strength-focused parenting intervention · parents’ perceived competence to respond in an...
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Shochet, I., Saggers, B., Carrington, S., Orr, J., Wurfl, A., & Duncan, B. (2019). A Strength-Focused Parenting Intervention May Be a Valuable Augmentation to a Depression Prevention Focus for Adolescents with Autism. Journal of Autism and Developmental Disorders, 1–21. https://doi.org/10.1007/s10803-019-03893-6
A Strength-Focused Parenting Intervention may be a Valuable Augmentation to a Depression Prevention Focus for Adolescents with Autism
Abstract
High depression rates for adolescents with autism indicate a need for a comprehensive prevention approach. Parents can promote parent-child factors that buffer adolescents from depression. However, parenting adolescents with autism presents challenges which can diminish parental self-efficacy and mental wellbeing with potential negative sequelae for their adolescents. This proof-of-concept study investigated the value of adding a strength-focused parenting intervention to a depression-prevention intervention for adolescents with autism. A Consensual Qualitative Research framework analysed 15 parents’ intervention experience. Parents reported that feeling isolated and unsupported by existing services motivated their participation, and they valued interacting with other parent participants. They also reported that the program enhanced wellbeing and parenting efficacy, reduced isolation, increased ability to parent calmly, and improved parent-adolescent relationships.
Keywords: autism spectrum disorder; autism; multilayered school-based intervention; parenting young adolescents with autism; parent self-efficacy and mental wellbeing; Resourceful Adolescent Parent Program RAP-P-ASD
A Strength-Focused Parenting Intervention may be a Valuable Augmentation to a Depression Prevention Focus for Adolescents with Autism
Autism Spectrum Disorder (ASD) is a heterogeneous neurodevelopmental disorder defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) as occurring across a spectrum of severity of pervasive symptoms that appear in early childhood and endure across the lifespan, with individuals varying greatly in terms of symptom expression and level of functioning. With the high rate of depression for young adolescents with autism (Mayes, Calhoun, Murray, & Zahid, 2011), and the likelihood that suicidality is more common in adolescents with autism than in adolescents with neurotypical development (Chen et al., 2017; Culpin et al., 2018; Hannon & Taylor, 2013), there is a pressing need for a comprehensive approach to depression prevention in this population. Previous research in this area has highlighted the importance of adding a parent focus to the prevention approach because caregivers (referred to as parents from hereon) offer a crucial resource to promote protective factors for young adolescents with autism (Mackay, Shochet, & Orr, 2017). However, parents of young adolescents with autism face increased challenges themselves which diminish their parental self-efficacy and mental wellbeing (Derguy, Michel, M’Bailara, Roux, & Bouvard, 2015; Karst & Van Hecke, 2012; Pottie & Ingram, 2008;
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Strength-Focused Parenting Intervention
2
Weiss, Tint, Paquette-Smith, & Lunsky, 2016; Zablotsky, Bradshaw, & Stuart, 2013), with potential negative consequences for their adolescents’ mental wellbeing (Kuhn & Carter, 2006; Weiss, Cappadocia, MacMullin, Viecili, & Lunsky, 2012; Weis et al., 2013). Furthermore, parents with the broader autism phenotype (BAP) or sub-threshold characteristics of autism that may be present in parents of adolescents with autism (Losh, Childress, Lam, & Piven, 2008) may struggle to support their adolescent to overcome difficulties that they themselves encounter. Hence, interventions that enhance parental self-efficacy, diminish the risk factors associated with the challenges of parenting, and help parents to promote core protective factors for the mental health of their adolescents with autism are needed to prevent depression in young adolescents with autism. We report here on the qualitative findings of a proof-of-concept study that uncovered the potential value of adding a strength-focused parenting intervention as an additional layer of a depression-prevention and psychological wellbeing promotion program that targeted young adolescents (defined herein as children aged 11 – 13 years).
Limitations of Depression Prevention Research for Adolescents with Autism
The prevalence of autism is increasing (Centers for Disease Control and Prevention, 2014). Symptoms of autism endure across the lifespan and are complicated by psychosocial difficulties such as depression and reduced psychological wellbeing that emerge in adolescence (APA, 2013), and when left untreated, are likely to extend into adulthood, reducing prospects of engaging in and completing tertiary education, and finding jobs and remaining employed (Taylor, Henninger, & Mailick, 2015). As prevalence estimates for depression in young adolescents with autism are as high as 54% (Mayes et al., 2011), effective interventions to prevent depression in adolescents with autism are important. Programs targeting depression prevention in children with neurotypical development have tended to intervene in early adolescence, as this is the developmental period immediately preceding the age of peak incidence (see Gladstone, Beardslee, & O’Connor, 2011 for review). School-based depression prevention programs for children with neurotypical development have been found to achieve a modest positive effect in depression prevention which increases when targeting adolescents at risk (Corrieri et al., 2014; Merry et al., 2011; Stice, Shaw, Bohon, Marti, & Rohde, 2009; Stockings et al., 2016). However, despite the increased risk of mental health problems in adolescents with autism, there has been a paucity of research on school-based depression prevention programs specifically for this population.
Recent research has implemented an adapted version of an effective depression program for adolescents (the Resourceful Adolescent Program (RAP-A); Shochet & Wurfl, 2015a, 2015b; Shochet, Holland, Osgarby, & Whitefield, 1998). RAP-A is used widely throughout Australia and internationally. Post-session integrity checklists completed by program facilitators, and post-implementation surveys and semi-structured interviews that gathered program evaluations from participants, indicate that RAP-A is well accepted by participants (e.g., Merry, McDowell, Wild, Bir, & Cunliffe, 2004; Shochet et al., 2001; Shochet & Ham, 2004). The adaptation (RAP-A-ASD) aims to improve coping skills, promote depression protective factors, and build resilience so as to foster mental health and wellbeing in young adolescents with autism (Shochet, Mackay, & Wurfl, 2011). RAP-A-ASD is delivered over 11 x 50-minute weekly sessions in schools by a trained facilitator with one young adolescent with autism at a time (for details see Mackay et al., 2017; Shochet et al., 2016). The Mackay et al. (2017) pilot randomised control trial (RCT) of RAP-A-ASD showed significant intervention effects on parent reports of adolescent coping self-efficacy (maintained at 6 month follow-up). In addition, qualitative outcomes reflected perceived improvements from the intervention for adolescents’ coping self-efficacy, self-confidence, social skills, and affect regulation. While these
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results were encouraging, there were no effects on depressive symptoms as reported by either the adolescents (on the Child Depression Inventory (Kovacs, 2003)) or their general mental health functionality as reported by the parents (on the Strengths and Difficulties Questionnaire (Goodman, 1997)). Consistent with Francis (2005) who argues the importance of considering the adolescent with autism within the family context, the authors concluded that a multilayered intervention at both the individual and parent level may increase effectiveness. Such an approach may provide the best opportunity to capitalise on the vital protective factors that parents provide for their young adolescents with autism in order to promote positive mental health and prevent depression for adolescents with autism (see Shochet et al., 2016 for multilayered conceptual model).
Vital Role of Parents in Adolescent Depression Prevention
Important parental factors have been found to buffer adolescents from depression. These include parent self-efficacy, parent affect regulation, parental expressions of caring and warmth, reduced parent-adolescent conflict, and parents’ ability to support their adolescents to develop increasing autonomy while maintaining close parental relationships (see Restifo & Bögels, 2009 for review).
Supporting parents’ self-efficacy (their perceived competency to meet the demands of caring for their adolescent (Coleman & Karraker, 1998)) plays a role in buffering their adolescents from depression. As documented extensively in the literature, parents with high self-efficacy are more likely to feel confident that they can adopt effective parenting skills and exert a positive influence during the adolescent years of their children with neurotypical development, with a reduction in adolescents’ depressive symptoms being one of many optimal psychosocial outcomes reported (e.g., Côté et al., 2009, Jones & Prinz, 2005; Steca, Bassi, Caprara, & Fave, 2011). Parents of adolescents with autism are at increased risk of diminished self-efficacy because caring for these adolescents presents additional parenting challenges compared to the challenges encountered when parenting adolescents with neurotypical development (Kogan et al., 2008; Siklos & Kerns, 2006; Weiss et al., 2016).
Parents’ affect regulation, their ability to regulate their own negative arousal, is closely linked to their self-efficacy as parents, and also plays a role in buffering their adolescents from depression. Parents’ perceived competence to respond in an adaptive manner to their own emotions, and to model this process to their adolescents with neurotypical development, has been found to impact on their adolescents’ ability to regulate distressed affect (e.g., Gross, 2015; Sheeber, Allen, Davis, & Sorensen, 2000). Parental mental wellbeing has been found to have a reciprocal positive effect on the mental health of the young adolescent with autism as well (Kelly, Garnett, Attwood, & Peterson, 2008). However, the additional parenting challenges experienced by many parents of adolescents with autism can have a detrimental effect on parents’ mental health, with parents who are struggling with their own mental health less able to regulate their negative arousal (Derguy et al., 2015; Karst & Van Hecke, 2012; Pottie & Ingram, 2008; Zablotsky et al., 2013). Parents of children with autism are at greater risk of developing anxiety and depressive disorders than parents of children with neurotypical development (Barker et al., 2011; Gau et al., 2012; Piven & Palmer, 1999). This risk is compounded by parents’ heightened susceptibility to social isolation due to time demands associated with caring for a child with autism, and parents’ diminished confidence to connect with others because of fears that their child will be judged unfavourably and/or rejected (Divan, Vajaratkar, Desai, Strik-Lievers, & Patel, 2012; Gray, 2001).
Parental expressions of caring and warmth towards their adolescents with neurotypical development, and parental involvement in pleasant interactions and activities with their adolescents
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convey a sense of acceptance, emotional closeness, availability and responsiveness to the adolescent, with higher levels predicting lower levels of depression in adolescents with neurotypical development (see Yap, Pilkington, Ryan, & Jorm, 2014 for review). Similarly, parental warmth and close parent-child relationships have been associated with improved outcomes for adolescents with autism (Woodman, Smith, Greenberg, & Mailick, 2015). However, the difficulties with socio-emotional reciprocity that young adolescents with autism experience, coupled with the high incidence of challenging behaviours they display, reduce opportunities for spontaneous adolescent-parent shared enjoyment (Seltzer et al., 2010).
Reduced parent-adolescent conflict is another parental factor that can buffer adolescents with neurotypical development from depression (Hale, van der Valk, Akse, & Meeus, 2008; Rueter, Scaramella, Wallace, & Conger, 1999). Challenging parental authority is a normative function of adolescence, with resulting parent-adolescent disagreements facilitating adaptive redefinition of family roles and responsibilities as adolescents mature (Laursen & Collins, 2009; Smetana, 2011). However, parent-adolescent disputes that result in protracted hostility are associated with diminished adolescent wellbeing and increased stress in the family system (Tucker, McHale, & Crouter, 2003). Adolescents who are securely attached to their parents are more likely able to disagree amicably with their parents, to view their parents through a realistic rather than idealizing lens, and to feel supported and understood by their parents (Allen et al., 2003). Conversely, those who are insecurely attached to their parents tend towards behaviours such as excessive reassurance seeking, and are more at risk of exhibiting depressive symptoms (Restifo & Bögels, 2009). The socio-communicative impairments experienced by young adolescents with autism, coupled with their increased susceptibility to disruptive and impulsive behaviour, increase the risk of parent-adolescent misunderstandings and conflict (Brereton, Tonge, & Einfeld, 2006; Orsmond, Seltzer, Greenberg, & Krauss, 2006). Furthermore, compared to children with neurotypical development, significantly fewer children with autism form secure attachment relationships with their parents (see Teague, Gray, Tonge, & Newman, 2017 for review), possibly due to the child’s interpersonal relatedness difficulties disrupting the understanding of the other’s needs and intentions in parent-child interactions (Cortina & Liotti, 2010; Stern, 2004).
Parents’ ability to support their adolescents to develop increasing autonomy while maintaining close parental relationships is yet another important parental factor that has been found to buffer adolescents with neurotypical development from depression. The adolescent developmental tasks of individuation and identity formation require simultaneous closeness and separation from parents and typically co-occur with increased conflict in the parent-adolescent relationship, adolescents’ greater reliance on peer relationships to satisfy their attachment needs, and adolescent cognitive advances such as increased perspective-taking abilities (Allen, 2008; Short & Rosenthal, 2008; Steinberg & Morris, 2001). Difficulties with peer relationships, emotion regulation and meta-cognition experienced by many young adolescents with autism have the potential to make these developmental tasks especially challenging for young adolescents with autism, thereby increasing their risk of depression (Brereton et al., 2006; Mayes et al., 2011; McPheeters, Davis, Navarre, & Scott, 2011). Furthermore, these difficulties can erode parents’ ability to support their adolescents with autism to develop increasing autonomy while maintaining close parental relationships, with the resulting stress impacting on parental mental health (Zablotsky et al., 2013).
Hence, parenting an adolescent with autism presents additional challenges for parents compared to the challenges encountered when parenting adolescents with neurotypical development (Kogan et al., 2008; Siklos & Kerns, 2006). These challenges to parents’ self-efficacy, affect regulation and mental health, combined with the social and emotional difficulties experienced by young
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adolescents with autism, can lead to heightened stress and conflict in the family system (Duarte, Bordin, Yazigi, & Mooney, 2005; Ghaziuddin, Ghaziuddin, & Greden, 2002; Hayes & Watson, 2012; Hoffman, Sweeney, Hodge, Lopez-Wagner, & Looney, 2009). Thus, it would appear that a program for parents that can facilitate the factors of parent self-efficacy and affect regulation, parental expressions of caring and warmth, reduced parent-adolescent conflict, and parents’ ability to support their young adolescents with autism to develop increasing autonomy while maintaining close parental relationships would be beneficial for preventing depression and suicide in these young adolescents.
Supporting Parents of Adolescents with Autism
Despite parents of young adolescents with autism struggling with their own self-efficacy (Weiss et al., 2016) and mental health (Barker et al., 2011; Derguy et al., 2015; Gau et al., 2012; Karst & Van Hecke, 2012; Piven & Palmer, 1999; Pottie & Ingram, 2008; Zablotsky et al., 2013), and parents identifying a need for parenting resources and support (Hartley & Schultz, 2015; Siklos & Kerns, 2006), the majority of interventions focus on the young adolescent with autism, with scant knowledge of, or attention to, the unique needs their parents encounter during their child’s transition from childhood to adolescence (Karst & Van Hecke, 2012). Parent interventions that run alongside adolescent depression-prevention programs can play an important role in boosting parents’ self-efficacy and mental wellbeing, and helping them to assist their adolescents to navigate their challenging teenage years with greater composure, affect regulation and connectedness (Shochet et al., 2001; Shochet & Ham, 2004). The lack of such interventions for parents of young adolescents with autism prompted the consideration of existing programs that have been developed for parents of young adolescents with neurotypical development. One such intervention is the Resourceful Adolescent Program for Parents (RAP-P; Shochet & Wurfl, 2016a, 2016b). RAP-P is a strength-based, parent-child focused, non-blaming resilience-building program that strives to harness parents’ strengths, promote their self-efficacy and help them to promote protective factors for the mental health of their adolescents.
A recent RCT of suicidal adolescents and their parents in an Australian outpatient clinic (N = 48) (Pineda & Dadds, 2013) indicates that RAP-P may be particularly effective when used with selective populations to help parents to manage their stress and to maintain empathy for their adolescents in difficult circumstances. The study compared a family intervention that included RAP-P plus routine care with routine care only. At post-treatment RAP-P was associated with greater improvement in family functioning (i.e., adolescent-parent relationships and parental self and affect regulation), greater reductions in adolescents’ suicidal behaviour, and greater reductions in adolescent psychiatric disability with gains maintained at 6-month follow-up. Changes in adolescent suicidality were largely mediated by the improvement in family functioning which appeared to be the mechanism of change. Thus, we have reason to be encouraged that an adaptation of RAP-P may add value to a suite of interventions for depression prevention in another selective population, that of young adolescents with autism.
The Resourceful Adolescent Program for Parents adapted for parents of young adolescents with autism (RAP-P-ASD) is based on an integration of cognitive-behavioural theory, Bowen Family Systems Theory (Kerr & Bowen, 1988; Titelman, 2014), and knowledge from developmental psychology of the maturational changes that occur naturally during adolescence as well as the specific problems faced by adolescents with autism. RAP-P-ASD draws on cognitive-behavioural strategies for stress management, and management and prevention of conflict (e.g., affect regulation). From the family systems perspective, RAP-P-ASD helps to promote higher levels
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of parental “differentiation of self” (i.e., parents’ ability to reduce their emotional reactivity and manage their emotions in the face of stress and anxiety). For example, parents develop a greater understanding of how they are more effective as parents when they can remain calm. Thus, RAP-P-ASD aims to improve the relationship bond between parents and adolescents, promote harmonious relationships, and prevent conflict. The program also aims to provide parents with greater levels of understanding and empathy for the developmental needs of adolescents in general, and the specific needs of adolescents with autism. For example, parents explore ways of supporting their adolescents to experience a greater sense of belonging at school and in other contexts.
The current study conducted a qualitative exploration of parents’ experience of participating in a proof-of-concept trial of the multilayered RAP intervention in which young adolescents with autism and their parents received RAP-A-ASD and RAP-P-ASD respectively. This trial was conducted within a broader project to promote wellbeing and mental health in young adolescents with autism (the School Connectedness Project; see Shochet et al., 2016 for details), and is referred to as the Adolescent Wellbeing Project from hereon. The aim of the current study was to develop an understanding of the experience of parents who participated in the parent program (RAP-P-ASD) in order to ascertain the value of adding a parenting intervention to an evidence-based, strength-focused resilience intervention designed to promote wellbeing and mental health in young adolescents with autism.
Method
Study Design
This was a qualitative study using the consensual qualitative research (CQR) approach (Hill, 2012; Hill, Thompson, & Williams, 1997; Hill et al., 2005). The main elements in CQR are the use of open-ended questions in semi-structured data-collection techniques, which allows for the collection of consistent data across individuals as well as a more in-depth examination of individual experiences; several judges throughout the data analysis process to foster multiple perspectives; a consensus to arrive at a judgement about the meaning of the data; an external auditor to check the work of the primary team; and domains, core ideas, and cross-analysis to detect common themes in the data (Hill, 2012; Hill et al., 1997, 2005).
Participants
Participants were drawn from the population of parents who participated in the Adolescent Wellbeing Project in 2016. The 2016 Adolescent Wellbeing Project was conducted across three urban schools in Brisbane, Australia, an urban city of approximately 2.3 million people. Criteria for adolescent participation in RAP-A-ASD included enrolment in the first two years of a secondary school participating in the intervention, and a diagnosis from a psychiatrist or paediatrician of ASD as per the DSM 5 (APA, 2013) or autistic disorder, Asperger’s disorder, or PDD-NOS as per the DSM-IV-TR (American Psychiatric Association [APA], 2000). As the cognitive demands of RAP-A-ASD require participants to be high-functioning, individuals with intellectual impairment, severe behavioural difficulties or psychosis were excluded. The opportunity to participate in RAP-P-ASD was offered to all parents or carers of adolescents (aged 11 – 13 years) participating in RAP-A-ASD, and the requirement for participation was the ability to attend at least one of the four RAP-P-ASD workshops. Twenty parents aged approximately 30 to 55 years and from low to middle socioeconomic backgrounds volunteered to attend RAP-P-ASD in 2016, and attendance was
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moderately high (30% attended all 4 workshops, 25% attended 3 workshops, 20% attended 2 workshops, and 25% attended only 1 workshop). Of these parents, 15 (5 males, 10 females) agreed to participate in this qualitative study. The sample size is consistent with that recommended by Hill et al. (1997, 2005) as being necessary to ensure validity in studies of this design, and was hence deemed appropriate for the exploratory qualitative design and to meet the study aims.
Procedure
RAP-P-ASD. This program was implemented according to the RAP-P-ASD treatment manual which is based on the RAP-P manual, and includes the autism-specific adaptations made to the RAP-P program. Changes included an extra session to provide parents with additional time and space to discuss the unique challenges of parenting young adolescents with autism, and additional activities to promote a sense of belonging and highlight the unique opportunities for personal growth that arise from parenting an adolescent with autism. Hence, RAP-P-ASD (see Table 1) consists of a series of four, weekly, group workshops of two and a half hours’ duration. The intervention was implemented in the second and third terms of the Australian school year (i.e., April to September 2016). Separate workshops were conducted for each participating school, and were facilitated by researchers from the Adolescent Wellbeing Project who had undergone the training required to become accredited RAP-P-ASD facilitators. In the first session, facilitators supported parents to identify their existing parental strengths in order to promote parental self-efficacy, explored the manner in which stress affects parents, and promoted an understanding of the efficacy of calm parenting. The second session addressed stress management for parents, provided information about adolescent development, and outlined strategies for promoting adolescent self-esteem and a sense of belonging at home and in the community. The third session focused on the important role that parents play in the life of the developing adolescent, explored strategies for balancing adolescents’ need for independence while strengthening the parent-adolescent relationship bond, and discussed the importance of promoting harmonious family relationships to reduce the stress in the family system. The final session concentrated on strategies for preventing and managing parent-adolescent conflict in order to consolidate family connectedness, and helped parents to reflect on the personal growth that their experience of parenting an adolescent with autism could provide.
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Table 1
RAP-P-ASD Program Content
Session Key message Content 1. Parents are
people too!Parents do a great job and deserve a pat on the back!
Parents identify the things they already do well as caregivers. Explore the effects of stress on parenting, and how parenting is more effective when caregivers remain calm.
2. What makes teenagers tick?
Parents are important in supporting the development of adolescents with autism.
Explore and develop stress management strategies for parents. Increase caregiver understanding of the development of adolescents with autism; and their priorities and stressors such as struggling to become independent, making their own decisions, and maintaining a strong relationship bond with their parents while forging their own identity. Explore ways to promote the self-esteem of adolescents with autism and increase their sense of value and inclusion in the family and community.
3. Consolidating family connectedness
Parents always have an important role in the lives of their adolescents with autism.
Explore supporting independence while maintaining a strong relationship bond with the developing adolescent. Discuss the importance of promoting harmonious family relationships.
4. Promoting positive family relationships
Positive family relationships increase self-esteem and wellbeing for all!
Explore successful ways of preventing and managing conflict in the parent-adolescent relationship. Reflect on personal growth as a result of parenting an adolescent with autism, and looking forward to a positive future with the adolescent.
Consent and data collection. Prior to participation, all participants were given a participant information sheet, and provided written consent to participate in the study, for interviews to be audio-recorded, and for the recordings to be transcribed and analysed post de-identification. Parent interviews were conducted one-on-one by telephone at a pre-arranged time in October and November 2016 by a researcher from the Adolescent Wellbeing Project who had not been involved in the program delivery. The interviews were of a semi-structured and mostly open-ended nature, as recommended by Hill et al. (1997), and participants were not given the interview schedule ahead of time. The questions used to guide the parent interviews included, “Can you remember the RAP
Parent Program you participated in?”, “What was your experience of the program?”, “What did
you like most about the program?”, “What did you like the least about the program?”, “Can you
give me any examples of when you have used something discussed in the program? Challenges
you might have approached differently?”, “Have you noticed any changes in your relationship
with your adolescent? If so, can you provide examples of some of these changes?”, “Have you
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noticed any changes in your adolescent?”, “Have you, or anyone else, noticed any differences in
yourself and/or in your parenting? If so, can you tell me more about this?”, “What would you tell
other parents about the program?”, and “What was your main reason for attending? Was that need
met?” Interviews lasted approximately one hour each and were recorded using a digital audio recorder. The audio recordings were transcribed verbatim by a research assistant not involved in the Adolescent Wellbeing Project, and the transcripts were checked for accuracy against the audio recordings and de-identified by a researcher from the Adolescent Wellbeing Project who had not been involved in the interviews.
Data Analysis
The CQR method (Hill, 2012; Hill et al., 1997, 2005) was adopted to analyse the transcript data in four stages. The CQR team consisted of four researchers from the Adolescent Wellbeing Project team, and an auditor who was not part of the research team. First, one member of the research team conducted an initial review of the transcripts and compiled a list of provisional domains (broad topic areas used to cluster information about similar topics) based on material in the transcripts. The four team members then met to review a sub-sample of three transcripts in order to test the validity of the provisional domains. Following this review, the team reached a consensual decision as to the final domains to be used in the analysis. Second, each team member read each transcript independently and organised the raw data in each domain into core ideas (summaries of what each interviewee had said, using fewer words and with more clarity), and then met as a team to discuss the core ideas until a consensus was reached. Third, one member of the research team collated the core ideas from each transcript and employed cross-analysis across all transcripts to identify common themes that occurred in each core idea within each domain. The common themes were then checked and discussed by the team until a consensus was reached. Fourth, one member of the research team tallied two quantitative scores for each common theme to provide an indication of the relative importance of the themes within each core idea. Consistent with CQR methodology, an unweighted score (1 – 15) was used to indicate the number of interview transcripts (which ranged from 1 – 15) in which the common theme appeared. A weighted score was used to indicate the total number of instances in which the common theme occurred across all the interview transcripts, including multiple instances within a single transcript.
The external auditor provided detailed feedback at each of the four stages of the analysis process. The auditor checked that all relevant raw material had been extracted, that the raw material was in the correct domain, that all important material had been represented in the core ideas, that the wording of the core ideas captured the essence of the raw data, that the cross-analysis had accurately identified the common themes that represented the data, and that the quantitative unweighted and weighted scores had been calculated correctly.
Results
Parents’ Experience of Participation
Using the CQR procedure to analyse the qualitative data gathered from the parent interviews meant that disagreements about the existence and wording of domains, core ideas and themes were discussed by the research team until a consensus that the analysis best portrayed what the parents were conveying was reached. For example, the wording of the third domain was honed from “Parents’ experience of changes in the parent-adolescent relationship as a result of participating
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in RAP-P-ASD” to “Parents’ experience of changes in parenting style and the parent-adolescent relationship”.
The CQR analysis identified seven domains. The four domains that best described parents’ experience of participating in the multilayered RAP intervention, and that are explored in detail in this paper, included parents’ reasons for participation in the RAP parent program, aspects of participation that parents experienced as helpful, parents’ experience of changes in parenting style and the parent-adolescent relationship, and parents’ experience of becoming more resourceful as parents as a result of participating in RAP-P-ASD. These domains, together with the core ideas, principal themes within each core idea, quantitative scores (unweighted and weighted) that provided an indication of the relative importance of themes within each core idea, and illustrative quotes from the raw transcript data for each theme, are set out in Tables 2 to 5. The themes are presented in rank order, with those having the highest weighted score at the top of the list within each core idea, and those with the lowest weighted score at the bottom of the list within each core idea. The six most salient common themes fell within the second domain, “Aspects of participation that parents experienced as helpful”. The most highly rated common theme, “validated and reinforced that parents are already doing a good job” was derived from comments that were made 71 times in the interviews by 11 parents (73%), and conveyed that RAP-P-ASD provided parents with much needed reassurance in the form of support and validation, and reduced their parenting anxiety. The second most highly rated common theme, “perceived as good and helpful for the parent themselves” was derived from comments that were made 52 times in the interviews by 12 parents (80%), and reflected that parents experiencing adversity associated with the challenges of parenting a young adolescent with autism perceived RAP-P-ASD to be a positive and beneficial experience. The third most highly rated common theme, “felt understood and no longer felt alone”, was formed from comments that were made 32 times in the interviews by 13 parents (87%), and conveyed that parents valued the connectedness with other parents that participation in RAP-P-ASD afforded. The fourth most highly rated common theme, “enjoyable”, was derived from comments made 26 times in the interviews by 11 parents (73%), and highlighted that participating in RAP-P-ASD had been a positive experience for these parents. The fifth most highly rated common theme, “informative”, was formed from comments that were made 19 times in the interviews by 7 parents (47%) who found the content of the program useful. The sixth most highly rated common theme, “would recommend it to other parents”, was derived from comments made 18 times by 12 parents (80%), and reinforced that these parents had found the program sufficiently useful that they would endorse participation to other parents.
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Tabl
e 2
Do
ma
in 1
: Pa
ren
ts’ R
ea
son
s fo
r P
art
icip
ati
on
in t
he
RA
P P
are
nt
Pro
gra
m
Cor
e id
eaC
omm
on th
emes
Impo
rtanc
eEx
ampl
es o
f illu
stra
tive
quot
esU
nwei
ghte
dW
eigh
ted
Seek
ing
supp
ort
Feel
ing
isol
ated
or a
lone
916
“You
can
feel
ver
y is
olat
ed”
“hav
ing
a ki
d on
the
spec
trum
can
be
a lo
nely
pla
ce to
be
a lo
t of t
he ti
me”
“t
here
doe
sn’t
seem
to b
e m
uch
in th
e w
ay o
f sup
port
netw
orks
for p
aren
ts”
“it c
an b
e [h
elpf
ul] f
or [p
aren
ts] t
o ju
st fe
el th
ey’re
not
on
thei
r ow
n”
Stru
gglin
g to
feel
effe
ctiv
e as
a
pare
nt6
8“I
don’
t rea
lly fe
el a
dequ
ate”
“w
e fin
d it
hard
to fe
el th
at w
e’re
doi
ng a
nyth
ing
wel
l” “It
’s al
way
s ab
out t
he n
egat
ive
of ‘w
e’re
stu
ck h
ere,
wha
t do
we
do?’
”
Feel
ing
over
whe
lmed
with
pa
rent
ing
a ch
ild w
ith a
utis
m6
7“It
's a
big
shoc
k w
hen
you
find
out t
hat t
his
is w
hat's
goi
ng o
n w
ith y
our c
hild
” “n
egot
iatin
g w
ith h
im is
impo
ssib
le b
ecau
se h
e do
esn’
t car
e ab
out a
nyth
ing.
I gu
ess
that
’s pa
rt of
th
e de
pres
sion
, but
if h
e do
esn’
t wan
t to
do s
omet
hing
, I’v
e go
t not
hing
to w
ork
with
bec
ause
he’
ll ju
st s
ay, ‘
I don
’t ca
re’”
“It ta
kes
a lo
t of p
atie
nce
and
a lo
t of c
alm
ness
to n
ot g
et s
o fru
stra
ted
with
him
” “I’
ve e
ven
thou
ght a
bout
livi
ng in
the
coun
try, s
o th
at w
hen
she
has
mel
tdow
ns, a
nd I’
m y
ellin
g …
ha
lf th
e ci
ty b
lock
doe
sn’t
hear
it”
Feel
ing
mis
unde
rsto
od3
5“W
ith th
e pa
rent
s w
ho d
on't
have
chi
ldre
n w
ith s
peci
al n
eeds
…it'
s di
fficu
lt on
a d
eepe
r lev
el fo
r pe
ople
to re
ally
und
erst
and”
“Som
e pe
ople
just
thin
k th
at th
ese
child
ren
can
be …
delib
erat
ely
diffi
cult
or c
halle
ngin
g …
.it's
very
up
setti
ng w
hen
I thi
nk p
eopl
e ju
st th
ink
he's
bein
g di
fficu
lt”
“peo
ple
say
‘It’s
just
her
teen
age
year
s’… th
ey d
on’t
real
ise
wha
t you
're g
oing
thro
ugh”
Pauc
ity o
f pro
gram
s fo
r par
ents
of
you
ng a
dole
scen
ts w
ith
autis
m
24
“I do
n’t t
hink
ther
e’s
a lo
t of s
uppo
rt to
hel
p pa
rent
s na
viga
te th
roug
h w
hat t
hey’
re e
xper
ienc
ing”
“o
ften
the
focu
s is
prim
arily
on
the
child
ren…
pro
babl
y le
ss fo
cus
on p
aren
ts”
“The
rela
tions
hip
betw
een
the
pare
nt a
nd c
hild
is in
terre
late
d [b
ut] m
any
prog
ram
s on
ly lo
ok a
t on
e an
d no
t bot
h”
12
Tabl
e 2
(con
t)
Cor
e id
eaC
omm
on th
emes
Impo
rtanc
eEx
ampl
es o
f illu
stra
tive
quot
esU
nwei
ghte
dW
eigh
ted
Know
ledg
e an
d pa
rent
ing
skill
s ac
quis
ition
Seek
ing
info
rmat
ion
on
pare
ntin
g a
youn
g ad
oles
cent
w
ith a
utis
m
914
“Som
etim
es w
hen
you’
re d
ealin
g w
ith a
n AS
D k
id …
you
don
’t kn
ow if
you
’re a
ctua
lly d
oing
th
e rig
ht th
ings
esp
ecia
lly if
the
kid
isn’
t beh
avin
g”
“To
help
edu
cate
and
sup
port
me
… to
then
hel
p su
ppor
t [m
y so
n]”
“See
how
oth
er p
eopl
e ar
e de
alin
g w
ith th
eir l
ittle
ASD
chi
ldre
n”
Und
erst
andi
ng d
evel
opm
enta
l ch
ange
s in
you
ng a
dole
scen
ts
with
aut
ism
34
“Und
erst
and
[her
] way
of t
hink
ing,
the
age
she’
s at
and
wha
t’s im
porta
nt to
her
” “T
here
’s a
lot o
f cha
nges
with
him
goi
ng in
to te
enag
e ye
ars.
I’ve
foun
d th
at h
e’s
beco
min
g m
ore
clos
ed a
bout
cer
tain
issu
es”
Bein
g be
tter p
repa
red
for
futu
re c
halle
nges
34
“It m
ight
hel
p m
e w
ith w
ays
to d
eal w
ith h
er if
she
… h
as a
n ou
tbur
st”
“You
look
at [
your
chi
ld] a
nd th
ink
‘Oh
my
God
, you
’re g
oing
out
into
the
big
bad
wor
ld
shor
tly’…
how
to h
ave
them
wel
l-adj
uste
d an
d co
ping
?”
To b
enefi
t my/
our y
oung
ad
oles
cent
with
au
tism
To li
nk in
with
oth
er
com
pone
nts
of th
e Sc
hool
C
onne
cted
ness
Pro
ject
45
“I w
as in
tere
sted
in w
hat [
my
son]
was
doi
ng b
ecau
se h
e do
esn’
t rea
lly s
ay m
uch”
“I
knew
it w
as a
foru
m to
hel
p us
to e
ngag
e th
e sc
hool
, and
the
com
mun
ity, a
nd h
ave
a lin
k w
ith th
em, w
hich
I re
ally
wan
ted”
To im
prov
e co
mm
unic
atio
n/
rela
tions
hip
23
“Be
in th
at s
ame
fram
e of
min
d”
“Lis
teni
ng is
… n
ot o
ne o
f my
stre
ngth
s”
Stre
ngth
en c
o-pa
rent
ing
To b
enefi
t the
oth
er p
aren
t2
4“I
wan
ted
to d
o it
for [
the
mot
her]
… I
thou
ght s
he’d
ben
efit m
ore
out o
f it”
“It
was
… a
way
to g
et [m
y hu
sban
d] in
for s
ome
pare
ntin
g tra
inin
g”
To h
elp
us to
par
ent t
oget
her
12
“I w
as re
ally
ple
ased
that
I co
uld
conv
ince
[the
fath
er] t
hat i
t was
impo
rtant
to c
ome
and
just
se
e w
hat i
t was
abo
ut -
to h
ave
that
oth
er p
ersp
ectiv
e. T
his
is a
noth
er w
ay o
f dea
ling
with
[s
ituat
ions
] … it
was
n’t j
ust m
e te
lling
him
”
Build
the
know
ledg
e ba
se
Assi
st w
ith re
sear
ch to
impr
ove
expe
rienc
e fo
r oth
er p
aren
ts o
f ad
oles
cent
s w
ith a
utis
m
44
“[It i
s pa
rt of
] ong
oing
rese
arch
that
mig
ht b
enefi
t oth
er p
eopl
e as
wel
l as
my
fam
ily”
“We
coul
d se
e th
e be
nefit
for o
ther
s …w
e do
n’t w
ant o
ther
par
ents
to h
ave
to g
o th
roug
h th
e sa
me
thin
g w
e di
d, w
e w
ant m
ore
info
rmat
ion
out t
here
and
mor
e su
ppor
t”
No
te. T
he u
nwei
ghte
d sc
ore
indi
cate
s th
e to
tal n
umbe
r of t
rans
crip
ts in
whi
ch th
e co
mm
on th
eme
appe
ared
. The
wei
ghte
d sc
ore
indi
cate
s th
e to
tal n
umbe
r of
inst
ance
s ac
ross
all
trans
crip
ts in
whi
ch e
ach
com
mon
them
e oc
curre
d.
13
Tabl
e 3
Do
ma
in 2
: Asp
ect
s o
f P
art
icip
ati
on
th
at
Pa
ren
ts E
xpe
rie
nce
d a
s H
elp
ful
Cor
e id
eaC
omm
on th
emes
Impo
rtanc
eEx
ampl
es o
f illu
stra
tive
quot
esU
nwei
ghte
dW
eigh
ted
Supp
ortiv
e an
d va
lidat
ing
Valid
ated
and
rein
forc
ed th
at
pare
nts
are
alre
ady
doin
g a
good
job
1171
“It’s
a ve
ry s
treng
ths-
base
d pr
ogra
m -
look
s at
the
stre
ngth
s of
the
pare
nts”
“T
hat f
eedb
ack
of b
eing
a g
ood
pare
nt, a
nd th
at I’
m d
oing
the
right
thin
g by
my
kids
. No
one
ever
tells
me
that
so
that
was
wor
th g
old
to m
e”
“It re
min
ded
me
that
I’m
doi
ng a
goo
d jo
b”
Ackn
owle
dged
the
chal
leng
es
of p
aren
ting
youn
g ad
oles
cent
s w
ith a
utis
m
22
“I gu
ess
I'm c
omfo
rted
that
oth
er p
aren
ts a
re g
oing
thro
ugh
… th
e sa
me
stuff
” “It
pro
babl
y ru
ns o
n a
diffe
rent
thre
ad to
how
oth
er p
aren
ting
prog
ram
s ru
n, a
nd
ackn
owle
dges
, pro
babl
y, th
e di
fficu
lty o
f thi
s pa
rticu
lar g
roup
of k
ids”
Posi
tive
expe
rienc
ePe
rcei
ved
as g
ood
and
help
ful
for t
he p
aren
t the
mse
lves
1252
“It w
as re
ally
hel
pful
” “T
he p
rogr
am w
as re
ally,
real
ly g
ood,
I ac
tual
ly g
ot h
uge
amou
nts
out o
f it”
“I
lear
ned
a lo
t”
Enjo
yabl
e11
26“I
enjo
yed
it”
“I lo
ved
ever
ythi
ng a
bout
the
prog
ram
” “T
here
wer
e so
me
funn
y m
omen
ts th
at w
ere
shar
ed”
“I re
ally
look
ed fo
rwar
d to
goi
ng”
Hel
pful
for o
ther
par
ents
33
“Hel
ping
oth
ers
in a
gro
up li
ke th
at b
ecau
se y
ou c
an s
hare
you
r ide
as”
“We
coul
d se
e th
e be
nefit
for o
ther
s”
Con
nect
edne
ss
with
oth
er
pare
nts
Felt
unde
rsto
od a
nd n
o lo
nger
fe
lt al
one
1332
“I w
asn’
t the
onl
y pa
rent
in th
at b
oat…
ther
e w
ere
othe
r par
ents
[who
] had
kid
s in
sim
ilar
situ
atio
ns…
so
it w
as c
onne
ctin
g… s
eein
g ot
her p
eopl
e ar
e st
rugg
ling…
you
nev
er m
eet t
hose
pe
ople
, nev
er h
ear a
bout
them
, so
mee
ting
them
was
gre
at”
“It a
llow
ed u
s to
sha
re e
xper
ienc
es th
at m
ade
us fe
el le
ss is
olat
ed”
Oth
er p
aren
ts’ s
torie
s he
lped
m
e to
real
ise
that
we
are
copi
ng b
ette
r tha
n so
me
45
“Tim
es w
here
oth
er p
aren
ts w
ere
talk
ing
abou
t [pa
rent
ing
chal
leng
es]…
. I s
ort o
f wen
t ‘W
e’ve
be
en th
ere,
we’
re a
ctua
lly in
a b
ette
r pla
ce th
an w
e w
ere’
” “H
earin
g w
hat o
ther
peo
ple
are
goin
g th
roug
h - i
t’s g
ood
to g
o [m
y lif
e is
] not
that
bad
”
14
Tabl
e 3
(con
t)
Cor
e id
eaC
omm
on th
emes
Impo
rtanc
eEx
ampl
es o
f illu
stra
tive
quot
esU
nwei
ghte
dW
eigh
ted
Use
ful
Info
rmat
ive
719
“It w
as v
ery
usef
ul”
“The
con
tent
was
goo
d an
d ve
ry in
form
ativ
e an
d ve
ry s
uppo
rtive
”
Wou
ld re
com
men
d it
to o
ther
pa
rent
s12
18“I
wou
ld h
ighl
y re
com
men
d th
ey d
o it…
it is
suc
h a
posi
tive
thin
g an
d yo
u le
arn
so m
uch
abou
t you
rsel
f and
the
way
you
par
ent.
It fa
r exc
eede
d m
y ex
pect
atio
ns”
“I’ve
alre
ady
told
ano
ther
par
ent a
bout
it”
Pick
ed u
p tip
s fro
m o
ther
pa
rent
s8
16“T
hey
talk
ed a
bout
this
inde
pend
ence
with
atta
chm
ent.
One
of t
he la
dies
talk
ed a
bout
her
so
n go
ing
on th
e bu
s - t
hey’
d do
ne th
e dr
y ru
n on
the
bus.
I sh
ould
pro
babl
y be
doi
ng a
bi
t mor
e of
that
sor
t of s
tuff
with
[my
son]
to tr
y an
d fin
d op
portu
nitie
s fo
r him
to g
et th
at
inde
pend
ence
” “L
earn
ed a
lmos
t mor
e fro
m th
e ot
her p
aren
ts -
how
they
app
roac
hed
som
ethi
ng”
“Hea
ring
thei
r sto
ries,
the
way
they
wor
ked
thro
ugh
thin
gs, t
he w
ay th
ey c
oped
”
Prov
ided
pra
ctic
al to
ols/
stra
tegi
es8
15“G
ave
us te
chni
ques
of t
hing
s th
at w
e co
uld
try th
at w
e ha
dn’t
thou
ght o
f, or
oth
er w
ays
arou
nd s
ome
of th
e is
sues
that
may
cro
p up
” “T
he th
ing
I mos
t too
k aw
ay w
as a
ll ab
out t
he c
alm
par
entin
g - t
hat i
s ve
ry h
ard
to d
o fo
r any
pa
rent
but
par
ticul
arly
for a
par
ent w
ith a
chi
ld o
n th
e sp
ectru
m”
Inte
grat
ed im
porta
nt id
eas
34
“I th
ough
t it w
as w
ell s
truct
ured
… m
ost o
f it c
over
ed d
iffer
ent s
tuff
that
had
com
e up
ove
r th
e ye
ars…
[and
it]b
roug
ht it
all
toge
ther
… [i
n a]
stru
ctur
e th
at…
follo
wed
…lo
gica
lly fr
om o
ne
wee
k to
the
next
”
Link
ed th
e pa
rent
ing
prog
ram
w
ith th
e ad
oles
cent
pro
gram
22
“The
y ex
plai
ned
wha
t [he
] wou
ld b
e do
ing
and
show
ed u
s a
Pow
erPo
int a
bout
som
e of
the
sess
ions
that
he
was
hav
ing”
“H
avin
g do
ne [r
isky
or r
esou
rcef
ul th
inki
ng] a
t the
par
ent t
hing
, I w
as th
en a
ble
to im
plem
ent
that
at h
ome
[with
my
child
]”
Take
-hom
e w
orkb
ook
22
“[The
faci
litat
or] s
aid
she
keep
s he
r RAP
wor
kboo
k, a
nd w
hen
she’
s no
t hav
ing
such
a g
reat
tim
e, s
he ju
st fl
icks
thro
ugh
it an
d it’
ll re
min
d he
r …I a
ctua
lly th
ink
that
’s a
good
idea
… th
ere
are
som
e gr
eat t
hing
s ab
out m
y ki
ds in
her
e”
Stre
ngth
ened
par
entin
g bo
nd
betw
een
sepa
rate
d pa
rent
s1
2“H
elpe
d us
… to
real
ise
… th
at w
e’re
bot
h on
the
sam
e pa
th …
no
mat
ter w
hat’s
hap
pene
d be
twee
n us
… w
hen
it co
mes
to th
e ki
ds …
we’
re a
gree
able
on
thin
gs”
15
Tabl
e 3
(con
t)
Cor
e id
eaC
omm
on th
emes
Impo
rtanc
eEx
ampl
es o
f illu
stra
tive
quot
esU
nwei
ghte
dW
eigh
ted
Atm
osph
ere
Prov
ided
an
oppo
rtuni
ty a
nd
spac
e in
whi
ch to
refle
ct8
16“It
giv
es y
ou s
ome
room
to th
ink
abou
t how
to d
o th
ings
, and
how
you
sho
uld
be d
oing
th
ings
bas
ed o
n ex
perie
nce
… h
ow to
app
roac
h th
ings
” It
was
kin
d of
a fo
rced
refle
ctio
n fo
r me
whi
ch is
a g
ood
thin
g be
caus
e I t
hink
that
I’ve
got
so
muc
h on
”
Prov
ided
a s
afe
and
wel
com
ing
spac
e8
11“It
was
a s
mal
l gro
up…
you
cou
ld li
tera
lly re
late
to p
eopl
e th
at w
ere
answ
erin
g, a
nd …
it be
cam
e a
bit m
ore
pers
onal
” “It
’s a
rela
xed
prog
ram
” “[T
he fa
cilit
ator
s] d
id a
goo
d jo
b of
mak
ing
us fe
el c
omfo
rtabl
e”
Felt
com
forta
ble
shar
ing
pare
ntin
g ex
perie
nces
69
“Eve
ryon
e w
as v
ery
open
abo
ut th
eir r
elat
ions
hip
with
thei
r chi
ldre
n an
d th
e da
ily s
tress
es
they
go
thro
ugh”
“It
was
n’t u
ncom
forta
ble
at a
ll to
be
mak
ing
com
men
ts”
“It p
rovi
ded
a sp
ace
that
was
sup
porti
ve a
nd n
on-ju
dgm
enta
l”
Wel
l fac
ilita
ted
grou
p7
8“[T
he fa
cilit
ator
s] w
ere
real
ly v
ery
open
. The
y w
ould
talk
abo
ut th
eir c
hild
ren
freel
y. Th
ey’d
ju
st b
ounc
e id
eas
off e
ach
othe
r”
“It w
as ru
n sm
ooth
ly a
nd p
rofe
ssio
nally
”
Stre
ngth
s-ba
sed
Hig
hlig
hted
stre
ngth
s of
you
ng
adol
esce
nts
with
aut
ism
57
“It’s
a ve
ry s
treng
ths-
base
d pr
ogra
m…
it re
ally
look
s at
the
stre
ngth
s of
the
kids
” “O
ur c
hild
ren
are
abso
lute
ly a
maz
ing,
and
they
can
do
real
ly fu
nny
thin
gs th
at m
ake
you
laug
h - i
t was
als
o go
od to
look
at o
ur p
ositi
ve fe
elin
g ab
out o
ur k
ids”
Hig
hlig
hted
par
ents
’ stre
ngth
s as
par
ents
45
“I ne
ed to
, as
a pa
rent
, rem
embe
r tha
t I’m
impo
rtant
too
and
my
stre
ngth
s as
a p
aren
t are
im
porta
nt a
s w
ell”
Acce
ssib
leSh
ort d
urat
ion
33
“Wha
t I li
ked
was
the
shor
tnes
s of
it. I
t was
n't f
orev
er”
Reca
ps c
ater
ed fo
r mis
sed
sess
ions
11
“I m
isse
d th
e se
cond
one
but
got
a re
cap
in th
e th
ird w
eek”
No
te. T
he u
nwei
ghte
d sc
ore
indi
cate
s th
e to
tal n
umbe
r of t
rans
crip
ts in
whi
ch th
e co
mm
on th
eme
appe
ared
. The
wei
ghte
d sc
ore
indi
cate
s th
e to
tal n
umbe
r of
inst
ance
s ac
ross
all
trans
crip
ts in
whi
ch e
ach
com
mon
them
e oc
curre
d.
16
Tabl
e 4
Do
ma
in 3
: Pa
ren
ts’ E
xpe
rie
nce
of
Ch
an
ge
s in
Pa
ren
tin
g S
tyle
an
d t
he
Pa
ren
t-A
do
lesc
en
t R
ela
tio
nsh
ip
Cor
e id
eaC
omm
on th
emes
Impo
rtanc
eEx
ampl
es o
f illu
stra
tive
quot
esU
nwei
ghte
dW
eigh
ted
Incr
ease
d pa
rent
-ad
oles
cent
co
nnec
tedn
ess
Impl
emen
ting
stra
tegi
es
lear
ned
toge
ther
46
“I sa
id, ‘
Is th
at ri
sky
thin
king
, or p
ositi
ve th
inki
ng?’,
and
she
wen
t ‘Th
at’s
risky
thin
king
’ and
I w
ent ‘
Wha
t's a
bet
ter w
ay o
f thi
nkin
g th
is th
roug
h?’”
Clo
ser r
elat
ions
hip
bond
55
“It's
give
n us
a b
it m
ore
of a
bon
d …
[our
rela
tions
hip]
defi
nite
ly h
as b
een
impr
ovin
g”
Hig
hlig
htin
g po
sitiv
es3
4“I
cam
e ho
me
and
ever
ythi
ng w
as d
one
and
they
wer
e ca
lm a
nd I
mad
e a
huge
fuss
of
them
… h
e ki
nd o
f loo
ked
puffe
d up
with
prid
e - l
iftin
g hi
s sh
ould
ers
a lit
tle b
it, h
oldi
ng h
is
head
up
high
, he
smile
d. W
hen
I pra
ised
him
, he
was
ver
y ha
ppy
and
grat
eful
”
Youn
g ad
oles
cent
is m
ore
affec
tiona
te to
war
ds p
aren
t2
2“H
e’ll
com
e up
and
just
hav
e a
brie
f hug
” “H
e to
ld m
e he
love
s m
e”
Impr
oved
co
mm
unic
atio
nM
ore
min
dful
abo
ut
com
mun
icat
ion
styl
e3
6“T
o ap
proa
ch h
er li
ke I’
d lik
e to
be
appr
oach
ed if
I w
as in
her
sho
es”
“Giv
e [h
im] s
ome
valid
atio
n th
at [I
] did
list
en, a
nd th
at [I
] mig
ht d
o so
met
hing
abo
ut it
in th
e fu
ture
… [i
nste
ad o
f] ju
st g
oing
, ‘W
ell,
we’
re d
oing
it m
y w
ay’”
Che
ckin
g un
ders
tand
ing
12
“We’
ve fo
und
it ve
ry im
porta
nt to
ask
[him
] wha
t he
thin
ks”
“Lea
rnin
g [th
at] h
is v
iew
and
per
spec
tive
is c
ompl
etel
y di
ffere
nt to
our
s”
Men
ding
rupt
ures
12
“I sa
id to
her
‘I’m
real
ly s
orry
that
I ye
lled’
, and
I ex
plai
ned
why
, and
she
told
me
wha
t she
felt,
so
we
had
a re
ally
goo
d di
scus
sion
aro
und
that
”
Redu
ced
confl
ict
Few
er a
rgum
ents
23
“Bei
ng a
ble
to ju
st ta
lk s
ome
thin
gs th
roug
h w
ithou
t hav
ing
like
a bi
g ar
gum
ent”
Pick
ing
the
natu
re a
nd ti
min
g of
our
bat
tles
33
“I sa
y, ‘I'
m n
ot g
oing
to ta
lk to
you
whi
le y
ou're
like
this
- yo
u're
not
goi
ng to
list
en’"
“If s
he’s
not m
eltin
g, th
en w
e re
spon
d in
a m
uch
mor
e po
sitiv
e w
ay”
Mor
e ne
gotia
tion
22
“I sa
id ‘A
ll rig
ht, y
ou c
an g
o to
bed
unt
il 10
:00.
I'm
goi
ng to
ring
you
, and
you
're g
oing
to g
et
up a
nd h
ave
a sh
ower
and
I'll
com
e ho
me
and
get y
ou a
nd ta
ke y
ou to
sch
ool’"
Und
erst
andi
ng n
eed
for
priv
acy
of y
oung
ado
lesc
ent
with
aut
ism
12
“[Sh
e sa
id] ‘
Ever
yone
wal
ks in
to th
e ba
thro
om w
hen
I’m th
ere’
and
I w
ent ‘
Wel
l, w
e w
ill
ende
avou
r to
knoc
k, o
k?’”
No
te. T
he u
nwei
ghte
d sc
ore
indi
cate
s th
e to
tal n
umbe
r of t
rans
crip
ts in
whi
ch th
e co
mm
on th
eme
appe
ared
. The
wei
ghte
d sc
ore
indi
cate
s th
e to
tal
num
ber o
f ins
tanc
es a
cros
s al
l tra
nscr
ipts
in w
hich
eac
h co
mm
on th
eme
occu
rred.
17
Tabl
e 5
Do
ma
in 4
: Pa
ren
ts’ E
xpe
rie
nce
of
Be
com
ing
Mo
re R
eso
urc
efu
l as
Pa
ren
ts a
s a
Re
sult
of
Pa
rtic
ipa
tin
g in
RA
P-P
-AS
D
Cor
e id
eaC
omm
on th
emes
Impo
rtanc
eEx
ampl
es o
f illu
stra
tive
quot
esU
nwei
ghte
dW
eigh
ted
Find
ing
pare
ntin
g ea
sier
Skill
s le
arne
d ar
e he
lpfu
l7
12“It
’s de
finite
ly h
elpe
d m
y pa
rent
ing
out a
littl
e bi
t”
“Hav
ing
a di
ffere
nt w
ay o
f thi
nkin
g ab
out c
onfli
ct -
you
don’
t fee
l lik
e yo
u’re
refe
reei
ng a
bo
mat
ch s
endi
ng e
very
one
to th
eir c
orne
rs u
ntil
they
cal
m d
own
agai
n”
“Fin
ding
sim
ple
way
s of
dea
ling
with
thin
gs -
it’s
so o
verw
helm
ing
for h
im”
“It’s
been
eas
ier t
o br
ing
her b
ack
dow
n w
hen
she’
s be
en a
ngry
”
Bein
g ca
lm m
akes
for e
ffect
ive
pare
ntin
g5
5“S
uper
cal
m p
aren
ting!
I try
to re
min
d …
to re
min
d m
ysel
f whe
n I f
eel m
ysel
f get
ting
angr
y to
ju
st ta
ke it
dow
n…yo
u ca
n’t p
aren
t pro
perly
unl
ess
calm
”
Mor
e in
sigh
tful
Bette
r abl
e to
con
side
r you
ng
adol
esce
nt’s
poin
t of v
iew
712
“Thi
nkin
g ab
out w
hat i
t's li
ke to
be
in m
y ch
ild's
shoe
s, w
hich
I te
nd to
forg
et. I
thin
k it'
ll he
lp
me
unde
rsta
nd h
im m
ore
… a
bout
how
the
wor
ld is
to h
im”
“I pr
obab
ly h
ave
a gr
eate
r app
reci
atio
n fo
r him
…try
ing
to fi
nd h
is p
lace
in th
is w
orld
and
fit i
n,
like
any
teen
ager
, is
diffi
cult”
Gre
ater
aw
aren
ess
of
alte
rnat
ive
met
hods
of
pare
ntin
g
23
“I w
as a
ble
to re
cogn
ise
thro
ugh
othe
rs w
hat I
sho
uldn
't be
doi
ng”
“It’s
mad
e us
mor
e aw
are
of b
uild
ing
conn
ectio
ns w
ith te
enag
ers”
Gre
ater
sel
f-aw
aren
ess
22
“I th
ink
my
expe
ctat
ions
tend
to b
e a
little
hig
h …
that
he
can
chan
ge h
is b
ehav
iour
…I w
ant t
o ch
ange
min
e an
d I'm
not
on
the
spec
trum
, and
yet
I fin
d it
chal
leng
ing
to c
hang
e”
Impr
oved
stre
ss
man
agem
ent
Mor
e pr
oact
ive
abou
t de-
esca
latin
g si
tuat
ions
58
“If I
notic
e th
at s
he's
getti
ng re
ally
anx
ious
and
stre
ssed
, I ju
st g
o, ‘Y
ou n
eed
to g
o an
d ta
ke
som
e br
eath
ing,
cal
m y
ours
elf d
own
and
then
we'
ll ta
lk a
bout
stu
ff’"
“Try
ing
to k
eep
mys
elf i
n lin
e fir
st b
efor
e I t
ry to
app
roac
h th
ings
”
Mak
ing
time
for s
elf-c
are
27
“Tak
ing
som
e tim
e ou
t for
me
so th
at I
can
cope
with
stre
ss b
ette
r”
“I’ve
org
aniz
ed a
cou
ple
of s
leep
over
s fo
r the
kid
s so
that
my
husb
and
and
I cou
ld h
ave
time
on o
ur o
wn”
Mor
e co
mpa
ssio
nate
tow
ards
m
ysel
f5
5“I’
ve b
ecom
e a
lot l
ess
hars
h on
mys
elf”
“F
or m
e, th
e ha
rdes
t par
t of t
he w
hole
cou
rse
was
lear
ning
sel
f-app
reci
atio
n”
18
Tabl
e 5
(con
t)
Cor
e id
eaC
omm
on th
emes
Impo
rtanc
eEx
ampl
es o
f illu
stra
tive
quot
esU
nwei
ghte
dW
eigh
ted
Und
erst
andi
ng
the
impo
rtanc
e of
in
depe
nden
ce
whi
le
mai
ntai
ning
pa
rent
-ad
oles
cent
re
latio
nshi
p bo
nd
Plan
ning
for i
ndep
ende
nce
whi
le m
aint
aini
ng p
aren
t-ad
oles
cent
rela
tions
hip
bond
23
“The
y’ve
act
ually
invi
ted
him
to g
o aw
ay fo
r a n
ight
with
them
…an
d ra
ther
than
put
him
in
that
pos
ition
whe
re h
e ha
s to
sho
w h
is fr
iend
s th
at h
e ju
st c
an’t
cope
[with
bei
ng a
way
ov
erni
ght],
we
just
… c
an p
ick
him
up”
Fost
erin
g in
depe
nden
ce w
hile
m
aint
aini
ng p
aren
t-ado
lesc
ent
rela
tions
hip
bond
23
“I th
ink
unde
rsta
ndin
g hi
s in
depe
nden
ce, b
ut a
lso
depe
nden
ce…
I had
n't r
eally
thou
ght a
bout
th
at to
o m
uch…
kids
wan
ting
mor
e in
depe
nden
ce, b
ut s
till w
antin
g to
be
a pa
rt of
the
fam
ily”
Feel
ing
mor
e su
ppor
ted
Con
nect
edne
ss w
ith o
ther
pa
rent
s2
3“I
said
to [a
noth
er p
aren
t], ‘L
et's
get e
ach
othe
r's n
umbe
rs a
nd tr
y an
d st
ay in
touc
h… w
e've
go
t som
ethi
ng in
com
mon
… th
e co
nnec
tedn
ess
and
the
unde
rsta
ndin
g th
at c
omes
thro
ugh
shar
ed e
xper
ienc
e…it
mig
ht b
e ni
ce fo
r the
kid
s to
mee
t as
wel
l’”
Incr
ease
d co
nfide
nce
in
pare
ntin
g ab
ility
Reco
gnis
ing
wha
t I d
o w
ell a
s a
pare
nt2
2“I
thin
k I'v
e go
t mor
e to
lera
nce
and
patie
nce
with
the
kids
bec
ause
I fe
el b
ette
r and
mor
e co
nfide
nt a
bout
wha
t I'm
doi
ng is
the
right
thin
g”
No
te.
The
unw
eigh
ted
scor
e in
dica
tes
the
tota
l num
ber o
f tra
nscr
ipts
in w
hich
the
com
mon
them
e ap
pear
ed. T
he w
eigh
ted
scor
e in
dica
tes
the
tota
l num
ber o
f in
stan
ces
acro
ss a
ll tra
nscr
ipts
in w
hich
eac
h co
mm
on th
eme
occu
rred.
19
While not presented in the tables, the three remaining domains included parents’ experience of change in their young adolescent with autism as a result of participating in the program, aspects of participation that parents experienced as challenging, and additional components that parents would like added to the RAP-P-ASD program. When reflecting on changes they had noticed in their young adolescents with autism as a result of their participation in the program, parents most frequently identified improvements in their adolescents’ emotion regulation, communication, and connectedness with family members. Regarding aspects of participation that parents experienced as challenging, two parents (13%) raised the preventative rather than treatment focus of RAP-P-ASD, and five parents (38%) said that childcare difficulties and being time-poor and over-committed got in their way of attending all four workshops. Concerning additional components for future versions of RAP-P-ASD, two parents (13%) requested ongoing support in the form of follow-up workshops that revised and reinforced program content, and child care for parents attending the face-to-face workshops
Discussion
Analysis using a CQR approach of the qualitative data gathered in one-on-one interviews with parents supports the expected impact of improved parent self-efficacy, affect regulation and mental wellbeing (Merry et al., 2004; Pineda & Dadds, 2013; Shochet et al., 2001; Shochet & Ham, 2004), and aligns with the important parent-child factors that have been found to buffer adolescents from depression. Highlights for parents of participating in RAP-P-ASD were that it diminished their sense of isolation and validated their parenting difficulties; boosted their self-efficacy by affirming their existing strengths, and increasing their confidence for adopting a non-reactive and calm parenting style; augmented their affect regulation by improving their stress management; increased their empathy for their young adolescent and enhanced parent-adolescent communication and connectedness; increased their understanding of a more optimal manner in which to assist their child with autism to navigate the developmental phase of early adolescence; and boosted their own wellbeing because they were able to manage the conflict in the family system in a more proactive and constructive manner.
Concerning the protective factors of parent self-efficacy and parent affect regulation, a primary motivation of parents for participating in RAP-P-ASD was to obtain much-needed emotional support because they (80%) were experiencing parenting a young adolescent with autism as isolating (e.g., “having a kid on the spectrum can be a lonely place to be a lot of the time”), challenging (e.g., “we find it hard to feel that we’re doing anything well”), and overwhelming (e.g., “negotiating with him is impossible because he doesn’t care about anything”). The experience of the parents in our study is congruent with reported experience in other studies of parents of children with autism where themes that emerged included parents feeling overwhelmed or stressed and in need of emotional support (Derguy et al., 2015; Divan et al., 2012; Gray, 2001; Kogan et al., 2008; Pottie & Ingram, 2008; Siklos & Kerns, 2006; Zablotsky et al., 2013), isolated (Derguy et al., 2015; Divan et al., 2012), and/or seeking parenting skills and knowledge about parenting a child with autism (Derguy et al., 2015; Divan et al., 2012), and highlights the importance of supporting parents’ self-efficacy, affect regulation, and mental wellbeing. Another motivation for participating in RAP-P-ASD that was endorsed by parents (60%) was to acquire knowledge and parenting skills that would enhance their parenting of their young adolescents with autism (e.g., “to help educate and support me … to then help support [my son]”). In keeping with the non-blaming, supportive and validating focus of RAP-P-ASD that strives to augment parents’ existing strengths and boost their self-efficacy, the majority of parents (73%) valued the supportive and validating manner in which the program conveyed an
20
understanding of their difficulties and reinforced that they were already doing a good job (e.g., “that feedback of being a good parent, and that I’m doing the right thing by my kids - no one ever tells me that so that was worth gold to me”). Parents (87%) concluded that attendance had been useful in that they had acquired information, practical tools and strategies that made them feel more equipped to parent their young adolescents with autism (e.g., “gave us techniques of things that we could try that we hadn’t thought of, or other ways around some of the issues that may crop up”). All parents (100%) reflected that participation was a positive, helpful and enjoyable experience (e.g., “the program was really, really good, I actually got huge amounts out of it”), that they (67%) were finding parenting easier (e.g., “finding simple ways of dealing with things… it’s definitely helped my parenting out a little bit”) and attributed these changes to adjustments they had made to their parenting style (33%) (e.g., “super calm parenting! I try to remind … to remind myself when I feel myself getting angry to just take it down…you can’t parent properly unless calm”), and managing their stress in a more proactive and constructive manner (47%) (e.g., “taking some time out for me so that I can cope with stress better”). The majority of parents (87%) appreciated the sense of connectedness with other parents of young adolescents with autism that the program fostered (e.g., “it allowed us to share experiences that made us feel less isolated”), and said that they would recommend the program to other parents (80%) (e.g., “I would highly recommend they do it… it is such a positive thing and you learn so much about yourself and the way you parent. It far exceeded my expectations”). Anecdotal information gathered from the parents who participated in this study reinforced that, in-line with previous research (e.g., Weis et al., 2012, 2016), these parents faced additional difficulties which may have diminished their affect regulation and their perceived self-efficacy as parents. Difficulties that parents reported included parenting more than one child with autism, financial difficulties, and social problems such a marital distress. Congruent with research suggesting that parents of children with autism may themselves have the BAP or sub-threshold characteristics of autism (Losh et al., 2008), some parents disclosed that they (or their partner) had their own diagnosis of autism or thought that they (or their partner) had a number of traits similar to the core features of autism. Parents with autism or traits of autism provided examples of times when they had struggled to support their young adolescent with autism to overcome difficulties that they themselves had encountered, including forming and sustaining friendships, regulating their emotions, and coping with change. The reduction in parenting isolation and anxiety about parenting self-efficacy as a result of participating in RAP-P-ASD was particularly valued by parents, and they took proactive steps to remain in contact with other RAP-P-ASD participants and voiced a desire for ongoing support. This suggests the need for a greater emphasis on providing ongoing emotional and practical support for parents of adolescents with autism, and it is acknowledged that a group program such as RAP-P-ASD can only address a small part of that ongoing need.
Regarding the protective factor of parental expressions of caring and warmth, a significant majority (53%) commented that their insight about their young adolescent and their parenting had increased (e.g., “I probably have a greater appreciation for him…trying to find his place in this world and fit in, like any teenager, is difficult”). Some parents (33%) remarked on favourable outcomes that resulted from them highlighting their young adolescents’ strengths (e.g., “our children are absolutely amazing and they can do really funny things that make you laugh - it was also good to look at our positive feeling about our kids”), while others (20%) noticed significant gains from praising desirable behaviour (e.g., “I came home and everything was done and they were calm and I made a huge fuss of them… he kind of looked puffed up with pride - lifting his shoulders a little bit, holding his head up high, he smiled. When I praised him, he was very happy and grateful”). There is extensive research to support the value of parental expressions of positive regard towards their adolescent (Yap et al., 2014), and expressions of parental warmth and close parent-child relationships have been
21
associated with improved outcomes for adolescents with autism (Woodman et al., 2015). These findings are therefore encouraging, although the long term sustainability outside of the immediate program effects are still to be determined. It may well be that parents under stress may not maintain the awareness of expressing a positive regard.
With respect to the protective factor and RAP-P-ASD aim of reduced parent-adolescent conflict, parents (33%) commented that their communication with their young adolescents with autism had improved (e.g., “learning [that] his view and perspective is completely different to ours”). They added that they (33%) had become more proactive about de-escalating potentially volatile situations (e.g., “if I notice that she’s getting really anxious and stressed, I just go, ‘you need to go and take some breathing, calm yourself down and then we’ll talk about stuff’”). A significant majority (53%) remarked that conflict in the family system had diminished (e.g., “being able to just talk some things through without having like a big argument”). Given the increased risk of conflict between parents and their adolescents with autism (Orsmond et al., 2006), these parent reports of de-escalation of conflict are encouraging. However, it is important to note that this was not the most highly endorsed benefit, with more research required to ascertain whether this finding reflects that a number of families did not experience conflict management as needed, or whether conflict management was unsuccessful. Relating to an aim of RAP-P-ASD to strengthen the adolescent-parent relationship bond, parents (53%) noticed that after participating in RAP-P-ASD they experienced a greater sense of connectedness with their adolescent through jointly implementing strategies learned in the program and feeling a closer mutual bond (e.g., “it’s given us a bit more of a bond … [our relationship] definitely has been improving”). They also remarked that they had been experiencing their adolescent as more affectionate towards them (e.g., “he told me he loves me”). These findings are consistent with those of Smith et al. (2008) who demonstrated in a large longitudinal study the importance of a positive family environment for improved developmental and behavioural functioning of adolescents with autism.
Although the protective factor of fostering parents’ ability to support their adolescents to develop increasing autonomy while maintaining close parental relationships was a component of the program, parents did not rate this component as frequently as might have been expected. Two parents (13%) reported an increased understanding of the importance of independence while maintaining the parent-adolescent relationship (e.g., “I think understanding his independence, but also dependence…I hadn’t really thought about that too much…kids wanting more independence, but still wanting to be a part of the family”), and two parents (13%) reported planning to assist their young adolescent to develop greater independence (e.g., “they’ve actually invited him to go away for a night with them …and rather than put him in that position where he has to show his friends that he just can’t cope [with being away overnight], we just … can pick him up”).
Strengths and Limitations
This qualitative study yielded valuable information about the experiences of parents who participated in the first manualised mental health promotion initiative developed for young adolescents with autism and their parents. Parents’ feedback about their experience of participating in RAP-P-ASD provided useful insights that mirrored findings from prior research and reinforced the need for interventions that provide support for parents of young adolescents with autism. The intervention appears to have ecological validity, is unique in that it adopts a focus that builds on participants’ existing strengths, and consistent with feedback from the multitude of parents who have participated in RAP over the past two decades (e.g., Merry et al., 2004; Pineda & Dadds, 2013; Shochet et al., 2001; Shochet & Ham, 2004), parents who participated in RAP-P-ASD experienced
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the program as improving their self-efficacy and mental wellbeing, and strengthening the parent-adolescent relationship. Importantly, findings highlighted a need for ongoing support for parents of young adolescents with autism that is currently unmet by existing services.
As this was a small scale, exploratory qualitative study, findings should be considered as an insight into the experiences of a sample of parents of young adolescents with autism in urban Australia. Generalisability to young adolescents with autism and their parents overall is reduced by the study’s modest sample size (N = 15), its relative homogeneity, and twice as many female than male parents participating which may have been influenced by scheduling of RAP-P-ASD workshops and parents’ difficulties arranging child care. Also, it must be acknowledged that individual biases of the CQR team members may have influenced the outcome of the domains, core ideas, and common themes extracted in the CQR analysis. Furthermore, the final domains, core ideas and common themes were not checked by the parent participants so it is not known whether they agreed with the analysis. Importantly, the long term sustainability of gains outside of the immediate program effects are still to be determined. While parents of young adolescents with autism are desperate for support that is unmet by existing services, and valued participating in RAP-P-ASD and reported realising positive outcomes, the heightened and enduring challenges that many parents of adolescents with autism experience may diminish treatment gains over time, as suggested by parents’ requests for additional and ongoing emotional and practical support.
Future Research
The experience of parents who participated in this multilayered intervention reinforces previous research that reported that parents of young adolescents with autism are desperate for parenting resources and support (Hartley & Schultz, 2015; Siklos & Kerns, 2006). The encouraging qualitative findings from this proof-of-concept trial endorse that parents valued engaging in a parenting intervention added to an evidence-based, strength-focused resilience intervention designed to promote wellbeing and mental health in young adolescents with autism, and justify a RCT with a larger sample of parents and adolescents to examine the effectiveness of the multilayered RAP intervention in which parents and their young adolescents with autism receive RAP-P-ASD and RAP-A-ASD. The resounding endorsement from parents of their sense of connectedness with other parents afforded by attending the RAP-P-ASD workshops (87%) suggests that the face-to-face model offers the optimal delivery option, hence future research should continue to offer the workshops and trial the addition of reinforcing adjunct material to sustain parents’ sense of connectedness after the conclusion of the workshops.
To cater for parents who are unable to attend the face-to-face RAP-P-ASD workshops (because of constraints such as living remotely, being time-poor, or having scheduling difficulties) or who require ongoing revision and reinforcement support in addition to the four RAP-P-ASD workshops, there is value in exploring the development of a hybrid model of RAP-P-ASD that uses communication technology to deliver the program content online, augments it with digital resources and telephone and/or online chat support, and could be accessed worldwide by English-speaking parents of young adolescents with autism. Such a hybrid would extend the reach of RAP-P-ASD to a wider, more ethnically, culturally and racially diverse population, including those living in rural and remote communities, and internationally, and might also help to lessen the sense of isolation experienced by many parents of young adolescents with autism. The authors of the manuscript are currently building a website to engage parents and caregivers on the core components of the RAP-P-ASD program. While a digital program cannot replicate face-to-face experience, there is sound evidence in e-health research that shows the effectiveness of psychosocial interventions delivered through
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technology (see Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014 for review).
Conclusions
The current study explored the value of adding a strength-focused parenting intervention to an evidence-based depression-prevention intervention for young adolescents with autism, within a broader project to promote wellbeing and mental health in young adolescents with autism (the Adolescent Wellbeing Project). Qualitative findings offer a valuable insight into the experience of parenting a young adolescent with autism, and reinforce that, congruent with the literature, parents who participated in the Resourceful Adolescent Program for Parents adapted for parents of young adolescents with autism (RAP-P-ASD) were seeking emotional and knowledge-based parenting support that is currently unmet by existing parenting services. As a first trial, RAP-P-ASD has good promise as evidenced by parent reports that participation diminished their sense of isolation, validated their parenting difficulties, boosted their self-efficacy, increased their empathy for their young adolescent and enhanced parent-adolescent communication and connectedness, increased their understanding of a more optimal manner in which to assist their child with autism to navigate the developmental phase of early adolescence, and boosted their own wellbeing.
To capitalise on the vital protective factors that parents provide for their young adolescents with autism, there is a need for multilayered interventions that harness parents’ strengths and diminish the risk factors associated with the challenges of parenting while promoting parent and adolescent wellbeing and mental health. The findings of this qualitative study provide support for the next step in this initiative: adding adjunct material to the face-to-face RAP-P-ASD model to increase the potential for ongoing reinforcement of content delivered in the RAP-P-ASD workshops, extending the reach of the program by developing a hybrid model of RAP-P-ASD that uses communication technology to deliver program content online and augments it with digital resources and telephone and/or online chat support, and conducting a RCT to examine the effectiveness of the program.
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Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institution and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed Consent
Informed consent was obtained from all participants included in the study.
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