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. Author manuscript; available in PMC: 2025 Apr 1.
Published in final edited form as: Autism. 2023 Aug 9;28(4):985–998. doi: 10.1177/13623613231191558

Comparative Effects of Mindfulness-Based Stress Reduction and Psychoeducational Support on Parenting Stress in Families of Autistic Preschoolers

Cameron L Neece a, Rachel M Fenning b, Holly E R Morrell a, Laurel R Benjamin a
PMCID: PMC10853488  NIHMSID: NIHMS1918798  PMID: 37555286

Abstract

Relative to parents of children with neurotypical development and other developmental disabilities, parents of autistic children experience higher levels of parenting stress, which are associated with deleterious consequences for parent mental and physical health and child functioning. Despite urgent calls to action, parenting stress is rarely addressed directly in interventions for families of autistic children, and less so in underserved and racial/ethnic minority populations where clinical needs are greater. This study tested the efficacy of Mindfulness-Based Stress Reduction (MBSR), compared to a Psychoeducation and Support (PE) intervention, in reducing parenting stress among diverse families of autistic preschoolers. Participants (N = 117) were randomly assigned to the MBSR or PE groups; assessments were conducted at baseline, immediately post-intervention, and 6- and 12-months post-intervention. Results indicated significant reductions in parenting stress across both the MBSR and PE intervention conditions; however, reductions in parenting stress were greater for parents in MBSR than in PE. Furthermore, the benefit of MBSR relative to PE increased over time, with significant group differences in parenting stress detected at 12-month follow-up.

Keywords: Mindfulness, Autism spectrum disorder, Parenting stress, Preschoolers

Parents of autistic children report higher levels of stress on average relative to parents of children with neurotypical development, genetic disorders, chronic illnesses, and other intellectual and developmental disabilities (IDD; Baker-Ericzen et al., 2005; Barroso et al., 2018; Estes et al., 2009; Dabrowska & Pisula, 2010; for a review, see Hayes & Watson, 2013). Approximately one-third of parents of autistic children report clinically-elevated stress levels, suggesting a high need for intervention (Davis & Carter, 2008). Despite urgent calls to action (Bearss et al. 2015; Oono et al., 2013), parenting stress has rarely been addressed directly in interventions for families of autistic children, and even less so in underserved and racial/ethnic minority populations where clinical needs are greater (Magaña et al., 2012). Recent investigations have drawn upon approaches such as Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 2013) to address parental well-being in families of children with unspecified or heterogenous diagnoses (e.g., Neece, 2014). Although early efforts are promising, more rigorous evaluation of MBSR involving active comparison conditions, longitudinal assessment, and inclusion of diverse well-characterized samples is needed. Moreover, the efficacy of MBSR has not been rigorously tested among families of autistic children.

Parenting stress is common in families of autistic children, and may be tied to variety of factors, including children’s core symptoms and co-occurring conditions, parents’ own mental health and related processes, as well as external stressors (e.g., Karst & Van Hecke, 2012; Benson, 2006). High levels of parenting stress have been associated with deleterious consequences for parent mental, physical, and relational health as well as parenting behaviors, intervention uptake, and broader family well-being in families of autistic children (Allik et al. 2006; Osborne et al., 2008; Rao & Beidel, 2009). Parenting stress also predicts subsequent child externalizing behavior problems, with longitudinal studies suggesting a mutually-escalating transactional relationship in which parenting stress and child behavior problems exacerbate one another over time (Lecavalier et al., 2006; Osborne & Reed, 2009). Although findings remain mixed regarding directionality of effects, several studies suggest the potential for parent-driven processes in early development wherein parenting stress predicts future child behavior problems more strongly than child behavior problems predict parenting stress in families of autistic children, indicating that parenting stress represents a primary predictor of child and family functioning in this population and an important target for early intervention (Lin et al., 2021; Osborne & Reed, 2009; Zaidman-Zait et al., 2014).

Parents of preschool-aged (i.e., 3 to 5-year-old) autistic children may face unique risks for clinically-elevated parenting stress. During this period in which developmental difficulties are often first recognized and early identification of ASD takes place (De Giacomo & Fombonne, 1998), parents may experience numerous stressors related to the timely acquisition of diagnostic and intervention services (Shattuck et al., 2009), including personal and emotional adjustments (e.g., reactions to diagnosis, recalibrating expectations and parenting; Wachtel & Carter, 2008), as well as a host of practical, logistical, financial, and related challenges (e.g., Grindle et al., 2009). Parents from underserved and racial/ethnic minority backgrounds face additional barriers to accessing and utilizing quality diagnostic and treatment services that may further compound parental strain (Rivera-Figueroa et al., 2022; Smith et al., 2020). Interventions that focus on reducing parenting stress in these diverse, high-need populations are crucial.

To date, parent support groups remain one of the most commonly used interventions for parents of autistic children, as they are relatively cost-effective and easily implemented (Clifford & Minnes, 2013). However, strong evaluation data are lacking and few studies have examined effects of support groups on parenting stress (for a review, see Rutherford et al., 2019). Other studies have used cognitive behavioral techniques to reduce stress in parents of autistic children and those with IDD. Although findings are promising, these studies have predominantly used no-treatment, treatment-as-usual, or waitlist-control comparisons, which often do not account for non-specific effects of provider contact (e.g., Gammon & Rose, 1991; Izadi-Mazidi et al.,2015; Mueller & Moskowitz, 2020; for reviews, see Da Paz & Wallander, 2017; Hastings & Beck, 2004). Additionally, several investigations have examined whether parent-mediated interventions, wherein the parent serves as the principal change agent for the autistic child, can alter parent outcomes as well. Unfortunately, effects on parents, including parenting stress, appear inconsistent across studies (see Kulasinghe et al., 2022 and Oono et al., 2013 for reviews). Moreover, emerging evidence suggests that parenting stress may attenuate the efficacy of behavioral interventions for autistic children (Osborne et al., 2008), highlighting the importance of addressing parenting stress directly in order to sustain intervention gains.

Recently, parent stress-reduction interventions have drawn on mindfulness-based approaches to improve parental well-being in families of autistic children (for reviews see Cachia et al., 2016; Hartley et al., 2019; Ferraioli & Harris, 2013). Given the severity and chronicity of daily stressors experienced by these families, mindfulness-based interventions, which focus on managing rather than eliminating stress, may be particularly valuable. Research in this area has largely examined the utility of mindfulness-hybrids using quasi-experimental designs (e.g., de Bruin et al., 2015; Hwang et al., 2015; Jones et al., 2018; Lunsky et al., 2021; Rayan & Ahmad, 2016; Ruiz-Robledillo et al., 2015; Ridderinkhof et al., 2018; Schwartzman et al., 2021), though some randomized trials have been conducted (Ferraioli & Harris, 2013; Lunsky et al., 2017). For example, Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2002), has been found to enhance quality of life and positive stress reappraisal (Rayan & Ahmad, 2016), improve parent mental health and related symptoms (Lunsky et al., 2017; Ridderinkhof et al., 2018; Schwartzman et al., 2021) and reduce parenting stress in parents of autistic children and adolescents (Ferraioli & Harris, 2013; Jones et al., 2018). The related Mindful Parenting intervention (Bögels & Restifo, 2013), has similarly been found to decrease stress in parents of autistic adolescents (de Bruin et al., 2015). Effects of mindfulness-hybrids for parents of autistic children and adolescents have been maintained over two (Schwartzman et al., 2021; Ridderinkhof et al., 2018), three (Ferraioli & Harris, 2013), and five months post-intervention (Lunsky et al., 2017).

Interestingly, somewhat less attention has been devoted to the applicability of traditional Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 2013) to families of autistic children. MBSR is the most empirically-supported stress-reduction intervention to date, with over three decades of extensive research demonstrating efficacy in reducing stress, anxiety, and depression, and promoting overall well-being across a variety of clinical and non-clinical populations (Grossman et al., 2004). MBSR targets stress reduction by fostering non-reactivity and non-judgment of internal experiences, which promotes acknowledgement of the experience of stress while reducing the emotional impact (Gu et al., 2015).

Utilizing waitlist-control designs (e.g., Neece, 2014; Neece et al., 2019) and active comparators (e.g., Dykens et al., 2014), several studies have demonstrated the efficacy of Kabat-Zinn’s (2013) manualized MBSR for improving parenting stress in families of children with heterogeneous IDD diagnoses and chronic conditions. Although these samples have sometimes included autistic children (e.g., Dykens et al., 2014; Neece et al., 2019), few studies have tested MBSR in families of autistic children specifically. Moreover, existing studies that have examined MBSR in parents of autistic children have combined MBSR with other interventions such as parent-implemented Early Start Denver Model (Weitlauf et al., 2020) or self-compassion interventions (Rojas-Torres et al., 2021). Thus, the unique effects of MBSR for families of young autistic children remain unknown.

Mindfulness interventions, and MBSR in particular, hold promise for reducing stress in parents of young autistic children. However, rigorous testing using a randomized design with an active comparator, a large, well-characterized, and diverse sample, and long-term follow-up is needed to further establish efficacy and support generalizability. The current study addressed these aims by: (1) conducting a population-specific randomized controlled trial of Kabat-Zinn’s (2013) manualized MBSR intervention involving an active comparison Psychoeducational support (PE) condition, (2) recruiting a sample composed of racially and ethnically diverse families of preschool-aged children with a well-characterized ASD diagnosis, and (3) performing longitudinal assessment of intervention effects up to 12 months post-intervention. We also employed methodologically stringent measurement of parenting stress to enable use of a latent variable approach, thereby enhancing internal validity and interpretability. We hypothesized that MBSR would be more efficacious in reducing parenting stress than PE as indexed by reductions in parenting stress immediately post-intervention and at 6- and 12-month follow-up.

Method

Participants

Participants included 117 families of autistic children aged 3 to 5 years who participated in the Stress-reduction Techniques for Enhancing Parenting Skills (STEPS) Project. Families were recruited through the community from September 2018 to March 2021. Families were primarily recruited from the Inland Empire Regional Center, which is a government agency that contracts services for individuals with developmental disabilities. Additional recruitment was completed through participating universities, community disability groups, local agencies that provide services for autistic children, local preschools, and community events for families of children with developmental disabilities.

Data were gathered across three separate cohorts, with assessments at baseline, immediate post-intervention, and at 6- and 12-months post-intervention. Procedures were primarily in person for the first two cohorts. However, due to the COVID-19 pandemic and prohibitions against in-person activities, the 6- and 12-month follow-up assessments for cohort 2 (n=36) were conducted virtually. All procedures for cohort 3 (n=51) were also completed virtually, with the exception of direct assessments of intellectual functioning and receptive language, which were completed once in-person activities resumed post-intervention.

Study inclusion criteria were: (a) child community ASD diagnosis—or waitlisted for a community ASD assessment—with diagnostic symptoms verified by study-administered assessments, (b) child age 3 to 5 years, and (c) parent ability to complete study procedures in English. Exclusionary criteria included: (a) positive screen for active parental psychosis, substance abuse, or suicidality according to the associated modules of the Structured Clinical Interview for DSM Disorders, Research Version Non-Patient Edition (First et al., 2002); (b) parent participation in an auxiliary mental health treatment or support group at time of randomization; and (c) child motor impairment that would prevent participation in the parent-child interaction tasks that were part of the larger assessment protocol (e.g., difficulty sitting independently). Families not meeting study eligibility were provided with appropriate community referrals. Table 1 presents sample demographic and clinical information. Most primary caregivers were mothers with relatively diverse racial/ethnical and socioeconomic backgrounds. Over half of primary caregivers endorsed clinically-significant parenting stress at baseline (> 85th percentile, Parenting Stress Inventory-Parental Distress scale). Most children were boys; the majority met DSM-5 (American Psychiatric Association, 2013) criteria for co-occurring ID according to study-administered assessments (IQ and adaptive behavior < 76), and exhibited clinically-elevated parent-reported behavior problems (Child Behavior Checklist; Achenbach, 2000).

Table 1.

Demographic and Clinical Characteristics of Participants

MBSR (n = 59) PE (n = 58) Significance Test
Child Characteristics
Male (%) 78 82.8 Χ2(1) = 0.425, p = .514
 Mean Age (SD) 4.370(0.878) 4.375(0.968) t(115) = 0.029, p = .977
 Race/Ethnicity (%)
White 22 17.2 Χ2(1) = 0.425, p = .514
Latinx 40.7 48.3 Χ2(1) = 0.684, p = .983
Black 5.1 5.2 Χ2(1) = 0.000, p = .408
Asian 3.4 8.6 Χ2(1) = 1.423, p = .233
Native American 0 0 --
Pacific Islander 0 1.7 Χ2(1) = 1.026, p = .311
Other 6.8 1.7 Χ2(1) = 1.827, p = .176
Multiracial 22 17.2 Χ2(1) = 0.425, p = .514
Mean IQ (SD) 68.595(21.588) 66.750(18.737) t(80) = −0.412, p = .681
Mean Adaptive Behavior (SD) 68.234(10.104) 69.365(8.843) t(97) = 0.594, p = .554
Intellectual Disability (%) 69.1 66 Χ2(1) = 0.115, p = .735
Mean ASD Symptom Level (SD) 7.281(1.611) 7.471(1.813) t(64) = 0.447, p = .656
Mean SCQ total score (SD) 21.745(5.376) 20.339(5.593) t(109) = −1.350, p = .180
Mean Receptive Vocabulary Score (SD) 72.455(28.166) 64.125(30.550) t(63) = −1.143, p = .257
CBCL Externalizing Problems (SD) 68.396(11.335) 66.491(11.393) t(104) = −0.863, p = .390
Clinically Elevated CBCL Externalizing Problems (T > 63; %) 67.9 67.9 Χ2(1) = 0.000, p = 1.000
Primary Caregiver Characteristics
Mean Primary Caregiver Age (SD) 34.559(7.541) 34.672(7.529) t(115) = 0.081, p = .935
Primary Caregiver Female (%) 93.2 87.9 Χ2(1) = 0.961, p = .327
Primary Caregiver Race/Ethnicity
(%)
White 20.3 22.4 Χ2(1) = 0.075, p = .784
Latinx 54.2 48.3 Χ2(1) = 0.416, p = .519
Black 5.1 6.9 Χ2(1) = 0.171, p = .680
Asian 3.4 8.6 Χ2(1) = 1.423, p = .233
Native American 0 0 --
Pacific Islander 0 1.7 Χ2(1) = 1.026, p = .311
Other 3.4 1.7 Χ2(1) = 0.325, p = .569
Multiracial 13.6 10.3 Χ2(1) = 0.287, p = .592
Primary Caregiver Education (%) Χ2(4) = 5.064, p = .281
High school or less 31 17.2
Some college 22.4 20.7
Technical Degree/AA 19 34.5
Bachelor’s Degree 13.8 15.5
Graduate Degree 13.8 12.1
Primary Caregiver Marital Status (%) Χ2(5) = 7.935, p = .160
Married 55.9 67.2
Living Together 15.3 13.8
Separated 3.4 8.6
Divorced 1.7 0
Widowed 1.7 3.4
Single 22 6.9
Mean Primary Caregiver
Mainstream Acculturation Status (VIA) Score (SD) 67.660(16.529) 67.210(15.126) t(100) = −0.144, p = .886
Parental Depression (CES-D) Score (SD) 19.481 (12.690) 16.962 (9.715) t(103) = −1.140, p = .257
Primary Caregiver Stress
Form Parental Distress Subscale 37.472(9.192) 37.434(8.354) t(104) = −0.022, p = .982
(SD)
Mean Family Impact Questionnaire, Negative Impact Subscale (SD) 37.170(13.964) 36.423(12.632) t(104) = −0.289, p = .773
Mean Parenting Daily Hassles, Intensity Subscale (SD) 59.660(17.402) 58.152(19.428) t(104) = −0.421, p = .675
Family Characteristics
Annual Gross Family Income (%) Χ2(4) = 2.607, p = .626
 <$30k 25.4 28.3
 $30k to <$50k 18.6 15.1
 $50k to <$70k 15.3 22.6
 $70k to <$90k 13.6 17
 >$90k 27.1 17
Primary Home Language (%) Χ2(2) = 5.698, p = .058
 English 91.5 80.7
 Spanish 0 8.8
 Other 8.5 10.5
Services in Past 6 Months
Primary Caregiver Mental Health Services (Yes; %) 34.5 31.6 Χ2(1) = 0.110, p = .741
Primary Caregiver Parenting Classes (Yes; %) 15.5 13.8 Χ2(1) = 0.069, p = .793
Any Target Child Services (Yes; %) 87.9 91.4 Χ2(1) = 0.372, p = .542
Any Target Child ABA (Yes; %) 56.1 53.4 Χ2(1) = 0.084, p = .772
Mean Number of Months of Target Child ABA (SD) 4.695(8.105) 4.966(8.792) t(115) = −0.563, p = .886
Mean Number of Sessions of Target Child ABA (SD) 11.271(16.329) 9.810(11.254) t(115) = 0.173, p = .575
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Note. Abbreviations: MBSR = Group receiving Mindfulness-Based Stress Reduction. PE = Group receiving Psychoeducational Support. SCQ = Social Communication Questionnaire.

CBCL = Child Behavior Checklist. VIA = Vancouver Index of Acculturation. CES-D = Center for Epidemiologic Studies Depression Scale. ABA = Applied Behavior Analysis Therapy.

Procedure

Procedures were approved by the Institutional Review Board of participating universities, with data collection centered at a single site. Interested parents contacted the research team by phone, postcard, or the study website. Following an initial phone screening, eligible families were scheduled for a baseline laboratory assessment and provided informed consent.

Baseline Assessment

A battery of standardized psychological assessments were administered to assess child cognitive functioning (Stanford-Binet-5 ABIQ; Roid, 2003), child receptive language (Peabody Picture Vocabulary Test-4; Dunn & Dunn, 2007), and ASD diagnostic status. Parents also participated in an interview to collect information on family demographics and service utilization, and to evaluate the child’s adaptive behavior (Vineland Adaptive Behavior Scales-3; Sparrow et al., 2016). In addition to lab assessments, parents completed a packet of questionnaires.

For Cohorts 1 and 2, ASD diagnostic confirmation was completed through a multi-method assessment involving administration of a standardized parent-report form, the Social Communication Questionnaire (SCQ; Rutter, Bailey et al., 2003), and direct testing with Autism Diagnostic Observation Schedule-2 (ADOS-2; Lord et al., 2012). One child did not meet the ADOS-2 criterion for ASD classification, but was retained following completion of an in-depth clinical best estimate. This child had an existing community diagnosis of ASD and met the age-adjusted clinical criterion on the SCQ (Corsello et al., 2007). Due to COVID-19 prohibitions on in-person activities, Cohort 3 diagnostic status was ascertained using a battery of parent-report measures involving two standardized questionnaires—the SCQ and the Social Responsiveness Scale-2 (SRS-2; Constantino & Gruber, 2012)—and administration of a comprehensive semi-structured interview, the Autism Diagnostic Interview-Revised (ADI-R; Rutter, LeCouteur et al., 2003). Nine children did not meet the diagnostic threshold on the ADI-R. Six of these children were retained in the sample following completion of clinical best estimate procedures. All six of these children had an existing community diagnosis of ASD and met the age-adjusted clinical threshold on the SCQ (Corsello et al., 2007). Five of the six children also met clinical criteria on the SRS-2.

At the conclusion of the baseline visit, families were randomly assigned to MBSR (n = 59) or PE (n = 58). Group size ranged from 14 to 26 for MBSR, and 16 to 21 for PE, χ2(2) = 0.757, p = .685. Figure 1 depicts the CONSORT diagram and flow through the study.

Figure 1.

Figure 1

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CONSORT Diagram

Participation Enhancement

Following intervention assignment, we deployed an adapted version of Nock and Kazdin’s (2005) Participation Enhancement Intervention (PEI) at the conclusion of the baseline visit (see also Fenning, Butter, Norris et al., 2022; Fenning, Butter, Macklin et al., 2022). Our adapted PEI represented a brief motivational interviewing module designed to optimize intervention engagement and reduce anticipated barriers. We worked individually with parents for 10 to 30 minutes to develop a collaborative plan to promote parent-identified intervention goals and to proactively address potential barriers to intervention engagement. PEI sessions were also deployed as needed to support engagement throughout intervention. Planned boosters were delivered after session 6 and post-intervention to promote follow-up.

MBSR Intervention

The MBSR intervention followed the established MBSR manual (Kabat-Zinn, 2013) and included eight weekly 2-hour group sessions, a 6-hour meditation retreat on the weekend after session 6, 30–45 minutes of daily home practice guided by instructional audio, and a MBSR parent workbook. Formal mindfulness exercises aimed to increase the capacity for mindfulness and included body scans, mindful yoga, and sitting meditation. Participants were also taught to practice mindfulness informally in everyday activities. Additionally, during groups, participants broke into dyads to discuss daily homework practice and met as a large group to discuss mindfulness practice in everyday life. The MBSR intervention was delivered by a certified MBSR instructor with over 20 years of experience and was co-led by a clinical psychology doctoral student who had experience with MBSR and received weekly supervision with the certified instructor.

Psychoeducational Support (PE)

In order to provide a rigorous test of the efficacy of MBSR in reducing parenting stress, we employed an active comparator matched for contact. The PE group ran concurrently with the MBSR group, and was conducted at the same time and location, but on different weekdays in order to avoid intervention contamination. The PE condition consisted of 8 weekly 2-hour sessions; a 6-hour family resource fair after session 6; daily homework that included monitoring progress on goals identified at the end of each session; and a parent workbook that provided information regarding their child’s development, disability, and associated considerations. To enhance external validity, the PE group was modeled after the support groups offered to parents of autistic children in the local community. Each session had a general topic for discussion (e.g., Preparing for Individualized Education Plan meetings, Parent Advocacy, Sibling Issues). At the start of each session, group leaders provided didactic instruction on the topic, then facilitated small- and large-group discussion. PE group sessions were led by parents of children with developmental disabilities who were identified as local community leaders working in the field. The PE groups were also co-led by clinical psychology doctoral students who received weekly supervision with a clinical psychologist and parent group leader.

Intervention Adaptations for COVID-19

Interventions for Cohort 3 were delivered virtually due to pandemic-related restrictions on in-person activities. Families were provided with a tablet and/or an internet hotspot as needed to facilitate intervention participation. Virtual session duration and format were consistent with in-person groups, with virtual groups using online breakout rooms to facilitate dyadic and small group discussions. The 6-hour meditation retreat (MBSR) and the resource fair (PE) were also conducted online.

Childcare

Childcare was provided for parents during all in-person MBSR and PE sessions. Given the virtual format, Cohort 3 did not receive childcare support, though we did troubleshoot barriers to participation associated with childcare needs.

Post-Intervention Assessment

After completion of the intervention, parents participated in post-intervention assessments as well as 6- and 12-month follow-up assessments. Assessments followed baseline procedures with the exception of child testing and the Vineland, which were not conducted. Study staff collected updated demographic and service information and parents completed the questionnaire packets again.

Community Involvement Statement

Family members of autistic individuals have been involved in all aspects of this study. Recruitment was conducted in partnership with community programs, and family members and community partners were involved in the development and implementation of PE intervention.

Measures

Demographic Information.

Child and parent ages, races, ethnicities, family income, child diagnoses, and services received were collected via parent interview.

Parenting Stress Measures.

To comprehensively examine parenting stress, we assessed: general distress, stress specific to the child’s condition, and daily parenting hassles. The Parental Distress subscale of the Parenting Stress Index-4, Short Form (PSI4-SF-PD; Abidin, 1995) was used to assess parents’ perceived general distress in the parenting role (study alphas .83– .88). The Negative Impact scale of the Family Impact Questionnaire (FIQ-NI; Donenberg & Baker, 1993), which asks about the child’s impact on the family relative to the impact of other children his/her age, was used to assess stress specific to the autistic child (study alphas .87 to .92). Finally, the Intensity subscale of the Parenting Daily Hassles questionnaire (PDH-I; Crnic & Greenberg, 1990) was used to assess parents’ perceived intensity of daily stressors related to caregiving demands and responsibilities (study alphas .90–.94).

Statistical Analysis

We performed intention-to-treat analyses using a series of two-level linear growth curve models to examine the outcome variable of parenting stress. Repeated measures across time at Level 1 were nested within individuals (primary caregivers) at Level 2. Time was defined according to study time points (Baseline, Post-Intervention, 6-month, and 12-month Follow-Up), and was centered at baseline for purposes of improved interpretability. Parenting stress was a latent variable defined by three indicator variables: PSI-4-SF-PD, FIQ-NI, and PDH-I. The FIQ-NI had the strongest overall reliability (α = 0.92), and was therefore used to set the metric for the parenting stress factor. The data were evaluated for and met the assumptions of multilevel modeling (e.g., Singer & Willett, 2003).

Preliminary analyses were conducted using SPSS 28 to identify potential covariates to include in the main analyses. We examined associations between each of the variables listed in Table 1 and all outcome indicator variables at each study time point. The following Level-2 variables were then selected as covariates due to having significant relationships with our outcome indicator variables: whether or not anyone in the family had received any type of mental health services in the six months prior to the baseline assessment (0 = No, 1 = Yes) and the number of months that the target child had received applied behavior analysis services at baseline; these two variables were centered to improve interpretability, ps < .05.

We also tested rates of attrition between the intervention groups. Individuals who were randomized but did not complete a post-intervention or follow-up assessment were defined as study dropouts There were no significant differences in attrition between the MBSR and PE groups, between intervention modalities (in-person vs. virtual), or across the three study cohorts. Additionally, we tested for differences between intervention completers and dropouts based on variables in Table 1. Intervention completers differed from those who dropped out in that they were more likely to have received mental health services for their child’s primary/secondary diagnosis and the target child was less likely to be Latinx. Mental health services were included as a covariate in our statistical models due to associations with all three outcome variables at multiple time points. Child ethnicity was not included as a covariate because it was not consistently associated with any of our outcome variables over time.

Finally, we tested for differences between study cohort affected by COVID (Cohort 3) and cohorts not affected by COVID (Cohorts 1 and 2) on all variables listed in Table 1 and all variables included in the multilevel models. There were few differences between the groups, and none of these differences were statistically significant after correcting for elevated familywise Type I error due to conducting so many analyses.

Multilevel models were tested in the following order: (1) the unconditional means model, (2) the unconditional growth model, (3) a model in which intervention group (0 = PE, 1 = MBSR) was allowed to predict baseline parenting stress, (4) a model in which Level 2 covariates (described above) were allowed to predict baseline parenting stress in addition to intervention group, and (5) a model in which intervention group was allowed to predict change in parenting stress over time. Each model was tested to determine if it fit the data significantly better than the previous model.

A missing values analysis indicated rates of missingness that varied from 0% to 35.7% (PDH-I), and missingness exceeded the traditionally recommended cutoff of 5% for our three outcome indicator variables (Graham, 2009). Therefore, we imputed missing data using Blimp 3 (Keller & Enders, 2021), which utilizes Bayesian imputation and an iterative Markov chain Monte Carlo (MCMC) algorithm, and assumes that the data are missing at random. This imputation method is preferable to more commonly used modern approaches such as multiple imputation and full information maximum likelihood estimation because it accounts for the multilevel structure of the data (Enders et al., 2020). We assessed convergence using potential scale reduction factor diagnostics and trace plots, and assessed whether the number of estimates for each parameter was sufficient by examining number of effective sample sizes (Gelman et al., 2014; Gelman & Rubin, 1992). Based on these metrics, we specified two MCMC chains with between 5,000 and 150,000 burn-in iterations and post burn-in iterations, depending on the model. Twenty multiply imputed data sets per model were then saved and imported into RStudio 2022.07.0 for multilevel analysis.

Blimp 3 was used for main effects and simple slopes analyses following significant cross-level interactions. Blimp provides the results of Bayesian estimation, which include posterior median estimates of parameters and their associated 95% credible intervals (95% CrIs). A Bayesian credible interval is interpreted as the probability that the true effect lies within a specified interval, given the evidence provided by the observed data (Hespanhol et al., 2019). The values of Bayesian credible intervals and traditional frequentist confidence intervals are often nearly identical in practice (Albers et al., 2018), and therefore we interpret a 95% CrI that does not include one as representing a statistically significant effect at p < .05.

Results

Intervention Fidelity.

Both groups were monitored for adherence to intervention targets. Independent research assistants observed each intervention session and completed intervention fidelity checklists. Interventionist fidelity scores were calculated according to the percentage of intervention components completed as outlined in the MBSR and PE group manuals. Collapsing across modalities and cohorts, the MBSR interventionists completed 98.03% of the possible fidelity items and the PE interventionists completed 97.89% of the possible fidelity items, t(4] = −.112, p > .05, 95% CI [−3.51, 3.23]. Overall total contact time for the MBSR group across cohorts was 1247.00 minutes (SD = 58.39) and 1107.67 minutes (SD = 161.33) in the PE group, which was not significantly different, t(4)= −1.41, p > .05, 95% CI [−414.35, 135.69].

Parenting Stress

The fifth and final model, in which intervention group was allowed to predict change in parenting stress over time, fit the data best (see Table 2). In that model, there were no differences in parenting stress at baseline between MBSR and PE (b = 0.194, p > .05). Parenting stress significantly decreased over time in both groups (b = −2.647, p < .0001), but that relationship was significantly stronger for participants in MBSR than for participants in PE (b = −1.970, p < .05). On average, parental distress decreased by 4.694 points at each time point for participants in MBSR (95% CrI [−6.055, −3.417]), and by 2.620 points at each time point for participants in PE (95% CrI [−4.018, −1.286]). Simple slopes analyses indicated that there was a significant difference in parental distress between the MBSR and PE groups at 12-month follow-up, such that the median estimate of the latent parental distress score was 5.906 points lower for the MBSR group than the PE group at that time point (95% CrI [−11.145, −0.720], respectively). There were no significant differences in parenting stress between the groups at baseline, immediate post-intervention, or 6-month follow-up (95% CrI −3.674, 4.153], 95% CrI [−5.292, 1.701], and 95% CrI [−7.897, 0.161], respectively; see Figure 2). Our model explained approximately 46.0% of the variance in parental distress at Level 1, 22.8% of the variance in the intercept (average baseline parental distress score) at Level 2, and 29.3% of the variance in the slope (change in parental distress over time) at Level 2.

Table 2.

Results of Multilevel Models Predicting Initial Status and Change in Parenting Stress Over Time

Parenting Stress
Fixed Effects
 Initial Status(π0i) Intercept (γ00) −0.217
Intervention Group (γ01) 0.194
Mental Health Services (γ02) 4.653*
Months of ABA (γ03) 0.365**
 Rate of Change(π1i) Intercept (γ10) −2.647***
Intervention Group (γ11) −1.970*
Random Effects
 Level 1 Within-Person (σ2e) 36.968
 Level 2 Initial Status (σ2ζ0) 52.94
Rate of Change (σ2ζ1) 3.919
R 2 R 2 e 0.460
R 2 0 0.228
R 2 1 0.293
Open in a new tab
*

p < .05.

**

p < .01.

***

p < .001.

Figure 2.

Figure 2

Open in a new tab

Change in Parenting Stress Over Time by Intervention Group

Note. PE = psychoeducation group and MBSR = mindfulness based stressed reduction group. Graph is adjusted for family mental health services in the six months prior to baseline and number of months of ABA at baseline. Parenting stress latent variable scores are reported.

Discussion

The current study stringently tested MBSR (Kabat-Zinn, 2013) efficacy in reducing parenting stress for parents of preschool-aged autistic children. Utilizing a racially/ethnically and socioeconomically diverse sample, we employed a methodologically rigorous design involving an active comparator, multiple measures of parenting stress, and long-term follow-up. All parents reported reduced parenting stress over time. However, MBSR reduced parenting stress more than did PE, and the benefit of MBSR increased over time, with significant differences emerging between groups at the final 12-month follow-up.

Although MBSR outperformed PE in reducing parenting stress over time (i.e., at 12-month follow-up), comparable improvements in parenting stress among parents in PE up to 6 months post-intervention suggest efficacy of both stress-reduction interventions for parents of young autistic children. Findings may also point to the benefit of PE in directly addressing the social support, informational, and services navigation needs of this population, particularly during a sensitive period for early intervention. Nonetheless, the informational and supportive benefits of PE may reach a ceiling. On the other hand, the steeper improvements found among the MBSR group (versus PE) at 12-months post-intervention may reflect parents’ sustained use—and continued benefit from—stress-reduction techniques taught in MBSR. Evidence of steady improvements in parenting stress up to 12 months post-intervention contrasts with existing literature which has assessed outcomes up to 6-months post-intervention at most and has largely found intervention effects to taper over time (e.g., Weitlauf et al., 2020).

A key contribution of the current study is the inclusion of an active comparator involving a manualized psychoeducation and support intervention, a service which is commonly offered to parents of children with developmental disabilities (Hastings & Beck, 2004), but lacks sufficient efficacy data. Our trial thus provides foundational evidence of the stress-reduction benefits of PE for underserved families. Although MBSR produced greater and more prolonged stress amelioration, evidence that both approaches confer benefit provides compelling options for supporting parents of young autistic children. Future research would benefit from examining potential moderators of intervention outcome in order to further refine and individualize clinical decision making.

This study possesses several strengths and addresses important gaps in the current literature. First, we utilized a well-characterized and racially, ethnically, and socioeconomically diverse sample. We assessed three different types of parenting stress that have been investigated in families of autistic children (general distress, stress specific to the child’s condition, and daily parenting hassles) to comprehensively examine this construct. Additionally, we employed a longer follow-up period than existing literature, which enhances the external validity of our findings. Taken together, this study provides the most rigorous test of the efficacy of MBSR for parents of autistic children to date.

Findings from this study must also be considered in the context of several limitations. The onset of the COVID-19 pandemic and associated restrictions on in-person activities changed our procedures mid-study and likely impacted parents’ stress levels and experiences in the interventions. Additionally, while the use of an active comparator was a significant strength of the study’s design, we did not have a no-intervention control group and therefore we cannot evaluate the benefit of the MSBR of PE interventions relative to normative changes in parenting stress over time. However, a recent waitlist-control mindfulness intervention for parents of autistic children found that control participants significantly increased in parenting stress over the course of two months without treatment (Schwartzman et al., 2022). We speculate that our underserved parents would have followed a similar or exacerbated trajectory in a no-intervention control group. Given the risks of untreated stress in this population and our focus on families experiencing high levels of strain, we opted for a stringent active comparison condition.

The present study explicitly focused on parenting stress. Future studies should examine the potential benefits of MBSR and PE for other facets of parental well-being (e.g., anxiety, life satisfaction, self-efficacy), parenting cognitions (e.g., parenting self-efficacy), and parenting behavior. Indeed, evidence suggests that parenting cognitions and behaviors may underlie associations between parenting stress and child externalizing behavior problems and that low resources may intensify these effects (Stephenson et al., 2022). Thus, future studies should also examine how changes in parent-level factors following MBSR and PE influence child outcomes in this population. Finally, since MBSR is an intensive intervention that requires a highly-trained interventionist that may not be available in most clinical settings, a future dismantling study identifying the key elements, intensity, and training required to enact significant change would facilitate broader dissemination, particularly to underserved communities.

MBSR and PE were efficacious in reducing stress for parents of preschool-aged autistic children. Stress amelioration was especially pronounced and lasting for parents receiving MBSR. Our results may inform efforts to disseminate evidence-based interventions that attenuate parenting stress in this population during a critical window for early intervention.

Statements and Declarations

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. Procedures were approved by the Institutional Review Board at Loma Linda University in collaboration with the additional participating universities. This work was supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health to the first three authors (R15HD091726-01A1). The authors have no relevant financial or non-financial interests to disclose.

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