Parent Training to Reduce Behavioral Problems in Children With Autism Spectrum Disorder in China

Child behavioral problems will be assessed using the Externalizing scale of the Child Behavior Checklist (CBCL) for Ages 1.5-5. The Externalizing scale measures child attention problems and aggressive behaviors using 24 items rated by parents based on child performance during the previous two months with a 3-point -type scale. The study will use the CBCL 1.5-5 for all families whose children will be between three to six years old. Lower scores suggest fewer behavioral problems. Research has shown sufficient test-retest reliability, internal consistency, convergent validity, and cross-cultural validity of CBCL 2-3 and CBCL 4-18 in China, but the evidence regarding the validity and reliability of this new version of CBCL 1.5-5 is currently limited. However, the CBCL 1.5-5 has shown good factorial validity among Chinese girls adopted into North American families; it has also demonstrated good internal validity with children with ASD.

ASD symptoms will be assessed using the Chinese version of the Autism Treatment Evaluation Checklist (ATEC), which comprise four subscales to measure child speech/language/communication, sociability, sensory/cognitive awareness, and health/physical/behavior. The scale has 77 items that are scored by parents. The health/physical/behavior subscale is rated using a 0 (not a problem)-to-3 (serious problem) point scale, whereas the other three subscales are rated using a 0 (not true)-to-2 (very true) point scale. Higher scores represent more ASD symptoms.

Over-reactivity parenting style will be measured using the Over-Reactivity subscale (5 items) of the Arnold-O'Leary Parenting Scale (PS). The PS assesses dysfunctional discipline practices reported by parents using a 7-point Likert-type scale. Higher scores indicate more dysfunctional parenting practices.

Supportive parenting style will be measured using the Supporting Positive Behavior subscale (7 items) of the Parenting Young Children Scale (PARYC). The PARYC Supporting Positive Behavior subscale is rated by parents from 1 to 7 regarding the frequency with which they engaged in such parenting strategies during the last month. Higher scores represent more positive and proactive parenting practices. Higher scores indicate more supportive parenting practices.

Parental mental health will be assessed using the Depression Anxiety Stress Scale-21 items (DASS-21), which consists of three self-report subscales (depression, anxiety, and stress) with each having 7 items that are rated from 0 (not apply to me) to 3 (apply to me very much or most of the time). Higher scores indicate a worse emotional state.

Family function will be assessed using the Chinese version of the Family APGAR scale, which consists of 5 items that are rated from 0 (never) to 2 (often) to examine the five functional components of adaptability, partnership, growth, affection, and resolve. Higher scores indicate that parents are more satisfied with their relationships with other family members.

Parental knowledge will be measured using of a questionnaire designed for the SREIA evaluation to assess parental understanding of ASD and child behaviors.

Parent satisfaction will be assessed at post-intervention only using a questionnaire based on the Incredible Years® Autism Programme End-of-Course Satisfaction Questionnaire and tailored to the SREIA programme and Chinese context. The questionnaire covers a range of topics including overall impression; teaching format; information and techniques; facilitators; and parent groups. It consists of 30 items rated with a 3-point Likert-type scale. High scores represent higher levels of satisfaction.

The level of participant involvement will be captured by calculating rates of attendance, engagement, and dropout. The attendance rate will be assessed with an attendance sheet, which will be reported by facilitators and collected once a day; engagement rate will be based on the percentage of families who complete assigned homework and tasks during the practice sessions, using an attendance and engagement registry; dropout rate will be calculated based on families who miss at least 10 days and are not able to provide post-intervention data.

Implementation fidelity will be measured using facilitator checklists. Facilitators will report whether they deliver the core components prescribed in the manual. The fidelity score will comprise the ratio of delivered components to prescribed components. Dosage will be calculated using hours of delivery.

Quality of delivery will be assessed by research staff observing parent group sessions and filling out a quality of delivery survey. It consists of 28 items rated with a 4-point Likert-type scale and additional space to provide qualitative comments. High scores represent higher quality of delivery.

Qualitative individual interviews will be conducted with around 15 parents, with the final number depending on when data saturation is reached. A semi-structured interview schedule will be developed to guide the interviews. The interview will cover the following topics: 1) understanding and use of skills, 2) perceived changes, 3) barriers to, facilitators of, and strategies to overcome the challenges of participation and engagement in the programme, and 4) acceptability and appropriateness of programme delivery and contents.

Focus groups will be conducted with around ten SREIA facilitators. A semi-structured interview schedule will be developed to guide the interviews. The discussion will cover the following topics: 1) barriers to, facilitators of, and strategies to overcome the challenges of program implementation, and 2) acceptability and appropriateness of program delivery and contents.

Qualitative individually interviews will be conducted with five program managers. he interviews with program managers will be structured to probe five dimensions that affect intervention impact including reach, effectiveness, adopt, implementation, and maintenance (RE-AIM).