Editorial: One Good Thing (Sometimes) Leads to Another: Demonstrating Mechanistic Connections Between Parent and Child Outcomes in a Community Implementation Autism Trial.
This is an important study for several reasons and shows a positive way forward for the design, execution, and analysis of intervention trials in the autism field. Brookman-Frazee et al.1 present a novel analysis demonstrating that their community training program, An Individualized Mental Health Intervention (AIM HI), which has been shown to improve behaviors that challenge in young children with autism,2 also leads to improvements in parental sense of competence (but not caregiver strain). This is in line with a limited number of other recent studies that have addressed the same issue.3,4 The present report adds to our knowledge in at least 2 important ways; both investigating the mechanisms of how these outcomes might come about. First, the study demonstrates that implementation of the training during the period of intervention, specifically, continuity across treatment sessions and the effectiveness with which a therapist pursued teaching a caregiver skill, mediated improvements in parental sense of competence at the end of treatment. Of note, these process or fidelity implementation ratings were blind coded by naïve raters trained to reliability on video-recorded sessions, an example of the high-quality methodology valued by expert trialists. Second, the authors not only show that changes in parental sense of competence during the intervention are associated with reductions in child behaviors that challenge at the end of the treatment period, they also conducted a formal mediation analysis that further demonstrates that changes in parental sense of competence during the treatment period are related to improvements in child outcomes at 12 and 18 months, long after the intervention period itself. There have long been calls highlighting the value of such mechanistic analysis to get "maximum value" from the precious resource of intervention trials,5 but these have only rarely been taken up in the autism intervention field.6.