155 Summary and general discussion 7 Chapter 4 describes the BEAR intervention and SCOPE (Social Communication Program supported by E-health) study protocol that were tested in a pilot study holding a small sample of infants, toddlers and their parents (n=6). The aim was to assess the feasibility of the research design and address any potential research challenges. Pilot results suggested that most parents and children show improvement across multiple levels (joint engagement, parental skills, and parental well-being) following the BEAR intervention, although some parents and children appear to experience a decline. At first impression, BEAR can be a helpful first step for parents in supporting their child’s needs with parents being actively involved during the whole process. For some children, this intervention will be the influx to more intensive and specialized healthcare, whereas for other children BEAR will function as a preventive intervention. Evidently, robust replication in a larger sample is needed. Based on the outcomes and insights gained from the pilot, the research protocol has been further revised and refined. Chapter 5 provides a detailed description of the SCOPE study protocol, subsequently to pilot adaptations. The SCOPE study and BEAR intervention were developed as an innovative strategy to improve detection and, most importantly, timely intervention. The BEAR-intervention, designed by Dietz and Oosterling (2019) and with input from experts from the Dutch national expertise network for autism in young children, is a pre-emptive, home-based, parent-mediated intervention suitable for infants and toddlers aged approximately 12-30/36 months who show a neurodevelopmental vulnerability (e.g. concerns regarding social communication, contact, flexible behavior and/or play). Without the need of an ASD diagnosis, BEAR is intended to be more acceptable and well-received by parents with relatively minor concerns or who are somewhat hesitant about seeking help or pursuing a diagnostic assessment. The intervention is delivered by a first-line healthcare professional and (ideally) supervised by a specialized mental healthcare professional. The aims of BEAR include: 1) enhancing parental awareness, 2) supporting child development and parent-child interaction and 3) guidance to follow-up care (if needed) and appropriate triage. The primary outcome measure was joint engagement in the parent-child interaction, as captured through video observations and assessed through the Joint Engagement Rating Inventory (JERI, Adamson, Bakeman & Suma, 2020). Secondary outcome measures included severity of ASD symptoms (as measured through the BOSCC and ADOS-2), parental skills such as scaffolding, following in, symbol highlighting and caregiver affect, parental stress and mental well-being and the overall fluency and connectedness of the parent-child interaction. Assessments were conducted before treatment (T1), right after treatment at 8 weeks (T2) and six months later (T3). Chapter 6 focuses on the short-term and six-month effects of BEAR, investigated in a cluster randomized controlled trial (RCT) that compared the effects of BEAR to a care-asusual (CAU) group, in a larger sample (n=55). Of this total sample, 40 infants and toddlers and their parents followed the BEAR intervention, whereas 15 received CAU. Results
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