Moderating Effects of Parental Characteristics on the Effectiveness of a Theory of Mind Training for Children with Autism: A Randomized Controlled Trial
Moderating Effects of?Parental Characteristics on?the?Effectiveness of?a?Theory of?Mind Training for?Children with?Autism: A?Randomized Controlled Trial
Danielle?M.?J.?de?Veld 0 1 2 3 4 5
Patricia?Howlin 0 1 2 3 4 5
Elske?Hoddenbach 0 1 2 3 4 5
Fleur?Mulder 0 1 2 3 4 5
Imke?Wolf 0 1 2 3 4 5
Hans?M.?Koot 0 1 2 3 4 5
Ram?n?Lindauer 0 1 2 3 4 5
Sander?Begeer 0 1 2 3 4 5
Danielle M. J. de Veld 0 1 2 3 4 5
0 1 2 3 4 5
0 Faculty of Health Sciences & Brain and Mind Centre, The University of Sydney , 100 Mallet Street, Camperdown, NSW 2050 , Australia
1 Institute of Psychiatry, King's College , 16 De Crespigny Park, London SE5 8AF , UK
2 Department of Clinical Neuro and Developmental Psychology & EMGO Institute for Health and Care Research, Vrije Universiteit , Van der Boechorststraat 1, 1081BT Amsterdam , The Netherlands
3 Collaborative Antwerp Psychiatric Research Institute (CAPRI), University Antwerp, Universiteitsplein 1 , 2610 Wilrijk, Antwerp , Belgium
4 Department of Child and Adolescent Psychiatry, Academic Medical Center , Meibergdreef 5, 1105 AZ Amsterdam , The Netherlands
5 De Bascule , Rijksstraatweg 145, 1115AP Duivendrecht , The Netherlands
This RCT investigated whether the effect of a Theory of Mind (ToM) intervention for children with ASD was moderated by parental education level and employment, family structure, and parental ASD. Children with autism aged 8-13? years (n = 136) were randomized over a waitlist control or treatment condition. At posttest, children in the treatment condition had more ToM knowledge, showed fewer autistic features, and more ToM-related behavior than children in the control condition. Children who had one or two parents with at least a college degree, and children with parents not diagnosed with/suspected of having ASD themselves benefitted from the training. These findings provide valuable information about family variables that need to be taken into account in treatment design and implementation.
Autism?; Treatment?; Randomized controlled trial?; Theory of mind?; Moderator
Randomized clinical trials are considered the gold standard
for investigating the effectiveness of psychological
interventions. However, beyond establishing that a treatment is
generally effective, it is important to determine for whom,
and under what circumstances, intervention is most
effective, in other words: what variables moderate treatment
success (Kraemer et?al. 2002). Although this information is
particularly crucial in trials involving a condition as
heterogeneous as autism spectrum disorder (ASD), there has been
relatively little systematic study of child or family factors
that are predictive of response in autism treatment trials.
The current study aimed to investigate parent
characteristics that may moderate the effectiveness of one of the most
common types of intervention for school-aged children
with ASD: social cognition training (Wierda et?al. 2015).
Parents play an essential role in children?s development
and their influence may be even more important in shaping
the development of children with ASD (Prizant et?al. 2003).
Problems with generalization of skills in autism are well
documented (cf. Plaisted 2001) and while children with
ASD can learn new skills during treatment, they typically
have difficulties generalizing these skills to other situations
(e.g. Begeer et? al. 2011). Parents can help their children
practice newly acquired skills in many different, real life
settings (Koegel and Kern Koegel 2006) and hence their
involvement in intervention may be crucial for wider
generalization and maintenance of treatment effects. The extent
of parental involvement in autism treatment programs
varies (Burrell and Borrego 2012) from active engagement as
therapist or co-therapist (up to 7? h per week; McConachie
and Diggle 2007) to a less intensive role of observer (e.g.
15? min per week; Begeer et? al. 2015); parental
participation also depends on whether a specific treatment is
parent-mediated (Nevill et? al. 2016) or directly child focused
(e.g. Begeer et? al. 2011). Nevertheless, despite the
potential importance of parent-involvement in treatments for
children with ASD, very little is known about how
parental characteristics affect treatment success (Karst and Van
Although various parental factors may potentially
influence treatment outcome, evidence for their impact is often
conflicting. Thus, it has been suggested that parents with
higher education levels may be better able to understand
and implement treatment techniques (Burrell and Borrego
2012), thereby promoting learning and generalization of
new skills in their child. In studies of neurotypical children,
for example, higher parental education is positively
associated with parents? achievement beliefs, higher economic
status, and a more stimulating home environment, all of
which may increase children?s learning opportunities and
attainments (Davis-Kean 2005). In the field of autism, Ben
Itzchak and Zachor (2011) found that higher maternal
education level was associated with greater gains in child
cognitive abilities following either an Applied Behavior
Analysis or eclectic center-based intervention. However, Magiati
et? al. (2007) found no relationship between parental
education level and children?s progress after 2? years of Early
Intensive Behavioral Interventions or autism specific
nursery provision. Both of these studies involved young
children and, to our knowledge, there are currently no studies
on the moderating role of parental education in treatments
for older children with ASD.
Parental employment and/or financial status may also be
associated with better treatment outcomes since being in
paid employment may decrease financial and other strains
on families. Evidence for this suggestion is partly based on
other clinical groups, e.g., obese children (R?bl et?al. 2013)
and children with disruptive behavior disorders (Shelleby
and Kolko 2015). In ASD, parent-reported financial strain
was correlated with poorer treatment outcomes in a sample
of young children with ASD (Gabriels et? al. 2001).
However, income did not predict the effectiveness of a
parenttraining program to reduce noncompliance in children with
ASD and disruptive behavior (Farmer et? al. 2012). Thus,
the specific relation between parental employment
status and treatment outcome in children with ASD remains
The wider family structure is another factor potentially
influencing treatment effectiveness. Thus, households
consisting of two biological or adoptive parents tend to report
less parental stress than single mothers or families with at
least one step-parent (NSCH 2011/2012). In line with this,
children with autism from intact, two-parent households
were found to gain most from a family-oriented treatment
program (compared to children from single or divorced
parents; Robbins et?al. 1991). Also, high levels of parenting
stress limited the effects of early teaching interventions and
pivotal response training for children with ASD (Osborne
et?al. 2008; Robbins et?al. 1991).
A further factor, about which surprisingly little is
known, is the impact of parental levels of autistic traits. If
parents themselves have features of the broader autism
phenotype (BAP; Parr et?al. 2015a) this might enable them to
identify more easily with their child?s difficulties. On the
other hand, if parents, too, have autistic-type limitations
in flexibility and learning, this could make it more
difficult for them to help their child acquire and generalize new
skills (Karst and Van Hecke 2012; Parr et? al. 2015b). For
example, parents with BAP traits may have difficulties in
recognizing situations that allow the child to practice newly
taught skills. BAP characteristics may also influence
parents? perspective on how feasible, and/or useful the
treatment is for their child (Gerdts and Bernier 2011), thereby
affecting their motivation to co-operate in therapy.
In this study, we investigated whether these particular
characteristics, i.e., parental education, employment, family
structure, level of autism traits, moderated the effectiveness
of a social cognition intervention (Theory of Mind (ToM)
training) for 8-to-13-year-old children with ASD.
Previous data from this randomized control trial (RCT) showed
that training improved children?s knowledge of ToM;
ToM-related behavior also increased and autistic features
decreased (Begeer et? al. 2015). A larger sample of
participants from the same RCT has since become available,
allowing us to test the potential moderating effects of these
parental characteristics. Specifically, we hypothesized that
the ToM training would be more effective for children:
I. With parents of higher education levels,
II. With parents in paid employment,
III. Growing up in a family structure with two biological
The analyses regarding parental ASD were of an
exploratory nature, as a lack of research in this area limits specific
The study was a randomized controlled trial with a
waitlist control group and an intervention group. The project
was approved by the Medical Ethics Committee of the VU
University Medical Center (Project No. 2010/241). The
trial protocol was registered at the Netherlands Trial
Register (http://www.trialregister.nl, Trial No. 2327) before it
started and published prior to completion of the data
collection (Hoddenbach et?al. 2012).
gave informed consent prior to study participation. Figure?1
shows participant flow through the study. Characteristics of
the sample are summarized in Table? 1. The mean number
of previously received treatments was 1.01 (SD = 1.56);
34.1% of children were using medication.
The sample comprised 136 children (90% boys) aged
between 8 and 13 years (M = 9.66, SD = 1.23) meeting the
eligibility criteria of: (1) an ASD according to the
DSMIV-TR (APA 2001), based on multiple assessments by
psychologists and psychiatrists not involved in this study; (2) a
verbal IQ score >70 based on the Peabody Picture
Vocabulary Test-III-NL (PPVT) (Dunn and Dunn 1997). Parents
Participants were recruited from De Bascule, an academic
center for child and adolescent psychiatry in Amsterdam,
Netherlands, between April 2010 and September 2015.
An independent researcher randomized the
participating children to the treatment or wait list control condition
using a digital random number generator. The
randomization outcome was shared with the study coordinator, who
Assessed for eligibility (n= 154)
Allocated to intervention (n = 74)
Received allocated intervention (n= 72)
Did not receive allocated intervention (due to
illness or time constraints) (n = 2)
Analysed (n = 68)
Excluded from analysis (n = 0)
Randomized (n = 142)
Allocated to waitlist control group (n = 68)
Lost to posttest (n = 0)
Fig. 1 CONSORT 2010 flow diagram of participant flow through the study
U = 2037.5, z = ?0.06, p = 0.95
Table 1 Baseline demographic and clinical characteristics of the ToM treatment and the waitlist control groups
ToM treatment total n = 68a
Waitlist control total n = 68a
SRS Social Responsiveness Scale
aSome data missing for some participants
informed patients about allocation outcome. In the
treatment group, pre-trial assessment took place immediately
prior to intervention, and post-trial assessment was
conducted immediately post intervention (baseline to post
intervention = 8? weeks). The waitlist control group was
assessed 8? weeks prior to intervention and re-assessed
immediately prior to intervention (baseline to post
intervention = 8? weeks). More detailed information on the
procedure is available in the published trial protocol at http://
www.trialsjournal.com (Hoddenbach et?al. 2012).
The ?Mini ToM intervention? is a manualized, weekly
intervention comprising eight 1-h sessions, provided to five
to six children at a time, all aged within 3? years of each
other. The training is delivered in a child psychiatric center
by certified therapists (licensed Counseling Psychologists,
M.Sc. or Ph.D., registered with the Mental Health
Council) who were trained to administer the therapy. The
program is based on a validated ToM intervention (Begeer
et?al. 2011; Steerneman et?al. 1996), and was shortened to
be more cost-effective whilst retaining the key elements of
the training and maintaining its effectiveness (Begeer et?al.
2015). All sessions followed the same structure: (1)
discussing the homework assignment; (2) games and exercises
related to the day?s theme (e.g. perspective taking, emotion
understanding); (3) children summarizing the session to
their parents; and (4) explanation of next week?s homework
assignment (including e.g. drawing an object from different
angles, observing emotions in everyday life). Parents were
involved in the training through two 1-h parent-sessions
that explained theory of mind, the ToM-training, and how
parents could help their children acquire these new skills
and promote generalization. More detailed information on
the treatment is available in the published trial protocol at
http://www.trialsjournal.com (Hoddenbach et?al. 2012).
Peabody Picture Vocabulary Test?III?NL (PPVT)
The PPVT (Dunn and Dunn 2004) was used to assess
children?s verbal ability. The PPVT provides a
standardized score and verbal IQ equivalent, and correlates highly
with the WISC-III verbal IQ (Hodapp and Gerken 1999).
Internal consistency is high (? between 0.92 and 0.98;
splithalf reliability between 0.86 and 0.97), as is test-reliability
(r between 0.91 and 0.94; Dunn and Dunn 2004).
Proximal Primary Outcome Measure: ToM Test
The ToM test (Muris et?al. 1999) was chosen to assess
children?s theory of mind knowledge. It comprises a
standardized, 72-item, interview for children aged 5?13? years, and
measures ToM knowledge at three levels (Elementary,
Intermediate, and Complex), with cognitive sub-stages
within each level (perception and imitation, emotion
recognition, elementary theory of mind, second-order belief
understanding, and understanding of complex humor).
Children are asked to look at a picture and/or listen to a
story and answer the corresponding question. Items are
scored 0 (incorrect) or 1 (correct); a higher total score
indicates greater ToM knowledge. Internal consistency of the
task ranges from 0.80 to 0.92; concurrent validity with
traditional ToM tasks is high (r between 0.37 and 0.77), and
test?retest reliability is satisfactory (ICC between 0.80 and
0.99; Muris et?al. 1999).
Distal Primary Outcome Measure: ToM Behavior
The ToMbc (Begeer et?al. 2015) was chosen to assess
ToMrelated behavior in everyday life. On this 8-item
questionnaire parents indicate the frequency, over the last week, of
specific ToM-related behaviors of their child across eight
domains of behavior (understood a joke, comforted
somebody, asked about someone?s feelings, figured out his/her
story was not interesting to others, apologized, paid close
attention to somebody?s story, spontaneously
complimented someone, asked an interested question). Frequency
of occurrence of each domain is rated from 0 (never) to 5
(very often). A higher total score indicates a higher
frequency of ToM-related behaviors. Reliability has been
found to be good (? = 0.81; Begeer et?al. 2015).
Distal secondary Outcome Measure: Social
Responsiveness Scale (SRS)
test?retest reliability (0.84?0.97), interrater reliability (0.76
and 0.95) are good (Bolte et?al. 2008).
Moderators (Parental Education, Parental
Employment, Family Structure, and?Parental ASD)
At pretest, parents completed a questionnaire regarding
several sociodemographic characteristics.
Parental education was assessed on a scale ranging from
1-primary school to 7-university education for both parents
separately. For use in the current study this information was
recoded to represent the number of parents (0?2) with at
least a college degree.
Parents were asked to indicate whether they were in paid
employment. The number of parents in paid employment
(0?2) was used in subsequent analyses.
Parents indicated the family structure in which their child
was currently growing up. For the present analysis, three
categories were distinguished: two biological parents; two
parents but consisting of either separated biological parents
(co-parenting) or one biological parent and one step parent;
and single parent.
Parents were asked to indicate if any family members, other
than the participating child, were either diagnosed with, or
suspected of having, an ASD. Due to the small number of
cases in which both parents were diagnosed with/suspected
of having an ASD, this variable was recoded to a dummy
variable indicating whether the child did (1) or did not (0)
have at least one parent with a diagnosis or suspicion of an
The SRS (Constantino and Gruber 2007) was chosen to
assess autistic features. It is a 65-item parent questionnaire,
divided into five subscales: social awareness, social
cognition, social communication, social motivation, and autistic
mannerisms. Parents rate each item from 0 (never true) to
3 (almost always true) and a higher total score indicates
more autistic features. Internal consistency (0.91?0.97),
Data were analyzed using hierarchical multiple linear
regression analyses. The first step included pretest values
on the respective dependent variable, and the main effects
for condition and the moderator under investigation. The
second step added the condition*moderator interaction.
Continuous moderator variables were centered by
subtracting their means. Categorical moderators were investigated
using dummy coding. Condition was coded as: 0 = control;
1 = treatment. Level of significance was set at p < 0.05.
Table?2 shows the results of all the regression analyses. The
main results are outlined below.
Because the nonparametric correlation between the child?s
verbal IQ and the number of parents with at least a
college degree was significant (rs = 0.24, p = 0.01), the child?s
verbal IQ was included in the first step of all regression
Step 1 models were all significant (ToM test:
F(4,108) = 31.05, p < 0.001, R2 = 0.54; ToMbc:
F(4,105) = 27.82, p < 0.001, R2 = 0.52; SRS: F(4,105) = 48.55,
p < 0.001, R2 = 0.65). Children in the treatment condition
showed better ToM knowledge (? = 0.35, p < 0.001), more
ToM-related behaviors (? = 0.22, p < 0.01), and fewer
autistic features (? = ?0.19, p < 0.01) at posttest than those in
the control condition. Higher child verbal IQ was
associated only with greater ToM knowledge (? = 0.17, p < 0.05).
There were no main effects of parental education. However,
adding the interaction term in Step 2 significantly improved
the model for the ToM test only (Fchange(1,107) = 8.13,
p = 0.005, Rc2hange = 0.03). Figure?2 indicates that the
treatment effect became more pronounced as the number of
college educated parents increased (i.e. the children in the
control group showed a smaller increase in ToM knowledge
from pre- to post-test with every increase in the number of
college-educated parents; ? = 0.27, p < 0.01).
All models for parental employment were significant at Step
1 (ToM test: F(3,117) = 40.99, p < 0.001, R2 = 0.51; ToMbc:
F(3,116) = 44.51, p < 0.001, R2 = 0.54; SRS: F(3,117) = 73.89,
p < 0.001, R2 = 0.66). Again, children in the treatment
condition showed better ToM knowledge (? = 0.35, p < 0.001),
more ToM-related behaviors (? = 0.17, p < 0.05), and fewer
autistic features (? = ?0.17, p < 0.01) than children in the
control condition. However, there were no main effects of
parental employment and adding the interaction terms did
not improve the models.
Step 1 models for family structure were all significant
(ToM test: F(4,117) = 29.95, p < 0.001, R2 = 0.51; ToMbc:
F(4,115) = 32.85, p < 0.001, R2 = 0.53; SRS: F(4,116) = 55.31,
p < 0.001, R2 = 0.66). As in the previous analysis, children
in the treatment condition showed better ToM
knowledge (? = 0.34, p < 0.001), more ToM-related behaviors
(? = 0.19, p < 0.01), and fewer autistic features (? = ?0.17,
p < 0.01) than children in the control condition. There were
no main effects of family structure, and adding the
interaction terms did not improve the models.
All models for parental ASD were significant at Step 1
(ToM test: F(3,116) = 36.58, p < 0.001, R2 = 0.49; ToMbc:
F(3,114) = 45.06, p < 0.001, R2 = 0.54; SRS: F(3,115) = 71.20,
p < 0.001, R2 = 0.65). Once again, children in the treatment
condition showed better ToM knowledge (? = 0.33,
p < 0.001), more ToM-related behaviors (? = 0.19,
p < 0.01), and fewer autistic features (? = ?0.16, p < 0.01)
than children in the control condition. There were no main
effects of parental ASD, but adding the interaction term in
Step 2 significantly improved the model for the ToM test
only (Fchange(1,115) = 4.96, p = 0.03, Rc2hange = 0.02). For
children without a parent diagnosed with/suspected of having
ASD, there was a significant treatment effect: children in
the treatment condition showed better ToM knowledge than
those in the control condition (? = ?0.21, p < 0.05).
However, for children with at least one parent with an ASD
diagnosis/suspicion there was no significant treatment
effect (? = 0.07, p = 0.62; see Fig.?3).
This study investigated whether parent characteristics
moderated the effectiveness of a ToM focused training for
children with ASD. Overall, the training was effective in
increasing ToM knowledge, increasing ToM-related
behaviors, and reducing autistic features. Examination of family
factors indicated no significant effects of parental
employment or family structure on any outcome measures. The
effects of parental education were mixed, in that there was
no association with outcome in the treatment group but
children in the control group showed smaller increases in
ToM knowledge as the number of parents with a college
education increased. Parental ASD negatively influenced
treatment effects on ToM knowledge but there were no
effects on ToM-related behaviors or child autistic features.
We had predicted an effect of parental education because
more highly educated parents may be better able to
understand and implement treatment techniques (Burrell and
Borrego 2012). Contrary to our hypothesis, in the
treatment condition, children with more highly educated parents
Table 2 Results of hierarchical multiple regression analyses predicting posttest scores on the different outcome measures
+p < 0.1; *p < 0.05; **p < 0.01; ***p < 0.001
0.56 (0.06) 0.36***
4.00 (0.74) 0.12***
0.40 (0.67) 0.00
Fig. 2 Pretest and posttest
scores on the ToM test
according to participant?s number of
parents with at least a college
Fig. 3 Pretest and posttest
scores on the ToM test
according to participant?s parental
pretest pos est
pretest pos est
pretest pos est
performed no better than children of less educated parents.
However, in the control condition, higher parental
education was associated with poorer child ToM knowledge. The
reasons for this are unclear but it is possible that for
control children without college-educated parents, the mere
administration of the ToM test provided a new learning
opportunity, thereby leading to a greater increase in ToM
knowledge among this group. This finding highlights the
need for more individually tailored interventions that take
into account factors such as existing knowledge and skills,
in both children and their parents.
The effect of the ToM training on ToM knowledge was
only significant for children whose parents were not
diagnosed with or suspected of having an ASD. This is
consistent with the suggestion that parents who are on the
spectrum themselves may have more difficulty helping their
children acquire and generalize new skills in treatment
(Karst and Van Hecke 2012; Parr et?al. 2015b). These
parents may benefit from additional guidance or coaching
during the treatment. Alternatively, their children might
benefit from the involvement of another closely involved adult,
such as a teacher or non-BAP grandparent.
Although increases in child ToM knowledge, the
primary outcome measure most closely related to the focus
of the intervention, were affected by parental education
and parental ASD, these factors did not affect more distal
outcome measures, notably parental reports of child
autistic features and ToM-related behavior. While treatment
did improve children?s functioning in these domains, effect
sizes were smaller than for the more proximal outcome
measure. There are many unexplored variables, such as
other family factors, school issues, and social relations (de
Rosnay et?al. 2014) that may have greater impact on
behavioral, rather than knowledge outcomes. For example, social
interactions with siblings, classmates or peers provide more
opportunities for the display of ToM related behaviors or
autistic features but the study design did not permit
investigation of behavioral change in these settings.
Contrary to our expectations, parental employment did
not moderate any treatment effects. However, the overall
positive effects of employment may become negative when
parents are too engaged with work and so less available to
their child. An additional explanation may be our relatively
crude measure of employment, which simply involved
how many parents were in paid employment. The
distribution of this variable was highly skewed, with only five
children having parents who were both unemployed,
limiting the chance of finding significant results. More detailed
information related to potential financial strain (i.e. family
income), might have produced a different result. Another
relevant approach would be to investigate the number of
hours worked by each parent, as previous research has
found that treatment was particularly effective for children
whose parents? combined number of hours in
employment was at least the equivalent of a full time job (R?bl
et?al. 2013). For this variable, investigating nonlinear
relationships may be more informative, as more hours in paid
employment might decrease financial strain, but at the
same time limit the amount of time a parent can spend with
the child on practicing new skills.
Finally, we failed to find the expected moderation effect
of family structure. One possible reason for this is that
although certain family structures may be more stressful
for parents (NSCH 2011/2012), this stress does not
necessarily relate to the child?s ASD. Family structure may also
be unrelated to the extent to which parents are involved in
treatment. A further, methodological explanation is that the
power to detect moderation was limited, as only 41 children
were not living with two biological parents.
Strengths of this study include its randomized
control design, with the RCT protocol being specified before
trial initiation (http://www.trialregister.nl, Trial No. 2327)
and published prior to completion of the data collection
(Hoddenbach et?al. 2012). The relatively large sample also
allowed for the analysis of parent characteristics potentially
related to treatment success. The findings here suggest that
parental education levels and parental ASD are important
areas for future investigations of moderators of treatment
outcome in children with ASD.
Limitations include the absence of detailed
diagnostic instruments, such as the Autism Diagnostic
InterviewRevised (Lord et?al. 1994) or the Autism Diagnostic
Observation Scale (Lord et? al. 2000), due to limited resources.
The inclusion of multiple primary child outcome measures
may also be considered a weakness but because of lack of
data on the relative sensitivity of any single ToM
assessment we chose to use a combination of measures tapping
different ToM aspects. This was indicated in the trial
protocol (http://www.trialregister.nl, Trial No. 2327), and
allowed us to assess whether the training and moderators
affected different aspects of ToM. The use of simple
categorical measures to assess family structure, parental
education/employment, and presence of autism in parents is
a further methodological limitation. With respect to the
latter variable, for example, a broader measure of autism
traits (e.g. Parr et?al. 2015a; Pickles et?al. 2013) might have
produced more meaningful results. Finally, although total
sample size was relatively large, some of the subgroups
were small, resulting in potential power issues for some
moderator analyses. Consequently, findings pertaining to
these variables (i.e. parental employment and family
structure) should be considered preliminary and require
replication in future research. Additional directions for future
research include the investigation of other parental
variables (e.g. hours parents spent reinforcing the training at
home; parenting stress; Osborne et?al. 2008), exploration of
interactions between different parental variables, and
replication in samples with lower verbal IQ scores.
In conclusion, as parents often play an important role in
interventions for children with ASD (Burrell and Borrego
2012), investigating which parent characteristics
moderate treatment effectiveness is important. The current
finding that parental education and parental ASD moderated
treatment effects provides valuable information that should
be taken into consideration in future treatment design and
Acknowledgments We would like to thank all the children, parents,
clinicians, and graduate students who were involved in the study.
Author contributions DdV analyzed the data, interpreted the
results, and drafted the manuscript; PH participated in the design of
the study, and helped draft the manuscript; EH participated in the
design and coordination of the study, and supervised the data
collection; FM and IW participated in the coordination of the study, and
supervised the data collection; HK and RL participated in the design
of the study and provided feedback on the manuscript; SB conceived
of the study, designed the study, participated in the interpretation of
the results, and helped draft the manuscript. All authors read and
approved the final manuscript.
Compliance with Ethical Standards
Conflict of interest DdV, PH, FM, IW, HK, and SB have no
conflicts of interest to declare. EH is currently employed at De Bascule,
at the unit that developed the reported intervention. RL is currently
employed at De Bascule, at a unit different from the one that developed
the reported intervention.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
Informed Consent Informed consent was obtained from all
individual participants included in the study.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
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