Building Parental Capacity: Outcomes of a Therapeutic Parent Group Run Concurrently with a Social Skills Group for Their Young Person

Abstract

Introduction: Raising a child with social communication and emotion regulation challenges, such as those experienced in the context of an autism spectrum disorder (ASD), is associated with family disruption and parental stress. Research shows that parents of children and young people with ASD can experience challenges in managing their child’s behaviour and experience a sense of disconnectedness, a lack of support from the “system”, and a broader lack of understanding within the community. Methods: A therapeutic parent group was held in parallel to a young person group working on social skills. The young person cohort included both boys and girls in early adolescence with neurodevelopmental diagnoses. The parent group provided a space for participants to focus on themselves, tune into their own emotions, and receive support in relation to their lived experiences of parenting. Parental outcomes were assessed using standard measures, and the experiences of the groups were captured qualitatively through focus groups with both parents and staff. Results: The project found that the therapeutic parent group was effective in supporting parents to feel less stressed and more in control, as well as less alone in their parenting journey. Qualitative data indicated that the groups filled an identified need within the service and were engaging and acceptable to parents.

1. Introduction

Young people (under 25 years) with autism spectrum disorders (ASDs) make up a significant proportion of presentations to tertiary-level community-based child and youth mental health services. Many of these autistic young people also experience accompanying co-morbidities, such as anxiety, depression, and ADHD [1,2]. As a result, the behaviour of these young people can be challenging to manage, and families and schools often struggle to provide effective tailored support to meet their needs. These challenging behaviours can often increase in adolescence when new social and developmental expectations become overwhelming and difficult to meet [3].

Autism spectrum disorders are characterized by deficits in communication, social skills, and emotional regulation. For parents of autistic children, these difficulties can result in stress, difficulties coping, and social isolation, particularly for mothers who bear the brunt of the child-caring work [4]. Social skills training is one intervention that has been shown to improve the functioning of young autistic people by assisting them to navigate their social world [5]. Improved functioning in the young person has the advantage of also reducing parental stress, while improved parental understanding and responsiveness to their child can further ameliorate the child’s social difficulties. Reducing social isolation for both the child and the parents has a further positive and protective effect [6].

Beyond the prolonged stress that parents can experience in their efforts to parent and support their autistic children [7], parents of autistic young people can experience significant stressors that reach beyond parenting of their child.

In recognition of this need for support for both young autistic people and their parents, a large, public child and youth mental health service in Melbourne, Australia, which was offering an established social skills program to small groups of pre- and early-adolescent young people with an identified ASD, developed and implemented a concurrent therapeutically focused parent group program.

Parents who participated in the groups reported experiencing stressors associated with their own mental health and/or a history of family violence, trauma, illness, and loss. Some of the families had more than one child who was diagnosed with ASD, and some had additional children with significant disability or mental health conditions. Some parents also presented as possibly on the spectrum themselves, while across the board there were struggles in family relationships, with some marriages noticeably fragile [8].

1.1. Program for Young People

Young autistic clients at the service were offered the opportunity to take part in the established Secret Agent Society Small Group Program 2nd edition © (SAS) [9]. The SAS was designed to develop social skills and the emotion regulation capacity of autistic children and young people using an engaging game-based approach that combines a computer game, small group sessions, parent training, and teacher handouts. Another aspect of the program involved the young person’s parents taking part in the last 30 min of each session, which helps parents to understand the child–group content and support skill practice between sessions (missions). Several studies have demonstrated that the SAS has a positive effect on social awareness and emotional regulation for young people, e.g., [10,11,12], particularly when there is consistent parent involvement.

1.2. Parent Program

Group therapy was specifically chosen as a support for parents to enable benefits by providing an outlet for parents to express their mood/stress levels [13], struggles, tensions, and complexities of daily life and to connect to and express often otherwise unspoken feelings regarding fear, worries, sadness, and grief [14] in relation to their child’s struggles [15]. Ideally, the group format also provides a sense of social support that can assist in improving cohesion and overall well-being in the family [16].

A key aim of the group was to provide an opportunity for parents to tune into their own emotions and to build their capacity to do so with their children [17,18]. The link between parent socialization practices and children’s emotional competence is well-established, and parents have been found to influence their child’s emotional competence through the following:

• The model they provide of the expression and regulation of their own emotions;
• Their reactions to their child’s emotions;
• Their discussions about and coaching regarding emotions with their child;
• The emotional contexts they put their child in [19,20,21,22].

At the beginning of each group, parents would take it in turns to provide a headline of their week. This task reflected the rollercoaster of life events from one week to the next for parents. This sharing contributed to a sense of normalization and reaffirmed the group members’ similarities with each other. Guided meditation was facilitated to separate parents from the hustle and bustle of making it into the session and bring focus to being present with the group.

A further focus of this therapeutic group was to provide a safe, supportive space for parents where they could connect with other parents in similar situations and feel a reprieve from their role as a parent of a struggling child. The therapeutic group allowed for a space for holding and tuning in, rather than finding solutions. Groups explored various issues, such as hope, parental vulnerability and shame, isolation, valuing different perspectives, and meeting their child where their child was at rather than holding unrealistic expectations. Social Thinking concepts, such as expected vs. unexpected behaviour [23], were also explored, and sharing the lived experience of the impact of having a child or pre-adolescent who was not innately socially motivated was encouraged. Family of origin and cultural difference were given space for expression, as well as similarities and differences in parenting between couples.

A key value of the group was to provide a culture that was accepting and inclusive of all parenting approaches, with no rights or wrongs. Their child’s weekly experience was also held in mind throughout the group, and time was set aside at the end of each session for one of the facilitators of the child/young person group to share feedback about the content and experiences within the group.

There have been no prior studies evaluating a co-occurring parent group with a therapeutic focus (as opposed to psycho-education and/or parent training, which has shown only limited effectiveness [24]) alongside a group teaching social skills to autistic children [25]. The aim of the present study was to evaluate the new parent-focused group therapy program to determine the importance of providing group therapy to parents alongside the existing social skills program for young people.

2. Materials and Methods

2.1. Participants and Procedure

The participants in this study were parents of young people who participated in the SAS group program as part of their treatment at a youth-focused mental health service. Parents were asked if they wished to participate in the new parent-focused group therapy to be run alongside the SAS. In addition, staff involved in the program were invited to participate in a reflective focus group to provide an additional perspective on the parents’ experiences.

The parent group therapy program was run by experienced clinicians who had an occupational therapy or speech therapy background. The parent group was held at the same time as the child or young person attended the social skills program and ran for 3 h each week.

Over the course of the data collection period, the social skills program for the adolescent and pre-adolescent young people along with the concurrent parent group were conducted three times. A fourth group was commenced, but due to COVID-19 interruptions, no data were collected from that group. The first group involved four boys who were in the transition phase between primary and secondary school (aged 11–13 years). All had an ASD diagnosis, one with co-morbid ADHD. The second child group consisted of seven boys, most of whom had come into the service for a neurodevelopmental assessment and were in primary school, who were slightly younger than the boys in the first group. Six had a diagnosis of ASD, one had comorbid GAD (Generalized Anxiety Disorder), and one had comorbid ADHD and PTSD. One child had a diagnosis of a developmental language disorder, a learning disorder, and ADHD.

The third child group included five pre-adolescent girls. Three had an ASD diagnosis and two were currently undergoing assessment but had not yet received a diagnosis. One child/parent participant pair dropped out of this group, but otherwise attendance across all groups was fairly consistent (

Table 1. Participants.

	Group 1	Group 2	Group 3
Child group	4 boys aged 11–13 years	7 boys aged 9–10 years	5 girls aged 8–10 years
Parent group	5 parents (one couple)	6 mothers 1 maternal grandmother	6 parents (one couple)

).

2.2. Measures

The evaluation project took a mixed-method approach to data collection to provide a more holistic understanding of the impacts of the new program rather than relying on any one method alone [26]. Quantitative data were collected at three time points: commencement of the program (pre-test), completion of the program (post-test), and six weeks following completion (follow-up). Parents completed questionnaires at each time point, including the measures embedded in the SAS program that capture the parent’s perceptions of their child’s social skills and emotional regulation as well as a tailored measure of “parent confidence” that is specific to the SAS program.

The Social Skills Questionnaire—Parent (SSQ-P) [27] is a measure of children’s social skills from the perspective of the parents. The SSQ-P contains 30 items (e.g., “Listens to others’ points of view during an argument”) that are rated on a scale from 0 (not true) to 2 (mostly true). Research has shown the SSQ-P to be a reliable and valid measure of a child’s social functioning [27].

The Emotion Regulation and Social Skills Questionnaire—Parent (ERSSQ-P) [28] measures parents’ views of their child’s emotional recognition and regulation. The ERSSQ-P contains 25 items (e.g., “Recognizes when other people are being sarcastic or teasing”) rated on a scale from 0 (never) to 4 (always). The ERSSQ-P has been shown to be a reliable and valid measure for assessing the emotional regulation and recognition of young people [28]. To evaluate the outcomes for the parent therapeutic group, two specific measures around parenting were added.

The Parenting Sense of Competency Scale (PSOC) [29] is a reliable, 17-item scale assessing parenting self-efficacy. All items (e.g., “I meet my own personal expectations for expertise in caring for my child.”) were rated from 1 (strongly disagree) to 6 (strongly agree). The PSOC has been shown to have good reliability and validity for both community and at-risk parents [30].

The Confusion, Hubbub, and Order Scale (CHAOS) is a 15-item measure of environmental confusion in the home [31,32]. All items (“We are usually always able to stay on top of things”) are measured from 1 (very much like our home) to 4 (not all like our home). The CHAOS has been shown to be a reliable and valid scale. Parent confidence was also measured using a single-item question on the SAS intake form and then asked again at each time point. Parents were asked “Please rate how confident you are in your ability to support your child’s social and emotional development.” Parents’ responses were measured on a scale from 0 (not at all confident) to 4 (very confident).

Qualitative data were collected through a total of four focus groups, with a group being held with parents at the conclusion of each group program. In one instance, two parents were unable to attend the focus group and were interviewed separately using the same focus group questions. In addition, a staff focus group was held following the third iteration of the group program to capture the staff’s experience and narrative of the program evolution.

This project was approved by the Alfred Health Human Research Ethics Committee, project number #670/18. All participants provided signed written consent to participate.

3. Results

Quantitative Measures

Five standard measures were completed at each time point (

Table 2. Parent outcome measures at commencement, completion, and three months following the SAS with concurrent parent therapeutic group program.

		Pre-Test		Post-Test		Follow-Up
Measure	N	Mean	SD	Mean	SD	Mean	SD
Parent confidence	10	2.20	0.63	2.85	1.38	3.00	1.13
SSQ-P	12	32.5	8.07	36.33	8.69	40.58	8.77
ERSSQ-P	12	45.91	11.74	55.66	11.47	57.75	9.72
PSOC	6	66.66	12.75	66.83	11.79	68.83	8.33
CHAOS	6	37.66	3.33	42.50	3.20	41.00	2.36

). The SAS measures (SSQ-P and ERSSQ-P) assess parents’ perceptions of their child’s outcomes (social skills and emotion regulation). The PSOC, CHAOS, and parent confidence measure assess parent outcomes. To determine whether there was any significant change in outcome measures across the three time points, a series of five repeated-measures analysis of variance (ANOVA) tests were conducted. Repeated-measures ANOVA was chosen to best measure within-subject change across more than two time points [33]. For each analysis of variance, the assumptions of normality and sphericity were met using the Shapiro–Wilk test of normality and Mauchley’s test for sphericity respectively. The results showed that for parents’ perceptions of their child’s social skills (SSQ-P), the total effect was significant (F(2) = 8.72, p = 0.002), indicating a statistically significant difference in social skills across the three time points. Post hoc tests using Bonferroni adjustment revealed that the increase in social skills was significant from time 1 to time 3 (mean difference = 8.08, SE = 1.98, p = 0.01) and from time 2 to time 3 (mean difference = 4.25, SE = 1.49, p = 0.047) but not from time 1 to time 2. The results showed that the main effect for parents’ perceptions of their child’s emotion regulation and social skills (ERSSQ-P) was significant (F(2) = 11.35, p < 0.001), indicating a statistically significant difference across the three time points. Post hoc tests using Bonferroni adjustment revealed a significant increase in perceptions of emotional regulation and social skills from time 1 to time 2 (mean difference = −9.75, SE = 2.68, p = 0.012) and from time 1 to time 3 (mean difference = 11.83, SE = 3.09, p = 0.01) but not from time 2 to time 3.

The results further showed that the main effect for parents’ Confusion, Hubbub, and Order Scale (CHAOS) was significant (F(2) = 4.243, p = 0.046), indicating that scores were significantly different across the three time points. However, the post hoc analysis using Bonferroni adjustment revealed that although scores on the CHAOS increased from time 1 to time 2 and from time 1 to time 3, these changes were not significant. Potentially, the non-significant post hoc tests were due to the low sample size (six) of parents who completed this measure at all three time points. Despite parents’ sense of competence and confidence increasing, the main effect for the parents’ sense of competence (PSOC) (F(2) = 0.538, p = 0.600) and the “parent confidence” measure (F(2) = 1.69, p = 0.212) were not significant, indicating no statistically significant difference in parent competence and confidence across the three time points. It is possible that these scores did not show significant changes due to commencement scores generally being already within or close to normal range.

4. Qualitative Results

4.1. Thematic Analysis

Data from the qualitative parent focus groups and interviews as well as the staff focus group were analyzed thematically according to the steps set out by Braun and Clarke [34] to determine common themes in the experience of taking part in the therapeutic group (

Table 3. Stages of thematic analysis [34].

Stage	Process
1. Becoming familiar with the data	This phase involved conducting the focus groups and transcribing the recordings. During the process, the researchers’ initial ideas were noted down.
2. Generating preliminary codes	Transcripts of the focus groups were read and re-read, and meaningful excerpts from parents and staff were identified and converted into a thematic table for further analysis
3. Searching for themes	The thematic table was analyzed according to the questions asked in the focus groups, and initial themes were identified based on their meaning and similarity between focus group participants.
4. Reviewing themes	Themes identified in phase three were reviewed and cross-checked with all data in the thematic tables, and any superfluous themes were removed or similar themes were combined.
5. Defining and naming themes	This stage involved a further refinement of themes and clarification of their meaning. Names of themes were also identified.
6. Producing a thematic report	This stage involved selecting the excerpts that best captured the themes.

).

4.2. Themes

4.2.1. Parents

Despite the adaptations that were implemented in the program over the course of its delivery over three iterations, the parent experience was remarkably similar in each group. While staff observed significant differences in the interactions and experiences of the parents in different groups, for the parents themselves, the experience seems to have been similarly received.

Value of the Group

All parents were able to identify benefits for themselves of participating in the parent program, as well as the benefits for their child from participating in SAS. The benefits for parents were around peer support/understanding, self-care, and building a different understanding of their child. Examples of parent comments highlight this, as follows:

“We haven’t just focused on ‘Oh shit, we’ve failed as parents.’, or what we haven’t done this week. We focused on what’s going well this week, as well. I think that’s important.”

“But to be able to actually say that and then to have somebody else in the group or everyone else in the group recognise that and see that in you and say, I actually get what you’re talking about. Like I’m, I’m there too, or I’ve been there too. I think that was the, for me that was the biggest thing that I took away from it, just that reassurance that, you know, you’re really not alone.”

“it’s helped us recognize patterns that she has and things that just can’t really be altered and now we’re better at just not trying to force her down particular paths that just don’t work for her.”

There was a recognition that attending the parent group was of great value to the parents, even though for some there was an initial reluctance to commit their time and even a resentment of having to participate themselves. For those parents, this reluctance had evaporated by the end of the program. In each case, the parents went on to establish an informal social group for the parents and children to catch up with each other following the end of the group program.

“What started as something that I didn’t understand why I would have to give up my own time for, became a space that I longed for and will miss so very much.”

The parents who came as couples spoke of the benefits for them in sharing that space, while some of the parents who came on their own, indicated a desire for their partner to also participate.

“It has helped us in our marital relationship join together as a team—we haven’t done that for years … we feel like we face things about our child now together and we haven’t been this close like this in years”.

“I would have loved to have brought [my husband] along … to have [him] there, it would be very empowering for the family unit I think”.

Uncertainty Regarding the Future

There were also comments from parents in each group regarding uncertainty going forward and the need for support in the future, even if the form of that support was uncertain.

“I think the biggest question now is, for us as a family, is we need to keep supporting this behaviour and stuff and where to from here and this is what I’ve been asking, I guess, anyone I meet. Let’s face it. I know he’s going to need ongoing support for this. This is just a start. This is not an end. What are the next steps? And, I guess, that’s not very clear.”

“It was a very, very positive experience from both sides, just wanted more, just wanted more.”

Confidence

Additionally, there was a building of confidence in the parents and in their parenting, which enabled parents to both advocate for their child and assist them to manage their own thoughts or feelings of inadequacy. Parents developed a better understanding of their child by doing the parent group work at the same time as their child went through the content of the social skills work covered in the child program and the content that arose in the parent group.

Meaning-Making

Providing this concurrent therapeutic space for parents allowed them to make meaning of their parenting experience. It led to an improved acceptance and understanding of diagnoses, feelings of being listened to, and feeling supported to share their parenting challenges and acknowledging their own grief.

“It’s an in-between space really isn’t it … where you’ve got friendships, and you’ve still got social groups developing, but you’ve also got the support of people to … to guide you through that.”

4.2.2. Staff

A staff focus group was held after the third parent group to capture the staff’s experience of implementing and adapting the parent therapeutic group. When the child social skills program was first discussed, staff saw a definite need for a tailored parent group in addition to the parent-focused psycho-education component included in the child program. In considering the complexity of the families and young people who present at this tertiary mental health service, one staff member recalled:

“what I distinctly remember was you know, very early in the piece thinking, ‘Okay, we really need to think about this differently’”.

Meeting Parents’ Needs through the Flexibility of the Program Design

Staff identified a need for a therapeutic space for parents to provide an opportunity for social support from peers in addition to cross-disciplinary support from clinicians. As the groups were conducted, there were changes made to meet the needs of participants, including both the child and the parents. In particular, reflecting on the parent groups and the success of the interactions within groups caused the staff to reconsider the criteria for inclusion.

“The first group … were more complex, were more process-driven, came with a lot more emotion vulnerability and a lot more to work with within the room. The second group, a lot of the parents had already had previous group experience in that field. … Some of them had already tried, had made connections prior to the group. And it felt like those parents were really there, in the interest of their child, for the child to have a social skills group, as opposed to a group of the parents, and I think that reframed how we thought about the third group. And I think the third group is probably a really good mix.”

This difference in the composition of the three parent groups was reflected in the way the therapists became involved in the group dynamic. The first and third groups allowed the therapists to join in an inclusive and cohesive way, whereas for the second group it was noticed that

“we [clinicians] weren’t included in the group. It was a very much an ‘us and a them’”.

This sense of cohesion within the group also informed group attendance. In the first group, parents strived to attend, even when their child did not want to come, and in the third group, one child really struggled to join the young person group and the parent struggled to put the child’s needs ahead of their own desire to be in the parent group.

“there was nobody who missed it and if there was any resistance in the child, the parent was coming, come hell or high water.”

“we even had, I think in that third group where you had a case where one of the girls desperately didn’t want to come, … and mum still came and, you know, tried, … which was really great, but I think we reflected later that mum so wanted to come to the parent group because I think she found it really valuable, that she didn’t call it [for the child] as soon as she might have”.

Focus on the Parent

Staff recognized the importance of keeping the focus on the parents rather than on the young person.

“We also work very hard at reframing and redirecting the group at times, we use certain tools in the group to make it really about the parents or to get into to reflect on their emotions and their own feeling states. And really trying to redirect it to themselves as opposed to the young person.”

Making this a safe space for parents to undertake this therapeutic work was also very important.

“I think it’s important also that what was shared by a parent in the parent group was kept very confidential between us … that space was quite protected for them.”

Achieving the Right Mix in the Group

There were also issues around managing demand for the service and forming workable and balanced groups. There was one additional child considered for the second group who in the end did not join as the family and clinicians concluded that the group was not the right mix for him. And, conversely, for the third group,

“we worked really hard to get that fifth family in the room and they didn’t manage to stay. So you kind of learned that if you, if you have to work too hard to get someone in to [the group], then it isn’t going to work.”

5. Discussion

The aim of the present study was to investigate the experience and impact of taking part in a new group therapy program for parents/carers of autistic children while their children took part in a concurrent social skills training program (the SAS). The results of the mixed-methods design showed that parents taking part in the group therapy program saw improvements in the child’s social skills and emotional regulation and that there was an overall change as their sense of environmental chaos in the home decreased. However, this decrease was not statistically significant. Similarly, quantitative results showed that parents’ sense of competence and confidence increased, but that this was not significant. Reflecting on the group, parents felt that the group was very valuable and meaningful, and it allowed them to feel better and more confident about parenting their autistic children, but they also reflected on a sense of uncertainty about the future after the groups had finished.

The findings of the present study align with the previous literature indicating the stress that can be felt by parents of autistic young people [7] and that social skills training programs can be beneficial for young autistic people [11]. The benefits of concurrent, novel group therapy also support previous findings regarding the benefits of social support for parents with autistic children [16,35]. Potentially, the very nature of the group being a place where people felt seen and heard and that they were not alone in their experiences could have helped to reduce the social isolation felt by families [6,15]. Although the quantitative findings did not highlight much difference in parent confidence and competence, the qualitive results indicate that parents gained a lot from the program, and it is likely that this could translate into positive outcomes for the family, such as family cohesion, which could improve the family’s quality of life [16,18], or less feelings of stigma that can perpetuate family stress [17].

6. Limitations

While the findings from this study were encouraging and highlight the importance of social support for parents, the small sample size means that the findings may not be generalizable to larger populations. However, the findings are consistent with the literature [17], and, potentially, with a larger sample size scale, some of the increases in perceived parent competence and confidence may have been more significant. Another limitation is that the present study did not capture the young people’s experiences of their parents taking part in the group. It would have been interesting to see if the benefits experienced by parents were also noticed by the young people themselves. In addition, the low sample size precluded analysis of other variables, such as the age and gender of either the parent or the child.

7. Conclusions

It is clear from this evaluation that the delivery of a concurrent therapeutic parent group alongside the social skills program for children delivered benefits for parents and families as well as the children involved, despite some initial resentment and an array of challenges common to working in a group setting with a highly diverse and complex client cohort. Quantitative data collected across the duration of each group and again six weeks following completion indicated statistically significant improvements in parents’ perceptions of their child’s social skills, as well as their emotion regulation and the degree of environmental confusion in the home (noise, crowding, and movement). The present findings suggest that interventions for families with autistic children may work best when focusing on both children and parents.

Consistent findings across all three groups demonstrate the effectiveness of the program in addressing the social skills needs of the children, as well as helping the parents to feel less stressed and more in control, thus establishing a virtuous circle of parent and child improvement. Follow-up data indicate that the improvements were maintained and, in some cases, extended over time. Qualitative data from parent participants illustrate the benefits parents felt, despite sometimes initial reluctance or logistical challenges. Qualitative data from staff illuminate the need for flexibility in developing and implementing this kind of group, identifying the right child and family for each group dynamic, and supporting parents to let go of their child and focus on themselves and the therapeutic benefits they received.