Effects of Family Factors on Joint Engagement in a Caregiver Mediated Intervention

Background: Intervention research in autism spectrum disorder (ASD) primarily focuses on child outcomes; however, increasing literature addresses caregiver well-being and its impact. Consideration of caregiver experiences related to intervention is critical, as factors such as low resources and stress can negatively impact outcomes (Obsborne et al, 2008; Gabriels et al, 2001). Stressors include increased time demands for caregivers and financial strains. These effects may be exacerbated in low resource families because of the additional demands of travel and time away from work that they may not be able to afford. The literature exploring the impact low resources have on outcomes is limited while the literature on caregiver stress is conflicting. Examining these underexplored factors could elucidate how intervention affects families and inform implementation modifications to maximize impact.

Objectives: Examine how family factors (i.e., resources and stress) affect joint engagement (JE) in a caregiver-mediated intervention for young children with ASD from predominately low resource families.

Methods: Children aged 2-5 (N=112) and their caregivers were randomized to a caregiver education module (CEM) or caregiver mediated module (CMM) informed by JASPER (Joint Attention, Symbolic Play, Engagement, and Regulation) intervention. This home based intervention lasted 12 weeks. Measures were administered at baseline and exit. In our sample, 66% were a racial/ethnic minority and 61.6% were low-income. Measures included the Parenting Daily Hassles (PDH) and Family Resource Scale (FRS); the PDH evaluates both the frequency and intensity of stressful daily events. JE was assessed from a 10-minute videotaped interaction between the caregiver and child, using a validated coding scheme. Linear mixed models were used to examine the association between PDH and FRS on JE and whether the associations differ by intervention.

Results: As noted previously, JE was significantly improved in the CMM group over the CEM group (Kasari et al, 2014). In this study, baseline hassle frequency positively predicted joint engagement (F(1,96)=4.38, p=0.039) at all time points, but baseline hassle intensity did not. There was a strong trend toward significant moderating effect of baseline hassle intensity (i.e., low versus high) on treatment effects on JE from baseline to exit (F(1,94)=3.75, p=0.056). Specifically, improvement in JE was more favorable in the CMM group regardless of having low or high hassle intensity. Overall hassle frequency positively predicted increases in JE in the CMM group, but hassle intensity did not predict improvements in JE from baseline to exit in either group. Chi-square analyses indicated that race/ethnicity was associated with baseline JE, but income and family resources were not.

Conclusions: Improvements in joint engagement were predicted by higher frequency and intensity of daily caregiver stress pre-intervention. While not consistent with our prediction, this relationship may suggest that families who encounter more caregiving stress are poised to benefit more from intervention focused on engagement. These results mirror other psychotherapy literature indicating that individuals with higher mental health symptoms can benefit most from treatment. Overall, results suggest that community interventions targeting this population, and with consideration of structure and schedule to ease time and financial burdens, can impact parent/child engagement.