The study explored whether occupation-based coaching, or OBC, could work effectively with school-age autistic children and their primary caregivers in a telehealth format. The study utilised the structure recommended by Dunn and Rush and Sheldon in earlier publications to do the occupational based coaching. So, they did not use the occupational performance coaching structure that was used in the articles I discussed last week. Whilst there are a lot of similarities between the approaches, as far as I am aware, OBC does not have a fidelity measure like OPC. OBC is embedded in the Ecology of Human Performance Model and principles of Early Childhood coaching. What makes this study particularly innovative is that it’s the first to apply this approach to both autistic children and their caregivers together via telehealth.

The researchers had three specific research questions: 

• First, what is the feasibility of completing OBC with autistic children and a primary caregiver? 
• The second goal was, what is the acceptability of telehealth OBC according to caregiver participants? 
• And third, what is the preliminary effect of telehealth OBC on child activity performance and participation, caregiver competence, and family quality of life?

Methods

The team used a single-group, pretest-posttest design. For feasibility, they tracked recruitment rates, retention rates, measure completion rates, and intervention adherence. They also measured intervention acceptability using the Telehealth Acceptability Questionnaire. To measure impact of the intervention for the child and family, they used a comprehensive battery including the Canadian Occupational Performance Measure, Goal Attainment Scaling, PROMIS Pediatric Sleep Measures, the Child and Adolescent Scale of Participation, the Parenting Sense of Competence Scale, and the Beach Centre Family Quality of Life Scale.

The intervention was based on the Ecology of Human Performance Model and principles of Early Childhood Coaching. During sessions, the therapists asked reflective questions about goal activities, past performance, and strategies the child or caregiver could use to make progress. Participants completed eight weekly 60-minute OBC sessions via Zoom over approximately 8 weeks.  Between sessions, families tried out these strategies at home. Caregivers participated in all sessions, whilst children participated at the caregiver’s discretion.

Participants

Ultimately, 12 caregivers and 13 children completed the intervention. The average child age was 9.2 years, and there were 9 males and 4 females. Five of the children had a diagnosis of autism spectrum disorder alone, whilst the remainder had co-occurring ADHD or anxiety. The caregivers were predominantly mothers with undergraduate or graduate degrees.

The Results

Feasibility Outcomes

• The study recruitment rate was 56.7%, with a retention rate of 76.5%. 
• Caregivers completed 97.7% of measures, well above the 90% benchmark.
• Children completed only 25% of measures, falling short of the 75% benchmark.
• Intervention adherence was excellent at 97.5%. 
• Most families completed all eight sessions, with two families finishing after seven sessions because they’d met their goals. Twelve of the 13 children participated in OBC sessions. 
• Intervention acceptability was high. Average ratings on the Telehealth Acceptability Questionnaire were 1.15 for telehealth items and 1.41 for OBC items (1 = “strongly agree,”.

Child and Family Outcomes

• Following intervention, the average increase in COPM performance and satisfaction was about 3 points. 
• The GAS scores indicate children had made some progress towards their goals
• Statistical analysis indicated the intervention showed large effect sizes on child performance on individual goals when measured on the COPM and GAS scores.
• There was limited change on the standardised measures, apart from a moderate effect on child sleep disturbance, which had a medium effect size 
• Small effects were found for child participation and family quality of life.
• We need to remember the sample size was small when reading this data.

Practical Takeaways

The outcomes of the feasibility study are promising, but we’ll need that larger, controlled study before drawing firm conclusions about OBC’s effectiveness for this population.

• This study supports the use of the online coaching model, like both articles I presented in episode three. 
• Families found it acceptable, manageable and valuable, particularly given the convenience of not travelling to appointments. 
• The occupational based coaching model supported these families to make some progress with their children’s goals after seven – eight sessions. 
• Although invited to attend, children often didn’t join the sessions, further research could investigate the reasons for this.
• The outcomes of the feasibility study are promising, but we’ll need that larger, controlled study before drawing firm conclusions about OBC’s effectiveness for this population.

The authors looked at how frequently family accommodations occurred and their impact on the child and family’s well-being. An additional element of their research was examining the role of parental distress tolerance in this dynamic.

As an aside, if you are doing any research or have an interest in autism and sensory over-responsiveness there are a lot of relevant references for you in the introduction to studies exploring the functional implications of sensory sensitivities.

Before we go any further, I’ll start with some definitions 

Family accommodation was considered as the ‘various changes families make, including making adjustments to a family’s activities and routines, actively participating in the symptoms or rituals characteristic of the disorder, providing assurance, and helping children to avoid related fears’.  This was measured using the Family Accommodations Scale for Sensory Over-Responsivity (FASENS). Whilst the scale is not in the article, it can be obtained by reaching out to the authors. It seems to be a research tool at this point, but there are some details in the supplementary table in an earlier article published in 2023, I’ve included the link to this in the show notes. This questions in the scale cover four areas

• Assistance in sensory avoidance in the past month
• Changes and modifications in family behaviours in the past month
• Emotional consequences to parent and family
• Functional and emotional consequences to the child

The current article grouped the scores into frequency, family impact and child impact categories.

Parental distress tolerance was defined as ‘a parent’s ability to persist with goal-orientated activities despite witnessing their child’s distress, especially during stressful tasks.’ This was measured using the Parenting Distress Tolerance Scale (P-DTS) 

Participants

This study explored the differences in and correlations between family accommodation and parental distress across three different groups of children:

• 48 typically developing children,
• 54 with sensory over-responsiveness (SOR),
• 57 autistic childre.

Children were aged 3-13 years and the study took place in Israel. Mothers completed the family accommodation and parental distress questionnaires.

The SS-P 2 was used to measure sensory over-responsiveness – with the authors using the sensitivity and avoiding subscales to indicate lower threshold to sensations. This was used to separate the typically developing and SOR groups. The autistic children needed to have a formal diagnosis and also be attending a specialist autism education setting. 

The total score on the Adapted SensOR Inventory was used in the statistical analysis to examine how sensory symptoms lead to family accommodation through parental distress tolerance.

Results

• Clinical groups (ASD: M = 24.84, SOR: M = 23.93) had significantly higher Total SOR scores than the TD group (M = 8.79)
• There were significant differences between the three groups on the three areas of the FASEN scale (frequency, family and child impact) and the TD group had lower scores
• Total SOR scores showed moderate to strong correlations with the FASEN scale – with higher total SOR scores aligning with increased family accommodation – suggesting that sensory symptom severity is a reliable predictor of family accommodation behaviours – but it is not the only factor driving these family dynamics.
• The amount of family accommodation was mediated by reduced parental distress tolerance. Essentially, when parents had a harder time managing their own stress in response to their child’s sensory challenges, they were more likely to accommodate.

Practical applications

Sensitivity to sensations increases child distress, and that likely prompts parents to accommodate more.  

More frequent accommodation may reinforce avoidance behaviours.  This raises questions for how we support families, as I know I am often asked about the best way to support the child, whether to encourage them to try and join in or not to. I think we need to exercise our clinical judgement with each individual child, but at the same time hold this piece of evidence in mind, as there are some cases where it could be really applicable.

Mother’s level of distress influenced family patterns. The authors suggest that part of our role to support families should extend to helping parents manage their own stress levels and overwhelm. I know in public health services we have very little time to do this, but it is definitely something we have more scope to do in private practice. I can see how this is really applicable to many of our families managing sensory sensitivities, as it’s so common that the parents also experience sensory differences, some which align with their child’s and some that do not and cause the parent a degree of distress.

Reference for the FASENS

Supplementary data table for this article: Ben-Sasson, A., Podoly, T. Y., & Lebowitz, E. (2022). Family Accommodation Scale for Sensory Over-Responsivity: A Measure Development Study. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.867508