Journal
JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY
Volume 56, Issue 2, Pages 162-170Publisher
WILEY
DOI: 10.1111/jcpp.12291
Keywords
Autism; measurement error; mediation; parent-child interaction; parent-focussed therapy
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Funding
- University of Manchester
- Manchester Biomedical Research Centre
- Medical Research Council [G0401546]
- UK Department for Children, Schools and Families
- UK Department of Health
- MRC [MR/K006 186/1]
- Medical Research Council [MR/K006185/1, G0401546] Funding Source: researchfish
- MRC [MR/K006185/1, G0401546] Funding Source: UKRI
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BackgroundThe PACT randomised-controlled trial evaluated a parent-mediated communication-focused treatment for children with autism, intended to reduce symptom severity as measured by a modified Autism Diagnostic Observation Schedule-Generic (ADOS-G) algorithm score. The therapy targeted parental behaviour, with no direct interaction between therapist and child. While nonsignificant group differences were found on ADOS-G score, significant group differences were found for both parent and child intermediate outcomes. This study aimed to better understand the mechanism by which the PACT treatment influenced changes in child behaviour though the targeted parent behaviour. MethodsMediation analysis was used to assess the direct and indirect effects of treatment via parent behaviour on child behaviour and via child behaviour on ADOS-G score. Alternative mediation was explored to study whether the treatment effect acted as hypothesised or via another plausible pathway. Mediation models typically assume no unobserved confounding between mediator and outcome and no measurement error in the mediator. We show how to better exploit the information often available within a trial to begin to address these issues, examining scope for instrumental variable and measurement error models. ResultsEstimates of mediation changed substantially when account was taken of the confounder effects of the baseline value of the mediator and of measurement error. Our best estimates that accounted for both suggested that the treatment effect on the ADOS-G score was very substantially mediated by parent synchrony and child initiations. ConclusionsThe results highlighted the value of repeated measurement of mediators during trials. The theoretical model underlying the PACT treatment was supported. However, the substantial fall-off in treatment effect highlighted both the need for additional data and for additional target behaviours for therapy.
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