136 Chapter 6 The intervention was not associated with effects on parental well-being, in particular with lowering parental stress or improving mental well-being. While many individual pre-emptive interventions are hypothesized to reduce parental stress, previous research shows mixed results in this area. For example, some studies report reduced parental stress (Estes et al., 2014; Salomone et al., 2021; van Noorden et al., 2022), while other studies found that parental stress can increase over time during intervention studies (Green et al., 2024). A recent study found that high parental stress is already present in early parenthood for parents with children diagnosed with ASD (Dijkstra-de Neijs et al., 2024). The results of our study do not support these findings, as overall parental stress scores of our participants fell within the normal range and consequently room for improvement was small or absent. One possible explanation is that the children in our study were younger (12-30 months) compared to those in Dijkstra-de Neijs’s study (3-7 years) and had not yet received an ASD diagnosis. Further research on the BEAR intervention and parental experiences, particularly focusing on mental well-being and stress, is needed to determine its effects on overall parental wellbeing. Qualitative research exploring parental experiences with BEAR could provide deeper insights into this issue, as well as into the question to what extend BEAR has been helpful for them as a first step towards suitable healthcare if applicable. Findings from previous research indicate that investing in parental skills is essential and can improve the quality of parent-child dyadic interactions (Salomone, Settanni, et al., 2021). This aligns with the current study’s findings, suggesting that the BEAR intervention may have a positive effect at the parent-child interaction level. The current study presents a potential treatment effect of the BEAR intervention in enhancing fluency and connectedness between dyads, as evidenced by sensitivity analyses on complete cases. Based on the results of sensitivity analyses (as presented in the Supplementary Materials), there is a large effect size of the BEAR intervention on the flow of the interaction between parent and child. However, this effect does not appear in the imputed data. Fluency and connectedness reflect the dynamics of the dyad, encompassing both the parent and the child (Adamson, Bakeman & Suma, 2020). The possible treatment effect found in this study, together with findings on parental skills, suggests that mostly parents benefit from BEAR, thereby enhancing the overall parent-child interaction. Although some results are promising, there are several limitations to this study. First, there is an uneven sample size, meaning that there were significantly more participants allocated to the BEAR group than the CAU group. This difference in participant allocation might be attributed to the open-label nature of the study and absence of an active CAU condition, what possibly created an additional barrier for PCPs to screen infants and toddlers if they were assigned to the control group. Previous research by our group shows that it can be challenging for PCPs to screen children and discuss concerns regarding a very young child’s
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