**4. Evaluation of parental involvement during intervention with children with ASD**

The heterogeneity in the symptomatology of ASD also reflects in several intervention outcomes [31]. Hence, it is difficult to identify one kind of intervention with the highest degree of efficacy compared with others, given that a specific intervention can be helpful for specific domains and patients but not for others [30, 32, 33]. A significant amount of research reported the efficacy of different kinds of intervention on the developmental trajectories of children with ASD during the intervention [19, 20, 22, 34]. Previous literature on parental involvement focused more on the evaluation of treatment response, considering the child outcomes demonstrating the improvements in both child's social engagement and their cognitive development [4], often without deepening dyadic and caregivers' variables associated with the response. Moreover, some research showed that without involving caregivers, a child's variables tend to remain more stable over time [9, 35]. Child gains are predominantly assessed through developmental outcome measures using standardized instruments such as Autism Diagnostic Observation Schedule [15] and Griffiths Scales [16]. However, these instruments, when used to assess the treatment outcomes longitudinally, might suffer from the issue of sensitivity to change. Standardized diagnostic and cognitive test items are, in fact, neither proximal to the treatment nor necessarily sensitive to small changes in social communication and interactive skills that may be occurring as treatment progresses. For this, the detection of change may be enhanced by using observational measures of social responsiveness [36]. In line with this, analyzing the dyad's interactive component through observational and behavioral measures might provide a sensitive-to-change perspective to investigate caregiver and child improvements in the relational context.

#### **4.1 Changes in child developmental trajectories**

In order to monitor preschool children with ASD during the parental-based intervention, children's developmental trajectories have been analyzed before and after treatment. Evaluating the developmental trajectories of about 30 preschool children with ASD, we found an improvement of both cognitive and sociocommunicative domains [18]. We found a significant improvement in the general quotient of children exposed to the early intensive intervention line with previous literature [27, 29, 37].

*An Intersubjectivity Parental-Based Intervention (I-PBI) for Preschoolers with ASD DOI: http://dx.doi.org/10.5772/intechopen.108672*

Specifically, our data showed that linguistic-communication abilities present the most improvements.

This may be in line with the ground idea of developmental models of treatment for ASD that focus on a wide range of socio-communicative abilities instead of rehabilitating specific areas of cognitive development [4, 21]. These findings may also be explained by the parental involvement that supports parents in displaying appropriate strategies in different contexts of the child's life, extending effective social interactions in naturalistic settings besides the laboratory room, leading to better children's outcomes.

Another fundamental aspect is the decreased general behavioral expressions of ASD significantly, especially considering the socio-communicative area [38]. The social-affect area focuses on communicative abilities and social affect and considers different modalities and their integration. This supports the idea that treatment impacts developmental trajectories by improving a wide spectrum of socio-communicative abilities, including receptive and expressive communication, but also precursors of verbal communication such as gestures, imitation, and joint attention, fundamental elements to initiate or respond adaptively to the social exchange. Furthermore, in line with previous literature, interventions tend to focus more on supporting cognitive and social abilities rather than the restrictive and repetitive behaviors that tend to be more stable over time [39, 40]. Despite this, in the intervention group, we found a slight change considering this domain, probably associated with the targeted work on anxiety reduction, emotions, and self-regulatory mechanisms during the parental-based intervention.

This study shed new light on the developmental trajectories of children with ASD, strengthening the importance of specific work on early relationships to gain better outcomes and integrating different techniques during the intervention to optimize the child's improvements.

#### **4.2 Changes in parent-child interaction**

Considering the role of caregiver-child interactions for the child's development in both typical and atypical contexts, our intervention focused on relationship-based principles that aim to restore interactive circuits. Given the importance of parental involvement in the therapeutic setting and the paucity of studies highlighting parental and dyadic changes during the intervention, we analyzed caregiver-child dyads with ASD with several observative instruments that assessed the affective quality, play skill abilities, and parental speech.

An interesting result is a significant improvement in the mother's general level of sensitivity, especially in the domain of awareness of timing during the interaction, suggesting that mothers were more likely to wait for the appropriate moment to propose or interrupt the child during dyadic exchanges. In line with this, previous literature reported significant parents' acceptance and comprehension of the child and more positive dyadic patterns [3, 41].

Further, some findings suggest that parents show changes in their interactive strategies pre and post-intervention [42], besides evolutions in child's behaviors. In line with this, parents showed an increased ability to structure adequately the exchange with the child. Particularly, they seem to structure just the right amount according to the child's needs, using both verbal and non-verbal strategies. These results are especially relevant in the context of ASD. In fact, given the impairments in communicative abilities, the use of verbal indications displayed by parents may not

be enough to scaffold an appropriate interaction effectively, and the use of nonverbal strategies plays a crucial role. While structuring is about guidance and mentoring, intrusiveness is the actual over-direction, over-stimulation, and interference in a child's behaviors and activities. In particular, parents seemed to be more able to follow the children's demands, interfering less with their activity. In line with this, verbal and physical interferences decreased significantly, indicating more suitability in dealing with children, which showed fewer signs indicating that the adult is intrusive in their activity. These results appear to be particularly relevant, considering that research in parenting in the context of neurodevelopmental disorders pointed out the tendency of caregivers to be more intrusive during interpersonal interchanges [43, 44]. Concerning the child, the increases found in the responsiveness domain might be influenced by more appropriate maternal behaviors during the intervention with parental involvement, which gives them the possibility to experience positive exchanges, first of all, mediated by the therapist and then gradually alone with the child. Therefore, the therapist gradually leaves space for the dyad, supporting them only when necessary to facilitate reciprocal attunement. By experiencing positive exchanges, parents might be more motivated and facilitated to reproduce specific social routines in the domestic context.

Another aspect that we took into consideration was play abilities during interactions since play skills are related to cognitive skills, and play is considered a primary opportunity for learning, especially when carried out in the context of child-adult interactions [45]. On this basis, dyadic play during intervention represents a key mediator of the whole interactive process [46]. After the intervention, parents' and children's play levels are more associated. In particular, the child's play was correlated with that of the parent after the intervention but not before, suggesting the presence of a greater ability for dyadic synchronization. This change reinforces higher levels of reciprocal syntonization, supporting the importance of directly intervening in the dyad to foster bidirectional exchanges.

Furthermore, considering the importance of parental linguistic elements in child development [47, 48], we also wanted to investigate longitudinal changes in parental speech pre and post-intervention. In fact, after the evaluation of affective and playful aspects during the intervention, we also aimed to examine how parents adapt their speech to their children over time. In line with the results considering increased relational affect, parents display more affective than informative speech after the intervention.

Further, parents increased their descriptions of the child's actions, suggesting an enhanced verbal structuring while sharing the attentive focus on what the child is doing during the exchange, supporting a non-intrusive linguistic style. It is relevant to note how sensitive and responsive modalities that parents acquired during the intervention also reflect on their linguistic speech directed to children. Linguistic and affective elements together seem relevant for the child's involvement.

#### **5. Conclusion**

The ground idea of the parental-based intervention is working with parents, rather than working for parents, to find personalized modalities to deal with a child with ASD. In fact, during treatment, parents acquire adequate strategies to respond to the child's signals, leading to more extended and more functional exchanges with the child. On the other side, it extends strategies in a more naturalistic setting, helping

#### *An Intersubjectivity Parental-Based Intervention (I-PBI) for Preschoolers with ASD DOI: http://dx.doi.org/10.5772/intechopen.108672*

the child maintain and generalize competencies. During intervention with parental involvement, the therapist acts as a promoter of the exchange, supporting both the partners in establishing functional and adaptive social routines in which caregivers can experiment with themselves adequately and pleasantly, following their spontaneous adaptation to the child.

Coherently, after the intervention, the affective quality of the exchange results in enhanced syntonization to the child's needs with greater structuring abilities in a less interfering way. The involvement of caregivers should not only consider the work in the therapeutic setting with the child and the therapist, but a guided re-elaboration provided by the therapist to the parents alone is necessary for decoding strategies, observing the strengths and weaknesses of their child and themselves as parents. Thanks to this, parents may have better tools to understand the child's communicative signs. The increased awareness becomes a protective factor in preventing secondary deficits emerging from dysfunctional interactions when the fathers do not understand the child's difficulties.

### **Acknowledgements**

We gratefully acknowledge the clinical staff of ODFLab and the families who participated in our studies.
