135 Short-term outcomes and six-month follow-up of BEAR 6 hypothesized direction without passing the significance threshold. In addition, effect sizes were in the medium range, suggesting that a larger sample size would potentially result in a significant effect. Compared to other pre-emptive interventions, BEAR is relatively short, consisting of five sessions (intake and evaluation excluded) and is delivered by a first-line healthcare professional whilst other pre-emptive interventions are more time-consuming and intensive, ranging from 10 to 34 weekly sessions (Law et al., 2022). Future research should explore the optimal dosage and intensity of the BEAR intervention to determine if significant changes at the child level can be achieved. It is also possible that a longer follow-up may be necessary to detect significant changes in joint engagement and other child outcomes (Salomone et al., 2021; Waddington et al., 2021), or perhaps adjustments are needed in (the delivery of) the BEAR intervention. In addition, as parent-child engagement also has a dyadic aspect, it is possible that improvements in engagement are more reflective of changes in parent behavior rather than in child behavior (Tiede & Walton, 2019) Regarding parent level, it was hypothesized that BEAR would enhance parental skills (scaffolding, symbol highlighting, following in and caregiver affect), improve parental well-being and lower parental stress. For parental skills, there were no treatment effects found on following in and symbol highlighting. Looking at scaffolding, there was a significant decrease for the CAU group directly after treatment phase (T2) and a significant increase at six months follow-up (T3) for the BEAR group but not at endpoint (T2), suggesting a sleeper effect. A sleeper effect is common in psychotherapy trials (Flückiger and Del Re 2017), indicating that more time is needed, even after completing the intervention, to consolidate what has been learned and to manifest treatment gains, in this case in improving parental scaffolding. The goal of scaffolding is to create a “zone of proximal development” (Vygotksy, 1987), meaning that parents facilitate and enhance the child’s abilities by providing appropriate guidance, enabling them to perform tasks and express themselves in ways they could not achieve themselves (Adamson, Bakeman & Suma, 2020). High scaffolding scores according to the JERI coding system require not only that parents successfully guide their child but also that the child responds to these strategies (Adamson, Bakeman & Suma, 2020). In the current study, parents in both the BEAR and CAU groups scored relatively low on scaffolding skills both pre- and posttreatment. This could be attributed to that most children were difficult interaction partners, as indicated by the severity of their ASD symptoms (measured by ADOS and BOSCC scores). For caregiver affect, findings indicate a positive treatment effect for parents who completed the BEAR intervention. Importantly, caregiver affect on the JERI does not only measure affect of parents/caregivers but also how it influences the parent-child interaction (Adamson, Bakeman & Suma, 2020). In summary, parental skills such as caregiver affect and scaffolding should be interpreted in the context of the overall dyadic interaction. Furthermore, previous research shows that improvement of parental skills can in turn promote social communication outcomes in the child (Settanni et al., 2024), suggesting that long-term follow-up of the effects of the BEAR intervention is needed to evaluate effects on child level.
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