteristics

No adverse events were reported.Baseline demographic and diagnosticinformation about children andparticipating parents are reported(Tables 1 and 2).

Aim 1: Treatment Effects on ParentOutcomes

Estimates from the longitudinal modelsconditioned on treatment group andcovariates for each of the outcomevariables are presented (Table 3).

Overall Change

Model estimates (including b weightsand SEs) for overall change across thesample for each outcome variable areplotted (Fig 2, Table 3). Across thesample, there was statisticallysignificant average improvementduring active treatment in allsubdomains of parenting stress (PD,PCDI, and DC), depression symptoms,and anxiety symptoms. For theparenting stress subscales anddepression symptoms, symptomsworsened slightly duringposttreatment data collection (Fig 2).Change in posttreatment slope foranxiety was not statisticallysignificant, indicating thatimprovement continued. There wereno statistically significant averagechanges during active treatment or

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posttreatment in life satisfaction ormindfulness.

Treatment Group Differences

Model estimates (including b weightsand SEs) for each outcome variableby treatment condition are plotted(Fig 3, Table 3). Groups were similarat baseline on all outcome variablesexcept for PD. During activetreatment, P-ESDM plus MBSR hadgreater improvements than P-ESDMin PD and PCDI. There was alsoa statistically significant treatmenteffect on mindfulness, with theP-ESDM plus MBSR parents’ effectincreasing during active treatmentand the P-ESDM group’s effectdeclining (Table 3, Fig 3). For PD,treatment group significantlyimpacted the change in slopeposttreatment: P-ESDM plus MBSRhad greater slowing of improvementposttreatment, resulting inposttreatment slopes similar to thoseof the P-ESDM group (Fig 3).Treatment group did not significantlypredict slopes (during activetreatment or posttreatment) for DC,depressive symptoms, anxietysymptoms, or life satisfaction.

Aim 2: Covariate Effects on TreatmentResponse

A second aim was to examine howkey covariates impacted response totreatment. As seen in Table 3, thecovariate most consistently related toparental functioning was childbehavior problems. Higher levels ofbehavior problems related to poorerparental functioning on all baselinevariables. Relative to parents ofchildren with low levels of behaviorproblems, parents of those with highlow levels of behavior problems werehigher on PD, PCDI, and depression atbaseline but experienced significantlygreater response to interventionduring active treatment(Supplemental Fig 4).

Parent sex significantly predicted allestimates of PD (Table 3,Supplemental Fig 5). Relative toTA

BLE3Estim

ates

From

Conditional

Multilevel

Modelsof

Change

inParent

Outcom

es

IndependentVariables

ModelEstim

ates,C

oefficient(SE)

PSI:PD

PSI:PCDI

PSI:DC

Depressive

Symptom

sAnxietySymptom

sLife

Satisfaction

Mindfulness

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

MBSRversus

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)

25.66

(4.53)

Child

age

20.45

(1.36)

25.34

(2.11)*

22.71

(1.27)*

22.24

(1.61)

23.18

(1.73)

†4.96

(2.23)*

5.64

(5.50)

Malechild

versus

femalechild

20.53

(1.78)

1.75

(2.08)

2.22

(1.55)

22.27

(2.58)

1.53

(1.88)

2.08

(2.42)

20.49

(5.00)

Maleparent

versus

femaleparent

4.40

(2.03)*

1.70

(2.00)

0.82

(2.19)

20.98

(1.34)

22.68

(2.03)

22.88

(2.33)

1.73

(6.93)

Parent

education

0.41

(0.44)

0.36

(0.52)

0.42

(0.43)

20.10

(0.80)

0.08

(0.52)

0.61

(0.61)

21.32

(1.36)

Autism

severity

0.18

(0.42)

20.18

(0.55)

0.13

(0.44)

20.74

(0.63)

20.28

(0.52)

0.60

(0.57)

21.60

(1.46)

Behavior

problems

0.52

(0.07)***

0.50

(0.10)***

0.47

(0.06)***

0.34

(0.12)**

0.41

(0.10)***

20.20

(0.11)

†21.17

(0.26)***

Activetreatm

entslope,random

21.42

(0.23)***

21.25

(0.23)***

20.92

(0.22)***

20.62

(0.21)**

20.78

(0.29)*

0.07

(0.17)

20.65

(0.58)

P-ESDM

plus

MBSRversus

P-ESDM

21.91

(0.45)***

21.38

(0.44)**

20.48

(0.48)

20.35

(0.45)

20.62

(0.65)

0.57

(0.40)

3.15

(1.44)*

Child

age

20.38

(0.49)

1.08

(0.60)

†0.46

(0.46)

0.16

(0.46)

0.03

(0.71)

21.08

(0.39)**

0.95

(1.15)

Malechild

versus

femalechild

20.27

(0.64)

20.51

(0.66)

20.73

(0.58)

0.47

(0.57)

20.60

(0.65)

0.66

(0.41)

21.00

(1.51)

Maleparent

versus

femalechild

22.91

(0.87)**

21.29

(0.86)

21.26

(0.91)

0.46

(0.38)

1.00

(0.67)

20.44

(0.42)

24.23

(1.97)*

Parent

education

0.09

(0.14)

0.02

(0.16)

20.01

(0.18)

20.13

(0.18)

20.13

(0.20)

0.03

(0.14)

0.41

(0.43)

Autism

severity

20.13

(0.15)

0.01

(0.19)

20.18

(0.17)

0.07

(0.16)

20.09

(0.19)

0.14

(0.14)

0.69

(0.48)

Behavior

problems

20.05

(0.02)*

20.07

(0.03)*

20.05

(0.03)

†20.07

(0.03)*

20.06

(0.04)

0.02

(0.03)

0.07

(0.07)

Posttreatm

entslope,random

1.67

(0.32)***

1.52

(0.36)***

1.19

(0.32)**

0.73

(0.24)**

0.58

(0.39)

20.22

(0.23)

0.80

(0.63)

P-ESDM

plus

MBSRversus

P-ESDM

1.68

(0.69)*

1.13

(0.75)

0.03

(0.69)

0.46

(0.56)

0.76

(0.88)

20.53

(0.54)

23.18

(1.61)

†

Child

age

0.83

(0.64)

21.49

(0.75)†

20.57

(0.60)

20.36

(0.54)

0.28

(0.98)

1.72

(0.56)**

20.86

(1.31)

Malechild

versus

femalechild

0.04

(0.83)

0.64

(0.75)

0.63

(0.68)

20.62

(0.71)

0.72

(0.81)

21.42

(0.51)**

1.19

(1.65)

Maleparent

versus

femalechild

4.42

(1.48)**

1.67

(1.65)

2.08

(1.52)

20.30

(0.43)

21.43

(0.90)

0.24

(0.55)

4.41

(1.82)*

Parent

education

20.24

(0.25)

20.10

(0.31)

20.05

(0.29)

0.15

(0.23)

0.25

(0.30)

0.05

(0.19)

20.58

(0.49)

Autism

severity

0.10

(0.24)

20.05

(0.30)

0.27

(0.25)

20.14

(0.20)

0.20

(0.27)

20.15

(0.18)

20.72

(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)

20.16

(0.09)

†

Slopeestim

ates

areadditive.Thus,the

averageslopeat

follow-upcanbe

calculated

byadding

theactivetreatm

entslopeandtheposttreatm

entslopeoffset

(eg,21.42

11.67

=0.25

forPD).

*P,

.05;**

P,

.01*;***

P,

.001;†

P,

.10.

86 WEITLAUF et al by guest on July 23, 2020www.aappublications.org/newsDownloaded from

mothers, fathers started out withhigher PD scores at baseline, improvedmore rapidly during active treatment,but then had greater slowing ofimprovement during posttreatmentwith scores that began rising duringthis time (whereas mothers stayedmore constant during posttreatment).Parent sex also predicted slopes formindfulness. Only mothers in theP-ESDM plus MBSR group increased inmindfulness during active treatment.Fathers declined in mindfulnessregardless of treatment group,although that decline was lesspronounced if they were in P-ESDMplus MBSR. Change was attenuated inall groups during posttreatment.

Child age predicted initial lifesatisfaction, change in slope duringactive treatment, and change in slopeposttreatment. Parents of youngerchildren at baseline had lifesatisfaction scores that improvedduring treatment but then declinedposttreatment. Parents of olderchildren showed the opposite pattern,

with scores that declined duringtreatment but improvedposttreatment (Supplemental Fig 5).

Other covariates had minimal or noimpact on treatment response. The sexof the child predicted posttreatmentresponse for life satisfaction but notresponse during active treatment.Child autism severity did not relate toinitial status or slopes for any parentaloutcome variables.

Follow-up Analyses

In addition to our primary analyses,we ran multilevel models to examinewhether the point estimates of parentfunctioning at the end of activetreatment (3 months) and the end offollow-up (9 months) differed bygroup. To do this, we reran themultilevel models for each outcomethat included treatment group andcovariates but changed the interceptfrom baseline to the 3-month follow-up and from baseline to the 9-monthfollow-up. Estimates representing thedifference between groups at each of

these time points are presented(Table 4). At the end of activetreatment, P-ESDM plus MBSR hadmarginally lower scores on PD andPCDI. These marginally significantdifferences persisted through the endof follow-up for PCDI. Note that noneof the group differences in pointestimates reached statisticalsignificance at P , .05.

DISCUSSION

This study provided MBSR to theparents of newly diagnosed youngchildren with ASD undergoing low-intensity, parent-mediated earlybehavioral intervention. Thiscombination treatment approachaddressed the well-established riskfor increased parenting stress andpsychopathology while also teachingparents foundational skills forinteracting with their children.

Relative to parents who receivedP-ESDM only, parents who receivedP-ESDM plus MBSR showed

FIGURE 2Model score plots showing average change across the sample during active treatment and follow-up. A, parental distress. B, parent-child dysfunctionalinteractions. C, difficult child. D, depression. E, anxiety. F, life satisfaction. G, mindfulness.

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significantly greater reductions in PDand perceptions of dysfunctional childinteractions. Other work hasdocumented that parent training maystabilize65 or reduce66 parentingstress. Our results suggest that givingparents stress-reduction strategiesmay enhance that potential. Althoughthere were differences in the rate ofchange, 3 months was not long enoughfor that to translate into statisticallysignificant group differences in parentfunctioning at the end of treatment.This suggests that detecting specific

point-in-time group-level differencesmay require a larger sample size orprolonged treatment exposure.

Self-rated mindfulness improved forP-ESDM plus MBSR but decreased forP-ESDM only. Gains in mindfulnessmade by the P-ESDM plus MBSRgroup during active treatment weremaintained during follow-up,suggesting that the impact of brief,targeted MBSR training may persistpast the intervention period. Bothgroups showed reduced depression

and anxiety symptoms during activetreatment. However, with theexception of anxiety, mostimprovements that were made duringactive treatment were slowly lost overtime with scores that approachedbaseline levels by 6-month follow-up.Thus, families may benefit fromongoing treatment to maintain initialgains. This contrasts with the findingsof Dykens et al,14 who noted sustainedgains in most outcomes other thananxiety, especially for mothers ofchildren with ASD.

FIGURE 3Model score plots showing change during active treatment and follow-up by treatment condition (P-ESDM plus MBSR versus P-ESDM) controlling forcovariates. 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.

TABLE 4 Relations Between Groups and Parent Outcomes at 3 and 9 Months After the Start of Treatment

3 mo 9 mo

Estimate SE Estimate SE

PSI: PD 22.49† 1.47 23.88 2.53PSI: PCDI 22.95† 1.59 24.45† 2.40PSI: DC 20.36 1.35 23.08 1.93Depressive symptoms 20.72 1.01 20.03 1.86Anxiety symptoms 20.89 1.81 20.05 1.52Life satisfaction 1.89 1.59 2.12 2.00Mindfulness 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.

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Covariates emerged as significantpredictors of some outcome variables.Fathers improved more during activetreatment but had greater slowing ofimprovement during follow-up.Fathers may warrant specificattention within the literature as anunderstudied group with potentiallydifferent pathways of stress andcoping.39–41,67–69 Parents whoinitiated treatment at a younger agereported higher levels of stress anddistress at baseline, improved quicklyduring treatment, but had slowedprogress during follow-up relative toslightly older children. Of note,children within our study were on thecusp of transitioning from Part C toPart B services within theDepartment of Education. The impactof changes in concurrent interventionuse on parent outcomes will beexamined in future publications.

Baseline child behavior problemswere related to higher baseline levelsof parenting stress and depression aswell as more rapid improvements inthese outcomes during intervention.It is unclear to what degree this maybe a function of all 3 variables beingself-reported or the phenomenon ofregression to the mean. The relationbetween child behavior problems andparenting stress in ASD is wellestablished70–73 but complex, withrecent work suggesting an iterative,interactive process.37 Future workshould consider how all of thesevariables may interact over timegiven the potential bidirectionalnature of these relationships.37

This initial diagnostic period foryoung children represents a criticalpoint worthy of attention. Higherlevels of parent stress may impacta family’s ability to obtain andimplement intervention.28,46,65 Thisperiod also represents an opportunityfor increased understanding andrelationship building betweenparents and young children, whosecore social and communicationsymptoms may be especiallychallenging for parents to interpret.

Importantly, however, baselineautism severity did not significantlyimpact initial scores on parentingoutcomes nor change in outcomesover time. Rather, it was parent-reported levels of behavioralchallenges that were significantlyrelated to parental stress anddepression.

Although this work was longitudinal,its follow-up time frame wasrelatively brief. Our sample size wasunderpowered to conduct subgroupanalyses and test mechanisms oftreatment response. Severalparticipants were lost to attrition,which was similar across groups andsplit between families that were lostto contact and families that movedaway. This suggests that adding anextra weekly MBSR visit was not toogreat a scheduling burden relative toP-ESDM only. Parents were allowed toreschedule missed sessions, whichadded variability to treatment length.Additionally, analyses included allparticipants who provided valid dataregardless of level of participation;this provided a more conservativeestimate of treatment effects.Although we collected information onfidelity of clinician P-ESDMimplementation, fidelity of parentimplementation was not tracked,preventing us from drawingconclusions about the impact ofMBSR on parents’ treatmentimplementation. Most participantsself-identified as white women,limiting generalizability of results toother groups, and information onparenting self-efficacy was notcollected. Most participating familieshad limited access to high-intensitytreatments, and it is unclear howMBSR would pair with otherintervention models. Also, althoughrandom assignment of children toa no-treatment group would beunethical, without an untreatedgroup, questions remain about whichlongitudinal effects are because oftreatment versus maturation oranother time-related correlate.

Finally, by nature of the study design,the P-ESDM plus MBSR groupreceived more intervention sessionsthan the P-ESDM group. Thus, it isunclear whether additional parentfunctioning gains made by theP-ESDM plus MBSR group are due togreater attention or the MBSRprogram itself. Future work shouldinclude attention-matched groups tofurther evaluate standaloneintervention impact. Examiningmindfulness as a mediator oftreatment on parenting stress willalso be important when determiningwhether MBSR is the mechanism ofaction, as will investigating theimpact of child response tointervention on parent outcomes.

This study suggests that high-quality,low-intensity early intervention wasassociated with improvements in PDand parenting stress. Adding MBSRresulted in additional improvementsin parenting stress. At no point didparents in P-ESDM plus MBSR showmore symptoms of stress than parentsin P-ESDM only, suggesting that theadditional requirements on parents’time did not seem to be harmfulwithin this time-limited interventionstudy. Findings may have implicationsfor systems that partner with parentsto care for young children as well aspractitioners who work directly withparents independent of childintervention. Future analyses willexplore whether particular profiles ofchildren and families are moreamenable to this combination.

ABBREVIATIONS

ASD: autism spectrum disorderDC: Difficult ChildMBSR: mindfulness-based stress

reductionPCDI: Parent-Child Dysfunctional

InteractionPD: Parental DistressPSI: Parenting Stress IndexP-ESDM: parent-implemented

Early Start Denver Model

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Address correspondence to Amy S. Weitlauf, PhD, Vanderbilt Kennedy Center, 230 Appleton Place, Private Mailbox 74, Nashville TN 37203. E-mail: amy.s.weitlauf@

vumc.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

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

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).

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

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DOI: 10.1542/peds.2019-1895K2020;145;S81Pediatrics 

A. Pablo Juárez and Zachary E. WarrenDykens,Catherine G. Herrington, Amy G. Nicholson, Madeline Santulli, Elisabeth M.

Amy S. Weitlauf, Neill Broderick, J. Alacia Stainbrook, Julie Lounds Taylor,Intervention for Autism: An RCT

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