159 Summary and general discussion 7 After pilot testing (Chapter 4) and more extensive testing through a cluster RCT (Chapter 6), we developed a clearer impression of the “types” of children and families represented in these studies, which allows for comparison against the proposed diagram outlined here below in Figure 1 and in Chapter 3 (i.e. “green” “yellow” or “red” categories). At first impression, most of the participants in our studies were boys who screened positive on the CoSoS questionnaire, exhibited ASD-related traits or other social-emotional and behavioral issues at an early age, and were raised in culturally diverse families, although most were from native Dutch families. Based on these findings, most of these children would likely be categorized within the “red” compartment of the diagram. It is however possible that despite these indicators, parents and preventive care professionals may not have shared the same level of concern, or that parents were not yet ready to seek referral to specialized mental health care and may have been offered BEAR for these reasons instead of a direct referral to specialized care. However, concrete data on these aspects is lacking. The hypothesis is that BEAR may be a more suitable intervention when a) concerns about a child’s development are still unclear, b) there are differences in concerns between parents and/or professionals, and/or c) parents are not yet ready to seek specialized mental health care. While initial results of the BEAR intervention seem promising in supporting this hypothesis, future research is essential to better assess the acceptability and suitability of BEAR as a pre-emptive intervention and evaluate this hypothesis. Thereby it is important to gain a deeper understanding of the experiences of parents and other important stakeholders (e.g., referral sources, BEAR professionals, and potentially municipalities) to better assess the appropriateness of BEAR as a pre-emptive intervention. An implementation study of the BEAR intervention is currently underway, with initial results anticipated by May 2025. Parental stress and family resilience Several studies have shown that parents of children with autism often experience higher levels of stress, which in turn can negatively impact the child’s behavior and development as well as the parent-child interaction(Hayes & Watson, 2013; Neece et al., 2012; Dijkstra-de Neijs et al., 2024; Warreman et al., 2023). The findings in this thesis suggest that, at group level, the participants in our RCT study (Chapter 6) did not yet exhibit severe parenting stress or mental well-being issues. A possible explanation could be the young age of the children involved and the availability of a low-threshold intervention that does not require a formal diagnosis. On the other hand, it is important to consider the potential limitations in how we measured parental stress and wellbeing outcomes, using only self-report tools like the OBVL and WEMWBS questionnaires. Additionally, it is possible that the parents who were invited to participate but declined were those experiencing higher levels of stress, which may have influenced their decision not to participate in our study. Furthermore, a low level of stress at group level does not preclude that there are parents who do experience considerable parenting stress and lower mental well-being. This is also reflected in our pilot study (Chapter 4), where 4 out of 6 parents reported high levels of stress. It could be possible that,
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