Mental Health Interventions for Parent Carers of Children with Autistic Spectrum Disorder: Practice Guidelines from a Critical Interpretive Synthesis (CIS) Systematic Review

Parent carers of children with Autism Spectrum Disorder (ASD) often report increased levels of stress, depression, and anxiety. Unmet parent carer mental health needs pose a significant risk to the psychological, physical, and social well-being of the parents of the child affected by ASD and jeopardize the adaptive functioning of the family as well as the potential of the child affected by ASD. This systematic review identifies key qualities of interventions supporting the mental health of parent carers and proposes practitioner-parent carer support guidelines. A search of four databases (Medline, PubMed, PsycINFO, and Social Science Data) was conducted to identify studies that met the following criteria: (1) an intervention was delivered to parent carers of a child with ASD under the age of 18 years; (2) the research design allowed for a comparison on outcomes across groups; and (3) outcome measures of the parent carers’ mental health were used. A total of 23 studies met the inclusion criteria. A critical interpretive synthesis approach was used to produce an integrated conceptualization of the evidence. Findings suggest practitioner guidelines to support the mental health and wellbeing of parent carers should include addressing the parent’s self-perspective taking and skill for real time problem-solving.


Introduction
Parents who are primary carers of a child affected with Autism Spectrum Disorder (ASD) are often found to experience higher levels of stress and poorer physical health when compared with parents of children of typical development [1][2][3], parents of children diagnosed with other disabilities [4,5], or when compared to the general population [6][7][8][9][10][11]. The parenting stress experienced by parents of a child affected with ASD therefore appears to pose a greater risk to the parents' psychological and health-related quality of life. ASD is a neurodevelopmental disorder characterized by deficits in social interactions and communication skills, both verbal and non-verbal, restricted interests, and stereotypical behaviors [12]. The manifestation of ASD symptoms may range from mild to severe and vary from individual to individual. It is estimated that 1 in 160 children worldwide (or 62.5 per 10,000) are identified with ASD [13], with Japan reported to have the highest prevalence of approximately 161 children per 10,000 identified with the disorder [14]. In the United States, the number are challenged with maintaining their own wellbeing. Our goal was to apply a critical integrative synthesis analysis to collate the emerging evidence from a diverse body of literature examining mental health supports for parent carers of a child affected by ASD. In sum, we synthesized the nature and results of mental health intervention studies delivered to parent carers of a child affected by ASD reported in studies that examined the effectiveness of mental health interventions as well as qualitative reports in order to provide health and allied-health professionals with practice guidelines that could be implemented into a standard practice of care to address the mental health needs of parent carers of a child affected by ASD.

Critical Interpretative Synthesis
Critical Interpretive Synthesis (CIS) is a systematic review that allows for triangulation of the evidence gathered from effectiveness (i.e., quantitative) and qualitative studies into new conceptual constructs, grounded in evidence and resulting from a critical interpretation of that evidence [41,42]. The synthesis results in the development of synthetic constructs, transforming the underlying evidence into new conceptual constructs and allow for various aspects of an identified phenomenon described in a diverse body of evidence to be expressed in a more comprehensive and useful way. These synthetic constructs, formed from the critical integration of findings across all studies included in the review, can then be organized into a coherent explanatory theoretical framework [42]. A CIS review of the broad and complex literature that intersects parenting, mental health, and ASD can provide more useful and pragmatic practice guidelines for practitioners and parent carers than what can be produced from conventional reviews alone (e.g., meta-analyses).

Search Criteria and Literature Search
The focus of the synthesis reported in this review was on interventions provided to parents of a child with ASD that resulted in the parent carers improved mental health. Studies included in this review met the following inclusion criteria: (1) an intervention was delivered directly to one or both parent carers of a child with ASD under the age of 18 years; (2) the study involved a research design allowing for a comparison across groups on the outcome of an intervention; (3) an outcome measure of parental mental health was used; and (4) the study was published in English in a peer-reviewed journal. Parent carers were defined as maternal mothers or paternal fathers who resided in the same home as their child with ASD and who had responsibility for the child's care. "Mental health" was defined in accordance with the World Health Organization definition of mental health-"a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" [43] (para. 1). Outcome measures included any instrument that assessed some aspect of mental health, including measures of stress, anxiety, depression, quality of life (including health-related quality of life), and subjective well-being. There were no publication date restrictions applied, and other systematic reviews or review-based articles were not included.

Search Procedure
A systematic search of the databases Medline, PubMed, PsycINFO, and Social Science Data was conducted using key search terms identified from relevant papers found in a preliminary search, and from a search of relevant Medical Subject Headings (MeSH) terms which were then incorporated into an expanded search strategy. The MeSH and text words for Autism (Autism, Autism Spectrum Disorder, ASD, developmental disorder, Asperger's Syndrome, Asperger's) were combined with MeSH and text terms for parent carers (mother, father, caregiver, carer, maternal, paternal), MeSH and text words for intervention (intervention, support, effects, improve, train, treatment, program), and MeSH and text words for mental health (mental health, mental wellbeing, psychological wellbeing, wellbeing, stress, depression, anxiety). Boolean "OR" was used to connect search terms within each set of text words, while "AND" was used to connect the four sets of text words. Terms that had plural forms (e.g., parents) were truncated (i.e., "*") and hyphenated words (e.g., well-being) were entered in both their hyphenated and non-hyphenated form. Since both quantitative and qualitative studies were desired, no qualifier was entered for research design.
The search was conducted from 15 May through 15 July 2017 by the primary author. Citations identified by the search were exported to the first author's RefWorks account for de-duplication. The first and second co-authors assessed remaining studies for relevance by screening titles and abstracts, discarding those that did not meet the inclusion criteria. Full-text versions of the retained studies were obtained and examined independently by the first and second co-authors for study eligibility. Reference lists of the retained articles were hand searched for potential additional articles. Additional articles found were reviewed in their full-text version by the first two-co-authors to ensure they met the eligibility standards. Inter-observer agreement of the retained studies was 100%.

Quality Appraisal
A quality appraisal of each qualitative study was conducted prior to the study being included in the final review and synthesis. The quality of a qualitative study is largely determined by the quality of the published report since there is no consensus on a set of specific standards [44]. The individual studies included in the present integrative synthesis were assessed using a published checklist [45] that identifies nine specific elements of the published report, each evaluated using a four-point Likert-type scale (4 = good, 3 = fair, 2 = poor, 1 = very poor). The nine elements included: (1) the abstract and title, (2) introduction and aims, (3) method and data, (4) sampling procedure, (5) data analysis, (6) ethics and bias, (7) findings and results, (8) transferability/generalizability, and (9) implications and usefulness. Scores for each article are summed with higher scores reflecting higher methodological quality (scores range from 9 (very poor) to 36 (very good). The first author assessed the quality of each study retained in the search and found the majority of the studies were of good methodological quality, with scores ranging from 24 to 35. The 2nd co-author randomly selected 30% of the studies and conducted an independent assessment. No significant disagreements occurred (scores between co-authors differentiated by no more than one or two points on average) and discrepancies were discussed until consensus was achieved. Both co-authors agreed that one particular study should be excluded based on having a score substantially lower than the other studies (score = 14) due to several noted and significant methodological limitations. Figure 1 provides the number of total identified citations and results of the eligibility screening process. The search yielded 2361 citations, with 942 citations determined to be duplicates. Of the remaining 1419 records, 1367 records were deemed ineligible following a review of the title and abstract information. Full-text articles were obtained of the remaining 52 studies and reviewed independently by both the first and second co-authors. A total of 29 studies were excluded by mutual consensus of the co-authors (see explanations provided in Figure 1) resulting in a total of 23 studies included in the synthesis.  Table 1 describes specific characteristics of the 23 studies included in this synthesis (authors and reference, country of origin, aim, design, data collection, analysis method, psychological construct(s) measured, measurement instruments, participant information, and the study's findings). The included studies reported outcomes for a total of 918 participants, with at least 70% being the mother of the child (two studies did not provide gender characteristics). Six studies were based on an experimental design with random assignment of participants to a control or treatment group, with the remaining studies using either a quasi-experimental pre-post design (n = 10), or mixed-methods design (n = 7). Studies included in the review were conducted in a total of 13 countries: Australia (n = 3), Canada (n = 1), China (n = 2), Greece (n = 1), India (n = 1), Iran (n = 3), Japan (n = 1), Jordan (n = 1), South Korean (n = 1), Spain (n = 1), Turkey (n = 1), United Kingdom (n = 1), and the United States (n = 6).  Table 1 describes specific characteristics of the 23 studies included in this synthesis (authors and reference, country of origin, aim, design, data collection, analysis method, psychological construct(s) measured, measurement instruments, participant information, and the study's findings). The included studies reported outcomes for a total of 918 participants, with at least 70% being the mother of the child (two studies did not provide gender characteristics). Six studies were based on an experimental design with random assignment of participants to a control or treatment group, with the remaining studies using either a quasi-experimental pre-post design (n = 10), or mixed-methods design (n = 7). Studies included in the review were conducted in a total of 13 countries: Australia (n = 3), Canada (n = 1), China (n = 2), Greece (n = 1), India (n = 1), Iran (n = 3), Japan (n = 1), Jordan (n = 1), South Korean (n = 1), Spain (n = 1), Turkey (n = 1), United Kingdom (n = 1), and the United States (n = 6). At three-month follow-up, mothers in the problem-solving education group reported higher use of social coping (both instrumental and emotional), and were significantly less likely than mothers in the control group to report clinically significant stress and depressive symptoms. No change in using problem-focused or avoidance coping skills  A statistically significant improvement was found in psychological health well-being and positive affect.

Study Characteristics
No changed was noted in anxiety or negative affect. Participants reported that the intervention helped them in relieving feelings of guilt that they had done wrong to accumulate bad karma and they were more aware of trying to accept people and things as they are. n = 13 (13 mothers; 1 father) Caregiver group: n = 6 (5 mothers, 1 father) Non-Caregiver group: n = 7 (7 mothers) A significant reduction in mood disturbances and afternoon cortisol levels occurred for all participants, but were more pronounced in the caregiver group of parents. All participants reported a decrease in depressive and somatic symptoms at the end of the program and improved self-perceived general health.
Samadi et al. [113], 2012, Iran To determine the effectiveness of a short group-based support course designed to increase parent's knowledge of ASD and interventions to promote child's development, boost parent's confidence and sense of empowerment, and encourage parents to provide informal support to each other Mixed design included pre-post, crossover design, within-group differences, between-group differences, questionnaires, interviews, paired t-tests, independent t-tests, content Intervention resulted in significant improvements on parental ratings of health, stress, and family functioning, and a significant increase in use of problem-focused coping strategies up to 4-months post intervention Both the PEBM and PEC interventions contained the same educational material, however the PEBM intervention included sessions that were skills based and action oriented while the PEC intervention emphasized nondirective, interactive discussion and counseling. There were no significant differences between the outcomes of the PEBM and PEC groups-both interventions reduced overall symptoms of parental distress, although the PEC intervention reduced the depressive symptoms in a larger percentage of parents. Post-traumatic growth was significantly higher among mothers in the intervention groups compared to control group. The difference was maintained at a 3-months follow-up.

Data Extraction
In order to ensure that none of the key aspects of the studies were overlooked, a grid was developed (see Table 2) that allowed for the recording of key concepts from each study based on the nature of the intervention, results of the study, perspectives reported by the participants, and the conclusions and observations of the investigators. Columns were constructed with the top row identifying the study's citation number, while the rows of the grid listed the key concepts drawn from each study. The concepts were then integrated across studies through a series of discussions among the co-authors regarding the similarities and differences of the individual concepts within the context of the various studies, producing a reduced number of transformed synthetic concepts which were then grouped together into a structure of higher order themes. These overarching, higher order themes identified a synthesized interpretation representative of the whole body of evidence.

Synthesis
Three major themes were identified as being central to improving the mental health of parents who have a child affected by ASD-access to social support with similar parent carers, receiving professional stress management and problem-solving training; and the provision of accurate information regarding ASD. Table 2 lists the major themes and their subthemes resulting from the integrated synthesis of evidence reported in the individual studies. The top row indicates the citation for the study.

Social Support
The role of social support was found to be an important factor in twelve studies that either specifically examined the role of social support in improving the psychological wellbeing of parents or included a group treatment condition in which parents were able to engage in discussions with other parent carers. The theme of social support encompassed the roles of informal networks, reduced isolation, and validation by similar parent carers.

Informal Networks
Seven studies [46,56,65,101,103,113,116] involved an intervention examining the role of social support and found parent carers involved in a parenting social group also reported decreased anxiety [65] and social stress [103,113], increased group cohesion [46], and improved health and family functioning [113] and quality of life [101]. The benefits of a parenting support group on measures of parental well-being was found to be maintained up to twelve months post intervention [115]. An asynchronous on-line support group appeared to not to be effective in reducing parenting stress, anxiety, or depression [56], suggesting the beneficial effect of social support may involve direct, real-time communication methods (e.g., face-to-face, telephone calls).

Reduced Isolation
Five studies found social support related to improvements in parents' psychological wellbeing was attributed to the increased awareness by parents that they were not alone in the challenges they faced parenting a child affected by ASD. Parents who reported feeling less socially isolated because of having access to other parents who were also engaged in the intervention reported a decrease in anxiety and stress [46,61,65,113,116].

Validation by Peers
Feedback from parents in eight studies [46,61,65,77,92,113,116,117] suggests that the validation they received from the other parents as an important factor to improvements of their wellbeing. These studies found social support was associated with increased group cohesion [46], confidence [65], and post-traumatic growth [117], as well as less hopelessness [61], stress [77,78,113], anxiety [61], depression [116]. The normalizing effect due to receiving support and empathy from other group members was reported by parents as a factor in facilitating their ability to cope and adjust their perspective to the parenting challenges they faced. Parents were able to recognize that their experience was not all negative but rather a different "normal".

Professional Training in Skill Development
Fourteen studies included professionally-led workshops based on cognitive-behavioral approaches that provided parents with various stress management strategies (nine studies), and problem-solving skill training (six studies).

Stress Management Strategies
Nine studies [46,49,61,70,75,92,96,105,108] involved interventions that provided training in various stress management strategies. Biofeedback was found to increased group cohesion and reportedly provided parents with a helpful strategy for dealing with their day to day stress [46], while mindfulness was associated with decreased mood disturbances [111], and increased psychological [92,105] and general health [70], as well as overall quality of life [105]. Progressive muscle relaxation was associated with decreased stress [75], and expressive writing, particularly writing related to describing the benefits of being a parent carer, was associated with decreased anxiety [96]. Interventions incorporating Acceptance and Commitment therapy, found the approach associated with decreased depression and distress, and increased psychological flexibility [49,89].

Problem-Solving Skills
Five studies [61,65,66,98,117] involved parents receiving training in problem-solving or coping strategies. These interventions were reported to be particularly useful to parents when the training was structured and focused on providing practical knowledge and skills for dealing with their child's behavioral problems and daily care. Skill training in problem-solving strategies appeared to be associated with parents' increased use of social support [61,66], increased confidence in addressing problems [65], promoted post-traumatic growth [117], and decreased parent carers' levels of anxiety [65], stress [66], and depression [98].

Gaining Knowledge Regarding ASD
Eight studies [61,65,72,77,78,103,113,116] examined the influence of providing parent carers with information about ASD and the types of resources and services that were available to them as a strategy for reducing parental stress and anxiety.

Understanding Autism Spectrum Disorder
Five studies [65,77,78,113,116] involved an intervention in which parents were provided with information regarding ASD and its related cognitive, emotional, and behavioral features. As parents' knowledge of ASD increased, stress, anxiety and distress was reduced [65,77,78,116], confidence and ratings of health increased [65,113], and the use of problem-solving skills increased [113].

Resources and Services
Four studies [65,72,78,103] involved interventions providing parents information about available resources and services from healthcare professionals as a strategy to address parental stress and anxiety. Parents who were provided with information regarding advocacy services, such as available educational, developmental, and behavioral treatment programs, and had assistance in identifying ways to fill service gaps reported a decrease in anxiety [65,78], stress [103], and were less distressed upon receiving their child's diagnosis [72].

Discussion
This systematic review applied a critical interpretive synthesis analysis that included both quantitative and qualitative studies in order to triangulate emerging evidence, and to formulate needed practice guidelines for health and allied-health professionals who provide mental health support to parent carers of a child affected by ASD. Three broad themes emerged from this synthesis of primary studies-the importance of social support by other parent carers, the effectiveness of training parents in stress management strategies and developing problem-solving skills, and the importance of providing parent carers with relevant and accurate information about ASD and available resources and support services. These themes can be effectively incorporated into strategies practitioners and their parent carer partners can utilize for improving not only the psychological well-being of parent carers, but also to influence the wellbeing of the child affected by ASD and other family members.
Perhaps one the most effective factors identified in the synthesis found to influence the well-being of parent carers was being engaged with other parent carers, such as through a parenting social support group. Networking with other parent carers allowed for parents to realize they were not alone in the challenges they faced [56] and provided parents with an important validation of their own value and experiences [56,61,65]. They could share stories with others who may have had similar experiences and discuss life's difficulties [46,61,65,66], exchange ideas and information about resources [46,61], and learn from other parents how they respond and cope with their child's behaviors, as well as the criticism often received from others regarding their child's behavior [46,61]. Through the support of other similar parent carers, parents are able to normalize their experience and become more aware of their child's needs rather than focusing on a comparison of their child to other children [65,77,92,113]. Receiving validation from others helped increase parent carers' confidence to cope with daily challenges and be more accepting of their child's behaviors [46,92]. Parents could also notice the positive changes in each other and provide continued support in the growth and well-being of the other parent carers [56].
Participating in professionally-led workshops in which parent carers were introduced to the practice of various stress management strategies (e.g., biofeedback, mindfulness), acceptance, and learned problem-solving skill strategies, had a positive effect on parents' mental health and psychological well-being [46,49,61,70,75,89,92,96,105,108]. Helping parents experience the practice and value of "being present", rather than ruminating over unresolved events in the past, or activating thoughts about anticipated future events, enhances the parents' ability to stay focused on the present situation in a non-judgmental way and promotes an awareness of choices the parent carer may have in response to a situation. Coupled with training in problem-solving strategies, providing training in stress management strategies has the potential to improve parents carers' wellbeing by increasing their confidence in effectively managing daily challenges, and their ability to be more accepting of others, including their child as well as themselves.
Workshops providing training in stress management strategies and problem-solving skills also functioned as social support groups, providing participants with opportunities to develop and practice new problem-solving strategies to the challenges they routinely faced while also learning from other group members about their experiences and strategies. Overall, stress management strategies helped parent carers learn a beneficial strategy for managing stress they were able to practice in their own home and utilize whenever they found themselves facing a difficult situation. Additionally, workshops provided parent carers with an opportunity for respite from their daily caregiving responsibilities.
Parent carers reported that receiving factual and accurate information regarding ASD helped decrease their feelings of stress and anxiety, often expressing relief after receiving information that helped explain their child's behaviors. Providing parents with a better understanding of how their child processed sensory information, and the relationship of that experience to the child's engagement in certain behaviors, was reported as making a difference in how parents related and reacted to their child, promoting better acceptance and understanding of the child behavior. When provided with an explanation that related their child's diagnosis to the child's behavior, parents' confidence in seeking appropriate services increased. With accurate and relevant knowledge about the nature of ASD, parents described being able to develop more effective strategies and tools that helped their child better cope with the sensory stimulation they experienced in their environment. Learning about the sensory aspects of autism and strategies that would help to support their child was reported as being highly valued by parent carers.
When developing a treatment plan to address the mental health needs of a parent carers with a child affected by ASD, including any, or all, of the above strategies, should be considered. Improved mental health and psychological well-being was reported by parent carers as a result of each of these strategies, often with strategies, such as receiving social support from similar parent carers, being imbedded into other strategies, such as group workshops on stress management and problem-solving. These strategies can form the framework for the development of strategies that could be delivered to parent carers of a child affected with ASD and perhaps expanded to address parent carers of children with other forms of neurodevelopmental disorders and chronic illness.

Strengths and Limitations of the Review
This review used a rigorous review method for a critical integrative synthesis involving a comprehensive search of published studies examining the effectiveness of an intervention designed to improve the mental health and psychological wellbeing of parents of a child affected with ASD and that met pre-determined inclusion criteria. Key factors were identified from a diverse body of literature that included both quantitative effectiveness studies as well as qualitative studies that provided the participants' perspectives regarding the benefits and limitations of the interventions, as well as their own beliefs, values, and feelings about their experience with the intervention. Although each study occurred within a different context, we were able to integrate and synthesize findings across primary studies in order to identify higher level constructs that could provide a more comprehensive understanding of the factors involved in effective interventions for addressing the psychological well-being of parents with a child affected by ASD.
It is acknowledged that the results of this study should be considered a beginning step in building a body of knowledge that would prove useful to health and professional mental health practitioners who provide support services to parent carers and their child affected by ASD. In spite of conducting a comprehensive search of the evidence, a synthesis of all forms of evidence is the desired standard, such as unpublished studies, dissertations, single-case studies, and conference presentations, to name a few. Such an undertaking, however, was not feasible given the time and number of personnel involved, thus it was necessary to limit the sampling of evidence to those that met our pre-determined criteria with the hopes that others will continue to expand upon the evidence we have provided.
It is also possible that others might have reviewed the studies included in the present synthesis and identified alternative overarching constructs. The purpose of a critical integrative synthesis is to generate theory [42], and we hope our findings will prove useful in the development of a theory that provides strong explanatory power regarding those factors that must be present in an effective, and efficient, strategy for enhancing the psychological well-being of parents who are experiencing significant distress due to the challenges of parenting a child affected by ASD. For example, there is a paucity of research examining the mental health experience of those parents who live in rural areas and have less access to resources, or are of a lower socioeconomic status, or belong to a minority ethnic population. Additional qualitative research is needed to provide the valuable perspective and insights of parent carers, which should lead to developing randomized controlled studies in order to compare intervention strategies and determine what works for whom and under what circumstances.

Implications of the Review and Practice Guidelines
This synthesis identifies several strategies that could be implemented by practitioners immediately in order to improve the mental health of parent carers of a child affected by ASD. First, incorporating an opportunity for parents to interact with other similar parents appears to be a very beneficial strategy for enhancing parents' psychological wellbeing. Facilities providing behavioral services to children with ASD should consider integrating support services for parents, such as forming parental support groups, in addition to the behavioral services being delivered to the child affected by ASD. Having a practitioner who is knowledgeable about ASD, and familiar with the issues and challenges parent carers face caring for a child affected by ASD, lead or participate in the support group would be beneficial so that parents could ask questions and obtain relevant and accurate information about ASD. Many parents may lack available child care and having a parent support group available at the facility where their child is receiving behavioral services may be the parent's only opportunity for beneficial social support and access to information. Parents should be encouraged to form relationships with the other parents so that the provision of peer support could potentially continue as the child ages and parents face new challenges. Practitioners could develop and lead parent support groups that include activities and training in various skills to enhance stress management, coping, and problem-solving practices. Incorporating parent support services formerly into the services being provided to the child at the treatment facility could be an important factor for facilitating the success of the child's treatment. Secondly, practitioners could serve as advocates for parents and help them find appropriate services and resources to ensure there are no gaps in services for the child. Health and mental health professional practitioners should discuss with parent carers the different aspects of their quality of life and ensure the parent is referred for appropriate services. Thirdly, health and mental health practitioners should provide parents with written information regarding the nature of ASD that could be shared with other family members, as well as guidelines for problem-solving, strategies for stress management, and available resources and services that might be beneficial for either the child or the parent. Treatment facilities that deliver behavioral interventions for children with ASD might consider integrating these described strategies into a package of mental health support services that parent carers could receive, ensuring that the wellbeing of both the child and parent carers are being effectively addressed.

Conclusions
Parents providing ongoing care to a child affected by ASD are found to be at higher risk for adverse mental health outcomes such as chronic stress, depression, and anxiety. Practice guidelines for the use by practitioners and parent carers of children with ASD should address the need for engaging with other similar parent carers, and enhance their generic problem-solving abilities, self-perspective taking, and sense of meaning as carers. Practitioners who address the state of the parent's mental health and psychological well-being will enhance the health-related quality of life of the parent carers, their families and their child with ASD. The implementation of the guidelines proposed in this integrative synthesis can potentially lead to greater/better cooperation with child care services, as well as an improved quality of life for parent carers and their child.