Oono Inalegwu P, Honey Emma J, McConachie Helen
Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.
Cochrane Database Syst Rev. 2013 Apr 30;2013(4):CD009774. doi: 10.1002/14651858.CD009774.pub2.
Young children with autism spectrum disorders (ASD) have impairments in the areas of communication and social interaction and often display repetitive or non-compliant behaviour. This early pattern of difficulties is a challenge for parents. Therefore, approaches that help parents develop strategies for interaction and management of behaviour are an obvious route for early intervention in ASD. This review updates a Cochrane review first published in 2002 but is based on a new protocol.
To assess the effectiveness of parent-mediated early interventions in terms of the benefits for both children with ASD and their parents and to explore some potential moderators of treatment effect.
We searched a range of psychological, educational and biomedical databases including CENTRAL, MEDLINE, Embase, PsycINFO and ERIC in August 2012. As this is an update of a previous review, we limited the search to the period following the original searches in 2002. Bibliographies and reference lists of key articles were searched, field experts were contacted and key journals were handsearched.
We included only randomised controlled trials of early intervention for children with ASD. The interventions in the experimental condition were mediated by parents; the control conditions included no treatment, treatment as usual, waiting list, alternative child-centred intervention not mediated by parents, or alternative parent-mediated intervention of hypothesised lesser effect than the experimental condition.
Two review authors (HM and IPO) independently screened articles identified in the search and decided which articles should be retrieved in full. For each included study, two review authors (IPO and EH) extracted and recorded data, using a piloted data collection form. Two review authors (IPO and HM) assessed the risk of bias in each study. We performed data synthesis and analysis using The Cochrane Collaboration's Review Manager 5.1 software.
The review includes 17 studies from six countries (USA, UK, Australia, Canada, Thailand and China), which recruited 919 children with ASD. Not all 17 studies could be compared directly or combined in meta-analyses due to differences in the theoretical basis underpinning interventions, the duration and intensity of interventions, and the outcome measurement tools used. Data from subsets of 10 studies that evaluated interventions to enhance parent interaction style and thereby facilitate children's communication were included in meta-analyses. The largest meta-analysis combined data from 316 participants in six studies and the smallest combined data from 55 participants in two studies. Findings from the remaining seven studies were reported narratively.High risk of bias was evident in the studies in relation to allocation concealment and incomplete outcome data; blinding of participants was not possible.Overall, we did not find statistical evidence of gains from parent-mediated approaches in most of the primary outcomes assessed (most aspects of language and communication - whether directly assessed or reported; frequency of child initiations in observed parent-child interaction; child adaptive behaviour; parents' stress), with findings largely inconclusive and inconsistent across studies. However, the evidence for positive change in patterns of parent-child interaction was strong and statistically significant (shared attention: standardised mean difference (SMD) 0.41; 95% confidence interval (CI) 0.14 to 0.68, P value < 0.05; parent synchrony: SMD 0.90; 95% CI 0.56 to 1.23, P value < 0.05). Furthermore, there is some evidence suggestive of improvement in child language comprehension, reported by parents (vocabulary comprehension: mean difference (MD 36.26; 95% CI 1.31 to 71.20, P value < 0.05). In addition, there was evidence suggesting a reduction in the severity of children's autism characteristics (SMD -0.30, 95% CI -0.52 to -0.08, P value < 0.05). However, this evidence of change in children's skills and difficulties as a consequence of parent-mediated intervention is uncertain, with small effect sizes and wide CIs, and the conclusions are likely to change with future publication of high-quality RCTs.
AUTHORS' CONCLUSIONS: The review finds some evidence for the effectiveness of parent-mediated interventions, most particularly in proximal indicators within parent-child interaction, but also in more distal indicators of child language comprehension and reduction in autism severity. Evidence of whether such interventions may reduce parent stress is inconclusive. The review reinforces the need for attention to be given to early intervention service models that enable parents to contribute skilfully to the treatment of their child with autism. However, practitioners supporting parent-mediated intervention require to monitor levels of parent stress. The ability to draw conclusions from studies would be improved by researchers adopting a common set of outcome measures as the quality of the current evidence is low.
患有自闭症谱系障碍（ASD）的幼儿在沟通和社交互动方面存在障碍，并且常常表现出重复或不依从行为。这种早期出现的困难模式对家长来说是一项挑战。因此，帮助家长制定互动和行为管理策略的方法显然是ASD早期干预的一条途径。本综述更新了一篇2002年首次发表的Cochrane综述，但基于新的方案。
评估家长介导的早期干预对ASD儿童及其家长的益处，并探讨一些潜在的治疗效果调节因素。
我们在2012年8月检索了一系列心理学、教育和生物医学数据库，包括CENTRAL、MEDLINE、Embase、PsycINFO和ERIC。由于这是对先前综述的更新，我们将检索限制在2002年原始检索之后的时间段。检索了关键文章的参考文献和引用列表，联系了领域专家并手工检索了关键期刊。
我们仅纳入了针对ASD儿童早期干预的随机对照试验。实验条件下的干预由家长介导；对照条件包括不治疗、常规治疗、等待名单、非家长介导的替代儿童中心干预，或假设效果低于实验条件的替代家长介导干预。
两位综述作者（HM和IPO）独立筛选检索中识别出的文章，并决定应全文检索哪些文章。对于每项纳入研究，两位综述作者（IPO和EH）使用预先试用的数据收集表提取并记录数据。两位综述作者（IPO和HM）评估每项研究的偏倚风险。我们使用Cochrane协作网的Review Manager 5.1软件进行数据合成和分析。
本综述包括来自六个国家（美国、英国、澳大利亚、加拿大、泰国和中国）的17项研究，共招募了919名ASD儿童。由于干预的理论基础、干预的持续时间和强度以及所使用的结局测量工具存在差异，并非所有17项研究都能直接比较或纳入荟萃分析。对10项评估旨在增强家长互动方式从而促进儿童沟通的干预措施的研究子集的数据进行了荟萃分析。最大的荟萃分析合并了六项研究中316名参与者的数据，最小的合并了两项研究中55名参与者的数据。其余七项研究的结果以叙述形式报告。在分配隐藏和结局数据不完整方面，研究中存在明显的高偏倚风险；不可能对参与者进行盲法。总体而言，在评估的大多数主要结局中（语言和沟通的大多数方面——无论是直接评估还是报告；观察到的亲子互动中儿童发起行为的频率；儿童适应性行为；家长压力），我们没有发现家长介导方法有获益的统计学证据，研究结果在很大程度上尚无定论且不一致。然而，亲子互动模式发生积极变化的证据很充分且具有统计学意义（共同注意：标准化均数差（SMD）为0.41；95%置信区间（CI）为0.14至0.68，P值<0.05；家长同步性：SMD为0.90；95%CI为-0.56至1.23，P值<0.05）。此外，有一些证据表明家长报告的儿童语言理解有所改善（词汇理解：均数差（MD）为36.26；95%CI为1.31至71.20，P值<0.05）。此外，有证据表明儿童自闭症特征的严重程度有所降低（SMD为-0.30，95%CI为-0.52至-0.08,P值<0.05）。然而，这种因家长介导干预导致儿童技能和困难变化的证据并不确定，效应量小且置信区间宽，随着未来高质量随机对照试验的发表，结论可能会改变。
本综述发现了一些家长介导干预有效的证据，最明显的是在亲子互动的近端指标方面，但在儿童语言理解和自闭症严重程度降低等更远端指标方面也有证据。此类干预是否能减轻家长压力的证据尚无定论。本综述强化了需要关注早期干预服务模式，使家长能够熟练地为其自闭症孩子的治疗做出贡献。然而，支持家长介导干预的从业者需要监测家长的压力水平。由于当前证据质量较低，研究人员采用一套通用的结局测量指标将有助于提高得出结论的能力。
