Find an experimental research study on the topic chosen in Week One for your Final Research Proposal. You may choose to include an experimental study which was included in the literature review you us

Multidisciplinary Parent Education for Caregivers of Children with Autism Spectrum Disorders Binbin Ji a,b , Mei Sun b, Rongfang Yi c, Siyuan Tang b,⁎ aSchool of Nursing, Hunan University of Chinese Medicine, Changsha, ChinabSchool of Nursing, Central South University, Changsha, ChinacThe second Xiangya hospital of Central South University, Changsha, China abstract This quasi-experimental study aimed to determine the effectiveness of a multidisciplinary parent education program focused on improving health-related quality of life (HRQOL) for caregivers of children with autism spectrum disorders (ASD). This study included 42 participants (22 intervention, 20 wait-list control) who were the main caregivers of children with ASD. Data were collected at baseline and post-intervention.

At the end of the multidisciplinary parent education program, signiﬁcant improvements were observed in the mental HRQOL, family functioning, self-efﬁcacy and positive coping style. The results indicate that a multidisciplinary parent education program, designed for caregivers of children with ASD, may have positive effects on caregivers' mental health-related quality of life, while having little effect on their physical health- related quality of life.

© 2014 Elsevier Inc. All rights reserved. The identiﬁed prevalence of autism spectrum disorder (ASD) has increased signiﬁcantly around the world over the last few decades (Australian Bureau of Statistics, 2011; Centers for Disease Control and Prevention, 2012; Kim et al., 2011). About 1 in 88 children has been identiﬁed with an ASD according to estimates from the CDC'sAutism and Developmental Disabilities Monitoring Network (2012).

In China, Professor Taoﬁrst reported four cases of children with ASD in 1982 and subsequently, about 1.8 million children with ASD have been reported across the country (Autism-World, 2008). Raising a child with ASD can be a challengeable experience for caregivers.

Previous studies show that caregivers of children with ASD have lower health-related quality of life (HRQOL) as compared to caregivers of typically-developing children (Allik, Larsson, & Smedje, 2006) and caregivers of children with other development disabilities or physical impairments (Abbedutao et al., 2004). In addition, caregivers' HRQOL impacts on the quality of care provided to the child (Beach et al., 2005). Consequently, improving HRQOL in caregivers of children with ASD is overdue.

Previous studies demonstrate that HRQOL of caregivers of children with ASD is affected by several variables, including demographics of the caregivers and care recipients (Lee et al., 2009), family functioning (Johnson, Frenn, Feetham, & Simpson, 2011; Khanna et al., 2011), social support (Khanna et al., 2011; Zablotsky, Bradshaw, & Stuart, 2013),caregiver burden (Khanna et al., 2011; Zablotsky et al., 2013), and maladaptive coping (Khanna et al., 2011; Zablotsky et al., 2013). Our previous research also found that besides the socio-demographic characteristics of children with ASD and their caregivers, family functioning, caregiver burden, coping style and social support are the main predictors of HRQOL of caregivers of children with ASD (Ji et al., 2014). Therefore, in order to improve caregivers' HRQOL, comprehensive interventions that incorporate these components are recommended.

Parent education is deﬁned as an educational effort that attempts to enhance or facilitate parent behaviors that will, in turn, inﬂuence positive developmental outcomes in the participants and their children (Smith, Perou, & Lesesne, 2002). Previous studies have conﬁrmed that parent education programs that include counseling components or focus on counseling aspects (managing emotions, cognitions and behavior) are useful for parents of children with ASD (Bitsika & Sharpley, 1999, 2000). A review of parent education programs for parents of children with ASD (Schultz, Schmidt, & Sticher, 2013), showed that parent education can increase knowledge and skills in caring for the children with ASD, with two potential beneﬁts: reducing parent stress and increasing parents' sense of competence. Currently, most parent education programs target on improving the child's behavior and communicative capacity. However, limited research has studied the impact of parent education on HRQOL of caregivers of children with ASD.

In one such study,Christodulu, Rinaldi, Knapp-Ines, Hiruma, and Costanzo (2012)found that families of children recently diagnosed with ASD beneﬁted greatly from participating in a multidisciplinary parent education program. Parents who participated reported improvements in overall quality of life following the program, and Archives of Psychiatric Nursing 28 (2014) 319–326 ⁎Corresponding Author: Siyuan Tang, PhD, Professor, Head of School, School of Nursing, Central South University, Changsha, China.

E-mail addresses:[email protected](B. Ji),[email protected](M. Sun), [email protected](R. Yi),[email protected],[email protected](S. Tang).

http://dx.doi.org/10.1016/j.apnu.2014.06.003 0883-9417/© 2014 Elsevier Inc. All rights reserved. Contents lists available atScienceDirect Archives of Psychiatric Nursing journal homepage:www.elsevier.com/locate/apnu also had greater knowledge of ASD (Christodulu et al., 2012).

Although the study byChristodulu et al. (2012)shed some light on the effectiveness of multidisciplinary parent education on quality of life among caregivers of children with ASD, there were a few limitations that restricted its generalizability. First, the study had a small sample size (only 14 parents participated in the program).

Second, the main aim of the study was to identify the impact of a multidisciplinary parent education program on stress, knowledge and quality of life. The impacts of a multidisciplinary parent education program on other predictors of quality of life, such as caregiver burden, family functioning, social support and coping style, were not studied. In the current study, we focused on a multidisciplinary parent education that incorporated four subjects (community nursing, psychiatry, psychology and special education), improving caregivers' HRQOL, through teaching ASD related knowledge and skills, and stress and mood self-management, and how to deal with family problems.

THEORETICAL FRAMEWORK The theoretical foundation ofthe multidisciplinary parent education intervention was based onKhanna et al.'s (2011) conceptual model of factors inﬂuencing HRQOL among caregivers of children with ASD. This conceptual model was also conﬁrmed in our previous study (Ji et al., 2014). Consistent with this conceptual model, Psychologist Albert Bandura (Luszczynska & Schwarzer, 2005) deﬁned self-efﬁcacy as one's belief in one's ability to succeed in speciﬁc situations. This sense of self-efﬁcacy can play a major role in how people approach goals, tasks, and challenges.

It is proposed that caregivers of children with ASD would beneﬁt from learning basic information about ASD; skills for taking care of children with ASD, strengthening positive coping style and mood self-management capacity were also included in this intervention.

Enhancing family functioning and utilizing social support were also included to improve health-related quality of life of caregivers of children with ASD. Perceived social support, coping style and family functioning were conceived as proximal outcomes, and caregiver burden, self-efﬁcacy and health-related quality of life as distal outcomes (seeFig. 1).

PURPOSE OF THE STUDY The main aim of the current studywas to assess the effectiveness of a multidisciplinary parent education program designed to improve health-related quality of life in caregivers of children with ASD.METHODS Research Design This research was conducted as a quasi-experimental study to assess the effectiveness of a multidisciplinary parent education program, prepared to improve health-related quality of life for caregivers of children with ASD.

Sample This is a quasi-experimental study, conducted in two autism rehabilitation centers in Hunan Province of China from June to July 2013. The study sample consisted of 50 caregivers of children with ASD in two autism rehabilitation centers (Ai-meng rehabilitation center and Xing-yuan rehabilitation center) in Hunan Province, China.

To prevent interaction and potential cross-contamination between the intervention group and the wait-list group, a cluster randomized trial was used. Caregivers in Ai-meng rehabilitation center were randomly assigned to the intervention group (27 caregivers), while caregivers in Xing-yuan rehabilitation center were randomly assigned to the wait-list control group (23 caregivers). However, 5 caregivers from the intervention group and 3 caregivers from the control group discontinued the sessions for various reasons. Therefore, theﬁnal intervention group consisted of 22 caregivers and theﬁnal control group consisted of 20 caregivers (seeFig. 2). Power analysis was based on the results of a pilot study. The power calculations (based on a power calculation of 80% and a signiﬁcance level of 5%) suggested that 22 caregivers in the intervention group and 20 caregivers in the wait- list control group would be sufﬁcient. Ethics approval was obtained from the Central South University Human Research Ethics Committee.

Written informed consent was obtained from each participant prior to their participation in the study.

The inclusion criteria were: (a) having a family member (0 to 14 years old) with a diagnosis of ASD according to theDSM-IVcriteria and ICD-10criteria (American Psychiatric Association, 2000);WHO, 1993and (b) being identiﬁed as the main caregiver of the child/children with ASD; and (c) being 18 years of age or older. Caregivers were excluded if they were cognitively impaired, or if they received payment for taking care of children with ASD, or if they had received any interventions focused on improving quality of life in the 6 months before the study.

INSTRUMENTS Socio-Demographic Variables of Caregivers and Children With ASD The socio-demographic information collected from the caregivers included: age, gender, educational level, religious belief, marital Fig. 1.Multidisciplinary parent education model for caregivers of children with ASD. 320B. Ji et al. / Archives of Psychiatric Nursing 28 (2014) 319–326 status, caregiver-child relationship, place of residence, employment status, number of children, and family income and caring time (hours spent caring for children with ASD per day). Participants were also asked to answer a personal-health questionnaire to identify their child's age, gender, rehabilitation time, age of diagnosis and payment of medical expenses.

Short Form-36 (SF-36) The Chinese version of the SF-36 (2nd edition) was adopted as a measure of HRQOL (Liu & Huang, 2010). It consists of eight subscales (36 items): physical functioning (PF); physical and emotional roles (RP and RE); body pain (BP); general health (GH); vitality (VT); social functioning (SF); mental health (MH); and one single item dimension on health transition. These domains can be further aggregated into a Physical Component Summary (PCS) and a Mental Component Summary (MCS) by weighting the eight domains, both of which are scored from 0 to 100 following a standard algorithm with higher scores representing better HRQOL (Liu & Huang, 2010). This questionnaire is widely used in the Chinese population, and as such demonstrates high reliability and validity (Gong, Zhang, Zhu, Sun, & Feng, 2004; Yang, Wang, Li, & Chen, 2009). In this study, the Cronbach's αfor internal consistency was 0.878.

McMaster Family Assessment Device (FAD) Family functioning was assessed using the FAD (Epstein, Baldwin, & Bishop, 1983). It consists of seven sub-scales with a total of 60 items:

problem solving; communication; roles; affective responsiveness; affective involvement; behavior control; and general functioning.

All items in the FAD are measured on a four-point Likert scale ranging from 1 (indicates a healthy answer) to 4 (indicates a pathological ﬁnding). The scores are calculated by averaging the scores on all items, with higher scores representing greater problems in family functioning.

The Chinese version of the FAD has been used in several studies and it shows good reliability and validity (Su & Duan, 2008). In this study, the Cronbach'sαfor internal consistency was 0.859.Simpliﬁed Coping Style Questionnaire (SCSQ) The simpliﬁed coping style questionnaire includes 20 items, aiming to measure Chinese people's coping style (Wang, Wang, & Ma, 2009). The coping styles in this questionnaire were classiﬁed into two categories: positive coping styles (12 items) and negative coping styles (8 items). Scores range from never (0) to always (3). A previous study (Xie, 1998) showed that the alpha coefﬁcients for the whole scale, positive coping style and negative coping style were 0.90, 0.89 and 0.78, respectively. In the present study, the Cronbach'sαfor internal consistency was 0.89.

Multidimensional Scale of Perceived Social Support (MSPSS) The MSPSS is a self-administered scale which aims to evaluate people's perceived social support from family, friends and signiﬁcant others (Zimet, Powell, Farley, Werkman, & Berkoff, 1990). It includes three domains with a total of 12 items: support from family (4 items); support from friends (4 items); and support from others (4 items).

Items are rated on a 7-point Likert-scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). The total score ranges from 12 to 84, with the higher score suggesting more social support. The Chinese version of the MSPSS (MSPSS-C) is reported to have good reliability and validity (Chou, 2000). A Cronbach'sαof 0.815 was obtained for the MSPSS-C in the current study.

Caregiver Burden Index (CBI) The CBI is a 24-item self-administered questionnaire, which is used to assess caregiver burden. The CBI includesﬁve domains of burden: time burden; burden of personal development limitations; physical burden; social burden; and emotional burden. All items are rated on a four-point scale. Higher scores indicate greater caregiver burden.Novak and Guest (1989)reported that Cronbach'sα value for subscales ranged 0.76–0.96. Good validity and reliability are reported for the Chinese version of CBI for the Chinese population (Chou, Lin, & Chu, 2002). Internal consistency, as assessed by Cronbach's alpha, was 0.875. Fig. 2.Theﬂow of participant through the study.321 B. Ji et al. / Archives of Psychiatric Nursing 28 (2014) 319–326 Childhood Autism Rating Scale (CARS) Severity of autism spectrum disorder symptoms was measured using the teacher-completed CARS (Schopler, Reichler, & Renner, 1988), a 15-item behavioral rating scale used to screen for ASD. Items are rated on a scale of 1 (normal) to 4 (severely abnormal). The higher scores indicate more severe autistic characteristics of the child, with a score of 36 or higher indicating mild to severe autism spectrum disorders (Li, Zhong, Cai, Chen, & Zhou, 2005). The Chinese version of the CARS has strong reliability and validity (Yin, Chen, Luo, & Li, 2011).

In this study, we surveyed the children's primary teachers in the rehabilitation centers using this scale.

The General Self-Efﬁcacy Scale (GSE) The general self-efﬁcacy scale is a 10-item psychometric scale that is designed to assess optimistic self-beliefs in coping with a variety of difﬁcult demands in life. The scale was originally developed in Germany by Matthias Jerusalem and Ralf Schwarzer in 1981,ﬁrst as a 20-item version and later as a reduced, 10-item version (Schwarzer & Aristi, 1997). Items are rated on a scale of 1 (not at all true) to 4 (exactly true). The sum score is calculated by summing the item scores, and ranges between 10 (lowest score) and 40 (highest score).

The higher the score, the greater self-efﬁcacy the respondent possesses.

The Chinese version of GSE wasﬁrst used in research with college students in Hong Kong (Zhang & Schwarzer, 1995). The Chinese version of the GSE has good reliability and validity, and is widely used in China (Xu, Liu, Xian, & Huang, 2010; Zhang & Schwarzer, 1995).

Multidisciplinary Parent Education Evaluation Form The authors developed an evaluation form to assess participants' satisfaction with the multidisciplinary parent education program. This form includes 4 items on the instructor, teaching strategies, course content and overall rating and an open question (suggestions and advice for future multidisciplinary parent education). Items are rated on a scale of 0 (extremely unsatisﬁed) to 10 (extremely satisﬁed). The sum score is calculated by averaging the scores on all items, with higher scores representing greater satisfaction with the multidisci- plinary parent education program.

Intervention The 8-week multidisciplinary parent education program involved once-weekly group classes and was implemented in June and July 2013. All sessions were approximately 90 minutes (10 minute break every 30 minutes) and were taught by a multidisciplinary team. The team included a special education teacher (also the mother of a child with ASD), a community nurse, a psychologist and a physiatrist. The detailed content of the multidisciplinary parent education is shown in Table 1. On the basis of the work ofKhanna et al. (2011)and our previous study, the multidisciplinary parent education focused on the mediators, such as family functioning, social support and coping styles. In addition, the knowledge and skills related to ASD and how to take care of children with ASD were also included. After completing the post-intervention data collection, caregivers in the wait-list control group received the multidisciplinary parent educa- tion for ethical reasons.

Data Collection Data were collected from the end of May through to the beginning of August 2013. Data collections in this study occurred in two parts.

The data include socio-demographic information of caregivers and children with ASD, which was collected prior to the intervention and the outcome variables pre- and post-intervention [data collection for both groups occurred at: baseline (1 week before the intervention) and post-intervention (1 week after the last of eight weeklysessions)]. The data collectors in this part were blinded to group assignment. An evaluation form was used to assess participants' satisfaction with the multidisciplinary parent education program, with eight toﬁfteen caregivers randomly chosen to complete the form after each educational session. The data collector was the course coordinator, who is theﬁrst author of this article.

Statistical Methods Summary descriptive statistics of caregivers' and recipients' socio- demographic data were counts and percentages for categorical variables, and means (SD) for continuous variables. Aχ 2test or an independent-samples t-test was used to examine the differences between the socio-demographic characteristics of caregivers and children in the intervention and control group; an independent- samples t-test was used to compare baseline variables between the intervention and control group; a paired-samples t-test was used to compare the pre- and post-intervention scores on the SF-36, FAD, CBI, MSPSS, SCSQ and GSE scores for the intervention and control caregivers. AP-value ofb0.05 was considered statistically signiﬁcant.

All statistical analyses were performed using SPSS statistical software version 18.0.

RESULTS There were 22 eligible caregivers allocated to the intervention group and 20 to the wait-list control group. Caregivers' average age was 34.10 years, 90% were female, 93% were married, 98% had no religious belief, 83% were the mothers, 76% were unemployed, and 50% were living in a small town or rural area. The average caring time was 18.62 hours. The proportion of caregivers who reported that they had received high school or higher education was 83% and 62% of families had income of less than RMB¥ 3000 per month (1US dollar is equal to approximately 6.0 RMB).

Most of the children were boys (83.0%), and 76% of the children were from one-child families. The mean age was 5.27 years and the mean rehabilitation time was 16.2 months. Most of the children were diagnosed with ASD at about 3 years old. According to the CARS assessment, 50% of the children had mild to severe autism.

The two groups did not differ on socio-demographic characteristics of the children with ASD and their caregivers (allPN0.05;Table 2).

The mean scores of HRQOL, family functioning, caregiver burden, coping style, social support and self-efﬁcacy of caregivers in the intervention and wait-list groups are shown inTable 3. There were no signiﬁcant differences between the intervention group and wait-list control group on outcome variables at baseline (allPN0.05;Table 3).

Table 4shows a comparison of the changes in HRQOL pre- and post-intervention scores between the intervention and control groups Table 1 Multidisciplinary Parent Education Content.

Week Teaching strategies Topic Week one Group (PPT, video) Deﬁnition and clinical manifestations of ASD Week two Group (PPT, case report) Diagnosis, treatment and prognosis of ASD Week three Group (PPT) Daily care, diet care, modiﬁcation of self-injurious behavior Week four Group (PPT) Massage, identiﬁcation of special talents Weekﬁve Group (PPT, role play) Management of Emotion (social support) Week six Group (PPT) Management of stress (positive copy style) Week seven Group (PPT) Importance of family members in development of children Week eight Group (case report, discussion) Family problems we are facing 322B. Ji et al. / Archives of Psychiatric Nursing 28 (2014) 319–326 (N= 42). Only the mean score of MCS was signiﬁcantly increased at theb.05 level in the intervention group.

A comparison of the changes in coping style pre- and post- intervention scores of caregivers in the two groups is shown inTable 5. The mean scores of positive coping style were signiﬁcantly increased at theb.05 level in the intervention group.

Table 6shows a comparison of the changes in pre- and post- intervention scores of caregivers in family functioning, social support, caregiver burden and self-efﬁcacy. For the intervention group, the mean score of family functioning was signiﬁcantly decreased at theb.05 level, and the mean scores self-efﬁcacy was signiﬁcantly increased theb.001.

Table 7displays the mean and standard deviations on measures of caregivers' satisfaction with instructor, teaching strategies, course content and overall rating.

DISCUSSION The purpose of this study was to determine the efﬁcacy of multidisciplinary parent education on HRQOL for caregivers of children with ASD in a controlled quasi-experimental design. Results indicate that there are signiﬁcant differences in measures of mental HRQOL, family functioning, self-efﬁcacy and positive coping style for caregivers in the multidisciplinary parent education condition compared with those in the wait-list control condition. However, there were no signiﬁcant differences in measures of physical HRQOL, caregiver burden, social support and negative coping style between caregivers in the two conditions.

In this study, HRQOL was conceptualized as including both physical HRQOL and mental HRQOL. A statistically signiﬁcant improvement in mental HRQOL was found after the multidisciplinary parent education in the intervention group. A recent study by Christodulu and colleagues recorded a similar result, and the study stated that parents of children with ASD reported improved overall quality of life following completion of a multidisciplinary parent education program (Christodulu et al., 2012). However, the multidis- ciplinary parent education did not show an improvement in physical HRQOL. One explanation is that as accepted byKhanna et al. (2011), the conceptual model of factors inﬂuencing HRQOL among caregivers of children with ASD explained very little variance in caregiver physical HRQOL. Therefore, the multidisciplinary parent education did not include much content focused on improving physical HRQOL.

Another explanation is that an 8-week intervention is too short to improve physical HRQOL, or that physical HRQOL could not be detected in a short time. A longer intervention may be needed and follow-up visits are required to assess the improvement of physical HQROL in future research. Focusing exclusively on physical HRQOL could certainly be an area for future research.

According toBristol (1984), a well-functioning family with a child with ASD is close-knit, able to express emotions, supportive of one another, and involved in outside recreational activities. A well- functioning family may better adapt to the burden of caring for a child with ASD. In this study, a signiﬁcant difference was found between the mean score of family functioning obtained before and after multidis- ciplinary parent education in the intervention group. A similar result was recorded byYildirim, Asilar, and Karakurt (2012) . Their study determined that education given by nurses to mothers of children with intellectual disabilities may be effective in increasing the perception of healthy family functioning. In this study, the multidis- Table 2 Comparison of Demographic Characteristics of Caregivers and Children in intervention and Control Group.

VariablesMean (SD)/frequency (%) χ 2/tP Intervention (n= 22) Wait-list control (n= 20) Characteristics of caregivers Gender Female 20 (90.9) 18 (90.0) Male 2 (9.1) 2 (10.0) 0.010 0.920 Age (years) 32.64 (7.63) 35.70 (8.74)−1.213 0.232 Educational level Primary school or less 1 (4.5) 0 (0) Junior high school 4 (18.2) 2 (10.0) High school 13 (59.1) 14 (70.0) College or above 4 (18.2) 4 (20.0) 1.612 0.657 Marital status Married 21 (95.5) 18 (90.0) Others 1 (4.5) 2 (10.0) 0.470 0.493 Religious belief Yes 0 (0) 1 (5.0) No 22 (100.0) 19 (95.0) 1.127 0.288 Caregiver–child relationship Mother 18 (81.8) 17 (85.0) Father 2 (9.1) 1 (5.0) Others 2 (9.1) 2 (10.0) 0.267 0.875 Place of residence Big city 5 (22.7) 5 (25.0) Medium-sized city 8 (36.4) 3 (15.0) Small town 6 (27.3) 8 (40.0) Rural area 3 (13.6) 4 (20.0) 2.612 0.455 Family income (RMB/month) Less than 999 1 (4.5) 1 (5.0) 1000–2999 15 (68.2) 9 (45.0) 3000–4999 6 (27.3) 7 (35.0) 5000 above 3 (13.6) 3 (15.0) 4.492 0.213 Employed Yes 4 (18.2) 4 (20.0) No 18 (81.8) 16 (80.0) 0.022 0.881 Number of child 1 17 (77.3) 15 (75.0) N1 5 (22.7) 5 (25.0) .030 0.863 Caring time (per day) 17.50 (8.48) 19.85 (6.51)−1.000 0.323 Characteristics of children Age (years) 4.93 (2.03) 5.65 (1.74)−1.229 0.226 Gender Boy 18 (81.8) 17 (85.0) Girl 4 (18.2) 3 (15.0) Age of diagnosis 2.87 (1.20) 3.46 (1.69)−1.305 0.199 Rehabilitation time (months) 17.02 (16.70) 15.30 (14.75) 0.308 0.760 CARS score 37.18 (7.51) 35.75 (5.51) 0.698 0.489 30–36 11 (50.0) 10 (50.0) ≥36 11 (50.0) 10 (50.0) 0.000 1.000 Table 3 Comparison of Outcome Variables at Baseline.

VariablesIntervention (n= 27)Wait-list Control (n= 22) tP SF-36 PCS 63.11 ± 7.42 63.54 ± 9.69−0.159 0.874 MCS 53.85 ± 9.10 51.00 ± 15.96 0.714 0.480 SCSQ Positive Coping Style 1.86 ± 0.60 1.83 ± 0.51 0.164 0.871 Negative Coping Style 1.16 ± 0.44 1.21 ± 0.43−0.351 0.728 MSPSS 60.64 ± 18.48 53.10 ± 13.21 1.506 0.140 FAD 2.31 ± 0.23 2.36 ± 0.26−0.655 0.516 CBI 54.64 ± 14.39 56.85 ± 17.32−0.452 0.654 GSE 23.23 ± 4.85 22.70 ± 4.57 0.362 0.719 Table 4 Comparison of SF-36 Subscales Scores Obtained by Intervention and Control Caregivers Before and After Multidisciplinary Parent Education (N= 42).

SF-36 subscales Pre-intervention Post-interventiontP PCS Intervention 63.11 ± 7.42 68.48 ± 15.38−1.463 0.151 Control 63.54 ± 9.69 66.65 ± 8.92−1.484 0.146 MCS Intervention 53.85 ± 9.10 59.95 ± 9.12−2.138 0.039 Control 51.00 ± 15.96 54.09 ± 13.96 0.714 0.480323 B. Ji et al. / Archives of Psychiatric Nursing 28 (2014) 319–326 ciplinary parent education included two sessions about how to deal with family problems (the importance of family members in development of children; and family problems we are facing). These two sessions were conducted by a special education teacher, who was also the mother of a child with ASD. Specially designed contents and positive examples both enhanced the effect of parent education on family functioning. Thus, theﬁnding indicates that a multidisciplinary parent education program is an effective intervention for family functioning in families with a child with ASD.

Coping is deﬁned as the process by which individuals respond to threats of stress, and coping strategies have been postulated as one mechanism of parental adaptation to the stresses associated with raising a child with a disability (Smith, Seltzer, Tager-Flusberg, Greenberg, & Carter, 2008.) Positive coping style and negative coping style are two major strategies of coping with stressors. It is interesting that a signiﬁcant result was found in positive coping style but not in negative coping style. Perhaps the negative coping style did not reach signiﬁcance as caregivers typically perceived changes of positive coping style outweighed the negative coping style.

Self-efﬁcacy refers to an individual's judgment of their capabilities to meet special environmental demands (Bandura, 1997). In this study, self-efﬁcacy represents beliefs about one's capabilities to take care of children with ASD, and manage the family environment. The ﬁnding of this study demonstrates that the multidisciplinary parent education program designed to improve caregivers' HRQOL could enhance their self-efﬁcacy. A similar result was reported byKuhn and Carter (2006). Their study determined that parent- and family-based interventions designed to support parental well-being and focused on parenting cognitions may enhance parenting self-efﬁcacy.

Our previous research found that the burden of personal development and time burden were the two heaviest burdens among caregivers of children with ASD (Ji, Tang, & Yi, 2012; Ji et al., 2014). This may be the main reason for the insigniﬁcant difference in the mean score of caregiver burden obtained pre- and post- intervention in the intervention group. The average caring time in this study was 18.62 hours per day, compared with 5.6 hours on weekdays and 6.8 hours on weekends inSawyer et al.'s (2010)study.In our study, about 76% caregivers were unemployed in order to take care of the children with ASD. Long caring time and unemployment both greatly affect caregivers' personal development and time burden.

Caregivers and families of children with ASD suffer greater burden in developing counties such as China than those in developed counties, partly because of a lack of knowledge and social support systems (Xiong et al., 2010; Xu, Cheng, Bai, Shi, & Zhang, 2006). However, these caregiver burdens could not be released by a single intervention, social and community support systems need to be developed for families with a child with ASD in China.

In the current study, social supports from families, friends and others were evaluated. As reported byMak and Kwok (2010), these supports are related to psychological well-being of parents of children with ASD. It was unexpected that the intervention appears to have had no effect on social support perceived by caregivers. One possible explanation is that Chinese caregivers of children with ASD intend to restrict disclosure to protect their social image and isolate themselves from others in their community [because they believe having a children with ASD is to“lose face”(Mak & Cheung, 2008)]. Another explanation is the poor public awareness of ASD in China, which may result in caregiversﬁnding difﬁculty with social support. In order to increase caregivers' perceived social support, caregivers should be educated and encouraged to utilize social resources. In addition, caregiver support groups asShu and Lung (2005)recommended should be built in communities. Programs designed to raise public awareness of ASD may be useful, too.

Participants' Suggestions for Future Studies When asked in the multidisciplinary parent education form about what they liked the least in the intervention and for advice and suggestions for designing future research studies, a few participants had ideas to share. First, most participants reported being highly satisﬁed with the multidisciplinary parent education program and wished for more and longer intervention, saying: I think these courses are very great, very good, and very informative. Parents urgently need this practical content combined with the daily care skills. Second, some participants wished for more practical knowledge and skills in how to deal with the children's behavioral problems, saying: skill guidelines and practical knowledge can help parents overcome the challenges of caring for children with ASD. Longer and more frequent interventions are needed. Finally, a number of participants suggested that an online platform, in the form of participant-to-participant and participant-to-instructor communication channel could be helpful for caregivers to consult and obtain information and skills outside of class and/or once the study was completed, saying: due to the limited teaching time, lots of knowledge and skills are difﬁcult to keep track of. It is recommended to establish online communica- tion platforms or QQ online communications (a Chinese instant massaging program). Table 5 Comparison of SCSQ Subscales Scores Obtained by Intervention and Control Caregivers Before and After Multidisciplinary Parent Education (N= 42).

SCSQ subscales Pre-intervention Post-interventiontP Positive coping style Intervention 1.86 ± 0.60 2.30 ± 0.38−2.744 0.009 Control 1.83 ± 0.51 1.94 ± 0.43−1.680 0.101 Negative coping style Intervention 1.16 ± 0.44 1.16 ± 0.55 0.008 0.994 Control 1.21 ± 0.43 1.13 ± 0.52 0.543 0.590 Table 6 Comparison of FAD, MSPSS, CBI and GSE Scores Obtained by Intervention and Control Caregivers Before and After Multidisciplinary Parent Education (N= 42).

Variables Pre-intervention Post-interventiontP FAD Intervention 2.31 ± 0.23 2.07 ± 0.23 3.36 0.002 Control 2.36 ± 0.26 2.30 ± 0.21 0.804 0.426 MSPSS Intervention 60.64 ± 18.48 62.47 ± 9.17−0.179 0.859 Control 53.10 ± 13.21 59.81 ± 11.29−1.751 0.088 CBI 56.85 ± 17.32 52.43 ± 11.10 0.978 0.334 Intervention 54.64 ± 14.39 51.37 ± 19.09 0.624 0.536 Control 56.85 ± 17.32 52.43 ± 11.10 0.978 0.334 GSE Intervention 23.23 ± 4.85 27.74 ± 2.81−3.367 0.001 Control 22.70 ± 4.57 22.19 ± 3.39 0.407 0.686 Table 7 Multidisciplinary Parent Education Evaluation Form [ x(s)].

SessionnContentTeaching strategies Instructor Overall rating Session one 10 8.90 (0.88) 8.50 (1.58) 8.30 (1.42) 8.60 (1.43) Session two 11 9.55 (0.82) 8.64 (2.24 8.64 (2.94) 9.09 (1.51) Session three 10 8.90 (1.29) 8.91 (1.29) 9.00 (0.67) 9.40 (0.70) Session four 8 9.75 (0.71) 9.88 (0.35) 9.75 (0.46) 9.50 (0.93) Sessionﬁve 13 9.69 (0.63) 9.92 (0.28) 10.00 (0.00) 9.85 (0.38) Session six 8 8.75 (1.89) 9.25 (0.95) 9.00 (1.41) 9.25 (0.96) Session seven 10 9.60 (0.70) 9.50 (0.97) 9.70 (0.48) 9.50 (0.53) Session eight 10 9.40 (0.84) 9.30 (1.06) 9.80 (0.42) 9.60 (0.52) Total 80 9.53 (0.81) 9.41 (1.28) 9.38 (1.39) 9.51 (0.95) 324B. Ji et al. / Archives of Psychiatric Nursing 28 (2014) 319–326 Limitations Limitations include the lack of follow-up, which may provide additional information about the long-term effects of multidisciplin- ary parent education on HRQOL of caregivers of children with ASD.

Thus, future research should involve long-term follow-up of partic- ipants. Another limitation of the study is that the program was applied only to caregivers within autism rehabilitation centers. These caregivers may have higher level HRQOL compared to those outside of rehabilitation centers. In addition, the small sample size of this study places limits upon quantitative methodologies and generaliz- ability. Nonetheless, the two centers were two of the largest autism rehabilitation centers in Hunan Province, and service a mixed group of caregivers from both urban and suburban areas. In China, most of the autism rehabilitation centers are run privately and the average number of children with ASD in these centers was less than twenty.

Compared with the small numbers of children with ASD in autism rehabilitation centers, most children with ASD are living at home.

Therefore, it is recommended that further studies on multidisciplinary parent education should incorporate more caregivers and be implemented outside rehabilitation centers. However, this study obtained a high participation rate (81.5% in intervention group and 87.0% in control group). As such, we are conﬁdent that these results contribute a useful understanding ofthe impacts of the multidisciplinary parent education program on caregivers of children with ASD.

Implications for Practice Although this was a quasi-experimental study, and the small sample size limits generalizations, there are some importantﬁndings for caregivers of children with ASD. First, according to the high participation rate and high satisfaction in this study, parent education programs targeting caregivers of children with ASD are welcomed by caregivers. Therefore, it is recommended that further studies on the multidisciplinary parent education should be frequently conducted with caregivers of children with ASD. Second, in order to enhance the effectiveness on family function and social support, further studies on the multidisciplinary parent education should be conducted not only with caregivers but also with other family members and friends.

Finally, as accepted byKhanna et al. (2011), the conceptual model of factors inﬂuencing HRQOL among caregivers of children with ASD explained very little variance in caregiver physical HRQOL. Therefore, other factors that may affect physical health of caregivers of children with ASD should be identiﬁed and integrated into the multidisciplinary parent education model.

CONCLUSIONS The results of this study have demonstrated that multidisciplinary parent education can be effective in reducing family problems, and improving positive coping style, self-efﬁcacy and mental HRQOL in caregivers with children with ASD. Parent education is increasing in China. Implementing such parent education programs in this area will be effective in improving quality of life and well-being for caregivers of children with ASD.

Acknowledgment This research was supported by Central South University (CX2012B083) awarded to Binbin Ji.

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