158 Chapter 7 Pre-emptive intervention: BEAR for infants and toddlers with a social-communicative vulnerability and their parents BEAR effectiveness The effectiveness of BEAR was investigated in this thesis through a pilot in a small sample (Chapter 4) and in a larger cluster randomized controlled trial (Chapter 6). Results revealed no significant treatment effects on child developmental outcomes, meaning that findings did not confirm our hypothesis that BEAR significantly improves the joint engagement skills of the child. However, changes observed in joint engagement and in ASD symptoms are in the hypothesized direction without passing the significance threshold. As parent-child engagement also has a dyadic aspect, it possible that improvements in engagement are more reflective of changes in parental behavior rather than child behavior (Tiede & Walton, 2019). This appears to be the case in our RCT study (Chapter 6), where parents who participated in the BEAR intervention showed significant improvements in caregiver affect and scaffolding compared to those receiving Care-As-Usual (CAU). 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). Looking at caregiver affect, a positive treatment effect occurred directly after treatment and was maintained six months later. 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). Parental skills such as caregiver affect and scaffolding should be evaluated 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 (Settani et al., 2024), suggesting that long-term followup of the effects of the BEAR intervention is needed to further evaluate effects on child level. 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 changes in joint engagement and other child outcomes (Salomone et al., 2021; Waddington et al., 2021), or perhaps that there are adjustments needed in (the delivery of) the BEAR intervention, or training of BEAR-professionals/therapists.
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